In vitro or extracorporeal fertilization is often the only way to solve the problems of infertile couples and it is basically a safe procedure. The most common of the expected complications is the discontinuation of the procedure – due to lack of response to the stimulations or the unacceptability of the egg and/or embryo. Among the complications, the problems related to the ovarian stimulation are also noteworthy – the injuries both during the egg retrieval process and revealed after the surgical procedure, the increased risk of developing multiple and ectopic pregnancies.
The unsuccessful in vitro fertilization is considered to be one of the most stressful stages of infertility treatment. Complications at this stage of treatment can lead to emotional tension, psychological stress, and depression, which in some cases may require the help of a psychologist. We addressed to Ani Morchiladze, Academic Doctor of Medicine, and fertility specialist at the In Vitro Clinic, to talk about the complications associated with in vitro fertilization.
– How often do we face the case when the ongoing procedure discontinue during in vitro fertilization?
The canceled in vitro fertilization cycles are the most common complication of the treatment. About 10% of the ongoing clinical protocols are terminated before the retrieval procedure, 8 to 10% discontinue immediately during the retrieval or in the early stages of embryonic development due to the unacceptability of biological material.
– It is known that a large number of hormonal preparations are used during the in vitro fertilization procedure. What are the side effects that can be caused by these preparations?
No single hormonal preparation has been developed up to date that would be absolutely safe and completely devoid of side effects. There are potential problems that can be identified at different stages of their use. Side effects of hormonal stimulation include the development of ovarian hyperstimulation syndrome, multiple pregnancies, possible ovarian torsion, or ovarian apoplexy (rupture).
– Why multiple pregnancies are considered a complication of in vitro fertilization? It seems that having two or even three children in one attempt should be more helpful.
Although multiple pregnancies with twins or triplets may be attractive to some couples, multiple pregnancies are often associated with complications for both mother and fetus. If in the case of two, three, or four offspring, babies were born as healthy as those from single pregnancies, there would certainly be no cause for concern or alarm.
– What complications may a woman face during her pregnancy with twins?
Side effects for mother, related to multiple pregnancies include:
- Pregnancy failure
- High blood pressure during pregnancy
- Increased probability of preeclampsia by 3-5 times
- Polyhydramnios (an excessive amount of amniotic fluid around the fetus)
- Frequent need to cesarean section.
- Prolonged hospitalization, which in itself increases the cost of medical care.
– Besides the mother, can the lives of children also be at risk during multiple pregnancies?
Of course, it is quite possible. Fetal complications during multiple pregnancies are mainly related to premature birth. The risk of premature delivery is 50% during pregnancy with two fetuses and it is 90% during pregnancy with three fetuses. Termination of a pregnancy before 30 weeks occurs in 7% of cases of the pregnancy with two fetuses and reaches 15% in the case of the pregnancy with three fetuses.
– What complications can accompany preterm delivery much earlier than planned?
Preterm newborns are more likely to experience serious, life-threatening health problems such as cerebral palsy and disability.
Babies born from multiple-birth pregnancies have a low average weight. The risk of disability of children under 1 kg exceeds 25%. Both early neonatal deaths and infant mortality rates are higher in the case of children born from multiple-birth pregnancies than those from single pregnancies. The mortality rate is <1% in the case of single offspring, which is 4.7% in the case of two offspring, and 8.3% in the case of three offspring. The congenital anomalies are 2 times higher in multiple births compared to single births.
– From the complications, you mentioned ovarian hyperstimulation syndrome. It is interesting, may this syndrome develop in all patients during in vitro fertilization?
Ovarian hyperstimulation syndrome (OHSS) is the most serious complication for all patients during in vitro fertilization. Any patient with a good ovarian follicular reserve, undergoing ovulation induction is considered a potential person for the development of the OHSS.
Ovarian hyperstimulation syndrome can be classified into minor, moderate, severe, and critical stages. The most critical cases are associated with the onset of pregnancy. Undoubtedly, severe and critical forms are very life-threatening complications related to ovarian stimulation.
– What symptoms should the patient pay attention to consult a doctor in due time and prevent the development of more severe forms of the disease?
Symptoms usually appear within a few days of the removal of the follicles. If pregnancy does not occur, symptoms of mild to moderate hyperstimulation syndrome pass into nothingness in a few days. At this time, the patient has abdominal distension and moderate pain, mild fatigue during physical activity, and increased psychoemotional stress. Ultrasound test visualizes enlarged ovaries at the expense of cysts and the presence of free fluid in the abdominal cavity
– How common the development of ovarian hyperstimulation syndrome is in the cycles of in vitro fertilization?
Despite precise and careful monitoring procedures, the mild form of the OHSS is found in 33% and the severe form in 3% of in vitro fertilization cycles.
Due to the preventive measures taken by our clinic, in the process of ovarian stimulation, the probability of developing severe forms of ovarian hyperstimulation syndrome has been reduced to zero in recent years. Severe complications of ovarian hyperstimulation syndrome are associated with blood clotting disorders, impaired renal function, and in some cases, ovarian integrity damage, caused by ovarian torsion or rupture. These complications require urgent hospitalization and in the case of the pregnancy, the immediate termination of pregnancy.
– Is it possible to determine in advance in which patient will ovarian hyperstimulation syndrome develop?
Risk factors contributing to the development of OHSS include:
- Excessive response to hormonal stimulation
- Polycystic ovary syndrome
- Young age
- Low body mass index (skinny women)
- Excessive growth of follicles and high concentration of estradiol in the process of stimulation
-What measures do you take to prevent the development of hyperstimulation syndrome?
At the In Vitro Clinic, we are following the most advanced strategies for managing this syndrome. The key element of prevention is to abstain from the transfer of “fresh” embryos during the stimulation cycle and to fertilize and reserve the eggs obtained by aspiration of follicles and only then move them to the cycle. No less important is the high protein diet, maximum restriction of cellular-rich products, and fluid loading.
– What complications may a patient face directly during the procedure of eggs removal?
The potential risks exist as at any surgical procedure, also during the egg retrieval process. Notably, these risks appear in both vaginal and laparoscopic approaches in the follicular aspiration.
-in the procedure of egg retrieval which method is considered safer for the patient – vaginal or laparoscopic?
In the process of egg retrieval using a vaginal approach, bleeding from the ovaries or vaginal fornix may develop, which is often minimal and does not require a blood transfusion (hemotransfusion – in 1 case out of 500). Much less commonly, complications include infection, which develops in 1 out of 300 patients and requires antibacterial therapy. Injuries to internal organs, mainly the intestines and urinary bladder, as well as damage to blood vessels, are also very rare during the procedure (1 case out of 1000).
With the laparoscopic approach during aspiration of eggs, in addition to the risk of injury to the above-mentioned anatomical structures, there is also the risk of complications associated with the use of general anesthesia. However, these cases are very rare in healthy women.
– What is the probability of development of the Ectopic pregnancy with in vitro fertilization?
Ectopic pregnancy develops in 2 percent of in vitro fertilization cycles. According to statistics from the World Health Organization, ectopic pregnancy accounts for 1% of all pregnancies. In 95% of ectopic pregnancies, the embryo remains in the fallopian tube. However, an ectopic pregnancy can also develop in the cervix, ovaries, or abdominal cavity.
– And if in vitro fertilization implies the transfer of embryos directly into the uterine cavity, i.e. by bypassing the fallopian tubes, then why does an ectopic pregnancy develop?
An interesting question. Of course, the embryo/embryos are transferred to the uterine cavity not blindly, but under ultrasound control, in the most desirable place for them. However, past inflammatory processes and the functional unhealthiness of the fallopian tubes may become a precondition for further migration of the transferred embryos beyond the uterine cavity.
– Should pregnancy necessarily be terminated in the case of ectopic pregnancy?
Implantation of the embryo outside the uterus causes life-threatening complications for both the mother and the fetus. The danger is, that the integrity of the organ, where the embryo is improperly implanted, is damaged over time thus creating a real risk of bleeding.
Several interesting cases have been recorded in our clinic during ultrasound examination, one amniotic sac in the fallopian tube, and the other amniotic sac directly into the uterine cavity. After visualization, our experienced surgeon – endoscopists performed emergency laparoscopic intervention. After the elimination of the ectopic pregnancy, the pregnancy of the uterine cavity was maintained, which in all three cases ended with a live birth in time.
Many years of experience of the In Vitro Clinic and a team of highly qualified medical staff are always at your service to prevent the expected complications associated with in vitro fertilization.