Is there an increased
chance of miscarriage following infertility treatment?
Miscarriage is estimated to occur in between 10 and 20% of pregnancies. A meta-analysis of assisted conception found a spontaneous miscarriage incidence of 22%. In a study in Ireland the outcome of pregnancies achieved by IVF were compared to those conceived spontaneously whilst awaiting treatment. There were 16.5% miscarriages in the IVF group compared to 5% in the spontaneous pregnancy group.
The psychological effects of miscarriage following infertility treatment cannot be underestimated. There is evidence that 50% of male partners suffer significant disturbance.
Related Medical Abstracts - Click on the paper title:-
- Incidence of spontaneous abortion among pregnancies produced by assisted reproductive technology. (2004-01)
- The lived experience of miscarriage after infertility. (2003-01)
- Polycystic ovarian syndrome and the risk of spontaneous abortion following assisted reproductive technology treatment. (2001-01)
- Pregnancy and miscarriage rates in 3978 donor insemination cycles: effect of age, parity and partner's infertility status on pregnancy outcome. (2000-01)
- Course and outcome of IVF pregnancies and spontaneous conceptions within an IVF setting (1995)
- Incidence of fetal loss in infertility patients after detection of fetal heart activity with early transvaginal ultrasound (1993)
Disorders of the Fallopian tube are more common in women with reduced fertility and there is an increased risk of ectopic pregnancy in those with a history of infertility. Even when embryos are transferred into the uterine cavity following IVF there is still a 4.5% chance of an ectopic compared to 1% in the general population.
Related Medical Abstracts - Click on the paper title:-
- Risk factors for ectopic pregnancy: a case-control study. (2006-01)
- Ectopic Pregnancy Risk With Assisted Reproductive Technology Procedures (2006-02)
- Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. (2003-01)
- Risk factors for ectopic pregnancy in assisted reproduction. (1999-01)
Is there an increased risk of an ectopic pregnancy following infertility treatment?
Disorders of the Fallopian tube are more common in women with reduced fertility and there is an increased risk of ectopic pregnancy in those with a history of infertility. Even when embryos are transferred into the uterine cavity following IVF there is still a 4.5% chance of an ectopic compared to 1% in the general population.
Related Medical Abstracts - Click on the paper title:-
- Risk factors for ectopic pregnancy: a case-control study. (2006-01)
- Ectopic Pregnancy Risk With Assisted Reproductive Technology Procedures (2006-02)
- Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. (2003-01)
- Risk factors for ectopic pregnancy in assisted reproduction. (1999-01)
What is a heterotopic pregnancy?
This is a multiple pregnancy with one embryo implanting in the uterine cavity and another is simultaneously ectopic. The natural incidence of heterotopic pregnancy is one in 30, 000. Infertility is associated with an increased risk of ectopic pregnancy and infertility treatment involving ovulation induction drugs increases the chance of multiple pregnancy. As a result of assisted conception, the incidence of heterotopic pregnancy has increased.
Ultrasound can assist early diagnosis of heterotopic pregnancy. In one study, two-thirds of the intrauterine pregnancies resulted in live births.
Related Medical Abstracts - Click on the paper title:-
- A comparison of heterotopic and intrauterine-only pregnancy outcomes after assisted reproductive technologies in the United States from 1999 to 2002. (2006-01)
- Heterotopic pregnancy (2006-02)
- Heterotopic pregnancy: two cases and a comparative review. (2006-03)
- Ruptured heterotopic pregnancy with successful obstetrical outcome: a case report and review of the literature. (2005-01)
- Heterotopic pregnancy after in vitro fertilization-embryo transfer. (2004-01)
What problems can occur with multiple pregnancy?
Infertility treatments involving ovulation induction are associated with an increased incidence of twins and higher order multiple pregnancy (4; Figure 11.1). The natural incidence of twins is one in eighty pregnancies and for triplets it is one in six thousand. Ovulation induction alone increases the incidence of twins four-fold. A study of twenty-four thousand IVF pregnancies found a 25-fold increase in the incidence of twins and a 350-fold increase in triplets.
Figure 11.1
Multiple pregnancy is regarded as 'high-risk' in obstetrics as all the potential complications of pregnancy occur more frequently. These include maternal problems such as anaemia, urinary tract infection, high blood pressure and bleeding. Miscarriage, premature delivery, poor placental function reducing the growth rate of the babies, perinatal mortality (stillbirths and babies dying in their first week) are all more frequent in twins. These problems are disproportionately more likely to occur with higher order pregnancies (Figure 11.2).
Figure 11.2
Related Medical Abstracts - Click on the paper title:-
- Preterm birth in twins after subfertility treatment: population based cohort study. (2005-01)
- Perinatal outcomes of in vitro fertilization twins: a systematic review and meta-analyses. (2005-02)
- The risk of mortality or cerebral palsy in twins: a collaborative population-based study. (2002-01)
- Comparison of risk factors for cerebral palsy in twins and singletons. (2002-02)
- Assisted reproductive technologies: Estimates of their contribution to multiple births and newborn hospital days in the United States (1996)
- Perinatal outcome of twin pregnancies obtained after in vitro fertilization: Comparison with twin pregnancies obtained spontaneously or after ovarian stimulation (1996)
- Perinatal outcome of triplet pregnancies following assisted reproduction (1994)
- Triplets and quadruplets born in Victoria between 1982 and 1990: The impact of IVF and GIFT on rising birthrates (1993)
- Outcome of twin, triplet, and quadruplet in vitro fertilization pregnancies: The Norfolk experience (1992)
- Births in Israel resulting from in-vitro fertilization/embryo transfer, 1982-1989: National registry of the Israeli association for fertility research (1992)
How can the pregnancy risks following infertility treatment be reduced?
The greatest risks are associated with multiple pregnancy and this is largely dependent on the use of ovulation induction agents (4). A common reason for anovulation is PCOS (Q7.2) and ovulation induction agents have frequently been employed. The arrival of metformin as an effective treatment that reverses the underlying cause of PCOS may reduce the need for ovulation induction.
IVF is associated with increased incidence of multiple pregnancy. The success of IVF has given it an element of glamour. Ultimately it is a matter of patient choice but it is my own view that there is a place for fully exhausting lower-tech treatments before resorting to IVF. Fertility units are compared by their pregnancy rates and 'take-home' baby rates. There is an understandable temptation to put back as many embryos as possible to achieve positive results (Figure 11.1). Those of us who are involved in the care of the resultant pregnancies see the joys of successful outcomes but our views are chastened when we see things go wrong (see 8). In the UK, the number of embryos that can be transferred into the uterus has been limited to three and there is current debate suggesting that we should further reduce to two. This is a move that many of us obstetricians would favour.
There is an advantage in pregnancies following infertility treatment being cared for by a team with a special interest in this area. Whilst I have no doubt that even greater vigilance is given in the care provided for pregnancies resulting from infertility treatment, there is evidence that successful outcomes occur slightly less frequently when compared with pregnancies achieved naturally. Doctors in general, and obstetricians in particular, are better placed than most to contemplate the miracles of nature. We do not intervene unless we believe that there is a definite advantage. When a pregnancy reaches term, there is no advantage for the baby to await events or to experience passage through the birth canal. An increasing proportion of women who have experienced infertility elect to be delivered by caesarean section.
There is a perceptible pressure to reduce obstetric intervention albeit mainly from those who have not experienced the occasional downside of natural childbirth. For those women who have experienced prolonged infertility and successful treatment, natural childbirth may seem less important than for others. There is an element of risk in every aspect of our lives and sadly there are times when even particularly precious pregnancies go wrong at the last moment. Usually, although not always, it is an unavoidable event of nature.
Related Medical Abstracts - Click on the paper title:-
- A two- versus three-embryo transfer: The oocyte donation model (2001)
- Obstetric and perinatal outcome of pregnancies after intrauterine insemination. (1999)
- Obstetric outcome in 232 ovum donation pregnancies. (1998)
- Triplets and embryo transfer policy. (1997)
- The economic impact of multiple-gestation pregnancies and the contribution of assisted-reproduction techniques to their incidence (1994)
I have conceived with infertility treatment. How will the pregnancy be managed?
Every pregnancy and baby is precious to the professionals privileged to care for you during pregnancy and childbirth and we recognise that a pregnancy following successful infertility treatment is particularly precious. Obstetricians must walk a tight-rope between allowing nature to take its course and intervention when this is to the benefit of mother or baby. When infertility treatment has been necessary, increased vigilance and intervention are necessary. We believe that there is a self-evident advantage when the team involved in your infertility treatment can continue care through the pregnancy.
The decision to undertake a Caesarean section is usually reached by taking into account a combination of factors. A history of infertility, particularly when pregnancy has been achieved after many years and with high-tech treatment, is considered to be one factor in favour of operative delivery. Maternal age tends to be higher and there may be concern about the function of the placenta. Multiple pregnancy may be an additional reason for opting for Caesarean section. The Caesarean section rate for women conceiving with IVF in the Irish study (5) was 55.7% compared to 10.9% in the group conceiving spontaneously whilst awaiting IVF.
The question of whether obstetricians undertake too many or too few Caesarean sections can never be resolved as it is impossible to define the ideal operative delivery rate. Ultimately it is for the individual informed couple, together with their obstetrician, to decide on their preferred type of delivery. Safety and patient satisfaction are the quality measures that matter. There has been a notable increase in the number of women electing to be delivered by Caesarean section.
Related Medical Abstracts - Click on the paper title:-
- Perinatal outcome and developmental studies on children born after IVF.(2001)
If we have infertility treatment will our baby be healthy?
In spontaneous conception, the one follicle that has become dominant that cycle is fertilised by the sperm that has beaten all the others in a race. There have been millions of sperm released during the ejaculation. The concept of natural selection is dependent on the idea that the fittest survive. Infertility treatment, particularly IVF, ICSI and cryopreservation circumvent natural selection. There has been understandable concern that these infertility treatments may be associated with an increased risk of congenital abnormality. Reassuringly, however, results reported from around the world indicate that there is no major increase in the rate of babies being born with abnormality.
Related Medical Abstracts - Click on the paper title:-
- Follow-up of children born after ICSI. (2002)
- Outcome and follow-up of children born after IVF-surrogacy (2001)
- Pregnancy and child outcome after oocyte donation (2001)
- Follow-up studies of children born after frozen sperm donation (2001)
- Review: Parent-child relationships and child development in donor insemination families (2001)
- Health of 227 children born after controlled ovarian stimulation for in vitro fertilization using the luteinizing hormone-releasing hormone antagonist cetrorelix (2001)
- Obstetric outcome and follow-up of children born after in vitro fertilization (IVF) (2000)
- Incidence of congenital malformations in children born after ICSI. (2000)information?
- The psychological status at school age of children conceived by in-vitro fertilization. (1999)
- Infants conceived using in-vitro fertilization do not over-utilize health care resources after the neonatal period. (1998)
- Stigma, disclosure, and family functioning among parents of children conceived through donor insemination (1997)
- Follow-up of a cohort of 422 children aged 6 to 13 years conceived by in vitro fertilization (1997)
- Donor insemination: Child development and family functioning in lesbian mother families (1997)
- Obstetric and perinatal outcome of pregnancies following intracytoplasmic sperm injection (1996)
- Intelligence and behaviour in children born after in-vitro fertilization treatment (1996)
- Growth and physical outcome of children conceived by in vitro fertilization (1996)
- Assisted reproduction: A reassuring picture (1996)
- The European study of assisted reproduction families: Family functioning and child development (1996)
- Pregnancy outcome following exposure to gonadotrophin-releasing hormone analogue during early pregnancy: Comparisons in patients with normal or elevated luteinizing hormone (1995)
- Outcome in children from cryopreserved embryos (1995)
- Birth characteristics and perinatal outcome of babies conceived from cryopreserved embryos (1994)
- A controlled study of the psycho-social development of children conceived following insemination with donor semen (1993)
- Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer (1991)
- Perinatal outcome and congenital malformations in in-vitro fertilization babies from the Bourn-Hallam group (1991)
Thank you for choosing to visit us.
This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.
- Perinatal outcome and developmental studies on children born after IVF.(2001)
