ART PREGNANCY

COMPLICATIONS

Prof. Aboubakr Elnashar

Benha university hospital, Egypt

elnashar53@hotmail.com

Aboubakr Elnashar

Complications of ART I. COMPLICATIONS OF OVULATION INDUCTION II. COMPLICATIONS OF OR

III. ART PREGNANCY COMPLICATIONS

IV. PSYCHOLOGICAL COMPLICATIONS

Aboubakr Elnashar

At every stage of ART: There is a potential for complications

some are dangerous& may be life threatening.

Role of reproductive medicine clinicians: 1. Prevention of these complications

2. Establish the critical balance between efficacy and safety

of ART.

Aboubakr Elnashar

INCIDENCE OHSS& OR complications: 1.3 % 4 major clinical complications: 2% Severe& moderate OHSS

Adnexal torsion

OR complications

Ectopic pregnancy.

Aboubakr Elnashar

All TT

cycles

First TT

cycle

Complication/1000

women

35 19 OHSS

2.5 1 Bleeding

11 5 Infection

93 42 Miscarriage

21 9.5 Ectopic

2 1 Other

5 2.5 Total

Aboubakr Elnashar

ART PREGNANCY

COMPLICATIONS

Aboubakr Elnashar

Maternal

I. First-trimester bleeding

II. Miscarriage

III.Ectopic Pregnancy

IV.Heterotopic Pregnancy

V. PIH, gestational DM, CS

VI.Placenta previa

VII.PTL

Foetal

I. Molar Pregnancy

II. Multiple Pregnancy

III. Congenital

Abnormality

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A. Maternal I. First-trimester bleeding

Incidence:

29 -36.2%

Cause:

A correlation was found with the number of embryos

transferred.

Consequence:

1. Increased 2nd trimester& 3rd trimester bleeding

2. PROM

3. Preterm contractions & PTL

4. NICU admissions

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II. Miscarriage Rate: 1523%

Causes: 1. Fertilization of postmature ova

2. Luteal phase defect

3. Adverse effects of handling the oocytes

4. False higher rate when compared to G population:

a. Different definitions of miscarriage,

b. Use of highly sensitive assays for b-hCG,

c. Close monitoring

d. knowledge that the embryos were transferred on a

particular day.

Aboubakr Elnashar

III. Ectopic Pregnancy Rate: 2 5% Tubal factor: 11%,

Endometriosis: 2%

Unexplained infertility: 3.5%

IVF: 2.8%

ICSI:1.3%

Within the IVF group, EP was inversely correlated with

maternal age.

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Causes: -The most significant risk factor:

Tubal pathology.

-Non significant factors:

Type of ovarian stimulation

E2 level

knee-chest or Lithotomy position at ET

Number of embryos transferred

Aboubakr Elnashar

Possible Factors Associated with

Ectopic Pregnancy in IVF Means of Prevention

Tubal disease, hydrosalpinx Pre-IVF salpingectomy or tubal

occlusion

ET: 1 Depth

Mid-fundal transfer, ultrasound-

guided transfer (controversial)

2 Amount of media used 1520 L of media

3 Number of embryos Reduced or single-embryo

transfer

4 Day 3 versus day 5

Controversial; some data

suggest fewer ectopics with day

5 transfer

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Sites: 1. Tubal

2. Bilateral tubal

3. Intramural

4. Ovarian

5. Abdominal

6. Cervical {reflux of embryos into the cervix after

transfer or trauma to the cervix during ET}.

Aboubakr Elnashar

Diagnosis: Highly sensitive -hCG assay& TVS The usual algorithms may not apply in ART {more than one embryo usually is transferred, affecting -hCG level}.

Marcus et al:

3-hCG levels& D13 progesterone combined with a history of PID: predictive value of 90 %

Mol et al:

D9 -hCG, after ET of >18 IU/L: EP is only 1%: expectant management (in an asymptomatic patient)

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Prevention: Prophylactic salpingectomy: Treat more than 89 %of

patients

Disadvantages:

1. Removes any chance of normal spontaneous

pregnancy

2. Not prevent interstitial pregnancies.

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IV. Heterotopic Pregnancy Rate: Spontaneous pregnancies:1 in 2,600 to 1 in 30,000

ART: 1 in 100 pregnancies.

Recent reviews: 1-3 in 1000 pregnacies

% Spontaneous

Pregnancies

% IVF Clinical

Pregnancies

1.3 2.2 Ectopic pregnancy

0.07 0.5 Heterotopic pregnancy

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Cause: Multiple ovulations& multiple ET in a population with tubal or pelvic disease.

Transfer of >4 embryos: increase risk

The technique of ET (volume& viscosity of medium, deep or superficial insertion of the catheter, and the

degree of difficulty): inadequate data to draw firm

conclusions.

Aboubakr Elnashar

Risk Delayed diagnosis: rupture, hage

Diagnosis

TVS

Treatment: 1. Laparoscopic removal

2. TVS guided instillation of hyperosmolar glucose into

the ectopic gestational sac

3. Potassium chloride injection with aspiration of the

tubal sac

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V. PIH, gestational DM, CS Are increased PIH: IVF Vs Non IVF: (15 Vs 4%)

IUFD: 2%

Reubinoff et al. only found increased risk of: CS

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VI. Placenta previa Rate: 3-6 folds higher in singleton pregnancies compared with naturally

conceived pregnancies.

Cause: Women with pregnancies conceived after ART:

1. Older

2. More often primiparous.

3. More likely to have a multiple pregnancy.

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VII. PTL PTL: Overall: 21.5-37% of births

Singletons: 5.513.0%

Low birth weight (

B. Foetal I. Molar Pregnancy

Incidence:

Difficult to be assessed.

Causes:

1. Use of immature ova after ovulation induction

2. Disruption of meiosis& loss of maternal

chromosomes {oocyte handling or degeneration}:

increase the risk of complete mole.

3. Postmature oocytes are more prone to polyspermy: heterozygous complete or partial molar pregnancy.

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Prevention: Modern molecular biology techniques

PGD

ICSI

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II. Multiple Pregnancy WHO recognized MP as a major complication of ART.

Rate: In natural conception: 1 in 80 pregnancies

In ART: 1 in 50 , even in countries where the number of

ET is limited to 3 embryos.

In ESHRE report 2006:

Singleton: 75.5%

Twin 23.2%,

Triplet 1.3%

Causes: Ovulation stimulation drugs

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Adverse outcomes: 1. Prematurity: short-term& long-term sequelae.

2. Neonatal mortality: 4 times as great among twins as

it is among singletons

3. Long-term disability e.g. cerebral palsy: increased.

4. Stress associated with rearing children

5. Cost of prenatal& neonatal intensive care: increased

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Prevention: ART success rate should be measured as a singleton

live birth rate& not as PR

1- Elective double ET :

Most European countries: reduced triplets& HOMP but

has had no impact on twin pregnancies

2-Elective single ET:

If significant risk of multiple gestation:

relatively young,

first or second IVF cycles,

number of good-quality embryos.

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ESET: Reduces:

multiple pregnancy &

live birth in a fresh IVF cycle.

3. Individualize protocols:

based on their risk of MP.

4-Multifetal pregnancy reduction (MFPR)

Disadvantages does not address the problem of twins. ethical dilemma psychological trauma It should never be considered as a standard line for

prevention of MP and HOMP.

It is only a rescue if other methods fail in the prevention

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5-Health education

of couples& the society on the hazards of MP&HOMP

6-Convince reproductive medicine physicians

-Obstetrical, neonatal, developmental& financial

consequences

-Measure of performance of ART is cumulative live birth

per patient not pregnancy rate per cycle

7-Convince policymakers

consequences of MP particularly cost

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III. Congenital Abnormality 1. General: Types

a. Major birth defects:

NTD, esophageal atresias, omphalocele, hypospadias, cardiac septal

defects

Incidence little risk 2 fold excess No higher rate of malformation in ICSI children than in IVF or naturally conceived children (large and reliable surveys)

Explanation:

-Increased maternal age.

-During IVF: embryo is exposed to mechanical, thermal& chemical

alterations.

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b. Chromosomal anomalies Slightly increased in ICSI

Predominantly sex chromosomes

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c. Imprinting disorders Due to errors in imprinting, a process by which certain genes from either the mother or father are normally

switched off.

e.g. Beckwith-Wiedemann syndrome (large tongue, organs,