World IVF Day: Dr. Aanchal Sablok on Managing High-Risk IVF Pregnancies

Dr. Aanchal Sablok: Fetal Medicine plays a crucial role in managing IVF pregnancies. From early assessment of the fetus to diagnosing complex abnormalities and performing fetal interventions like CVS, amniocentesis, and therapeutic procedures, fetal medicine is essential in optimizing healthy pregnancy outcomes.

Dr. Aanchal Sablok: It has been observed that IVF pregnancies are at a high risk of complications:

1. Pertaining to implantation: IVF pregnancies have a higher risk of bleeding in early pregnancy, implantation of the placenta in the lower uterine segment (placenta previa), and ectopic pregnancies.

2. IVF pregnancies also carry a high risk of multiple pregnancies, i.e., twins and triplets, as a result of multiple embryo transfers. Additionally, they are more prone to embryo splitting, resulting in higher-order pregnancies with the same genetic makeup.

3. Recent research indicates a higher risk of preterm labor, preterm births, fetal growth restriction, and stillbirths.

4. Although not conclusively proven, IVF pregnancies may also carry a higher risk of fetal structural malformations. This could be due to background maternal factors such as advanced maternal age and underlying medical conditions like diabetes.

All these factors necessitate the involvement of a fetal medicine specialist for proper management of IVF-conceived pregnancies.

Dr. Aanchal Sablok: The most common procedure carried out in IVF-conceived pregnancies is fetal reduction.

As IVF pregnancies are at a higher risk of embryo splitting, resulting in more monochorionic pregnancies, fetal therapy procedures such as laser photocoagulation, radiofrequency ablation, interstitial laser procedures, and bipolar cord coagulation are performed more frequently in IVF-conceived pregnancies compared to naturally conceived high-order pregnancies.

Dr. Aanchal Sablok: The choice of screening test depends on factors such as maternal age, first-trimester NT/NB scan findings, the type of high-order pregnancy (twins, triplets, and their types), and family history of genetic disorders, rather than the fact that it is an IVF-conceived pregnancy.

A thorough knowledge of maternal-fetal medicine is required to decide which test to offer for screening of chromosomal abnormalities and genetic syndromes.

Dr. Aanchal Sablok: With advancements in ultrasound technologies, anomalies can be detected as early as during the NT/NB scan done at 11–13+6 weeks of gestation. Certain anomalies like anencephaly can be detected even during the 8–10 week ultrasound.

Dr. Aanchal Sablok: Meta-analyses indicate that there are associations between in vitro fertilization (IVF), with or without intra-cytoplasmic sperm injection (ICSI), and congenital malformations. However, it remains unclear whether this association is due to infertility, factors related to the procedure, or a combination of both.

Distinguishing the risks associated with IVF alone versus IVF with ICSI is also challenging. Pooled estimates show that the rate of major congenital malformations is 475.8 (95% confidence interval: 304.9 to 735.2) per 10,000 births among singleton pregnancies achieved through IVF with or without ICSI, compared to 317.6 (95% CI: 145.2 to 680.8) for naturally occurring pregnancies. This results in an absolute difference of 158.2 per 10,000 births. Not all organ systems are equally affected by these malformations.

Moreover, a systematic review has reported higher rates of total congenital heart disease (CHD) in the IVF population—whether with or without ICSI—compared to naturally occurring pregnancies, with rates of 1.30% versus 0.68%, respectively.

Dr. Aanchal Sablok: A 1.5% rate of karyotypic anomalies has been reported in couples referred for IVF (1.8% in men and 1.2% in women). Genetic screening is well-established for certain infertile populations, including those with severe sperm abnormalities, primary amenorrhea, premature menopause, and recurrent pregnancy loss.

Among men with oligospermia or azoospermia without obstruction, 8% to 15% carry a microdeletion in the Y chromosome. This has implications when ICSI is performed, as gene defects that would otherwise be naturally eliminated might be passed on.

Studies also report a significantly increased rate of de novo chromosomal abnormalities in ICSI pregnancies compared to naturally conceived ones.

Dr. Aanchal Sablok: Couples who have undergone IVF are often mentally exhausted. When a fetus is diagnosed with an abnormality or an IVF pregnancy becomes high-risk, the couple can feel lost.

A fetal medicine expert works closely with the obstetrician and IVF doctor to manage high-risk pregnancies. Fetal medicine ensures proper counselling and, when possible, treatment of the fetus to ensure a healthy pregnancy outcome. Detection of an abnormality does not always mean the pregnancy must be terminated.

Dr. Aanchal Sablok: Not only in IVF pregnancies but in all pregnancies, early scans can raise concerns. This is where counselling and reassurance play a vital role. After a detailed evaluation of the fetus, placenta, and amniotic fluid, if the concern is not life-threatening, the couple should be reassured that not every abnormality means termination.

Some abnormalities only become apparent at a particular gestation, while others may resolve. Proper counselling, review scans, a multidisciplinary approach, and expert opinions from clinical geneticists, pediatric specialists, and surgeons go a long way in providing clarity and support.

Dr. Aanchal Sablok: Fetal imaging and therapy play a crucial role in improving outcomes in IVF pregnancies. Timely diagnosis and treatment are vital for healthy outcomes.

Since multiple pregnancies are more common in IVF, the need for fetal therapeutic interventions is also higher. These pregnancies require frequent and detailed fetal analysis and, at times, fetal interventions.

From identifying a short cervix to prevent preterm labor to laser photocoagulation in complicated monochorionic twins, fetal medicine has played a major role.

Dr. Aanchal Sablok: Infertility is a stressful diagnosis, and its treatment can be mentally and financially draining. As fetal medicine doctors, we understand how devastating it can be for a couple when, after a successful IVF conception, the fetus is diagnosed with an abnormality.

But I want to reassure them that not every abnormality results in termination or a poor outcome. With proper diagnosis and timely intervention, a healthy pregnancy outcome is possible.