Parulekar SV
In vitro fertilization (IVF) is
the most important achievement in the management of infertility. It has given
babies to a large number of couples who could not have any before this
treatment was available, and hope to many more. Owing to the relatively recent nature
of this treatment and the complex processes involved, including use of drugs,
manipulation of the reproductive endocrine system, and manipulation of the
ovum, sperm and embryos, there is grave concern about the short and long term
outcomes of IVF. During the process, the patient may experience symptoms like
nausea or vomiting, reduced urinary frequency, breathlessness, faintness,
severe abdominal pains and bloating and excessive weight gain (all due to
ovarian hyperstimulation syndrome). Egg retrieval may cause vaginal bleeding,
infection, and injury to the urinary bladder or bowel. The risk of venous thromboembolism after IVF is twice that with spontaneous pregnancies, related to ovarian hyperstimulation syndrome. This rise is in the first trimester. Obstetric problems associated
with IVF include multifetal pregnancies, prematurity, intrauterine growth
restriction, placenta previa, placental abruption, perinatal mortality, preeclampsia,
need for cesarean delivery, and birth defects. These risks are increased not
only with multiple pregnancies, but also with singleton pregnancies. It is not
known as yet whether they are due to IVF or underlying causes of infertility. The
rates of miscarriage are similar to those in spontaneous conceptions. The risk
of ectopic pregnancy with IVF is 2-5%. There is a significant financial,
physical and emotional stress on the couple. Emotional problems are common,
especially when the IVF procedure is not successful. A significant rise (0.8%)
is seen in sex chromosomal aberrations after intracytoplasmic sperm injection
(ICSI). The risk of congenital malformations is increased after use of assisted
reproductive techniques (ART) than with natural conceptions, especially of cardiovascular
malformations. It is similar with IVF and ICSI. Children born with IVF are more
likely to require rehabilitation than controls. Cerebral palsy tends to
occur more often in IVF babies. There is a small association between IVF and
cancers of early childhood, especially hepatic cancers. As the babies conceived
with IVF grow, more problems may come to light. Perhaps the procedure is
disrupting the genome in a non-fatal manner, with effect on specific organs
which may manifest after years. Until we have all the answers, we should
continue to counsel patients, screen the couple for genetic conditions,
especially infertility-associated conditions, consider embryo reduction in
higher order multifetal pregnancy and look for and treat complications during
pregnancy.