IVF Pregnancy -Is it different? A presentation by Dr Laxmi Shrikhande the leading IVF specialist in India IVF (In Vitro Fertilization) pregnancy can be both similar to and different from natural conception in several ways. In IVF, fertilization of the egg occurs outside the body in a laboratory setting, typically involving the extraction of eggs from the ovaries and combining them with sperm in a petri dish. Once fertilization is successful, the resulting embryos are transferred to the uterus for implantation

1. • Immediate Past Chairperson ICOG –Indian College of
OB/GY
• National Corresponding Editor-Journal of OB/GY of
India JOGI
• National Corresponding Secretary-AMWI Association
of Medical Women, India
• President –ISOPARB Vidarbha Chapter 2019-21
• Chairperson-IMS Education Committee 2021-23
• Chairperson-fertility enhancement Committee-
ISOPARB
• Member-SAFOG Education Committee
• President-Association of Medical Women, Nagpur
AMWN 2021-24
• Senior Vice President FOGSI 2012
• President Menopause Society, Nagpur 2016-18
• President Nagpur OB/GY Society 2005-06
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra
 Nagpur Ratan Award @hands of
Union Minister Shri Nitinji
Gadkari
 Received Bharat excellence Award
for women’s health
 Received Mehroo Dara Hansotia
Best Committee Award for her
work as Chairperson HIV/AIDS
Committee, FOGSI 2007-2009
 Received appreciation letter from
Maharashtra Government for her
work in the field of SAVE THE
GIRL CHILD
 Delivered 22 orations and
450 guest lectures
 Publications- 42 National &
21 International
 Sensitized 2 lakh boys and
girls on adolescent health
issues
Awards
Positions

2. IVF Pregnancy -
Is it Different ?
Dr Laxmi Shrikhande
Consultant –Shrikhande Hospital & Research Centre
Nagpur

3. ART Pregnancy
Assisted reproductive technology (ART) now accounts for 1.6%
of all infants and 18.3% of all multiple-birth infants in the United
States.
 Although most of these pregnancies are uncomplicated, IVF is
associated with several adverse maternal and perinatal
outcomes.

4. Why are ART pregnancies at higher risk?
Maternal age
Pre-existing co-morbidities
Cause of sub-fertility itself
Drugs for ovarian stimulation
Previous surgeries
IVF procedures

5. Kabhi Khushi Kabhi Gam…..
ART can alleviate the burden of infertility on individuals
and families, but it can also present challenges -
high rates of multiple delivery,
preterm delivery, and
low birth-weight delivery

6. ART pregnancies – are they different?
Reported to be associated with higher risk of complications, which can
be-
Due to multifetal pregnancies
Regardless of multiple gestation

7. Obstetric complications
Increased risk of obstetric complication from ART appears to apply to
twin gestations as well as singletons.
When compared with the non-ART dichorionic twins, the ART
neonates had an increased risk of preterm birth (RR 1.13, 95% CI
1.00-1.29), very preterm birth (RR 1.39, 95% CI 1.07-1.82), LBW (RR
1.11, 95% CI 1.00-1.23), and congenital malformations (RR 1.26, 95%
CI 1.09-1.46).
Luke B, Gopal D, Cabral H, et al. Adverse pregnancy, birth, and infant outcomes in twins: Effects of maternal fertility status and infant
gender combinations The Massachusetts Outcomes Study of Assisted Reproductive Technology. Am J Obstet Gynecol 2017.

8. RISKS ????
 Mother
 Fetus

9. ART Pregnancy- Maternal Risks
Miscarriages or Ectopic
 15% in women < 35,
 25% in women >35 and < 40
 35% in women > 42.
Multiple pregnancy
 Abortion
 Gestational hypertension
 Placental abruption
 Placenta previa.
 rate of obstetrical interventions
 Induced labour
 Elective Caesarean delivery
Psychosocial impact

10. ART Pregnancy- Fetal Risks
Chromosomal
 De novo (mainly sex) chromosomal abnormalities in IVF-ICSI
babies for male-factor infertility
 Aneuploidy in pregnancies adapted for maternal age and
number of fetuses
Multiple births
 Prematurity
 Low birth weight
 Neonatal Morbidity & Mortality

11. The best way to protect the mother's
health and that of the baby regardless of
how the pregnancy occurred is good
Antenatal surveillance .

12. Why Antenatal surveillance ??
1.Triage mothers to High Risk & Low Risk
2.Screen the fetus for
Chromosomal errors
Structural Defects
Growth abnormalities
3.Predict and prevent maternal complications
4.Decide the time and mode of safe delivery

13. Is there a standard protocol?
NO

14. Antenatal care
Continue Progesterone Support
How long? Individualize for every patient profile.
Micronized progesterone vaginally is the drug of
choice.
Continue folic acid supplementation
Continue Thyroid medication if she is already on it
Continue prescribed medicines by ART consultant

15. Antenatal care
Routine Blood Tests
Additional blood tests for Monitoring -
Look for rising hCG titres
Case specific
Haemoglobinopathy screening

16. O H S S
“Abundance,
like want,
ruins many”.
~ Romanian Proverb ~

17. Patterns of OHSS
Early OHSS
generally presents 3–7 days after hCG administration
acute effect of ovulatory hCG, and it can occur in
patients who do not become pregnant.
Late OHSS
presenting 12–17 days after hCG.
late OHSS is induced by endogenous hCG from the
trophoblast of the implanting pregnancy.
Wheelan JG 3rd, Vlahos NF. Fertil Steril 2000; 73:883–896.

18. Management of OHSS
Principles
 Monitoring
 Supportive therapy
 Maintenance of intravascular volume
 Prevention/treatment of complication
 Counseling - Signs and symptoms of OHSS

19. Management of OHSS
 OUTPATIENT CARE
 Limit activity
 Weigh daily
 Monitor I/O
 Daily follow up
 Report if symptoms
worsen or
weight gain > 2lb/day
 INPATIENT CARE
 Monitor
 Vitals every 4 hours
 I/O
 Daily weight & AG
 Hematocrit,TC,DC,
 Serum electrolytes, RFT
 LFT,PT, APTT on admission
repeated if necessary
 ICU
 Renal faillure,
 ARDS,
 DIC

20. Mild to Moderate OHSS
Increased fluid intake.
Frequent physical exams and ultrasounds.
Daily weigh-ins and waist measurements to check for drastic
changes.
Measurements of how much urine you produce each day.
Blood tests to monitor for dehydration, electrolyte imbalance
and other problems.

21. Who are at risk for OHSS ?

22. Prevention is better than cure
Avoid HCG – Cancellation of cycle

23. Which Protocol ?
Antagonist Protocol
Agonist Trigger
Freeze all embryos
OHSS free clinic

24. First trimester
What would you advise / look for?

25. New shift
 Some very important complications that occur later in pregnancy can be
predicted in the first trimester itself.
 Inverted pyramid helps in dividing cases into high risk & low risk in the first
trimester
Nicolaides KH. Turning the pyramid of prenatal care. Fetal Diagn Ther 2011;29: 183–96.

26. USG @ 6-7 weeks
 Exact dating of pregnancy
 Ectopic pregnancy/ Heterotopic pregnancy
 Missed abortion
 Single /Multiple pregnancy
 If Multiple-Chorionicity

27. Miscarriage
Following ART the risk of miscarriage may seem a bit higher
than in spontaneous pregnancies, but
 this is thought to be due to earlier pregnancy detection on
the one hand,
 and to older maternal age on the other

28. Multiple Births
 The major complication of IVF is the risk of multiple
births
 This is directly related to the practice of transferring
multiple embryos at embryo transfer.

29. Can Multiple Births be prevented?
• Strict limits on the number of embryos that may be transferred have
been enacted in some countries (e.g. Britain, Belgium) to reduce the
risk of high-order multiples (triplets or more), but are not universally
followed or accepted.
• Spontaneous splitting of embryos in the womb after transfer can
occur, but this is rare and would lead to identical twins.

30. Vanishing Twin
 In IVF twins are more often conceived than born. Most vanish in due
course of time
 Still the true incidence of vanishing twins is difficult to assess.
 According to one data it was estimated that ∼30% of these twins will
ultimately result in singletons and <10% will end in a complete
abortion.

31. Monochorionic twins
 More complications because of shared placenta
 TTTS
 Single twin demise
 Mono amnionicity
 TRAP
 Conjoined twins
 When monochorionic twins were compared with dichorionic twin
pregnancies , the rate of fetal loss was significantly higher in the former.

32. Management of monochorionic twins
 Chorionicity established early
 USG surveillance starts at 16 weeks for
TTTS & growth discordance
 Scan every 2 weeks
 If uncomplicated,deliver at 36-37
weeks

33. TTTS
 Main feature is growth discordance
 If growth discordance >25% , intense
surveillance started
 NST twice weekly
 If non-reactive NST ,biophysical profile done
 Doppler studies is done to follow up growth
restriction
 Interventions when needed

34. Multiple pregnancy
AIM of ANC
 Prolongation of gestation age, increase fetal weight.
 Improve PNM and morbidity.
 Decrease incidence of maternal complications.
ANC
 Consultant-led team
 Embryo reduction in higher order multiple gestations
 Best after 11 weeks-10% risk of miscarriage
 Visits - Every two weeks.
 Iron and folic acid to avoid anemia.
 Assess cervical length and competency.
 Careful watch for complications

35. Multiple pregnancy
Maternal Risks-
 Hyperemesis gravidarum
 Abortion
 Hypertensive disease, 4x more common than singletons
 Gestational diabetes
 Preterm delivery
 Anaemia
 Hydramnios in 12%, primarily in monozygotic twins
 Reflux, abdominal discomfort, back pain, leg swelling,
 Bladder symptoms and Hemorrhoids
 APH (PP and Abruptio, as larger placental area and PET)
 Thromboembolic disease: appropriate prophylaxis and Rx

36. Fetal Risks-
• Perinatal Morbidity
• Perinatal mortality
• Preterm delivery
• Low birth weight.
Multiple pregnancy

37. Monitoring after Single twin demise / fetal reduction
 Baseline coagulation profile for mother
 Usually preterm labor starts
 Counsel regarding prognosis for second twin
 17% risk of neurological damage
 Early delivery not warranted as preterm
delivery may harm the surviving twin
 CS not needed

38.  Embryo reduction in higher order multiple gestations
 Best after 11 weeks
 10% risk of miscarriage
Embryo reduction

39. Embryo reduction
 The most common method is to inject potassium chlorideinto the
fetus's heart; the heart stops and the fetus dies as a result.
 Generally, the fetal material is reabsorbed into the woman's body.
 While the procedure generally reduces the over-all risk level for the
remaining fetus or fetuses.

40. IVF Multiple Births have Good Outcome
 However, despite the risks, some recent evidence suggests that twins
conceived by IVF actually have a 40% decreased outcome risk for
complications than spontaneous twin conceptions.
 Experts believe that this could be due to high level of prenatal
monitoring received from the moment of conception.

41. Are congenital anomalies increased in IVF pregnancies?
 Meta-analyses demonstrate associations between IVF/ICSI and congenital malformations,
although it remains unclear if this association is due to infertility, factors associated with
the procedure, or both.30-32 It is also difficult to distinguish the risk associated with IVF
alone versus IVF with ICSI.
 Therefore, we recommend a detailed obstetrical ultrasound examination (CPT
76811) be performed for pregnancies achieved with IVF and ICSI (GRADE 1B).33
30.Chen L, Yang T, Zheng Z, Yu H, Wang H, Qin J. Birth prevalence of congenital malformations in singleton pregnancies resulting from in vitro
fertilization/intracytoplasmic sperm injection worldwide: a systematic review and meta-analysis. Arch Gynecol Obstet 2018;297(5):1115-1130.
31.Hoorsan H, Mirmiran P, Chaichian S, Moradi Y, Hoorsan R, Jesmi F. Congenital Malformations in Infants of Mothers Undergoing Assisted Reproductive
Technologies: A Systematic Review and Meta-analysis Study. J Prev Med Public Health 2017;50(6):347-360.
32.Wen J, Jiang J, Ding C, et al. Birth defects in children conceived by in vitro fertilization and intracytoplasmic sperm injection: a meta-analysis. Fertil Steril
2012;97(6):1331-7.e1-4.
33.AIUM Practice Parameter for the Performance of Detailed Second- and Third-Trimester Diagnostic Obstetric Ultrasound Examinations. J Ultrasound Med
2019;38(12):3093-3100.

42. Are CHD risks increased in IVF pregnancies?
 Several studies report higher rates of total congenital heart disease (CHD) in the IVF/ICSI population
compared with naturally occurring pregnancies, while other studies report that the incidence of CHD
in IVF pregnancies without other risk factors is not significantly different from baseline population
rates.34 The cost-effectiveness of routine screening for CHD in pregnancies following IVF has also
been questioned.35,36
 We suggest fetal echocardiography be offered to patients with pregnancies achieved with IVF
and ICSI (GRADE 2C).37
34.Giorgione V, Parazzini F, Fesslova V, et al. Congenital heart defects in IVF/ICSI pregnancy: systematic review and meta-analysis. Ultrasound Obstet Gynecol
2018;51(1):33-42.
35.Bjorkman KR, Bjorkman SH, Ferdman DJ, Sfakianaki AK, Copel JA, Bahtiyar MO. Utility of routine screening fetal echocardiogram in pregnancies conceived by in vitro
fertilization. Fertility and Sterility 2021.
36.Chung EH, Lim SL, Havrilesky LJ, Steiner AZ, Dotters-Katz SK. Cost-effectiveness of prenatal screening methods for congenital heart defects in pregnancies conceived by
in-vitro fertilization. Ultrasound Obstet Gynecol 2021;57(6):979-986.
37.AIUM Practice Parameter for the Performance of Fetal Echocardiography. J Ultrasound Med 2020;39(1):E5-e16.

43. Antenatal care
Hyperemesis-challenge with so many medications
Discuss options for prenatal screening for
congenital structural abnormalities
Biochemical
Sonographic screening

44. Antenatal care-11-13 weeks
Self egg versus donor egg cycle
 Screening for the baby:
 Combined test –Double Marker
 USG – NT & Soft tissue Markers
 assessing normal fetal growth
 Vanishing twins
 Need for fetal reduction
 Cervical length
 P/S exam
 CVB/ NIPT

45. Prenatal diagnosis
 Nuchal translucency measurement with maternal age is the best
method for aneuploidy screening
 Advantage: fetus specific
 Structural anomaly scan for NTDs
 Combine NT scan with Uterine artery Doppler,
 Tricuspid flow and DV -95-97%

46. Screening for Trisomy 21 at 11- 14 weeks for
India
2-stage (contingency) screening proposed
RISK ESTIMATE BY ONLY USG N.T. AND OTHER MARKERS
Fetal NT
Nasal bone and
ductus venosus
tricuspid
regurgitation at 12
wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Free B hCG
PAPP-A
THIS WILL SAVE
TIME
MONEY
OPTIMUM USE OF OUR
SKILL
DOUBLE MARKER
TEST
Scan 20w NIPT

47. Antenatal care
 Screening for the pregnant woman:
 Gestational diabetes
 Pre-eclampsia and preterm labour
 Placenta Previa
 Asymptomatic bacteriuria
 Chlamydia.

48. Cervical length screening routine to prevent
preterm labour and for guideline for cx stitch
Asymptomatic singleton pregnancy a tvs cl <25 mm in second trimester
Screen at 11-13 weeks and then at 22-24 weeks
Recent evidence says cx stitch does not help and progesterone may be
the only treatment option here.
Routine mcdonald stitch practise should be individualised

49. ANC care @ 18-20 weeks
Self egg versus donor egg cycle
Quadruple Marker
Anomaly scan
Cervical length
P/S exam
NIPT/Amniocentesis
Fetal ECHO @ 22 weeks

50. PIH
 A cohort study of over 5 Lakh women was done to determine the risk
of preeclampsia in women undergoing ART, including IVF, compared
with women who had a natural conception.
 After adjusting for maternal age, interbirth interval, and presence of
new partner, women undergoing ART had a small increase in odds of
preeclampsia in their second and third pregnancies compared with
women who did not require ART (OR 1.3 for second pregnancy and
1.8 for third pregnancy) .
Tandberg A, Klungsøyr K, Romundstad LB, Skjærven R. Pre-eclampsia and assisted reproductive technologies:
consequences of advanced maternal age, interbirth intervals, new partner and smoking habits. BJOG 2015; 122:915.

51. PIH in OD cycle
• In a meta-analysis of 19 studies (mainly retrospective) that compared
the risk of preeclampsia and gestational hypertension in pregnancies
conceived via oocyte donation (OD), other ART, and natural
conception, pregnancies achieved with OD had more than double the
risk of preeclampsia when compared with other methods of ART and
a more than fourfold increased risk compared with natural
conception (OR 2.54, 95% CI 1.98-3.24 and OR 4.34, 95% CI 3.10-6.06,
respectively) .
Masoudian P, Nasr A, de Nanassy J, et al. Oocyte donation pregnancies and the risk of preeclampsia or
gestational hypertension: a systematic review and metaanalysis. Am J Obstet Gynecol 2016; 214:328.

52. In pregnancies achieved with IVF,does low-dose aspirin
prophylaxis reduce the risk of fetal & placental
complications?
 IVF and underlying infertility are associated with adverse perinatal outcomes, including
hypertensive disorders of pregnancy.47 The United States Preventative Services Task Force
states IVF is a moderate risk factor for preeclampsia and recommends low-dose aspirin if
an additional moderate risk factor is found.48
 We do not recommend low-dose aspirin in patients with an IVF pregnancy as the
sole indication for preeclampsia prophylaxis; however, if one or more additional risk
factors are present, low-dose aspirin is recommended (GRADE 1B).
47.Tandberg A, Klungsoyr K, Romundstad LB, Skjaerven R. Pre-eclampsia and assisted reproductive technologies: consequences of advanced
maternal age, interbirth intervals, new partner and smoking habits. BJOG 2015;122(7):915-22
48.Davidson KW, Barry MJ, Mangione CM, et al. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: US Preventive Services
Task Force Recommendation Statement. Jama 2021;326(12):1186-1191.

53. PIH/PTB/LSCS in OD Cycle
 A different meta-analysis of 11 studies that compared oocyte
donation (OD) pregnancies with pregnancies resulting from
autologous oocyte IVF or ICSI reported that women with OD
pregnancies had a nearly fourfold increased risk of developing
preeclampsia or pregnancy-induced hypertension compared with
autologous IVF/ICSI pregnancies (OR 3.92, 95% CI 2.62-5.16).
 The increased risk was independent of maternal age.
 In secondary analysis, OD pregnancies were also associated with an
increased risk of preterm delivery and cesarean delivery.
Jeve YB, Potdar N, Opoku A, Khare M. Donor oocyte conception and pregnancy complications: a systematic
review and meta-analysis. BJOG 2016; 123:1471.

55. Is the prevalence of spontaneous preterm birth higher in IVF pregnancies?
 A meta-analysis of singleton pregnancies demonstrated that IVF is associated with higher odds of preterm
delivery, low birthweight, and very low birthweight compared with naturally occurring pregnancies.40
 Preterm birth has been recognized for several decades as the primary independent cause of increased rates of
several adverse neonatal outcomes, including neonatal encephalopathy and perinatal mortality, in IVF
pregnancies.
 Such risks are more than double in the presence of IVF twin gestations. Subfertility is also a major risk factor for
prematurity.41 Although there may be an increased risk for spontaneous preterm birth with IVF pregnancies, the
utility of serial cervical length measurement to screen for preterm birth risk is unknown when the sole indication
is IVF.
 Although visualization of the cervix at the 18 0/7 to 22 6/7 weeks of gestation anatomy assessment with
either a transabdominal or endovaginal approach is recommended, we do not recommend serial cervical
length assessment as a routine practice for IVF pregnancies (GRADE 1C).42,43
 In addition, progesterone supplementation initiated for IVF cycles is not indicated after 12 weeks of gestation if it
was solely initiated for IVF purposes without any other indication. Discontinuation of progesterone
supplementation initiated for the sole purpose of IVF is recommended by 12 weeks.
40.Jackson RA, Gibson KA, Wu YW, Croughan MS. Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol 2004;103(3):551-63.
41.Pinborg A, Wennerholm UB, Romundstad LB, et al. Why do singletons conceived after assisted reproduction technology have adverse perinatal outcome? Systematic review and meta-
analysis. Hum Reprod Update 2013;19(2):87-104.
42.Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol 2021;138(2):e65-e90.
43.McIntosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol
2016;215(3):B2-7.

56. Is the prevalence of fetal growth restriction higher in IVF pregnancies?
 An increased risk of small for gestational age (SGA) infants is documented for singleton
IVF pregnancies. Meta-analyses have described a higher risk of SGA babies in IVF/ICSI
pregnancies from fresh cycles compared with frozen cycles.41,44-46
 The optimal gestational ages for fetal growth scans and their frequency in the presence of
additional risk factors (eg, placental implantation anomalies or maternal age >40 years)
are presently unknown.
 We suggest an assessment of fetal growth in the third trimester for IVF pregnancies;
however, serial growth ultrasounds are not recommended for the sole indication of
IVF (GRADE 2B).
44.Maheshwari A, Pandey S, Shetty A, Hamilton M, Bhattacharya S. Obstetric and perinatal outcomes in singleton pregnancies resulting from the transfer of
frozen thawed versus fresh embryos generated through in vitro fertilization treatment: a systematic review and meta-analysis. Fertil Steril 2012;98(2):368-77.e1-9.
45.Sha T, Yin X, Cheng W, Massey IY. Pregnancy-related complications and perinatal outcomes resulting from transfer of cryopreserved versus fresh embryos
in vitro fertilization: a meta-analysis. Fertil Steril 2018;109(2):330-342.e9.
46.Wennerholm UB, Henningsen AK, Romundstad LB, et al. Perinatal outcomes of children born after frozen-thawed embryo transfer: a Nordic cohort study from
the CoNARTaS group. Hum Reprod 2013;28(9):2545-53.

57. Third trimester
 Close monitoring for fetal growth
 Close monitoring for preterm labour
 Pay special attention to Placenta-praevia, adherent
Sun LM, Walker MC, Cao HL, et al. Assisted reproductive technology and placenta-mediated adverse pregnancy
outcomes. Obstet Gynecol 2009; 114:818.
Romundstad LB, Romundstad PR, Sunde A, et al. Increased risk of placenta previa in pregnancies following
IVF/ICSI; a comparison of ART and non-ART pregnancies in the same mother. Hum Reprod 2006; 21:2353.

58. Are placental anomalies increased in IVF pregnancies?
 IVF pregnancies are associated with higher risks for abnormal placental shape (bilobed placenta,
accessory placental lobes), placenta previa, marginal or velamentous cord insertion, and placenta
accreta spectrum compared with naturally occurring pregnancies.
 All of the above manifestations of placental implantation disorders appear related and can occur
together.
 Therefore, we recommend a careful examination of the placental location, placental shape,
and cord insertion site be performed at the time of the detailed fetal anatomy ultrasound,
including evaluation for vasa previa (GRADE 1B).
 Targeted screening via transvaginal sonogram should be considered in all IVF pregnancies with
velamentous cord insertion, succenturiate or bilobed placentas, or resolved placenta previa to rule
out vasa previa.38,39 Due to the ongoing risk of vasa previa in the setting of resolved placenta previa,
reassessment for vasa previa is warranted when reassessing placental location at 32 weeks of
gestation.
38.Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. Am J Obstet Gynecol 2015;213(5):615-9.
39.Sullivan EA, Javid N, Duncombe G, et al. Vasa Previa Diagnosis, Clinical Practice, and Outcomes in Australia. Obstet Gynecol 2017;130(3):591-598.

59. Placenta Praevia
• In a meta-analysis of 15 cohort studies comparing ART-conceived with
naturally conceived dichorionic twins, women with ART dichorionic
twins had nearly three times the risk of placenta previa as women
with naturally conceived dichorionic twins (RR 2.99, 95% CI 1.5-5.9) .
Qin JB, Wang H, Sheng X, et al. Assisted reproductive technology and risk of adverse obstetric outcomes in dichorionic
twin pregnancies: a systematic review and meta-analysis. Fertil Steril 2016; 105:1180.

60. Antenatal corticosteroids
• A single course of corticosteroids is recommended for pregnant
women between 24 0/7 weeks and 33 6/7 weeks of gestation
who are at risk of preterm delivery within 7 days, including for
those with ruptured membranes and multiple gestations.

61. Antenatal corticosteroids
• It also may be considered for pregnant women starting at 23 0/7 weeks of
gestation who are at risk of preterm delivery within 7 days, based on a family’s
decision regarding resuscitation, irrespective of membrane rupture status and
regardless of fetal number.

62. Antenatal corticosteroids
• Administration of betamethasone may be considered in pregnant women
between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of
preterm birth within 7 days, and who have not received a previous course of
antenatal corticosteroids.

63. Antenatal corticosteroids
24-34 weeks [Grade A recommendation]
More effective when delivered after 24 hours and upto 7 days after 2nd
dose [Grade A]
Repeated doses not needed
Consider rescue dose if initial dose before 26 weeks

64. Fetal Care
 Combined Screening,Fetal ECHO, LBW, IUGR…
 NT,soft tissue markers,double marker,
 dedicated anomaly scan, quadruple marker,
 3 D USG,
 serial USG,
 Doppler…
 Fetal Kick Count

65. Is the prevalence of stillbirth increased in IVF pregnancies?
 Pregnancies achieved with IVF have a two to three-fold increased risk of
stillbirth even after controlling for maternal age, parity, and multifetal
gestations.40,49-51
 Given the increased risk of stillbirth, we suggest weekly antenatal
fetal surveillance beginning by 36 0/7 weeks of gestation for
pregnancies achieved with IVF (GRADE 2C).52
49.Bay B, Boie S, Kesmodel US. Risk of stillbirth in low-risk singleton term pregnancies following fertility treatment: a national cohort study.
BJOG 2019;126(2):253-260.
50.Marino JL, Moore VM, Willson KJ, et al. Perinatal outcomes by mode of assisted conception and sub-fertility in an Australian data linkage
cohort. PLoS One 2014;9(1):e80398.
51.Wisborg K, Ingerslev HJ, Henriksen TB. IVF and stillbirth: a prospective follow-up study. Hum Reprod 2010;25(5):1312-6.
52.Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828. Obstet Gynecol 2021;137(6):e177-e197.

66. Stillbirth
A national cohort study from Denmark of low-risk ART pregnancies
reported stillbirth rates of 0.1 percent following IVF and 0.3 percent
after ICSI .
 For low-risk patients, it is not known if the increased stillbirth risk is
related to the treatment or the underlying subfertility.
Bay B, Boie S, Kesmodel US. Risk of stillbirth in low-risk singleton term pregnancies following
fertility treatment: a national cohort study. BJOG 2019; 126:253.

67. The Various Methods of Antepartum Fetal Surveillance
1) Clinical assessment by uterine growth
2) Fetal movement count by the mother
3) Ultrasound for fetal growth
4) Non stress test and cardiotocography
5) Vibroacoustic stimulation test
6) Contraction stress test
7) Nipple stimulation test
8) Biophysical profile
9) Modified biophysical profile
10) Doppler studies
11) Fetal lung maturation studies
12) Placental grading

68. Antepartum Fetal Surveillance
• The goal of antepartum fetal surveillance is to reduce the risk of stillbirth.
• Antepartum fetal surveillance techniques based on assessment of fetal heart
rate (FHR) patterns have been in clinical use for almost four decades and are
used along with real-time ultrasonography and umbilical artery Doppler
velocimetry to evaluate fetal well-being.

69. Kick Chart
Every kick / roll is 1
movement
Count 10 movements
everyday
Call doctor & come for
CTG / USG assessment

70. About baby’s movements
An active baby is usually a healthy baby. You
will feel your baby stretch, kick, roll and turn
every day. Some babies are more active than
others. All babies have periods of sleep during
which they are not as active. You will get to
know your baby’s pattern of movements and
when your baby is most active.
You should feel your baby’s movements
throughout the day, each day from 28 weeks of
pregnancy until the baby is born.
When during my pregnancy should I count
my baby’s movements?
Your health care provider may ask you
to count your baby’s movements once
every day.
If you think there is a decrease in your
baby’s movements this is an important sign that
your baby may not be well. Count your baby’s
movements to be sure that you feel at least 6
movements in 2 hours.
Reference:
Society of Obstetricians and Gynaecologists of Canada (2007).
Fetal Health Surveillance : Antepartum and Intrapartum Consensus
Guideline. Journal of Obstetrics and Gynaecology Canada. 29(9).
FETAL MOVEMENT
COUNT CHART
PLEASE BRING THIS CHART WITH YOU EACH
TIME YOU SEE THE DOCTOR/MIDWIFE
IMPORTANT PHONE NUMBERS:
DOCTOR:
MIDWIFE:
HOSPITAL:
DUE DATE:
OTHER INSTRUCTIONS:
For 24-hour nurse advice and health information call
Health Link Alberta:
1-866-408- LINK (5465)– Toll Free
In Calgary call 403-943- LINK (5465)
In Edmonton call 780-408-LINK (5465)
ADDRESS:
NAME:
HS0001-132 (2012/11)
How do I count my baby’s movements?
• Get into a comfortable position – lying on
your side or sitting. Place one or both of your
hands on your abdomen.
• Count each time that you feel your baby
move. If you feel many movements all at
once, count each movement that you feel.
• Write down the date and the time that you
start counting on the fetal movement chart.
• Make a mark on the chart each time your baby
moves.
• Stop counting when you have counted 6
movements.
• Write down the time you stopped counting.
• Do not count for more than 2 hours
What if I don’t feel 6 movements in 2 hours?
Count your baby’s movements once a day. You
should feel 6 or more movements in 2 hours.
If you count fewer than 6 movements in 2 hours
do not wait. Go to the hospital or birthing unit.
Your baby’s heart rate and movements will be
checked using a fetal monitor. This is called a
non-stress test or NST.
If you live too far from a hospital or birthing
unit, immediately contact your health care
provider for advice.

71. In pregnancies achieved with IVF, does delivery at 39
weeks reduce the risk of adverse perinatal outcomes?
 It is currently unknown whether elective delivery at 39 weeks reduces the risks of maternal morbidity
and improves perinatal outcomes in IVF pregnancies compared with expectant management.
 A systematic review revealed that in asymptomatic uncomplicated singleton gestations, induction of
labor between 39 0/7 and 40 6/7 weeks does not increase the risk of cesarean delivery compared
with expectant management but does not reduce the rates of adverse perinatal outcomes, including
perinatal death, low Apgar score at 5 minutes, or need for NICU admission.53
 In the absence of studies focused specifically on timing of delivery IVF pregnancies, we
recommend shared decision-making between patients and healthcare providers when
considering induction of labor at 39 weeks of gestation (GRADE 1C).54
53.Saccone G, Della Corte L, Maruotti GM, et al. Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A
systematic review and meta-analysis of randomized trials. Acta Obstet Gynecol Scand 2019;98(8):958-966.
54.Lagrew DC, Kane Low L, Brennan R, et al. National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean
Births-Supporting Intended Vaginal Births. J Obstet Gynecol Neonatal Nurs 2018;47(2):214-226.

72. Multiple pregnancy-Intra Partum Care
Labour management
 IV line
 Delivery in theatre ?
 Twin CTG machine ?
 Two resuscitation trolleys
 Two obstetricians
 Two paediatricians
 Inform NICU
PPH
 IV line
 Blood grouped and saved
 Oxytocin infusion following delivery

73. Foetal monitoring
 Comparisons of EFM and intermittent auscultation show that
EFM offers no long-term benefits in either low or high-risk
pregnancies (although it may have short-term benefits
especially when oxytocin is used).
 Comparisons of EFM and intermittent auscultation show that
EFM increases the likelihood of cesarean and vaginal
instrumental delivery, infection and cerebral paisy in premature
babies.

74. LSCS for all ART pregnancies ??

75. LSCS on demand ?? Mahurat LSCS ??

76. Perinatal Mortality
 PM rates appear to be increased as much as fourfold
due, at least in part,
 to the obstetric complications discussed above,
 LBW, and
 multiple gestation.
Jackson RA, Gibson KA, Wu YW, Croughan MS. Perinatal outcomes in singletons following in vitro
fertilization: a meta-analysis. Obstet Gynecol 2004; 103:551.

77. Post partum care
 Puerperal psychosis
 Lactation problems
 Monitoring co-morbidities
 Neonatal care

78. Maternal Morbidity
• In a retrospective cohort study of over one million deliveries between
2008 and 2012, severe maternal morbidity was nearly twice as likely
in pregnancies conceived with ART compared with non-ART
pregnancies after controlling for maternal age, parity, comorbid
conditions, history of prior cesarean delivery, and year of delivery .
Martin AS, Monsour M, Kissin DM, et al. Trends in Severe Maternal Morbidity After Assisted Reproductive Technology in
the United States, 2008-2012. Obstet Gynecol 2016; 127:59.

79. Maternal Morbidity
When the same data set was analyzed for antenatal hospitalization,
women with ART pregnancies had an increased risk of antenatal
admission and longer hospitalizations compared with non-ART
pregnancies .
Martin AS, Zhang Y, Crawford S, et al. Antenatal Hospitalizations Among Pregnancies Conceived With and Without Assisted
Reproductive Technology. Obstet Gynecol 2016; 127:941.

80. Severe maternal morbidity
Severe maternal morbidity – IVF conceived pregnancy may increase
the risk of severe maternal morbidity .
Braat DD, Schutte JM, Bernardus RE, et al. Maternal death related to IVF in the Netherlands 1984-2008. Hum Reprod 2010;
25:1782.

81. Severe maternal morbidity
 In a cohort study that used propensity score matching and controlled
for multiple factors, including maternal age and multiple gestation,
IVF was associated with a nearly 40 percent increased risk of severe
maternal morbidity compared with spontaneous conception; the
absolute risk of severe maternal morbidity was low (30.8 [IVF] versus
22.2 [spontaneous] per 1000 births) .
 Postpartum hemorrhage, ICU admission, and sepsis were the most
common indicators of severe morbidity.
Dayan N, Joseph KS, Fell DB, et al. Infertility treatment and risk of severe maternal morbidity: a propensity score-matched cohort study. CMAJ
2019; 191:E118.

82. Mortality
Every procedure does have some inherent risks, including IVF
Risk of maternal mortality among IVF pregnancies is "really
extremely low.
Underlying health issues in women who turn to IVF to get
pregnant may affect their risk profiles.

83. Counseling
 Risks are rare but they are real and need to be taken into
account when thinking about using IVF to have a baby.
 Many couples may downplay or even ignore the risks due to
their desire to have children.
 Women need to be screened before IVF to make sure they are
appropriate candidates. If women have any underlying diseases
or conditions that could worsen during pregnancy – counseled
accordingly.

84. Counseling before IVF
 Worsening of pre-existing medical conditions
 Increased risk of chromosomal abnormalities
 risk of multiple pregnancy
 Risks associated with advanced maternal age
 psychosocial impact

85. Psychological effects
 If fetal reduction done
 Death of one twin
 Frequent ultrasound monitoring
 Anomaly in one fetus
 Risk of Preterm delivery
 Financial burden
 Job worry

86. Medico legal issues
 Failure to diagnose twins
 Frequency of tests
 Late detection of growth problems
 Wrong estimation of gestational age

87. Key take aways
Pregnancies achieved by IVF with or without ICSI are at
higher risk for obstetrical and neonatal complications than
spontaneous pregnancies, and close surveillance during
pregnancy should be considered.

88. Key take aways
 It remains unclear if these increased risks are attributable
to the underlying infertility, characteristics of the infertile
couple, or use of assisted reproductive techniques.
 Multiple gestations remain a significant risk.

89. Key take aways
Treat each pregnancy as a high-risk pregnancy.
Multidisciplinary approach- ART specialist, high- risk
Obstetrician, Fetal Medicine specialist, Neonatologist
Early screening and prediction of potential problems.

90. My World of sharing happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

91. Questions

92. The Art of Living
Anything that helps
you to become
unconditionally happy
and loving is what is
called spirituality.
H. H. Sri Sri Ravishakar