1. Pregnancy after ART: management
and complications in the first
trimester
Sesh Kamal Sunkara
Assisted Conception Unit
Guy’s & St Thomas’ NHS Foundation
King’s College London

2. Pregnancy following ART
Multiple pregnancies
Ectopic pregnancies/ heterotopic pregnancies
• Bleeding in early pregnancy
• Miscarriage
OHSS

3. Multiple pregnancy
• Multiple pregnancies should be considered a
complication of ART
• Infertility therapy-associated multiple
pregnancies: an ongoing epidemic
• Multiple pregnancy rates following ART remain
high globally

4. • Higher frequency of monozygotic multiple
pregnancies with ART (1.2% vs 0.4%) (Derom et al.,
LANCET 1987; Sills et al., Hum Reprod 2000)
• Similar incidence of monozygotic twinning with
cleavage stage and blastocyst transfers (Papanikolaou
et al., Fertil Steril 2010)
• No increased frequency with ICSI or assisted
hatching (Sills et al., Hum Reprod 2000)
Multiple pregnancy

5. Multiple pregnancy risks
Foetal
– Pre-term delivery (11.8%
twins vs 1.6% singletons
born before 32 weeks)
– Cerebral palsy (4-6 times
higher risk in twins)
– Perinatal mortality (6
times higher in twins)
Maternal
– PIH (20% with twins vs 1–
5% with singletons)
– PET (30% with twins vs 2-
10% with singletons)
– Gestational diabetes (12%
with twins vs 4% with
singletons)
– Higher rates of caesarean
section with twins

6. First-trimester bleeding and pregnancy outcome in singletons after assisted
reproduction
Petra De Sutter, Julie Bontinck, Valerie Schutysers, Josiane Van der Elst, Jan Gerris and Marc Dhont
Human Reproduction Vol.21, No. 7 pp.1907-1911, 2006
Advance access publication February 24, 2006
 253 singleton pregnancies with 1st trimester bleeding and
1179 without bleeding
 Mean number of embryos transferred significantly higher
in study group
 Study group had significantly higher risk of 2nd, 3rd
trimester bleeding, pre-term delivery, low birth weight
infants

7. • Study cohort were older, more likely to be
primiparous or have had a previous miscarriage
• Miscarriage rate was slightly higher in the ART
group after adjusting for age (RR 1.20; 95% CI
1.03, 1.46)
• How did they define miscarriage?
Miscarriage and ART

8. Miscarriage rate
Miscarriage: Fresh IVF vs FET

9. Ectopic pregnancy
Obstet Gynecol. 2006;107:595-604.
Ectopic pregnancy risk with assisted reproductive technology procedures.
Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC.
•Ectopic pregnancy rate calculated from data of
ART pregnancies in the US between 1999 – 2001
•Ectopic pregnancy rate 2.1%; 2009 ectopic
pregnancies of 94118 ART pregnancies

10. • Risk factors for ectopic following ART
– Tubal disease
– Endometriosis
– Female non-tubal causes of infertility
• Significantly lower ectopic pregnancy rate with
oocyte donation cycles
Ectopic pregnancy

11. Ectopic pregnancy
A comparison of heterotopic and intrauterine-only pregnancy outcomes after
assisted reproductive technologies in the United States from 1999 to 2002
Heather B. Clayton, M.P.H., Laura A. Schieve, PhD., Herbert B. Peterson, M.D., Denise J. Jamieson, M.D.,
M.P.H., Meredith A. Reynolds, PhD., and Victoria C. Wright, M.P.H.

12. OHSS
• Late onset OHSS especially exacerbated with
multiple gestation (Papanikolaou et al., Hum Reprod 2005; Papanikolaou
et al., Fertil Steril 2006)
• Paucity of data on the relationship between OHSS
and pregnancy complications
• Inconsistent data on the association between OHSS
and miscarriage (Abramov et al., Hum Reprod 1998; Mathur and Jenkins,
BJOG 2000; Raziel et al., Hum Reprod 2002)

13. Management of OHSS
• Recognition of risks particular to pregnancy
– Haemoconcentration
– Thromboembolism
– Deranged of renal function, liver function
• Adequate hydration
• Thromboprophylaxis
• Treatment of ascites, pleural effusion

14. Congenital anomalies
Davies MJ et al., NEJM 2013

15. Ovarian torsion
• Ovarian torsion is a rare but existing
complication
• Symptoms could be masked if co-existing OHSS
• Prompt diagnosis and intervention
Lazaridis et al., BMJ Case Report 2013

16. Conclusion
• Aim of ART is to achieve a safe pregnancy
• Avoid iatrogenic risks
• Prompt recognition and management of
complications