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Precautions after ivf pregnancy , lifecare centre ,IVF icsi

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PREGNANCY Outcome following
IVF-ICSI
HURDLES IN EARLY PREGNANCY
lifecare IVF centre
lifecare centre ,Multiple Pregnancy
Pregnancy
&
Co-morbidity
obestetric & neonatal outcome following IVF-ICSI

Publicado en: Salud y medicina
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Precautions after ivf pregnancy , lifecare centre ,IVF icsi

  1. 1. PREGNANCYOutcome following IVF-ICSI Dr.Sharda Jain
  2. 2. Over 300 ppts are available on slideshare.net ***for use of public/Doctors www.slideshare.net / Lifecarecentre
  3. 3. IVF PREGNANCIES ARE INCREASING WORLDWIDE !! • Today there are more than 5.0 million births with I.V.F. • In Australia 4% of total births are following IVF • In western world ..the figure is around 1-2% • In India ..it is around 0.1%
  4. 4. DEMAND FOR I.V.F.--.I.C.S.I. is increasing in INDIA In India there are 1 lac IVF cycle in year 2015 & is likely to cross 2.6 lac IVF cycles by 2020
  5. 5. PRECAUTIONS TO BE TAKEN IN IVF PREGNANCY Most of the IVF patients become exceedingly elated when the result of their pregnancy test is positive as their trails and hard work during the tough period have culminated something fruitful…..
  6. 6. ALL PREGNANCIES FOLLOWING I.V.F. ARE HIGH RISK PREGNANCIES • Woman must be sensitive and careful not to become complacent ..as road ahead is difficult • All complications of pregnancy are more in couple where female factor is dominant • It is pertinent to note that ICSI patient with male factor does not cause adverse outcome.
  7. 7. Outcomes Associated with “Untreated infertility” There is increasing evidence that infertility or subfertility is an INDEPENDENT RISK FACTOR for Obstetrical complications and adverse Perinatal outcomes, even without the addition of ART (level II)
  8. 8. • In Australia the average age of women going for IVF with her own eggs is 36 years In India no such data is available • It is estimated that average age of Indian mother following self IVF cycle is same that is 35-36 years ,while for donor cycle it is 42 years IT IS A FACT---MOTHERS WITH I.V.F.PREGNANCY ARE 5 YEARS ELDER THAN WOMEN WHO CONCEIVE NATURALLY
  9. 9. FIRST TRIMESTER IS MOST DIFFICULT
  10. 10. FIRST TRIMESTER IS MOST DIFFICULT ! • A positive BHCG test corroborates pregnancy • Still unsure about pregnancy location and viability • While most pregnancies result in a baby, about -25 - 35% pregnancies fail to beyond 12 weeks. • It holds true for all natural pregnancies, not just IVF pregnancies after infertility • Always remember that older women, have a higher risk of miscarriage as compared to younger women.
  11. 11. IVF pregnancies require close monitoring in the first month itself (level 3) • To ensure that everything proceeds smoothly • Initially, serial blood tests are done every 3 days, to check if the HCG levels are doubling • Once the HCG level exceed 1000 mIU/ml, then vaginal ultrasound are done to confirm that the pregnancy is in the uterus and is growing well
  12. 12. MISCARRIAGE AND A.R.T
  13. 13. HURDLES IN EARLY PREGNANCY • EARLY PREGNANCY LOSS…DUE TO BIOCHEMICAL PREGNANCY IS DISTINCT & DIFFERENT ENTITY AS COMPARED TO FIRST TRIMESTER MISCARRIAGE.. • ACCORDING TO W.H.O. & ESHRE …ULTRASOUND EVIDENCE OF PREGNANCY IS ESSENTIAL FOR COUNTING IT AS CLINICAL PREGNANCY.
  14. 14. BIOCHEMICAL PREGNANCY • BIOCHEMICAL PREGNANCY IN I.V.F. PREGNANCIES IS CONSISTENTLY AROUND 15 to 20 %...Though the range varies from 11 to 35 % • IN OUR SERIES OF CONSECUTIVE 800 PREGNANCIES , CHEMICAL PREGNANCY RATE WAS 12.5%...WHICH IS DUE TO ADVANCED MATERNAL AGE i.e. 40 years plus, POOR QUALITY OF EMBRYO AT TIME OF TRANSFER.
  15. 15. Early pregnancy complications • CLINICAL MISCARRIAGE RATE after I.V.F. are believed to be consistently around 10-15% attributed to ADVANCED AGE,PCOD,OBESITY &OTHER COMORBIDITIES • However, It is pertinent to note that the problem of Bleeding is seen in more than 50% cases , more so in patients of PCOS • There is a positive correlation between the risk of abortions & the intensity of ovarian stimulation No difference in the miscarriage rates when comparing couples who have had both fresh & frozen cycles unless PGD testing is done CLINICAL MISCARRIAGE & MISSED ABORTION RATE IN OUR SERIES 13.75%
  16. 16. Reasons for increased Pregnancy loss are unclear! However, Maternal age –esp over 40 years Smoking, and Poor embryo quality at transfer have been shown to be associated with an increased risk of pregnancy loss following ART
  17. 17. It is interesting to note …… • Frozen cycles babies have less problem • ICSI does not increases rate of miscarriage, adverse peri natal or maternal risk over standard IVF • Use of donor oocytes fair much better than self I.V.F cycles
  18. 18. Fact about Fresh v/s Frozen cycles • It is our experience & there is growing evidence that pregnancy outcomes are better for CRYOPRESERVED EMBRYOS fertilized in vitro than for fresh embryo transfers • This finding supports policy of freezing all embryos in PCOS to give good prognosis , and also reassures any women considering IVF (II-2A)
  19. 19. OVERALL 30% OF WOMEN WITH POSITIVE PREGNANCY RATE WILL LOSE THEIR PREGNACY BEFORE THE END OF FIRST TRIMESTER • IN OUR SERIES OF 800 CONSECUTIVE CASES THE MISCARRIGE RATE [CHEMICAL PREGNANCY RATE +CLINICAL MISCARRIAGE RATE] WAS 26.25% • THE HIGH LOSS RATE HIGHLIGHTS THE IMPORTANCE OF REPORTING live birth following ART rather than pregnancy rate.
  20. 20. ECTOPIC PREGNANCY
  21. 21. 2% Of All Pregnancies Are Ectopic • Some earlier case series shows a higher incidence of ectopic pregnancy at about 4% following ART • Most large prospective studies show a rate of • 2.0 – 2.2 % which is similar to that of the general population • This change is probably because early in the development of ART, tubal disease was the major indication for ART In our series of consecutive 800 IVF cycles 1.25%
  22. 22. It is interesting to note ……. • ICSI with IVF is associated with a significantly lower risk of ectopic Pregnancy, because • ICSI is often selected for couples with male factor infertility rather than tubal factor • Oocyte donation (1.5%) and gestational surrogacy (0.9%) have lower rates of ectopic than IVF or the general population
  23. 23. IN OUR SERIES OF 1000 ART PREGNANCIES…ECTOPICS WERE TWO BOTH WERE MANAGED MEDICALLY IN OUR SERIES OF 800 ART PREGNANCIES…ECTOPIC pregnancy were 10 (1.25%) 2 were operated & 8 were MANAGED MEDICALLY with methotrexate
  24. 24. Multiple Pregnancy
  25. 25. THERE IS EPIDEMIC OF MULTIPLE PREGNANCY WITH I.V.F. • Multiple pregnancy is the most powerful predictive factor for adverse maternal, obstetrical, and perinatal outcome • Couples should be thoroughly counselled about the significant risks of multiple pregnancies associated with ART. • The figure is around 20%....while in few earlier studies it crossed 40 to 50 %
  26. 26. In our series of consecutive 800 IVF cycles rate of twins was 7.5% & triplets 2.5% This low rate is because we do believe in blastocyst transfer if possible . If the joy multiplies by 2 , Problems also multiplies by 2
  27. 27. Stillbirth & Neonatal death rate in I.V.F. Pregnancy
  28. 28. STILLBIRTH & NEONATAL DEATH RATE It is universal experience that … women undergoing IVF-ICSI are more likely to experience a stillbirth or neonatal death (nearly twice ) as compared to women who conceive naturally WE COULD SAVE ALL BABIES ONCE MATURITY WAS 28 WEEKS PLUS & BABY WEIGHT WAS 1KG PLUS. 14 cases with twin pregnancies had extreme premature births[26 to 28 wks ]…..& we could not save only 4/28 [all twins] between 26 to 28 weeks. Rest went home after stay of over a month in tertiary care Nursery
  29. 29. LOW BIRTH WEIGHT & PREMATURITY
  30. 30. PROBLEM OF LOW BIRTH WEIGHT & PREMATURITY • Women who conceived by I.V.F. are more likely to have a low birth weight or very low birth weight baby • The risk of preterm delivery before 32 weeks and 37 weeks is increased by two-to threefold in women seeking ART treatment
  31. 31. It is interesting to note that the problem of decreased Amniotic Fluid ,risk of preterm birth and low birth weight appears to be more significant with Female -factor Infertility Moreover, the risk also applies to women with a previously recorded infertility diagnosis, who conceive naturally a risk that seems to be accentuated in women requiring oocyte donation Fertil Steril 2008; 90:1662-1673/Fertil Steril 2005; 83:1650-1658 PROBLEM OF DECREASED AMNIOTIC FLUID, LOW BIRTH WEIGHT & PREMATURITY
  32. 32. Singleton Pregnancies and Perinatal Outcome Preterm Birth & Low Birth Weight • Among singleton pregnancies I.V.F. is associated with increased risks of PTB and low birth weight infants • Until sufficient research has clarified the independent roles of infertility and IVF, couples should be counselled about the risks associated with treatment (II-2B)
  33. 33. Placentation Issues
  34. 34. Placentation Issues • Higher rates of placenta prevail & abruption are observed in IVF pregnancies compared to non-IVF pregnancies • Frozen cycles are associated with decreased risk of placenta prevail and abruption
  35. 35. Placenta Previa and ART Two Theories
  36. 36. Placenta Previa and ART • Metabolic changes in an embryo during culture • Uterine stimulation causing contractility during embryo transfer leading to increased frequency of implantation in the lower segment • Recent study has suggested reduced endometrial thickness during IVF is associated with higher incidence of placenta previa
  37. 37. Pregnancy & Co-morbidity
  38. 38. MEDICAL DISORDERS OF PREGNANCY • Increased medical complications in pregnancy are noted in ALMOST 50% women who conceived through IVF • These include hypertensive disorders in pregnancy and gestational diabetes • May be age-related/PCOD
  39. 39. Gestational Diabetes • Increased risk of gestational diabetes is seen in both singleton and twin pregnancies after IVF • May be related to the background risk of PCOS increased BMI & maternal age This contention remains controversial
  40. 40. CONGENITAL MALFORMATIONS
  41. 41. CONGENITAL MALFORMATIONS • Two large meta-analysis have demonstrated …an increase in congenital malformations following IVF— ICSI compared with naturally conceived pregnancies • However, in AUSTRALIAN BIRTH REGISTRY..NO DIFFERENCE IN CONGENITAL MALFORMATION after adjusting for potential confounding factors was found • In our experience ..there was NO increase in malformation rate in follow up of 800 IVF pregnancies including 80 multiple pregnancies ( 1 heart disease,1 hydrocephalus & 2 case of talepes)
  42. 42. Foetal structural & chromosomal, problems associated with IVF • All pregnancies achieved by ART, routine anatomic ultrasound for congenital structural abnormalities is recommended between 18 and 22 weeks • Pregnancies conceived by ICSI may be at increased risk of chromosomal aberrations, including sex chromosome abnormalities • Diagnostic testing should be offered after appropriate counselling
  43. 43. Preimplantation Genetic Screening • Clinical application of preimplantation genetic testing in IVF must balance the benefits of avoiding disease transmission with the medical risks and financial burden of IVF (III-B) • PGS for aneuploidy is associated with inconsistent findings for improving pregnancy outcomes • Any discussion of PGS with patients should clarify that there is no adequate information on the long- term effect of embryo single cell biopsy (I-C)
  44. 44. Mode of Delivery
  45. 45. Caesarean section • Caesarean section rates in women who have had an IVF pregnancy are higher than those who have naturally conceived • Mainly because of maternal anxiety & patient preference rather than clear obstetric indications •IN OUR SERIES CAESAREAN SECTION RATE WAS 90 % AFTER 28 WEEKS JUST BCZ OF PATIENT PREFERENCE
  46. 46. Neonatal outcomes following ART The neonatal outcomes following ART pregnancies are reassuring compared to the spontaneously conceived population, but long- term follow-up studies of these children into adulthood are required WE HAD FOUR NEONATAL DEATHS DUE TO EXTREME PREMATURITY….BCZ OF WEIFGT LESS THAN 1 KG & GESTATION LESS THAN 28 WEEKS
  47. 47. To conclude …… • 30 % women with positive pregnancy tests following IVF will loose their pregnancies before the end of first trimester • 20 TO25 % of IVF pregnancies are twins or higher order multiple gestation • Pregnancy complications eg ,prematurity and IUGR are more often following IVF even in singleton pregnancies
  48. 48. To conclude …… • Single most important factor for poor pregnancy and neonatal outcome is multiple pregnancy • Elective single embyro transfer should be done for all cases • These points should be discussed with all couples planning to undergo IVF - ICSI
  49. 49. SUMMERY Improve success rate of IVF through blastocyst transfer & using PREIMPLANTATION GENETIC SCREENING (PGS) in your I.V.F. lab
  50. 50. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339 9599044257 011-22414049 WEBSITE : www.lifecareivf.in www.lifecarecentre.in www.lifecareabs.in ISO 14001:2004 (EMS) …..Caring hearts, healing hands ISO 9001:2008 Helpline : 9599044257 Web.www.lifecareivf.in Helpline : 9910081484 26 Year In your service

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