ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar

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  • ART PREGNANCY

    COMPLICATIONS

    Prof. Aboubakr Elnashar

    Benha university hospital, Egypt

    [email protected]

    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

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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.

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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)

    Aboubakr Elnashar

  • Prevention: Prophylactic salpingectomy: Treat more than 89 %of

    patients

    Disadvantages:

    1. Removes any chance of normal spontaneous

    pregnancy

    2. Not prevent interstitial pregnancies.

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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.

    Aboubakr Elnashar

  • 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.

    Aboubakr Elnashar

  • Prevention: Modern molecular biology techniques

    PGD

    ICSI

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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.

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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

    Aboubakr Elnashar

  • 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.

    Aboubakr Elnashar

  • b. Chromosomal anomalies Slightly increased in ICSI

    Predominantly sex chromosomes

    Aboubakr Elnashar

  • 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,