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Medically Complicated IVF Patient
1. Dr. Kaberi Banerjee
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
• MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
• MRCOG, London, UK
• Commonwealth Fellow in Reproductive Medicine, London UK.
• More than 8000 IVF, ICSI, Donor and Surrogacy Cases
• Awards:
• Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
• India Today Excellence Award in Field of Medicine 2015
• BL Jhaveri National Award in Medicine 2015
• Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
•MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
•MRCOG, London, UK
•Commonwealth Fellow in Reproductive Medicine, London UK.
•More than 8000 IVF, ICSI, Donor and Surrogacy Cases
•Awards:
•Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
•India Today Excellence Award in Field of Medicine 2015
•BL Jhaveri National Award in Medicine 2015
•Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.
3. IVF
• Complex series of procedures
• Infertile females with medical
disorders – More complicated
treatment
– May affect fertility
– Aggravation of medical
conditions
– Life threatening for pregnancy
– Teratogenic effects on fetus
• Identify high risk cases (before
IVF treatment)
5. Hypertension (HT)
• Not affect fertility/ IVF
treatment
• Should shift to antihypertensive
(safe in pregnancy)
• IVF may aggravate the
condition
– Ovarian stimulation a/w marked
stimulation of renin- angiotensin-
aldosterone system
BP
6. Hypertension (HT)
• For IVF
– Control of BP
– BP monitoring
– Standard protocol for
ovarian stimulation
7.
8.
9.
10. Diabetes
(Low fertility)
• Type I Diabetes
– Dysfunction of HPO axis
– Disruption in hypothalamic pulsetile
secretion GnRH & basal level of
LH
– Antiovarian autoantibodies
– Hashimoto’s thyroiditis
• Type II Diabetes
– A/w PCOS, obesity
– Insulin resistance alterations in
the level of IGFBP, IGF1 and SHBG
stimulates increased androgen
secretion
• Impaired sexual arousal and
inadequate lubrication
11. Diabetes
(Before IVF)
• Tight control of blood
glucose levels (to prevent
congenital malformations
in fetus)
– Diet
– Exercise
– Metformin & Insulin
12.
13. Heart diseases
• May affects fertility
– A/w PCOS
• Cardiac fitness for IVF
treatment (Esp. Anesthesia)
and pregnancy
• For IVF
– Standard protocol for ovarian
stimulation (Avoid OHSS)
• Surrogacy option
14.
15. Epilepsy
• Low fertility
– A/w endocrinopathies – Prolactin,
or FSH & LH
– A/w PCOS
– Libido
– Antiepileptic drugs - SHBG
• Shift to pregnancy safe
anticonvulsants (levetiracetam,
lamotrigine)
• Neurological fitness for IVF
treatment (Esp. Anesthesia) and
pregnancy
• For IVF
– Standard protocol for ovarian
stimulation (Avoid OHSS)
• Surrogacy option
16.
17. Thromboembolic conditions
• Not affect fertility
• DVT after IVF
– Rare
– Life threatening
– High risk factors:
Antithrombin, Protein C &
S def, APC resitance,
MTHFR 677T
polymorphism
18. Thromboprophylaxis
• Compression stockings and
LMW heparin
• Should be commenced 48h
after OPU (to reduce
hemorrhagic
complications)
• Extended throughout first
trimester
• If thrombophilia detected -
extending prophylaxis
throughout pregnancy
19.
20. Endocrine disorders
• Affects fertility
• May aggravate the
condition (if not treated
prior to IVF)
• Rarely life threartening
• May affect fetus
21. Acromegaly
• Growth hormone excess
• A/w high IGF-I & prolactin
levels
• Treated with trans-sphenoidal
resection
• For IVF
– Optimize blood glucose and
prolactin levels
– Ovarian stimulation with
combined FSH & LH (in v/o
hypogonadotropic condition d/t
Sx)
• During pregnancy -
– maternal morbidity (GDM, HT)
– fetal morbidity and mortality
22. Disorders of HPA axis
(Low fertility)
• Cushing syndrome (Hypercortisolism)
– Hypogonadism
• Addison’s ds. (Hypocortisolism)
– Premature ovarian failure (low estrogen
and high gonadotropin levels)
• Congenital adrenal hyperplasia (CAH)
due to 21-hydroxylase deficiency
– Adrenal or ovarian overproduction of
androgens and progestins
– Classical CAH: Good prognosis for normal
fertility (when testosterone
concentrations are within normal limits)
– Non classical CAH: Improves fertility with
endocrine, surgical and psychological
management
23. Disorders of HPA axis
(For IVF)
• Cushing syndrome
– Endocrinologist Reference – optimize oversecretion of cortisol
– Discontinue progestogen antagonists prior to IVF
– Medical & Surgical treatment
– Regular administration of physiological doses of hydrocortisone (to reduce
stress)
– Ovarian stimulation with FSH & LH
• Addison’s disease
– Corticoid substitution
– Immunotherapy with corticosteroids
– IVF wuth donor eggs recommended
– Cryopreservation of ovarian tissue in unmarried females
• Congenital adrenal hyperplasia
– Correction of hyperandrogenism
– Single daily dexamethasone regimens
– During pregnancy - sex of the fetus (whether glucocorticoid treatment is
indicated)
25. Disorders of HPT axis
(Maternal and Fetal Effects)
• Hypothyroidism
– Impairment of fetal brain development (d/t
insufficient transfer of maternal thyroid hormones
to fetoplacental unit)
• Hyperthyroidism
– Prone to iatrogenic hypothyroidism a/w fetal
maldevelopment and mortality
26. Disorders of HPT axis
(For IVF)
• Before IVF
– Tight control of thyroid function
– Thyroid Ab screening in euthyroid women with
recurrent IVF failure
• During IVF
– Natural-cycle IVF: HCG for ovulation (For
compensating LH levels)
– IVIg (positive for antithyroid Ab)
– Good luteal support
29. Hyperprolactinemia
(During IVF)
• Ovarian stimulation
– Prl and estradiol levels
– Estrogens - ability of dopamine to inhibit Prl
secretion
– Progesterone - induce acute release of Prl
(through an increase in GnRH)
– Transitory hyperprolactinemia - no. of larger (>
12 mm) follicles and with more mature oocytes
and better IVF success rates
32. Malignancies
• Affects fertility
• Options –
– Urgent IVF
• Embryo cryopreservation
• Oocyte cryopreservation
– Ovarian tissue cryopreservation
• Use of gonadotropins,
tamoxifen or letrozole
(depending on estrogen
dependent tumors)
• Surrogacy can be considered
33.
34. Systemic lupus erythematosus (SLE)
• Low fertiity
– Ovarian failure secondary to
cyclophosphamide therapy
– Implantation failure d/t
presence of antinuclear
antibody (ANA)
• Fitness (Immunologist) for IVF
treatment and pregnancy
– Exacerbation of SLE
– maternal & fetal morbidity
and mortality
35. Systemic lupus erythematosus
• IVF indicated and performed only in patients
– With normal creatinine
– After complete remission of autoimmune disease
for at least 1–2 years
• Options
– IVF with donor eggs
– Surrogacy
36.
37. HIV seropositive cases
• Not affect fertility
• Main objective
– To prevent vertical and
horizontal transmission
• Fitness from Physician
– Low viral load -Plasma HIV
RNA viral counts and CD4
status
– Introduction of HAART
38. HIV seropositive cases
• Standard protocols for
ovarian stimulation
• Universal precautions for
OPU
• Embryology laboratory
– Separate work-stations and
incubation and embryo storage
facilities
• Sperm washing
• IVF ICSI
• During pregnancy
– Serial HIV-RNA PCR testing at
beginning of each trimester, At
delivery and 3 months
postpartum
39.
40. Obesity
• Low fertility
– leptin secretion from adipose
tissue
– Anovulation
– A/w PCOS
• For IVF treatment
– Difficult to plan d/t menstrual
irregularity
– More FSH dose for stimulation
– Difficult intubation
– Complications at oocyte
collection
– Difficult ultrasound identification
of follicles
– Difficult embryo transfer
43. Conclusion
• Prior identification and
preparation of high risk
cases
– Enable clinician to avoid
problems in advance
– Anticipate the necessary
management
– Optimize outcomes
