Antenatal care of pregnancy after Artificial reproductive technology (ART)

1. RECENT UPDATES OF ANTENATAL
CARE IN CASES OF ART
PREGNANCY
DR KOKILA DESAI

2. Dr. Kokila H Desai
o Dr. Desai is been practicing in Surat at Shivam Hospital and Vaishali
maternity centre, since last 20 years.
o She is the Core Fertility Specialist at Morpheus Shivam International IVF
Center Surat.
o She is attached to Apple Hospital, Sunshine Global hospital, Apollo clinic,
Mission Hospital .
o She did her graduation and post-graduation from M.S. University, Vadodara.
o She has taken Advance Laparoscopy training and sonography training from
various institutes of MUMBAI, KOCHI, PUNE, AHMEDABAD.
o She was first to start OPD based hysteroscopy under local anaesthesia in
South Gujarat .
o She has received Advance Training in Reproductive Endocrinology & ART
from Bad Munder, Germany.
o She was awarded with SULU RUDRA SINHA AWARD for junior endoscopy
surgeon in AICOG Delhi 2008 for “Hysteroscopy under local anaesthesia”.

3. o Dr. Kokila had presented paper on “recurrent sponteneous abortion” in
SOGOG 1993, paper on “clinicosonography appraisal of adenomyosis” in
SOGOG 1995, paper on “Yoga in pregnancy” in AICOG 2006-07 ,won QUIZ
prize in SOGOG 2 times.
o Invited as faculty in west zone conference for topic of “Yoga in Labour” .
o Presented a lacture on hysteroscopic removal of cornual pregnancy in IFS
2015, panelist in IFS 2016,2017,talk on OVUM PICK UP in IFS Kochi 2018.
o Conducting HYSTEROSCOPY WORKSHOP IN SOGOG 2016, Surat .
o Invited as faculty to talk on AMH in 6th annual meet of IABS, Bhavnagar.
o Faculty in state conference , SOGOG, YUVA IAGE , YUVA ISAR, ISAR, IFS .
o Invited by BOGS, BHARUCH O&G society, IMA , BGDC, SMC to deliver a
talk in CME.
o Life member of IMA,SCA,ISAR,IFS,IMS,IAGE.
o Member of SOGS,ESHERE,ASRM.
o Treasurer of IFS GUJ. CHAPTER.
Dr. Kokila H Desai

4. ART – Artificial Reproductive Technology
• DO THESE CASES REQUIRE SPECIAL CARE ?
• No
yes

5. Reproductive Health
Accepted 08 January 2019 and published on 29th JANUARY2019.
• Care plans for women pregnant using assisted
reproductive technologies: a systematic review
• Maria P. Velez, Candyce Hamel, Brian Hutton, Laura Gaudet, Mark Walker, Micere Thuku, Kelly D.
Cobey, Misty Pratt, Becky Skidmore,Graeme N. Smith
• Reproductive Health volume 16,
Article number: 9 (2019) Cite this article
• 2422 Accesses,3 Citations,6 Altmetric,Metricsdetails

6. Reproductive Health
Accepted 08 January 2019 and published on 29th JANUARY2019.
• Method
• This review has been reported with guidance from the PRISMA reporting guideline
• Eligibility criteria
• Criteria to identify eligible publications for the current review were established using the
PICOS (Population-Intervention-Comparators-Outcomes-Study design) framework.
• Population
• The population of interest included women becoming pregnant with involvement of ART
(e.g., Intra-Uterine Insemination (IUI), In Vitro Fertilization (IVF), Intracytoplasmic Sperm
Injection (ICSI), and surrogacy).
• Areas of interest
• Any CPGs addressing the recommendations and plans for the care of ART pregnant women
were included

7. Reproductive Health

8. Reproductive Health
Result
The following key clinical messages were prevalent:
1-obstetrician or trained midwife
2-multiple pregnancy is main risk factor so embryo reduction
can be offer.
3-prenatal genetic and anatomical screening
4- antithrombotic therapy and hypothyroid therapy is same .
5- psychosocial care and counselling

9. Reproductive Health
• Conclusion
• There is a lack of CPGs specific to ART pregnancies. While we
identified a small number of recommendations for ART
pregnancies, specific interventions and models of care aiming
at decreasing adverse maternal and perinatal outcomes
following ART should be developed, implemented, and
evaluated.

10. • We should bear in mind that all conceptions should be
considered ‘precious’ whether natural or assisted. There are a
few differences that should be kept in mind while dealing with
IVF pregnancies.
• The list below states the common differences:
1- age
2 -miscarriage
3-multiple pregnancy
4-obstetric complications and perinatal risk
5-congenital malformation

12. • Aim--To explore the antenatal experiences of females and males who
have successfully conceived through infertility treatment.
• Result-Analysis of the interviews suggested females and males
experienced a ‘gap’ in their care, in terms of time and intensity, when
discharged from the fertility clinic to standard antenatal care
• Conclusion--Females and males who have successfully undergone
infertility treatment may require additional support in primary care
to address anxiety during pregnancy, enable disclosure of negative
feelings, and to help them prepare for childbirth and parenthood.

13. •What is the difference and why ????

14. Importance of Corpus luteum
in maintenance of pregnancy
• CL produces progesterone and estradiol.
• Progesterone makes the endometrium receptive and
facilitates implantation.
• hCG produced form the trophoblast rescues the CL up to 9
weeks so that the progesterone supplied by it maintains the
pregnancy.

15. Major differences between
an IVF & natural conception
• functioning or non functioning corpous luteum . CL is
absent in donor and freeze-thaw cycles.
• Use of GnRH analogues to prevent LH surge decreases
progesterone .
• Aspiration of granulosa cells also contribute towards
Progesterone deficiency.

16. Role of HCG in IVF conceptions
• HCG extracts Progesterone from Corpus
luteum.
• can be given every 3rd / 4th day . Only in cases of
self stimulated fresh cycle . IUI cycle .

17. Progesterone supplementation
• Micronized Progesterone- Vaginally/ Orally
• Dydrogesterone(Duphaston) Orally
• Injectable Progesterones

18. Estrogen supplementation
• In donor & freeze thaw cycles it is essential to supplement
estrogen to balance the absence of CL
• u can use estrogen 8-12 mg orally in divided doses
• Estrogel is available can be used transdermal appplications .
• vaginal estrogen can also be used if patients can not tolerate
oral .

19. Vital supports of early pregnancy
• Progesterone and Estrogen are vital for the continuation of
pregnancy.
• From ninth week onwards placenta performs the task of
supplying essential nutrients to the fetus. The vascular
channels connecting the placenta and fetus become wide
secondary to trophoblastic invasion.
• fully function of placenta establish at 18- 20 weeks .
• So u can start tapering doses of estrogen from 11 weeks
onwards and progesterone from 12th week onwards .

20. Thromboprophylaxis with LMH
Only to high risk group 20/40IU depending on weight of pt
• Obesity
• Smoking
• Age more than 40 y.
• F/H OR Past H/O thrombosis.
• Thrombophilia patients .
• APPLA, ACA positive cases .
• Frozen thaw ET cycle.
• Pt having hypertention and or Diabetes .
• severe OHSS, and fresh transfer done - thromboprophylaxis for 3
months.

21. FMF approach

22. Aspirin for prevention of preeclampsia
• 150 mg.of Aspirin at bed time from 11-14 weeks of
pregnancy to 36 weeks of pregnancy.
• Low molecular weight heparin also can be given daily till
34-36 weeks pregnancy

23. Perinatal risks
• Multiple conceptions and multiple births
• Preterm birth
• Low birth weight and small for gestational age
• Congenital anomalies
• Vertical transmission of genetic diseases
• Perinatal mortality

24. Multiple conceptions and multiple births
• Chances of twin is 25% as compare to 2-4% in natural
conception .
• Risks increase disproportionately in relation to the number of
fetuses.
• Risk of monozygous twins increase by two-fold compared
with natural conception.
• Monozygosity also being associated with higher rates of
adverse outcomes.
• Vitthala S, Gelbaya TA, Brison DR, Fitzgerald CT, Nardo LG. The risk of monozygotic twins after assisted reproductive
technology: a systematic review and meta-analysis. Human Rep

25. PRETERM BIRTH
• Multiple pregnancy per se is a clear risk factor for preterm birth
• 23% increase risk of preterm birth in IVF.-elective or spontaneous In
singletons also two-fold increased risk of preterm birth
• spontaneous and elective preterm births have largely different etiologies,
principally reflecting infection and placental dysfunction, respectively.
• duration and cause of infertility can influence the risk of preterm birth.
• early fetal loss in a multiple gestation can increase the risk of preterm birth
for the remaining singleton.
• Use of high doses of hormones ,vaginal insertion of progesterone, high
chance of developing gestational diabetes all together increase risk of
infection .
• Perinatal Risks Associated with IVF (Scientific Impact ... – RCOG
www.rcog.org.uk › guidelines › scientific-impact-papers › sip_8

26. Low birth weight and small for gestational age
• Preterm – low birth weight
• In singletons relative risk of babies being small for gestational
age is also increased by approximately 40–60%, suggesting that
factors other than preterm birth are responsible.
• The characteristics of the mother and father and the treatment
cycle may also influence the risk of LBW.
• Pinborg A, Lidegaard O, la Cour Freiesleben N, Andersen AN. Consequences of vanishing twins in IVF/ICSI pregnancies. Hum
Reprod 2005;20:2821–9 11. McDonald SD, Han Z, Mulla S, Ohlsson A, Beyene J, Murphy KE
• McDonald SD, Han Z, Mulla S, Murphy KE, Beyene J, Ohlsson A. Preterm birth and low birth weight among in vitro fertilization
singletons: a systematic review and meta-analyses. Eur J Obstet Gynecol Reprod Biol 2009;146:138–48.

27. Congenital anomalies
• Between 3% and 5% of all infants are diagnosed with a
congenital anomaly soon after birth.
• IVF is associated with a 30–40% increased risk of major
congenital anomalies compared with natural conceptions.
• underlying infertility
• gastrointestinal, cardiovascular and musculoskeletal
defects and specifically septal heart defects, cleft lip,
oesophageal atresia and anorectal atresia.18,19
• Hansen M, Bower C, Milne E, de Klerk N, Kurinczuk JJ. Assisted reproductive technologies and the risk of
birth defects – a systematic review. Hum Reprod 2005;20:328–38.

28. Vertical transmission of genetic diseases
• increased prevalence of structural chromosomal abnormalities in infertile men and
women:
• 4.6% prevalence of autosomal translocation and inversions in oligospermic men,
• 1.14% prevalence of autosomal reciprocal balanced translocations in infertile women
• Microdeletions of the long arm of the Y chromosome (Yq), in particular the AZF region,
• single gene disorders such as cystic fibrosis are associated with infertility,
• Increasing evidence that epigenetics may contribute to abnormal embryo and
trophoblast development,
• Human imprint syndrome -Beckwith-Wiedemann syndrome (BWS), Angelman syndrome
(AS) and maternal hypomethylation syndrome.
• Perinatal Risks Associated with IVF (Scientific Impact ... – RCOG www.rcog.org.uk › guidelines › scientific-
impact-papers › sip_8
• Schreurs A, Legius E, Meuleman C, Fryns JP, D’Hooghe TM. Increased frequency of chromosomal abnormalities in female
partners of couples undergoing in vitro fertilization or intracytoplasmic sperm injection. Fertil Steril 2000;74:94–6.

29. Specific IVF and related procedures
1-Preimplantation genetic diagnosis/screening--associated with a
substantial increased risk of perinatal death compared with standard
ICSI
2-Blastocyst culture -sex ratio in favour of males, increase risk of
preterm birth and risk of congenital malformations was also
significantly higher.
3-Assisted hatching- increase clinical pregnancy rate but not live birth
rate
4-In vitro maturation of Immature oocyte –similar obstetric outcomes and congenital
anomaly rates between babies born following IVM, IVF and ICSI have been reported but based on only 67 cases .
• Liebaers I, Desmyttere S, Verpoest W, De Rycke M, Staessen C, Sermon K, et al. Report on a consecutive series of
581 children born after blastomere biopsy for preimplantation genetic diagnosis. Hum Reprod 2010;25:275–82.

30. Maternal morbidity
• Maternal age--Increasing maternal age
• Recipients of donor oocytes-perimenopausal age ,hypertention
• Polycystic ovary syndrome- gestational diabetes, pregnancy-
induced hypertension, pre-eclampsia, and preterm birth, high
incidence of twin and its complications
• Multiple pregnancy- hyperemesis gravidarum, hypertensive
disorder of pregnancy ,IUGR, preterm , anaemia.
• Reddy UM, Wapner RJ, Rebar RW, Tasca RJ. Infertility, assisted reproductive technology, and adverse pregnancy outcomes:
executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol 2007;109:967–
77..

31. USG
• 3D and 4D sonography may require to
rule out all congenital organ anomalies
and genetic abnormality.
• Doppler flow should also monitor
carefully to detect placental pathology
earliest .
• High Chance of Twin to T transfusion in
Monogygotic twins .
• Look for IUGR and Oligohydramnios to act
in time .
• Increase chance of placenta previa and
abruptio placenta should be kept in mind .

32. Psychosocial care and counselling
• Fertility staff should refer or offer additional psychosocial care
to patients .
• Additional worry due to socio-echonomic challenge.
• A guideline from the ESHRE provided information for all
fertility clinic staff (e.g., doctors, nurses, midwives, counselors,
social workers) on when they should refer patients for
additional psychosocial care after a successful pregnancy with
ART treatment.
• Gameiro S, Boivin J, Dancet E, de Klerk C, Emery M, Lewis-Jones C, et al. ESHRE guideline: routine psychosocial care in infertility
and medically assisted reproduction-a guide for fertility staff. Human reproduction (Oxford, England). 2015;30(11):2476–85.

33. Impending hormonal imbalance
in IVF conceptions
• Risk of Hypothyroidism increases in IVF pregnancies.
• Liver function tests & renal function tests should be
monitored.

34. Betnesol prophylaxis- Should it be given to all
women carrying IVF pregnancy?
• Single course of betnesol as a routine to accelerate fetal
lung maturation in women at risk of preterm birth.
• evidence comes from high income countries and hospital
settings; results may not be applicable to low‐resource
settings with high rates of infections.

35. Role of Neuroprotective Magnesium Sulfate
• Fetal exposure to magnesium sulfate in women at risk for
preterm delivery significantly reduces the risk of cerebral palsy
without increasing the risk of death.

36. Cervical encircalage
• Not all ART cases require enciercalage .
• All twins I prefer .
• All single tone < 3.0 cm cervical length.

37. • The place for prophylactic cerclage in the infertile patient with established cervical incompetence
who conceived twins after septum reduction.
• The data from this study strongly suggest that the use of prophylactic cervical cerclage may be
beneficial in improving reproductive outcomes in infertile patients with known cervical
incompetence and status post hysteroscopic surgical correction of uterine septum that
subsequently conceived twin gestations via IVF-ET treatment. Each patient suffered pregnancy loss
due to cervical insufficiency.
Facts Views Vis Obgyn. 2017 Jun; 9(2): 71–77.Published online 2017 Oct
25 PMCID: PMC5707775 PMID: 29209482

38. Summary – take home message
1-b HCG –if positive – check doubling at 48 hrs
2- s. progesterone level
3- we check –CBC, S.TSH, RBS, Urine Micro and -R, S.Creatinine,
SGPT,
4- HCG – to support function of corpus luteum only to self fresh
cycle.
5- USG- after 10-15 days to rule out -ectopic
- missed abortion
- cardiac activity
- multiple pregnancy
We continue same medication till 12 weeks

39. At 11-13 weeks
• USG- very important to rule out trisomy
- see nucheal fold thicknesss ,R/O neural tube defect
- multiple pregnancy –embryo reduction
-double marker test –
- pregnancy associated plasma proteins( PAPP-A)
Low MoM of < 0.5 has found to be associated with
IUGR, preterm birth, pregnancy induced HT.
- doppler study of uterine Artery resistance .

40. 2nd trimester
• Stop –estrogen support with tapering it in next 15 days if
Thaw ET
• Reduce dose of progesterone in next 30 days.
• Start IRON and Calcium
• Vaginal antifungal insertion prophylactic.
• we check for CBC and urine micro urine and cervical swab
culture sensitivity to R/O infection .
• GTT- to R/O gestational Diabetes,
• Monitoring BP to detect hypertention .

41. 2nd trimester
• USG – between 16- 19 weeks to R/O anatomical abnormality
-look for cervical length if its < 3.0 CM or in case of all twin
we go for circalage .
• If singleton pregnancy with cervical length >3.0 CM , we do cervical
and urine culture sensitivity test . Antibiotics sos
• stop all hormone support and add tocolytics if needed
• Progesterone support SOS.
• Any patient come with APH or threatened preterm birth –
admission .
• If doppler normal – stop LMH if started prophylactically.

42. 3rd Trimester
• Multiple pregnancy – betnesol 12 mg two doses 12 hours apart
• Singleton pregnancy –we give at 32 weeks .
• All patients having high risk of developing HT ,DM than LMH
continue till 28-32 weeks .
• Patient having APPLA , ACA, thrombophilia and previous H/O
thrombosis - continue till 36 weeks .
• If suspect any obstetric complication –admission
• Delivery at 37-38 completed weeks of pregnancy .