Potential Complications of Assisted Reproduction Technologies

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

Ovarian Hyperstimulation Syndrome

Gonadotropins stimulate the ovaries to produce many follicles and therefore the ovaries may increase in size. Mild hyperstimulation may be seen in up to 10 to 20% of women undergoing treatment. In most cases, the ovaries are slightly enlarged, causing mild abdominal tenderness and bloating. However, in 1% of patients, severe hyperstimulation can occur. The ovaries can increase in size in some cases causing fluid to accumulate around the ovaries, dehydration, swelling of the abdomen, and tenderness. Rare cases of blood clots, kidney damage, ovarian twisting, chest and abdominal fluid collection have also been reported. Bed rest and hospitalization with careful monitoring of fluids is sometimes required when severe hyperstimulation occurs.

Hyperstimulation symptoms tend to resolve in 7 to 10 days, however if the patient becomes pregnant, the condition can last 4 to 6 weeks.

The key to controlling the hyperstimulation syndrome is in its recognition and prompt medical intervention. Therein lies the importance of frequent office visits for ultrasounds and blood test throughout the stimulation period so that the physician may adjust medication dosages as needed and assess the patient.

Bleeding and Infection

Egg retrieval by ultrasound guidance is a minor surgical procedure that allows most patients to return to work the following day. Removing the eggs with a special needle entails a slight risk of bleeding, infection, and damage to the bowels, bladder, or nearby blood vessels. Approximately 1 patient in 1,000 will require major surgery to repair damage from complications related to eggs retrievals. Ultrasound guidance, however, aids the highly skilled physician to visualize the ovaries and as well as surrounding organs to perform the retrieval with the outmost care. Our patients are carefully monitored after the procedure to promptly detect possible complications. All patients also receive intravenous antibiotics during the egg retrieval to reduce the risk of infection. The combined use of these preventative measures have been extremely effective at preventing the occurrence of pelvic infection.

Multiple pregnancy

There is a potential for multiple pregnancy whenever more than one embryo is transferred into the uterus. While with the transfer of 3 embryos, the multiple pregnancy rate is 15-30 %, with 5 or more embryos this can increase to more than 40 %. Most of the multiple pregnancies are twins, but triplets, quadruplets, and more have been described.

Ovarian Cancer

Controversial studies link gonadotropins to the development of ovarian cancer. Although the studies are contradictory, some researchers have reported an increase in ovarian cancer in women who use injectable gonadotropins, while others show no such correlation. Until further research is available, it is the Center's feeling that all the fertility drugs need to be used prudently and be appropriately monitored for limited amounts of time.

Psychological Risks

Couples undergoing assisted reproduction procedures have described the experience as an "emotional roller coaster". The treatments are time-consuming, costly, and are more likely to fail than to succeed in a given cycle. Couples may become frustrated, angry, and resentful in their quest for pregnancy. At times, these feelings can lead to depression and feeling of low self-esteem; especially in the immediate period following a failed attempt at pregnancy. The support of family members and friends is very important at this time, however some couples may wish to seek psychological counseling as an additional means of support. Our Center has available an experienced psychologist specializing in infertility to help couples deal with the grief, tension, and anxieties associated with assisted reproduction treatment.


Selective Reduction

 

Selective reduction is a technique that is used when multiple embryos have implanted as the result of assisted reproductive technologies. The procedure is usually performed between 9 to 12 weeks gestation to selectively abort the extra embryos. Selective reduction is performed by a perinatologist on an outpatient basis by inserting a needle guided by ultrasound either through the abdomen or vagina to inject potassium chloride into the fetus. The incidence of miscarriage associated with this procedure is felt to be 4 to 5%.


The decision of whether or not to undergo selective reduction can be a traumatic one, and couples who have invested time and effort to achieve pregnancy may often be unprepared to make this choice. If this procedure is morally or ethically unacceptable, then the number of embryos transferred should be strictly limited. It is helpful for couples considering selective reduction to undergo professional counseling prior to the procedure.

 

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How many embryos do I transfer?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

The goal of IVF is to provide couples the best possible chance for pregnancy with the lowest risk for multiple pregnancy. When transferring embryos that have developed for 3 days, the Center recommends transferring 3 embryos, based on the knowledge that pregnancy rates increase, up to a point, as the number of embryos transferred per cycle increases.

With the advent of blastocyst culture, it is possible to transfer a smaller number of embryos while maintaining excellent pregnancy rates. Typically, 2 blastocysts are transferred on day 5.

It is important to understand that the number of embryos transferred may vary from couple to couple depending on the quality, quantity, and stage of their embryos, patient's age and medical history; as well as their stance on selective reduction.



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What is Assisted Fertilization?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

In some cases of male infertility, the usual mixing of egg and sperm may not result in a fertilized egg. A technique termed ICSI (intracytoplasmic sperm injection) in which a single sperm is injected directly inside the egg with a microscopic needle, may offer a solution to those with severe male infertility. This technique is performed in the laboratory the day of the retrieval using mature eggs.



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What is Assisted Hatching?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

When the embryo is ready to implant, it hatches out of the outer shell and begins to burrow in the uterus. Assisted hatching is a procedure performed by the embryologist under the microscope which involves making a small tear in the protective outer coating of an embryo to facilitate hatching. In older patients and in cases of previously failed IVF attempts, assisted hatching may improve the chances of the embryo implanting into the womb. Assisted hatching is not performed on "fresh" (not previously frozen) blastocysts.

Patients prepare for assisted hatching by taking antibiotics and steroid pills starting a day before the transfer and continuing for a total of 4 days. These measures are taken to protect the embryo from possible immune or bacterial assaults once they are transferred.



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What are Blastocysts?

From the fertility booklet The A.R.T. of Fertility: A patient guide
by the Fertility & IVF Center of Miami

Blastocysts are embryos that have developed for 5 to 6 days after fertilization. A healthy blastocyst is ready to hatch from its outer shell by the end of the 6th day and implant into the endometrial lining within 24 hours. Currently only about 20-40% of embryos mature into blastocysts, but those that do survive have a better chance to implant and develop into a baby. Why transfer blastocysts? Blastocyst culture can provide a natural selection of the best embryos instead of random selection among good quality embryos on "day 3". Blastocysts are a viable option whenever a good number and quality of embryos exist. When only a limited number of embryos are available on the third day, there is no advantage to continue culture to a blastocyst.

Since blastocysts have a higher potential for implantation, fewer of them are transferred, generally two. Transferring fewer embryos translates into a lower risk for multiple pregnancy, and this is paramount for those couples that want to avoid selective reduction.



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