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

1. PREGNANCYOutcome following
IVF-ICSI
Dr.Sharda Jain

2. Over 300 ppts are available on slideshare.net
***for use of public/Doctors
www.slideshare.net / Lifecarecentre

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. 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. 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. 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. 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. • 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. FIRST TRIMESTER IS
MOST DIFFICULT

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. 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. MISCARRIAGE AND
A.R.T

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. 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. 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. 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. 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. 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. 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. ECTOPIC PREGNANCY

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. 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. 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. Multiple Pregnancy

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. 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. Stillbirth & Neonatal
death rate in
I.V.F. Pregnancy

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. LOW BIRTH WEIGHT
&
PREMATURITY

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. 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. 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. Placentation Issues

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. Placenta Previa and ART
Two
Theories

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. Pregnancy
&
Co-morbidity

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. 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. CONGENITAL
MALFORMATIONS

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. 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. 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. Mode of Delivery

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. 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. 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. 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. SUMMERY
Improve success rate
of IVF through
blastocyst transfer &
using
PREIMPLANTATION
GENETIC SCREENING
(PGS) in your I.V.F. lab

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