Dr Richa Sharma, Dr Amit Basnotra
Infertility is not so uncommon problem and it affects about 15 percent of couples and prevalance is more related to the early reporting and diagnosis.
What could be causes ?
It can be multifactorial with some fraction as unexplained or idiopathic
There can be certain conditions like endometriosis and the polycystic ovary syndrome (PCOS) which can limit the outcomes further ranging from affect successful implantation and pregnancy outcome. Assisted conception is definitely a blessing for many as it helps overcome or circumvent many of the problems presented by the subfertile couple.
IVF is the most advanced technique and topmost in hierarchy of ART but it has its limitations not only in terms of the success rate but also the abortion risks which adds to the stress of the couple
Miscarriage or abortions can happen as such also in 10% and 30% of all spontaneous pregnancies.
What are the Ifs and Buts In Minds of couples ?
The main questions arising are –
Will ART increase the rate of miscarriage
Will ART add on to abnormalities of the fetus
Age of the Couple
Couples attending the infertility clinic tend to be older than the average couple attending an antenatal clinic. Couples with subfertility may have tried for a pregnancy for several years before seeking medical advice and may then have attended their gynecologist for investigation and possibly simple treatments before being referred for assisted conception. Women may also choose to delay starting a family, for example while establishing a career. Such a delay leads to a greater incidence of ovulatory dysfunction, endometriosis, and the possibility of developing gynecological pathology necessitating surgery, such as ovarian cysts, fibroids, and tubal damage. In addition to the problem of becoming pregnant, the older woman has a high chance of miscarriage.
Gender and Abortion Risks
Its not only the female partner age which matters but age of male also has an impact
Chromosomally abnormal spermatozoa that achieve fertilization may lead to the development of an abnormal fetus and the risk also increases with advancing paternal age.
Previous History of pregnancy losses
70-80% of couples with secondary infertility often presents with a poor obstetric history and with pregnancy losses prior to treatment so they fall into high risk category so need a detailed investigations first than directly enolling them for IVF or any other treatment therapy.So it needs an Individualised approach and not a blind and blanket therapy.
There can be imbalance of certain hormones like luteinizing hormone which can happen in conditions like PCOS which can be one of the reasons of miscarriage, possibly through an adverse effect on oocyte maturation leding to both a lower pregnancy rate and a much higher miscarriage rate compared with those in women with normal serum LH concentrations
Poor Endometrial receptivity
This can be another factor which can be resulting from disordered prostaglandin synthesis exerted an effect by altering the endocrine or endometrial environments
Obesity and PCOS
Obesity is a common finding in women with the PCOS and a moderate elevation of body mass index to between 25 and 27.5 kg/m2 is associated with a poor response to treatment besides increased rate of miscarriage, independent of LH levels so that’s why its advisable to have BMI with in range before planning any treatment
Diagnosis of pregnancy
Pregnancy can be diagnosed by as early as 24 hours after conception, with the measurement hCG that is usually assayed. hCG can be measured in maternal serum and urine from between 8 and 11 days post-ovulation. It the The intensity of early pregnancy monitoring is much greater in assisted than natural conceptions. Pregnancy can be diagnosed is therefore possible to determine the outcome of an assisted conception cycle in the late luteal phase and so women may know whether they are pregnant before the expected commencement of menses. With the advent of sensitive assays for hCG it has been possible to obtain a better idea of the incidence of pregnancy failure in both natural and assisted
Pregnancy which can happen can be- Pre clinical, biochemical, clinical and vanishing embryo.
Especially when the hcg titres are low it can be a weak pregnancy or ectopic or may be a sign of underlying abnormality
Management of miscarriage
Management depends on the status of the pregnancy which needs to be confirmed by your treating doctor and accordingly can be expectant or active, depending upon the clinical situation and the patient’s wishes.
Expectant management – awaiting spontaneous and complete resolution of the abortus
Active management -Its via medical or surgical means when there is an emergency or when waiting for days or weeks can put patient at risk as first priority is safety and preserving future fertility
Counseling and Support
Couples who go through such situations get broken and need support and counseling both by the treating physician and family.
In conclusion, the overall spontaneous miscarriage rate is similar to that expected for the general population. Indeed the abortion rate in treated, subfertile women might be lower than that of the so-called normal population especially under 30 years age group. It has also been reported by various studies and papers that drugs used in assisted conception regimens do not appear to affect adversely the incidence of congenital abnormalities but at par with the natural conception except if there is some high risk factor or the predisposition.
(The authors are Senior IVF and Fertility Consultant and Senior Gastroentrologist)
Dr Richa Sharma, Dr Amit Basnotra