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Risks and complications of IVF treatment
  1. Multiple pregnancy
  2. Problems associated with ovarian stimulation
  3. Adnexal torsion
  4. Ectopic pregnancy

Failure of IVF treatment

It is important to know the risks before embarking on IVF treatment.

This is the most common complication of treatment. The likely reasons for this failure are canceled cycles (approximately 10% of treatment cycles will be abandoned before egg collection), failure to collect eggs (about 1%), failure of fertilization (about 5%), and failure of implantation (this could be due to defective embryo or endometrium, or poor synchronization).

A significant portion of normal embryos are chromosomally abnormal and this proportion increases with advanced maternal age.

The IVF (in-vitro fertilization) procedure is considered by some, to be one of the most stressful infertility treatments. Failure of treatment can result in emotional strain, psychological stress and depression. Some couples may require psychological counseling. In addition, couples may encounter physiological difficulties if a multiple pregnancy occurs.


Multiple pregnancy

In the majority of patients, fewer than 20% of the embryos are implanted after embryo transfer to the uterus, so two or more embryos are usually replaced which results in high-order multiple pregnancies. The latest data from the USA (SART 2002) concerning multiple pregnancies showed that 32% of deliveries after in-vitro fertilization (IVF) were twins and 7% were triplets or more. In the United Kingdom (HFEA patient's guide 2002), 25% of deliveries after IVF were twins and 1.7% were triplets.

It is important to note that in the United Kingdom, the maximum number of embryos to be replaced per cycle is three. In order to reduce the risk of multiple pregnancy, the HFEA in the United Kingdom (August 2001) has decided to reduce the number of embryos to be transferred from three to two. In exceptional circumstances a three eggs or embryos transfer may be performed. This will be case specific and indications might include clinical and laboratory criteria. Countries have different regulations and restrictions with regard to the number of embryos to be transferred.

Ultrasound scan showing multiple pregnancy.

Although the prospect of twin or triplets may seem attractive to some couples, high order of multiple pregnancies is associated with increased risks of maternal and fetal complications. In addition, multiple pregnancies place enormous strains for the parents including financial difficulties, emotional distress and physical exhaustion.


Problems associated with ovarian stimulation by fertility drugs

The fertility drugs used to stimulate ovulation are associated with several complications.

There is no drug that is absolutely safe and completely free of side effects. The fertility drugs that stimulate ovulation are rarely associated with complications. There are potential problems, which may occur and include: side effects of fertility drugs,ovarian hyperstimulation syndrome (OHSS), multiple pregnancy,adnexal torsion (ovarian twisting) and the risk of ovarian cancer.

The committee on the safety of medicine in the UK has advised that no medical products using urine sourced in a country which has reported case(s) of variant form of human Creutzfeldt Jakob disease; this includes metrodine high purity (February 2004).

Ovarian hyperstimulation syndrome (OHSS)

This is the most serious complication of IVF. Any patient undergoing ovulation induction is at risk of developing OHSS, although some more than others. Ovarian hyperstimulation syndrome may be classified as mild, moderate or severe by symptoms and signs. the worst cases seem tends to be associated with pregnancy. Severe OHSS is a life threatening complication following ovarian stimulation.

The symptoms usually begin 4-5 days after the egg collection. The majority of women have a mild or moderate form of the syndrome and invariably resolve within a few days unless pregnancy occurs, that may delay recovery. Patient may complain of pain, a bloated feeling and mild abdominal swelling. In a small proportion of women, the degree of discomfort can be quite pronounced.

In some cases cysts appear in the ovaries (ovarian cysts) and fluid may collect in the abdominal cavity causing discomfort.

Very rarely, in about 1-2% of cases the ovarian hyperstimulation is severe and the ovaries are very swollen. The woman will feel ill, with nausea and vomiting, abdominal pain. Fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. Reduction in the amount of urine produced. These complications require urgent hospital admission to restore the fluid and electrolyte balance, monitor progress, control pain and in some very serious cases, termination of pregnancy. Complications associated with severe OHHS include blood clotting disorders, kidney damage and twisted ovary (ovarian torsion).

Incidence of OHSS

Despite careful monitoring, a small number of women (about 3-5% of the treatment cycles) may develop OHHS.

Causes of OHSS

Over response to fertility drugs. Cause is unknown. But, women at risk of developing OHHS include.

  • Women with polycystic ovaries.
  • Younger women.
  • High estrogen hormone levels and a large number of follicles or eggs.
  • Administration of GnRh agonist.
  • The use of hCG for luteal phase support.

Management and treatment options for OHSS

  • Withhold hCG administration when the blood estrogen levels and ultrasound scans show a high risk of severe OHHS.

Ultrasound scan of severe ovarian hyperstimulation syndrome (OHSS).

  • Proceed with egg collection, inseminate the eggs but have any viable embryos frozen and not proceed to fresh embryo transfer in that cycle and undergo subsequent frozen embryo transfer treatment cycle.
  • Coasting to stop the gonadotropin stimulation and continuing the agonist suppression until estrogen levels declines to acceptable levels before proceeding to egg collection.


Adnexal torsion

Adnexal torsion (ovarian twisting) can be treated by surgery.

The term adnexal torsion refers to when the stimulated ovary twists on itself, cutting of its own blood supplies. Ovarian torsion is a rare complication of IVF treatment. The overall risk is about 0.2%. It is greater in the presence of OHSS. Ovarian torsion may cause severe pain and tenderness in the lower abdomen.

If not treated early enough the twisted ovary may die (gangrene). Treatment is surgery to untwist the ovary and even removing it sometimes.


Ectopic pregnancy

Ectopic pregnancy is a potentially life threatening condition. Ectopic pregnancy is a well-known but comparatively rare, complication of assisted conception treatments.

What is an ectopic pregnancy?

Ectopic pregnancy is any pregnancy that occur outside the cavity of the womb.