1. Embryo development
Day 0
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6

2. to reduce the risk of multiple pregnancies
Embryo transfer
Replacing 1-2 embryos
to reduce the risk of multiple pregnancies

3. IVF An effective treatment for different causes of infertility
Live birth rate 30-50%
~25-30% of embryos will implant

4. Factors affecting IVF success
Age of women
Number of treatment cycles
Ovarian response
Others: smoking, obesity, hydrosalpinges, uterine fibroids etc.
Endometrial receptivity

5. Complications Ovarian stimulation Egg collection Embryo transfer
Ovarian hyperstimulation syndrome (OHSS)
Ovarian carcinoma
Egg collection
Bleeding
Pelvic infection
Embryo transfer
Multiple pregnancy
Ectopic pregnancy
Psychological

6. Reduction of multiple pregnancy
Reducing the number of embryos replaced i.e. replace SINGLE embryo or blastocyst
Fetal reduction

7. 1+1 Vs 2 embryos 1+1 (n=330) 2 (n=331) P value Live births Fresh cycle
91 (27.6%)
142 (42.9%)
<0.001
Frozen cycle
29 (16.4%)
----
Cumulative cycles
128 (38.8%) NS
Multiple births
1 (0.8%)
47 (33.1%)
(Thurin et al., NEJM, 2004)

8. OHSS 5 % moderate (Delvigne 2002)
2% required hospitalization (Papanikolauo 2005)
Life-threatening condition
Estimated mortality 3/100,000 cycles

9. OHSS Ovarian enlargement and abdominal distension
Nausea, vomiting & abdominal pain
Decrease in urine output
Ascites, hydrothorax & generalized oedema
Haemoconcentration & thromboembolism
Liver failure and renal failure

10. OHSS management
Reduced by identifying high risk patients and choosing appropriate stimulation protocols (GnRH antagonist protocol, mild stimulation, progesterone for luteal phase support)
In cases of excessive response – agonist to induce LH surge in antagonist cycles, freeze all embryos, hydroxyethyl starch and cabergoline

11. OHSS-Principles of management
Careful monitor of vital signs, BW, abdominal girth, CBP, Hct, RFT, LFT, clotting studies
Pelvic U/S to assess ascites & ovaries
CXR if respiratory symptoms or signs
Mild/moderate can be managed as outpatient
Paracetamol/codeine for pain; avoid NSAID
Admit for inpatient management in severe cases

12. OHSS-Principles of management
Adequate fluid intake – IV fluid (N/S and colloids) if the patient cannot tolerate oral fluid
Diuretics should be avoided unless oliguria persists despite adequate intravascular expansion and under careful haemodynamic monitoring
U/S guided paracentesis in case of tense ascites
Anticoagulation should be considered in patients admitted for severe or critical OHSS

13. Congenital abnormalities
~30% increase in the risk of birth defects following IVF (Hansen et al., HRU, 2013)
Higher rate of de-novo chromosomal anomalies in ICSI offsprings (1.6% Vs 0.5%)
mainly higher no. of sex chromosomal anomalies and partly a higher no. autosomal structural anomalies (Bonduelle et al., 2002)

14. 1.32 (1.24, 1.42)

15. Neonatal outcomes of singletons following ART Vs spontaneous conceptions
Relative risk (95% CI)
Very preterm (< 32 weeks) (2.03 to 5.28)
Preterm (< 37 weeks) (1.80 to 2.32)
Very low birth weight (< 1500 g) (2.07 to 4.36)
Low birth weight (< 2500 g) (1.50 to 1.92)
Small for gestational age (1.15 to 1.71)
Caesarean section (1.44 to 1.66)
NICU admission (1.16 to 1.40)
Perinatal mortality (1.11 to 2.55)
(Helmerhorst et al., BMJ, 2004)

16. Longterm health outcomes
May increase the incidence of high blood pressure, elevated fasting glucose, total body fat composition, advancement of bone age and potentially subclinical thyroid disorder
Increase the incidence of cerebral palsy and neurodevelopmental delay related to prematurity and low birthweight
Potential increase in the prevalence of early adulthood clinical depression and binge drinking
(Hart and Norman, HRU, 2013)

17. Thank you for attention