Risks of Assisted Reproduction Techniques

What is OHSS and how can it be triggered?

Ovarian Hyper-Stimulation Syndrome or OHSS is one of the most common complications affecting the ovaries of some women following ovarian stimulation during a cycle of In-Vitro Fertilization (IVF).

OHSS is triggered by the fertility drugs utilized for ovarian stimulation. The more potent the treatment used, the higher the risk of developing this syndrome. OHSS is more common in women under 30 years of age, or in women that may have Poly-Cystic Ovary Syndrome (PCOS).

When does OHSS develop and what are its symptoms?

OHSS can develop at two different stages of the cycle. Most commonly, it appears the week following ovarian stimulation and egg collection. It usually lasts 7-10 days and if the patient is not pregnant, the symptoms disappear and she fully recovers. This is triggered by the injection of the human Chorionic Gonadotropin (hCG) hormone that is employed for the maturation of the eggs.

OHSS can also happen when the patient is pregnant. In these instances, it is caused by the embryo’s production of the hCG hormone, which acts on the ovaries triggering the syndrome. In a small number of serious OHSS cases, the symptoms can last for several weeks and become worse, increasing the risk of other pregnancy complications, such as deep vein thrombosis, breathing difficulties or renal failure.

The clinical symptoms of OHSS include:

• Abdominal bloating and pain
• Nausea
• Vomiting
• Diarrhea
• Tenderness in the area of the ovaries

In case, you experience any of the above symptoms following IVF treatment, you need to contact us immediately. If AAFC is closed , you have to go to the emergency room of any hospital. Although, we identify patients with high risk of developing OHSS, it can sometimes happen unpredictably in low-risk women.

How do we avoid OHSS from happening?

When we identify a patient being at risk of developing OHSS, we prevent its effects by taking the following measures:

• We reduce the dosage of the Gonadotrophin hormones during IVF.
• We perform ovarian stimulation with Gonadotrophin Releasing Hormone (GnRH) agonist (in antagonist cycles).
• We freeze the eggs and continue with IVF after alleviation of the symptoms, when there is no danger of OHSS happening during pregnancy.
• We reduce stimulation of the ovarian sacs or follicles for the production of more than one mature egg, by stopping the Follicle Stimulating Hormone (FSH) injections for a few days. This measure is known as coasting.
• We perform a mini-IVF, or in extreme cases, when we have an indication that a serious case of OHSS is possible, we cancel the fertility treatment for safety reasons.

What is bleeding post egg-collection and how can it be caused?

Egg collection is an easy procedure, but it is invasive and considered to be a minor surgery. In order to retrieve the eggs from where they are growing in the ovarian sacs or follicles, the surgeon inserts a device with a needle through the vagina and cervix. Using ultrasound imaging, the needle is then used to pierce each of the follicles for the release and collection of the matured eggs.

The multiple piercings to the follicles cause bleeding, which normally stops after egg retrieval due to natural mechanisms of blood coagulation. However, rarely and for unknown reasons, the bleeding may continue for a much longer period of time.

How is post egg-collection treated?

In cases of extensive bleeding after egg collection, the patient is monitored closely. If the problem persists, a surgery or laparoscopy will be employed in order to stop the bleeding from the ovaries. In such extreme scenarios, the next step of In-Vitro Fertilization (IVF), embryo transfer, is cancelled.

 

What is multiple pregnancy in IVF?

Our goal following an In-Vitro Fertilization (IVF) cycle is conception and birth of a healthy baby with minimum risk for both the mother and the developing fetus. Fertility treatment often leads to multiple pregnancies, which are linked to a number of maternal and fetal complications.

What are the risks of multiple pregnancy?

At least 1 in every 12 twin pregnancies results in one of the babies dying (stillbirth) or being born with a significant disability. The risks increase with higher order pregnancies, for instance with triplets or quadruplets. In these instances, the main issue is the fact that the babies have to be delivered before the full term of the pregnancy is completed. These premature babies can be affected short or long term, as they experience complications and develop a number of medical conditions(breathing and / or heart problems, cerebral palsy and neurological damage among others).

Additionally, the mother undergoing a multiple pregnancy is at risk of developing High Blood Pressure (HBP), gestational diabetes, pre-eclampsia or intra-uterine growth retardation.

How do we avoid a multiple pregnancy?

Here in AAFC, we reduce the risk of multiple pregnancy by:

• Cancelling the Intra-Uterine Insemination (IUI), when we see the potential for more than 3 eggs in a cycle (observation of more than 3 follicles in the ultrasound transvaginal scan).
• Encouraging the transfer of one embryo, by a process called elective Single Embryo Transfer (eSET), depending on individual circumstances and the prospective mother’s age.

What is an ectopic pregnancy?

An ectopic pregnancy occurs when the early embryo implants outside of the uterine cavity. Commonly, an ectopic implantation happens in one of the fallopian tubes, or rarely, in the ovary.

Ectopic pregnancies are not a side-effect of Assisted Reproductive Techniques (ARTs) alone, as they can happen spontaneously in fertile women. However, the chances of an ectopic pregnancy in women having In-Vitro Fertilization (IVF) are higher (2.5%), in comparison to normal pregnancy (1%). This could be because women undergoing an ART may have an underlying and undiagnosed problem with their fallopian tubes.

How do we avoid the risk of an ectopic pregnancy?

Here at AAFC, we diagnose an ectopic implantation at the early stages of the pregnancy (approximately 14 days after a positive pregnancy test). In more than 95% of these cases, a medical treatment can solve the problem without the need for surgery. Occasionally, however, a laparoscopy may be required to remove the ectopic pregnancy and the damaged fallopian tube.

What are the symptoms of an ectopic pregnancy?

Symptoms of an ectopic pregnancy include:

• Mild or severe one-sided low abdominal pain
• Abnormal vaginal bleeding or discharge

An ectopic pregnancy is potentially a life-threatening condition, and an early diagnosis is vital, as it can cause rupture of the fallopian tube and internal bleeding.

If you experience any of the above ectopic pregnancy symptoms before your planned scan, please contact us immediately.

How do we avoid the risk of an ectopic pregnancy?

Here at AAFC, we diagnose an ectopic implantation at the early stages of the pregnancy (approximately 14 days after a positive pregnancy test). In more than 95% of these cases, a medical treatment can solve the problem without the need for surgery. Occasionally, however, a laparoscopy may be required to remove the ectopic pregnancy and the damaged fallopian tube.

What is ovarian torsion?

Ovarian torsion is a rare condition in which an ovary and often part of the fallopian tube become twisted and rotate up to 360 degrees. As a result, the blood supply to the ovary is restricted, and if not treated, it can cause an irreversible damage to the organ.

Ovarian torsion is triggered as a severe complication of ovarian cysts and accounts for nearly 3% of gynecologic emergencies. The risk of an ovarian torsion is higher during pregnancy, due to a longer ovarian ligament, or due to a cyst forming within the hormone-producing structure of corpus luteum.

What are the symptoms of ovarian torsion?

Symptoms of ovarian torsion include:

• One-sided severe or acute abdominal pain
• Nausea and vomiting
• Faintness or dizziness

In case, you experience any of the above symptoms following In-Vitro Fertilization (IVF) treatment, you need to contact us immediately.

How can ovarian torsion be treated?

Here in AAFC, we diagnose ovarian torsion with Doppler sonography, and correct it through laparoscopy without further complications.

However, if the ovary is cut off from its blood supply for a long time, then the damage is irreparable. As a result, the organ undergoes necrosis and surgical removal becomes the only option.

Assisted reproduction in patients with medical conditions

Underlying medical conditions can often be a determining factor in assisted reproduction outcome, as they impose a number of risks for both the mother and the baby. If you suffer from any chronic conditions, including the ones discussed in the sections for obesity, diabetes mellitus, High Blood Pressure (HBP) and genetic conditions, you need to discuss it with your doctor during your preconception consultation. Appropriate treatment and potential management of any underlying conditions can greatly minimize the risks involved.

Obesity: The World Health Organization (WHO) defines obesity as a condition of abnormal or excessive fat accumulation that may impair health. The Body Mass Index (BMI) is a measure of whether someone is over- or underweight and is defined by a person’s weight in kilograms over their height in squared meters (kg/m2). According to WHO: