1. Thrombophilia Rose Marie Meier Reproductive medicine Genk - Belgium

2. Thrombophilia Predisposition for thrombotic events Deep vein thrombosis Pulmonary embolism

3. Thrombo-embolic disease Asociation with poor reproductive outcome Mayor cause of maternal mortality IVF increase 3 fold the risk (2.66 / 1000) Absolute incidence 1 / 1000 Implantation failure and recurrent pregnancy loss Severe OHSS 4,1 % Scott N. Throm Res 2013 Women with >2 IVF-ET increase find of thrombophilia factor Qublan H. Hum Fertil (Camb) 2008

4. Rova K. Fertil Steril 2012 Venous thromboembolic events (VTE) & IVF

5. Thrombophili a Classification Hereditary AcquiredAntiphospholipid syndrome

6. Davenport W. Obstet Gynecol Clin N Am 2014 aPL antibodies interfere with phospholipids utilized to induce coagulation increasing adhesion and aggregation of platelets PL Anticoagulant

7. Pregnancy PL Anticoagulant Hypercoagulability state

8. Ovarian stimulation PL Anticoagulant Hypercoagulability state HcG effect

9. Clinical validity What is the association between thrombophilia and VTE and poor reproductive outcomes ??

10. Factor V Leiden ✓ Most common inherited thrombophilia ✓ Genetic mutation -> G-to-A substitution (G1691A) ✓ Heterozygote 3 - 8 % ✓ Homozygote 1:5000 Risk VTE Risk poor rep outcome Homozygous OR 43.4 Heterozygous OR 8.3 Battinelli EM. Thrombosis 2013 Risk 1 in 500 pregnancies IVF?

11. Rey E. The Lancet 2003 RPL<13w Non RL Non RL>19w

12. Bradley LA. Genet Med 2012 RPL

13. Phrotrombin ✓ Second most common inherited thrombophilia ✓ Genetic mutation -> G-to-A substitution (G20210A) ✓ Heterozygote 2 - 3% ✓ Homozygote 1:10.000 Risk VTE Risk poor rep outcome RPL OR 2.05 Texto Rosendaal FR. Thromb Haemost. 1998 Davenport W. Obstet Gynecol Clin N Am 2014 Homozygote OR 24.4 Heterozygote OR 6.8 Risk 1 in 200 pregnancies IVF?

14. RPL<13w Non RL RPL Rey E. The Lancet 2003

15. Bradley LA. Genet Med 2012

16. Protein S and C deficiency ✓ Both necessary for the activation of factors V and VIII ✓ Inherited or acquired ✓ Prevalence Prot C heterozygote 0,5 % Risk VTE Risk poor rep outcome Risk 1 in 113 pregnancies Prot S OR 3.2 Prot C OR 4.8 Battinelli EM. Thrombosis 2013 Rey E. The Lancet 2003 IVF?

17. Antithrombin Deficiency ✓ Small protein that inactivates factor Xa and thrombin ✓ Asociation with severe coagulopathy ✓ Inhereted or acquired thrombophilia ✓ Prevalence 1:600 - 1:1000 Risk VTE Risk poor rep outcome OR 4.7 56 % pregnancy loss Davenport W. Obstet Gynecol Clin N Am 2014 Risk 1 in 42 pregnancies McNamee K. Best Pract Res Clin Obstet Gynaecol 2012 IVF?

18. MTHFR Association with thrombophilia is controversial Mutation in C667T gene results in higher level of homocysteine Risk TE disease Risk poor outcome Rey E. The Lancet 2003 OR 0.7 Battinelli EM. Thrombosis 2013

19. Antiphospholipid Antibodies ✓ 1– 5 % of healthy women vs 18,8 % in IVF patients ✓ Important treatable cause of recurrent miscarriage ✓ Treatment increase live birth rate to 80 % Lupus anticoagulant Anticardiolipin antibodies Anti-beta 2 glycoprotein Lassere M. Throm Res 2004 Rai & Regan L. Lancet 2006

20. Antiphospohlipid Antibodies Risk VTE Risk poor rep outcome OR 15.8 LAC late RFL OR 7.79 Battinelli EM. Thrombosis 2013 aCL early RFL OR 3.56 late RFL OR 3.57 Opatrny L. J Rheumatol 2006

21. Battinelli EM. Thrombosis 2013

22. Diagnosis Bradley LA. Genet Med 2012 Factor V Leiden Screening: APC resistance 90-95 % likelihood of mutation Confirmation: DNA analysis of F5 (gene encoding factor V) Factor II Screening: prothrombin level is not reliable Confirmation: DNA analysis of F2 (gene encoding factor II) Prot C deficiencyantigen assay activity assay Antithrombinantigen assay activity assay Prot S deficiencyactivity assay Free and total antigen assay Lupus anticoagulant Anticardiolipin antibodies IgG IgM Khor B. Am J Hematol 2010 Marlar MA. Am J Hematol 2011

23. Clinical utility A test has clinical utility when results change clinical management, health outcomes improve, and the benefits outweigh known or potential harms

24. Qublan H. Hum Fertil (Camb) 2008 83 women 3 or more IVF failures and at least 1 thrombophilic defect Enoxaparin 40mg/day vs placebo

25. Thromboprophylaxis reduces the fetal loss 15 fold Folkeringa N. Br J Haematol 2007

26. Empson MB. Cochrane Database Syst Rev 2012 13 Studies (849 participants) Unfractionated heparin + AAS reduce fetal loss 54 % AAS alone no significant benefit Prednisone + AAS increase prematurity and gestational diabetes Intravenous inmunoglobulin +/- heparin or AAS increase prematurity, PL

27. Battinelli EM. Thrombosis 2013 Recommendations for inhereted thrombophilia (no IVF patients)

28. Until now... Association Thrombophilia & Recurrent implantation failure Thrombophilia & Recurrent Miscarriage Potential rol of LMWH in patients with RIF and thrombophilia Thrombophilia & IVF increase risk of VTE

29. When we should ask for thrombophilia?

30. Davenport W. Obstet Gynecol Clin N Am 2014

31. Evidence 1A in recurrent pregnancy loss Trombofilie screening Anti-cardiolipine as IgM Anti-cardiolipine as IgG Lupus anticoagulans Homocysteïne Factor II (protrombine) mutatie APC-resistentie (screening FV Leiden) Proteïne C Proteïne S Anti-trombine III

32. Antithrombotic therapy should be based on an individual risk/benefit assessment Conclusion Evidence IA for aPL antibodies Recurrent miscarriage or Repeated implantation failure Thrombophilia screening..... we need more evidence Before start IVF ideally Cost-effective?

34. Akthar MA. Cochrane Database Syst Rev 2013

35. Potdar N. Hum Repr Update 2013

36. Women with ≥3RIF LMWH + IVF/ICSI improve in 79% LBR and reduce in 78% MR NNT with LMWH would be 7.7 to achieve one live birth

37. Data: 1. LMWH reduce venous thrombosis events in ART (RR 0,3) 2. ART increase the risk of VTE during pregnancy Chest 2012

38. Qublan H. Hum Fertil (Camb) 2008

40. Studies in article from Rey, The Lancet 2003

41. APS

43. Clinical utility Since hypercoagulability might results in RPL, anticoagulant agents could potentially incerase the LBR LMWH prevent thrombin formation and has inhibitory effect on the binding of phospholipids with antibodies, thus protecting the trophoblast from injury; promoting the successful implantation and subsequent placentation Qublan H. Hum Fertil (Camb) 2008