16
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
Pregnancy after ART management and complications in the first
trimester Sesh Kamal Sunkara Assisted Conception Unit
Guyrsquos amp St Thomasrsquo NHS Foundation Kingrsquos College London
Pregnancy following ART
Multiple pregnancies
Ectopic pregnancies heterotopic pregnancies
bull Bleeding in early pregnancy
bull Miscarriage
OHSS
Multiple pregnancy
bull Multiple pregnancies should be considered a complication of ART
bull Infertility therapy-associated multiple pregnancies an ongoing epidemic
bull Multiple pregnancy rates following ART remain high globally
bull Higher frequency of monozygotic multiple pregnancies with ART (12 vs 04) (Derom et al LANCET 1987 Sills et al Hum Reprod 2000)
bull Similar incidence of monozygotic twinning with cleavage stage and blastocyst transfers (Papanikolaou et al Fertil Steril 2010)
bull No increased frequency with ICSI or assisted hatching (Sills et al Hum Reprod 2000)
Multiple pregnancy
Multiple pregnancy risks
Foetal
ndash Pre-term delivery (118 twins vs 16 singletons born before 32 weeks)
ndash Cerebral palsy (4-6 times higher risk in twins)
ndash Perinatal mortality (6 times higher in twins)
Maternal
ndash PIH (20 with twins vs 1ndash5 with singletons)
ndash PET (30 with twins vs 2-10 with singletons)
ndash Gestational diabetes (12 with twins vs 4 with singletons)
ndash Higher rates of caesarean section with twins
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Pregnancy following ART
Multiple pregnancies
Ectopic pregnancies heterotopic pregnancies
bull Bleeding in early pregnancy
bull Miscarriage
OHSS
Multiple pregnancy
bull Multiple pregnancies should be considered a complication of ART
bull Infertility therapy-associated multiple pregnancies an ongoing epidemic
bull Multiple pregnancy rates following ART remain high globally
bull Higher frequency of monozygotic multiple pregnancies with ART (12 vs 04) (Derom et al LANCET 1987 Sills et al Hum Reprod 2000)
bull Similar incidence of monozygotic twinning with cleavage stage and blastocyst transfers (Papanikolaou et al Fertil Steril 2010)
bull No increased frequency with ICSI or assisted hatching (Sills et al Hum Reprod 2000)
Multiple pregnancy
Multiple pregnancy risks
Foetal
ndash Pre-term delivery (118 twins vs 16 singletons born before 32 weeks)
ndash Cerebral palsy (4-6 times higher risk in twins)
ndash Perinatal mortality (6 times higher in twins)
Maternal
ndash PIH (20 with twins vs 1ndash5 with singletons)
ndash PET (30 with twins vs 2-10 with singletons)
ndash Gestational diabetes (12 with twins vs 4 with singletons)
ndash Higher rates of caesarean section with twins
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Multiple pregnancy
bull Multiple pregnancies should be considered a complication of ART
bull Infertility therapy-associated multiple pregnancies an ongoing epidemic
bull Multiple pregnancy rates following ART remain high globally
bull Higher frequency of monozygotic multiple pregnancies with ART (12 vs 04) (Derom et al LANCET 1987 Sills et al Hum Reprod 2000)
bull Similar incidence of monozygotic twinning with cleavage stage and blastocyst transfers (Papanikolaou et al Fertil Steril 2010)
bull No increased frequency with ICSI or assisted hatching (Sills et al Hum Reprod 2000)
Multiple pregnancy
Multiple pregnancy risks
Foetal
ndash Pre-term delivery (118 twins vs 16 singletons born before 32 weeks)
ndash Cerebral palsy (4-6 times higher risk in twins)
ndash Perinatal mortality (6 times higher in twins)
Maternal
ndash PIH (20 with twins vs 1ndash5 with singletons)
ndash PET (30 with twins vs 2-10 with singletons)
ndash Gestational diabetes (12 with twins vs 4 with singletons)
ndash Higher rates of caesarean section with twins
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
bull Higher frequency of monozygotic multiple pregnancies with ART (12 vs 04) (Derom et al LANCET 1987 Sills et al Hum Reprod 2000)
bull Similar incidence of monozygotic twinning with cleavage stage and blastocyst transfers (Papanikolaou et al Fertil Steril 2010)
bull No increased frequency with ICSI or assisted hatching (Sills et al Hum Reprod 2000)
Multiple pregnancy
Multiple pregnancy risks
Foetal
ndash Pre-term delivery (118 twins vs 16 singletons born before 32 weeks)
ndash Cerebral palsy (4-6 times higher risk in twins)
ndash Perinatal mortality (6 times higher in twins)
Maternal
ndash PIH (20 with twins vs 1ndash5 with singletons)
ndash PET (30 with twins vs 2-10 with singletons)
ndash Gestational diabetes (12 with twins vs 4 with singletons)
ndash Higher rates of caesarean section with twins
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Multiple pregnancy risks
Foetal
ndash Pre-term delivery (118 twins vs 16 singletons born before 32 weeks)
ndash Cerebral palsy (4-6 times higher risk in twins)
ndash Perinatal mortality (6 times higher in twins)
Maternal
ndash PIH (20 with twins vs 1ndash5 with singletons)
ndash PET (30 with twins vs 2-10 with singletons)
ndash Gestational diabetes (12 with twins vs 4 with singletons)
ndash Higher rates of caesarean section with twins
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
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 Vol21 No 7 pp1907-1911 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
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
bull Study cohort were older more likely to be primiparous or have had a previous miscarriage
bull Miscarriage rate was slightly higher in the ART group after adjusting for age (RR 120 95 CI 103 146)
bull How did they define miscarriage
Miscarriage and ART
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Miscarriage rate
Miscarriage Fresh IVF vs FET
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Ectopic pregnancy
Obstet Gynecol 2006107595-604
Ectopic pregnancy risk with assisted reproductive technology procedures Clayton HB Schieve LA Peterson HB Jamieson DJ Reynolds MA Wright VC
bullEctopic pregnancy rate calculated from data of ART pregnancies in the US between 1999 ndash 2001
bullEctopic pregnancy rate 21 2009 ectopic pregnancies of 94118 ART pregnancies
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
bull Risk factors for ectopic following ART
ndash Tubal disease
ndash Endometriosis
ndash Female non-tubal causes of infertility
bull Significantly lower ectopic pregnancy rate with oocyte donation cycles
Ectopic pregnancy
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
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 MPH Laura A Schieve PhD Herbert B Peterson MD Denise J Jamieson MD MPH Meredith A Reynolds PhD and Victoria C Wright MPH
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
OHSS
bull Late onset OHSS especially exacerbated with multiple gestation (Papanikolaou et al Hum Reprod 2005 Papanikolaou et al Fertil Steril 2006)
bull Paucity of data on the relationship between OHSS and pregnancy complications
bull 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)
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Management of OHSS
bull Recognition of risks particular to pregnancy
ndash Haemoconcentration
ndash Thromboembolism
ndash Deranged of renal function liver function
bull Adequate hydration
bull Thromboprophylaxis
bull Treatment of ascites pleural effusion
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Congenital anomalies
Davies MJ et al NEJM 2013
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Ovarian torsion
bull Ovarian torsion is a rare but existing complication
bull Symptoms could be masked if co-existing OHSS
bull Prompt diagnosis and intervention
Lazaridis et al BMJ Case Report 2013
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
Conclusion
bull Aim of ART is to achieve a safe pregnancy
bull Avoid iatrogenic risks
bull Prompt recognition and management of complications
