14) Subfertility - Complications of ART Flashcards
Percentage blood volume loss in OHSS
20%
Incidence of OHSS
Mild - 1/3
Moderate + Severe - 3-8%
Severe - 1-2%
0.3% Hospitalisation Rate
Risk factors for OHSS
Previous OHSS PCOS Increased antral follicle count Increased AMH Successful conception Age <30 Low BMI
When does early OHSS occur and what is it due to?
Within 7 days of trigger and due to trigger.
When does late OHSS occur and what is it due to?
10 or more days after trigger and due to endogenous hCG from early pregnancy
Features of mild OHSS
Abdominal pain
Abdominal distension
Ovarian volume <8
Features of moderate OHSS
Moderate pain
USS ascites
Ovarian volume 8-12
Nausea +/- vomiting
Features of severe OHSS
Clinical ascites Ovarian volume >12 Oliguria (<300ml/day or 30ml/h) Haematocrit >0.45 Na < 135 K > 5 Albumin <35 Osmolality <282
Features of critical OHSS
Tense ascites or large hydrothorax Oliguria/anuria ARDS Thromboembolism Haematocrit >0.55 WCC>25
Which cases of OHSS should be reported to HFEA and which to MMBRACE?
Any severe/critical OHSS should be reported to HFEA. Any deaths to MMBRACE.
Outpatient management of OHSS
- For mild/moderate and some severe
- Oral fluid (drink to thirst and aim >1L/day)
- Monitor UO and seek medical RV if <1L/day or positive balance >1L
- Avoid NSAIDs
- Thromboprophylaxis if severe
- Paracentesis of ascitic fluid
- Review every 2-3d
When does OHSS resolve over?
7-10 days
When is inpatient management of OHSS indicated?
- Needed for analgesia
- Worsening despite outpatient management
- Unable to tolerate oral fluids
- Critical OHSS
- Unable to attend for follow up
How much albumin is used in OHSS?
25% HAS 50-100g over 4 hours
Indications for paracentesis
Severe abdominal distension and pain
Shortness of breath secondary to ascites
Oliguria despite fluid
How long should thromboprophylaxis be given for?
7 days from cure of symptoms if not pregnant or until end of 12th week if pregnant
Obstetric risks associated with OHSS
PET
Premature labour
Single biggest adverse effect of ART
Multiple pregnancy
Increased rate of multiple pregnancy compared to spontaneous conception
20 x increased
Multiple birth rate
Now around 12% (target is 10%)
Risk of monozygotic twins in ART compared to spontaneous
Spontaneous 0.4%
ART: 0.7-3%
Types of ART that increase risk of monozygotic twins
Blastocyst transfer and ICSI
Number of women have single embryo transfer
30%
Cancer risk secondary to ART
No increased risk in cervical cancer or endometrial cancer.
No increased risk in breast cancer but may be small increase in women <25y.
No increased risk in ovarian cancer but may be increased borderline tumours.
Prevalence of ectopic pregnancy after IVF
2-8%
Prevalence of heterotopic pregnancy after IVF compared to spontaneous
Spontaneous: 1 in 30,000
IVF: 8 in 1000
Incidence of minor vaginal bleeding after oocyte retrieval
18%
Incidence of pelvic infection after oocyte retrieval
0.1-0.6%
Incidence of severe intra-abdominal bleeding after oocyte retrieval
0.05-0.2%
Effect of ART on menopause age
None
Effect of ART on childhood cancers
Conflicting data.
Maternal progesterone increases risk of acute lymphocytic leukaemia and tumours of sympathetic nervous system.
Effect of ART on preterm birth
Increased (2 x risk increase in singletons, 23% increase in multiples)
Effect of ART on growth
Increased risk of SGA and low birth weight
Effect of ART on chromosomal abnormalities
Increased risk
What are the imprinting conditions associated with IVF?
Beckwith-Wiedemann syndrome, Angelman, maternal hypomethylation syndrome
Maternal risks of ART
Increased risk PIH/PET/GDM/CS/Obstetric haemorrhage
Risk of PIH if donor eggs used
16-40%
Effect of IVF on 1st trimester screening?
PAPP-A levels significantly lower.
