The document discusses various risks associated with pregnancies resulting from assisted reproductive technologies (ART) like IVF. It notes that ART pregnancies have slightly higher risks of early pregnancy loss, ectopic pregnancy, multiple pregnancies, gestational diseases, birth defects, and poorer perinatal outcomes. However, it also states that some of these risks may be due to underlying infertility issues rather than the ART procedures themselves. The document advocates for close monitoring of ART pregnancies and suggests more research is needed to fully understand all risk factors.
2. Introduction
Rate of IVF-ICSI increasing- 1.3-4.2% of all births
Approx 1 million children borne out of IVF in USA
Risk of following complications also continuously
increasing:
miscarriages
Birth defects
multiple pregnancy
gestational diseases
Prematurity, LBW, IUGR & PTB
Increased operative deliveries
3. Early pregnancy loss
Biochemical pregnancy- failure to
demonstrate an embryonic sac on USG in
a patient with β-hcg positive in blood or
urine
Blighted ovum- failure to demonstrate a
fetal pole in a patient in which gestational
sac is visible
Missed abortion- Failure to demonstrate a
heart beat in a foetus
18-22% of all spon pregnancies
12-48% in all ART pregnancies
6. EPL
it is concluded that even after adjustment for confounding factors
conception through FET remained an independent risk factor for
EPL. Other modes of conception were not related with EPL
A small increase in sp abortions after ART is there
which primarily is related to the underlying causes of
infertility and rather than the procedure( Wang et al 2004)
Is the fertility treatment itself a risk factor for early
pregnancy loss? Ragaa et al. 2011
7. Ectopic pregnancy in IVF
General population-2%
ART- 2-8%
After tuboplasty- upto 40% depending upon
extent, site and type of surgery done
After recanalisation-6%
Heterotopic preg-1:100 to 1500 in ART as
compared to 1: 30000 spon preg
Cervical pregnancy
8. Risk factors for EP
Spon pregnancies
- Prev EP
- PID
- Tubal disease/
surgery
- Smoking
- Age>35
ART
- Tubal disease
- Endometriosis
- Specific ART
procedure
- Embryo implantation
potential
9. Other possible risk factors
Blastocyst transfer?
Assisted Hatching?
Frozen embryo transfer?
Deep fundal transfer?
High transfer volume?
Multiple embryo transfer?
None of the above are found to have
any effect on occurrence of EP
10. Ectopic pregnancy after assisted reproductive
technology: what are the risk factors?
Chang, Hye Jina,b; Suh, Chang Sukb,c, curr opin,2010
Summary: Different hormonal milieu, the
reproductive health characteristics of infertile
women such as distorted tubal function, technical
issues of IVF procedures, and the estimated
embryo implantation potential are possible risk
factors. How each factor contributes to the risk of
occurring ectopic pregnancy after assisted
reproductive technology is uncertain and needs
further investigation
11. Ectopic Pregnancy in
IVF
Laparoscopic salpingectomy in
hydrosalpinges enhances the success of
IVF (Strandell 2000; Johnson 2002)
ART do not increase the risk of EP,
however specific characteristics of the
female patients do
12. Multiple pregnancy In IVF
Spon pregnancies
Rate- 3.26%
Twins- 1in 100deliveries
Triplets- 1 in 1000
Quadruplets- 1in 10000
Monozygous
twinning(30%) -
3.5/1000
Dizygous twinning
(70%)
ART
Rate- 26.4%
Twins- 1 in 60 to 70
Higher order- 3-4 times
increase
MZ- 5-10 times increase
Transfer of higher No of
embryos inc risk of DZ
as well as higher order
gestations(MZ less)
13. US data
3.26% of all births
60% from natural conceptions
21-32% from OI/SO
8-16% from ART
Higher order gestation- 20% from natural
39-67% from OI/SO
13-44% from ART
14. Higher order are generally polyzygotic
Cochrane review 2009 has not found
asso with AH
No association with Blastocyst transfer
No association with the type of culture
medium
17. Multiple pregnancy
Is there a difference in outcome of sp conceived
Vs ART conceived twins?
Conflicting results
Singletons after Ivf have worse outcome than SC
but multiples have 40% lower risk of morbidity
(Helmerhorst et al,2005)
No diff in morbidity ( Shebl et al2005)
Risk of prematurity & SGA are comparable after
controlling for MZ along with other maternal factors &
concluded that worse outcome in SC twins could be
due to more No of MZ( Andrea et al.2002)
18. vanishing twin syndrome
Disappearance of one of the two
gestational sacs or the embryo after
documented fetal activity is known
Incidence- 12-38%
Survivor twin more affected when demise
occurs >8wk (MC twins)
20. Effect of OHSS on
pregnancy
Obstetric outcome of in vitro fertilized
pregnancies complicated by severe ovarian
hyperstimulation syndrome: a multicenter
study. Yoram Abramov, M.D,2002
Conclusion(s): Among patients who have severe
OHSS after IVF treatment, the pregnancy rate and
the rates of multiple gestation, miscarriage,
prematurity, low birth weight, pregnancy-induced
hypertension, gestational diabetes, and placental
abruption are significantly higher than those reported
previously for pregnancies conceived with the use of
assisted reproductive techniques
24. Subfertility and adverse outcome
Subfertility correlates with adverse
outcome (Henriksen, OG 1997; Pandian, HR 2001; Basso, HR
2003; Thomson, OG 2005; Zhu, BMJ 2006)
Perinatal mortality and time-to-pregnancy >12
months (Draper, Lancet 1999; Basso, HR 2005)
25. Gestational diseases in
ART
Cochrane review 2006- ( levelIA)
Preg achieved by IVF/ICSI are at higher risk for Obs &
Perinatal complications than SC.
Increased incidence of Pl. Previa, Placental
insufficiency, Abruptio, PIH/ PE or Prematurity
Close surveillance duirng preg should be considered
It is unclear whether inc risk is due to underlying
infertility, charac. of infertile couple or use of ART
Higher operative delivery
Higher risk of LBW & SGA
26. ASRM press release 2011
Singleton obs outcome depends upon the tech
used & the cause of infertility with poorest risk
factor for prematurity & LBW being uterine
environment
Gobbon et al 2006- (review of SART data)
All types of female infertility except unexplained
associated with PTB & LBW, uterine factor being
poorest
Male factor was not associated with LBW
28. Elective single embryo transfer and perinatal outcomes: a
systematic
review and meta-analysis
Rosheen Grady et al, fertil steril 2012
Result(s): Sixteen studies were included (eight RCTs, eight cohort studies).
Compared with DET-conceived infants, eSET-conceived singletons were less
likely to be born either preterm (RCT-based relative risk [RR] 0.37, 95%
confidence interval [CI] 0.25–0.55) or with LBW (RCT-based RR 0.25, 95% CI
0.15–0.45; cohort study RR 0.51, 95% CI 0.29–0.91). However, compared with
spontaneously conceived singletons, eSET gestations had higher risks of PTB
(RR 2.13, 95% CI 1.26–3.61), placenta previa (RR 6.02, 95% CI 2.79–13.01),
gestational diabetes (RR 1.69, 95% CI 1.19–2.42), and ectopic pregnancy (RR
6.40,95% CI 4.38–9.35).
Conclusion(s): Elective single embryo transfer is associated with decreased
risks of PTB and LBW compared with DET but higher risks of PTB compared
with spontaneously conceived singletons
29. possible explanations for
poorer outcome
Infertility alone
IVF procedure itself
Heightened monitoring or intervention by health
care providers
Placenta previa occurs more often in singletons
borne out of SET or DET while abruptio is more
common in SET singletons as compared with spon
conceived ( Antonio et al,Hum reprod,2010)
30. Growth and development of Ivf
children
Data scarce with conflicting results as long term
studies still underway
1) Birth defects in ART- slightly increased
Hansen et al,2005 - risk increased by OR 2 even after
controlling for confounding factors like maternal age,
parity & sex of baby
Katalinic et al,2004- OR of 1.2% for CMF but risk goes
down after controlling for other factors
31. Birth defects
No increased risk in multiple preg.(indirectly
through inc in monozygosity)
No increase in CMF in ICSI as compared to IVF
( Bonduelle et al.1998)
Causes- Technique?
Genomic Imprinting disorders
Subfertility per se
32. Birth defects
Genomic imprinting disorders higher in ART
- Beckwith-wiedemann syd
- Angelman syd
Possible causes-
- effect of in-vitro culture conditions?
- severity of male factor infertility?
- subfertility per se?
33. 2. Childhood cancers- no increased risk
3. Growth & physical development- no significant
difference
4. Neurological sequelae- cerebral palsy &
epilepsy have found to be increased in few
studies(Ericson et al2002,Stromberg et al 2002) ,but more related
to LBW & LGA.
5. Pubertal development & fertility- can be a concern
as in-utero elevated sex steroids exposure is
found in ART pregnancies.
34. 7. Genetic risks of ICSI-
Concern arises due to use of naturally unselectd
sperm for insemination
Men with azoo or s. Oligo have 5.8% incidence of
ch. Anomalies
Klinefelter’s syd is MC abnormality in Azoospermia
Offsprings have a slightly increased risk for sex
chromosome aneulpoidy
Proper genetic counselling & screening must
before undergoing ICSI for severe male factor
infertility