Does ovarian stimulation for in-vitro fertilization induce a hypercoagulable state?

Use of anticoagulants to improve pregnancy outcomes in couples positive for M2 haplotype: A systematic review

BACKGROUND

Placental mediated pregnancy complications (PMPC) are common, often recurring, and pose a significant health risk to mother and fetus. Evidence suggests that the hypercoagulable state associated with many PMPC, could reflect reduced expression of Annexin 5 (ANXA5), a naturally occurring anticoagulant protein in placental tissue. The ANXA5 M2 haplotype is a genetic variant, which results in reduced expression of ANXA5 protein. M2 haplotype carrier couples may therefore be at increased risk of PMPC. Evidence regarding the effectiveness of anticoagulation to prevent PMPC is inconsistent. Furthermore, studies have not selected or stratified for M2 haplotype carriers, in whom there is a predisposition to hypercoagulability, to assess the effectiveness of anticoagulation, which may vary from those without the M2 haplotype.

OBJECTIVES AND RATIONALE

The aim of this study was to systematically review the current evidence to assess whether anticoagulant treatment improves pregnancy outcomes in couples positive for M2 haplotype.

SEARCH METHODS

The review was registered on PROSPERO (CRD42022343943). A comprehensive literature search was performed using MEDLINE, Embase and Cochrane collaboration databases from inception to January 2023. Two reviewers assessed the articles for eligibility and extracted the data simultaneously. Primary outcome was successful pregnancy and live birth. Secondary outcomes included PMPC (implantation failure, miscarriage, pre-eclampsia, preterm birth and fetal growth restriction).

OUTCOMES

From a pool of 410 references, 10 were selected for full text review, of which three studies (a post hoc analysis of a randomised controlled trial, cohort study and a case report) were included in this review. Included studies comprised of 223 individuals, 129 of whom who received anticoagulation treatment after testing positive for M2 haplotype. The studies collectively showed an improvement in pregnancy outcomes in M2 haplotype positive individuals however, given the heterogeneity of studies, it was not possible to conduct a meta-analysis and draw firm conclusions.

WIDER IMPLICATIONS

Current evidence is limited, such that the value of screening couples for the M2 haplotype to select or stratify for treatment with prophylactic anticoagulation remains unknown. Thus, further studies including well designed, large, multi-centre randomised controlled trials are required to assess whether anticoagulation treatment will be effective in improving pregnancy outcomes in M2 haplotype couples.

GnRH Antagonist Protocol Enhances Coagulation During Controlled Ovarian Stimulation for IVF

Changes in coagulation and fibrinolysis have been reported in women undergoing controlled ovarian hyperstimulation (COH) supporting a potential hypercoagulable condition related to this treatment. This study aimed at evaluating the changes in fibrin clot properties and thrombin generation induced by two different COH protocols: long with gonadotropin-releasing hormone agonist (GnRH-a) and GnRH antagonist (GnRH-ant). Primary outcomes included determination of plasma fibrin clot properties, including clot permeability (K_s) and efficiency of fibrinolysis using clot lysis time (CLT), along with thrombin generation (prothrombin fragments 1 + 2) and endogenous thrombin potential (ETP) and fibrinolysis inhibitor levels. One hundred twenty-nine infertile women were included in the final analysis. The GnRH-ant protocol resulted in increased ETP (+ 9.8%) and reduced K_s (- 2.4%). Conversely, COH with the GnRH-a protocol reduced thrombin generation by decreasing both ETP (- 6.6%) and F1 + 2 (- 30.8%) together with favorably altered fibrin clot properties represented by increased K_s (+ 21.7%) and reduced CLT (- 13.8%) as well as decreased PAI-1 levels (by 2.5 times). The GnRH-ant compared to the GnRH-a protocol increased PAI-1 levels (+ 77.3%), thrombin generation (9.3% higher ETP), and K_s (+ 13.7%). In the GnRH-a group, post-COH K_s was 14.3% higher (K_s ≥ 7.92 × 10^-9 cm²) in women with positive vs. negative pregnancy outcomes. Our results show that the GnRH-ant protocol enhanced thrombin generation and slightly decreased fibrin clot density. COH with the GnRH-a reduced thrombin generation and improved fibrin clot features. This trial was registered (NCT04166825). Clinical Trial Registration Number: NCT04166825.

The Pathophysiology of Hypercoagulability and Infertility

Alongside an interplay of a multitude of factors, attainment of a favorable pregnancy outcome is predicated on successful implantation, which in itself is a complex process anchored by balanced interchange with the hemostatic system. Among other etiologies, failure of implantation can result in infertility, and lead affected couples to consider assisted reproductive technology (ART) in an effort to fulfill their desire for procreation. Given the critical role of the hemostatic system in the process of implantation, documentation of a hypercoagulable state during controlled ovarian stimulation in the context of in vitro fertilization, as well as the potential association of its derangement in the setting of thrombophilia, with infertility, ART, ovarian hyperstimulation syndrome, and failure of implantation are explored. Additionally, current evidence addressing the relationship between ART and thromboembolism is examined, as is the role of therapy with heparin and aspirin to decrease thrombotic risk and improve ART-related pregnancy outcomes. Evidence-based recommendations from relevant professional societies are summarized.

An enhanced clot growth rate before in vitro fertilization decreases the probability of pregnancy

Background

The shift towards hypercoagulation during in vitro fertilization (IVF) can lead to the impairment of embryo implantation and placental blood circulation, which is believed to be a factor in an unsuccessful IVF cycle.

Objectives

To assess coagulation in women with infertility before the start of an IVF cycle and during treatment to reveal the association between coagulation imbalance and IVF outcome.

Patients/Methods

We conducted a prospective cohort observational study including 125 participants who underwent fresh IVF cycles. Blood samples were collected at five time points: before IVF, one week after the start of controlled ovarian stimulation (COS), on the day of follicular puncture, on the day of embryo transfer (ET) and one week after ET. Coagulation tests (clotting times: activated partial thromboplastin time (APTT) and prothrombin; fibrinogen and D-dimer concentrations; thrombodynamics) were performed.

Results

Women with an elevated clot growth velocity (>32.3 μm/min, detected by thrombodynamics) before IVF demonstrated a higher risk of negative IVF outcomes (adjusted RR = 1.38; 95% CI 1.28–1.49; P<0.001). During the procedure, we observed increases in prothrombin, fibrinogen and D-dimer concentrations, a slight shortening of APTT and a hypercoagulation shift in the thrombodynamics parameters. The hemostasis assay values during COS and after ET had no associations with IVF outcomes.

Conclusions

Hypercoagulation in the thrombodynamics before the start of IVF treatment was associated with negative IVF outcomes. After the start of COS, all tests demonstrated a hypercoagulation trend, but the hypercoagulation did not influence IVF outcome. This research is potentially beneficial for the application of thrombodynamics assay for monitoring hemostasis in infertile women prior to an IVF procedure with the goal of selecting a group requiring hemostasis correction to increase the chances of pregnancy.

Oocyte cryopreservation for women with GATA2 deficiency

PURPOSE

To describe controlled ovarian stimulation (COS) in a population of women with GATA2 deficiency, a genetic bone marrow failure syndrome, prior to allogeneic hematopoietic stem cell transplant METHODS: This is a retrospective case series of nine women with GATA2 deficiency who underwent oocyte preservation at a research institution. Main outcomes measured include baseline fertility characteristics ((antimullerian hormone (AMH) and day 3 follicle-stimulating hormone (FSH) and estradiol (E2)) and total doses of FSH and human menopausal gonadotropins (HMG), E2 on day of trigger, and total number of metaphase II oocytes retrieved.

RESULTS

The mean age was 24 years [16-32], mean AMH was 5.2 ng/mL [0.7-10], and day 3 mean FSH was 5.1 U/L [0.7-8.1], and E2 was 31.5 pg/mL [< 5-45]. The mean dose of FSH was 1774 IU [675-4035], and HMG was 1412 IU [375-2925] with a mean E2 of 2267 pg/mL [60.7-4030] on day of trigger. The mean total of metaphase II oocytes was 7.7 [0-15]. One patient was diagnosed with a deep vein thrombosis (DVT) with pulmonary embolism (PE) during COS.

CONCLUSION

This study is the first to analyze the outcomes of COS in women with GATA2 deficiency. The response to ovarian stimulation suggests that oocyte cryopreservation should be considered prior to gonadotoxic therapy. However, due to the risk of potentially life-threatening complications, it is prudent that patients are properly counseled of the risks and are evaluated by a multi-disciplinary medical team prior to COS.

Microparticles reveal cell activation during IVF – a possible early marker of a prothrombotic state during the first trimester

Cell-derived microparticles (MPs) are known to be elevated in a number of diseases related to arterial and venous thromboembolism (VTE), such as acute myocardial infarction, VTE (deep-vein thrombosis and pulmonary embolism) and peripheral arterial disease. IVF-associated pregnancies have previously been shown to be associated with an increased incidence of VTE, mechanisms behind being unknown and sparsely studied. Our objective was to assess cell activation during IVF through analysis of MP levels and phenotype following ovarian stimulation. Thirty-one women undergoing IVF were included and blood samples were collected at down regulation of oestrogen and at high level stimulation with 10- to 100-fold increased endogenous oestrogen levels. MPs were analysed by flow cytometry and phenotyped according to size and protein expression. We found that overall phosphatidylserine positive platelet-, endothelial- and monocyte-derived MPs significantly increased following ovarian stimulation with increased levels of platelet activation markers CD40 ligand and P-selectin. Furthermore, there was an increase in endothelial-derived MPs exposing activation marker E-selectin and monocyte-derived MPs, while neutrophil-derived MPs decreased slightly. In conclusion we found a major increase in MPs and markers indicating cell activation in parallel with the profound oestrogen boost during IVF. To assess whether these changes in MPs are associated with thromboembolic events requires extended longitudinal studies.

Impact of blood hypercoagulability on in vitro fertilization outcomes: a prospective longitudinal observational study

Background

Blood coagulation plays a crucial role in the blastocyst implantation process and its alteration may be related to in vitro fertilization (IVF) failure. We conducted a prospective observational longitudinal study in women eligible for IVF to explore the association between alterations of coagulation with the IVF outcome and to identify the biomarkers of hypercoagulability which are related with this outcome.

Methods

Thirty-eight women eligible for IVF (IVF-group) and 30 healthy, age-matched women (control group) were included. In the IVF-group, blood was collected at baseline, 5–8 days after administration of gonadotropin-releasing hormone agonist (GnRH), before and two weeks after administration of human follicular stimulating hormone (FSH). Pregnancy was monitored by measurement of βHCG performed 15 days after embryo transfer. Thrombin generation (TG), minimal tissue factor-triggered whole blood thromboelastometry (ROTEM®), procoagulant phospholipid clotting time (Procoag-PPL®), thrombomodulin (TMa), tissue factor activity (TFa), factor VIII (FVIII), factor von Willebrand (FvW), D-Dimers and fibrinogen were assessed at each time point.

Results

Positive IVF occurred in 15 women (40%). At baseline, the IVF-group showed significantly increased TG, TFa and TMa and significantly shorter Procoag-PPL versus the control group. After initiation of hormone treatment TG was significantly higher in the IVF-positive as compared to the IVF-negative group. At all studied points, the Procoag-PPL was significantly shorter and the levels of TFa were significantly higher in the IVF-negative group compared to the IVF-positive one. The D-Dimers were higher in the IVF negative as compared to IVF positive group. Multivariate analysis retained the Procoag-PPL and TG as predictors for the IVF outcome.

Conclusions

Diagnosis of women with hypercoagulability and their stratification to risk of IVF failure using a model based on the Procoag-PPL and TG is a feasible strategy for the optimization of IVF efficiency that needs to be validated in prospective trials.

A New Perspective on the Risk of Hypercoagulopathy in Ovarian Hyperstimulation Syndrome Using Thromboelastography

Thromboelastography (TEG) provides real-time assessment of hemostasis by measuring the viscoelastic properties, coagulation factor, and platelet activity in whole blood samples. In this prospective case-control study, we wanted to investigate whether blood clot formation assessment, using TEG, can identify a hypercoagulable state in women with severe ovarian hyperstimulation syndrome (OHSS). Thirty-six women who were hospitalized with severe OHSS were allocated to the OHSS group and 32 women undergoing controlled ovarian hyperstimulation but who did not develop OHSS were allocated to the control group. The TEG indices were compared between women with severe OHSS and controls. All the coagulation indices assessed by TEG were significantly different in the OHSS group compared to the controls, depicting a hypercoagulable state. Median coagulation index was 3.6 (interquartile range: 2.80-4.15) and 1.45 (interquartile range: 0.20-2.30) in study group and controls, respectively ( P < .001). Our results show that TEG can be used to depict a hypercoagulable state in women with severe OHSS.

The hidden world of anti-phospholipid antibodies and female infertility: A literature appraisal

Even though the association of anti-phospholipid antibodies (aPL) with infertility is debated, infertile women are commonly screened for aPL. To review evidence, a systematic PubMed search was conducted to retrieve papers addressing (i) the association between aPL and infertility, (ii) the positivity rate of criteria and non-criteria aPL in women with infertility, (iii) the association between aPL and assisted reproduction technologies (ART) outcome, (iv) the efficacy of medical treatments on ART outcome, and (v) the effects of ART on thrombotic risk. A total of 46 papers were considered; several limitations emerged: (i) wide heterogeneity in study populations, (ii) non-prospective design in 90% of studies, and (iii) aPL cutoffs not conforming to international guidelines in more than 75% of studies; aPL positivity not confirmed in 89% of studies. Most studies evinced an association between infertility and anti-β2GPI antibodies and almost all non-criteria aPL. The association rate with infertility was below 50% for lupus anti-coagulant, anti-cardiolipin antibodies (aCL), and anti-phosphatidic acid antibodies. According to our estimates, overall positivity rates of criteria and non-criteria aPL tests are 6% and 3% among infertile women, 1% and 2% among controls, respectively. A significant difference in the positivity rate of patients versus controls emerged for aCL only. Five of 18 studies reported a detrimental effect of aPL on ART outcome. Only one of the six studies assessing the effects of treatment on ART outcome among aPL-positive infertile women reported a benefit. All relevant studies reported no increase in the rate of thrombosis among aPL-positive women undergoing ART.

Preliminary proteomic analysis on the alterations in follicular fluid proteins from women undergoing natural cycles or controlled ovarian hyperstimulation

PURPOSE

To study the differences in protein expression profiles of follicular fluid (FF) between controlled ovarian hyperstimulation (COH) and natural ovulatory cycles.

METHODS

Twelve infertile women undergoing in vitro fertilization and embryo transfer (IVF-ET), with matched clinical information, were retrospectively recruited in the IVF center of our university hospital, including six undergoing COH and another six with natural cycles. FF was sampled from dominant follicles with mature oocytes. Protein expression profiles in each FF sample were analyzed respectively using two-dimensional gel electrophoresis. Differentially expressed proteins were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and validated by western blotting. Differentially expressed proteins were further analyzed using Ingenuity Pathway Analysis (IPA) software.

RESULTS

Two proteins were downregulated and 11 proteins were upregulated (change ≥1.5-fold, P < 0.05) in the COH group. We identified one down-egulated and seven upregulated proteins using MALDI-TOF MS. Four differentially expressed proteins, including transferrin, complement component C3 (C3), haptoglobin and alpha-1-antitrypsin (AAT), were further validated by rate nephelometry and western blotting analyses. The IPA analysis revealed a significant network involved in the humoral immune and inflammatory responses.

CONCLUSIONS

The eight differentially expressed proteins were related to immune and inflammatory responses in the ovary. Our results provide new insights into the influence of COH on follicular (spp) development and IVF outcomes.

Thrombosis following ovarian hyperstimulation syndrome

The aim of this review is to analyse the pathophysiology and complications of thrombosis in conjuction with ovarian hyperstimulation syndrome (OHSS) following ovulation induction and to suggest practical guidelines usefull for the prevention and treatment. Although the incidence of thrombosis varies from 0.2% among in vitro fertilization (IVF) cycles and up to 10% for severe cases of the syndrome, it represents the most dangerous complication of OHSS. Different changes in haemostatic markers have been found to create a state of hypercoagulability, but no single standard test is available to estimate the state of thrombosis. The role of markers for thrombophilia is controversial. Thromboses are mostly venous (67-75%) involving upper limbs and neck, then arterial (25-33%) which are mainly intracerebral. The predominant sites of venous thromboembolism in the upper part of the body may be explained by higher concentrations of estrogens drained through lymphatic ducts from ascites and by compression of rudimentary branchyal cysts. Once early diagnosis is established, it is crucial to use an anticoagulant treatment with heparin proceeded with thromboprophylaxis. However, identification of patients at risk and preventive measures of OHSS are the best means in reducing the risk of thrombosis after ovarian stimulation.

Plasma concentrations of D-dimer and outcome of in vitro fertilization

Background

The activation of blood coagulation could contribute to the failure of in-vitro fertilization (IVF) techniques. The aim of this study was to assess the predictive value of D-dimer levels for pregnancy outcome in women undergoing IVF.

Findings

A prospective study was performed in 105 women undergoing IVF. D-dimer was measured before and one week after the administration of recombinant human chorionic gonadotropin (r-hCG). The primary outcome of the study was clinical pregnancy. The mean age was 36 years (range 26 to 43 years). The main indications for IVF were infertility due to a tubaric (n = 21, 20%) or male factor (n = 37, 35%) and idiopathic infertility (n = 30, 29%) which altogether accounted for 84% of the total. Clinical pregnancy was achieved by 40/105 (38%) women of whom 32 (80%) delivered a live child. On the day of r-hCG administration, D-dimer concentrations were significantly higher in patients not achieving a clinical pregnancy (141 ng/dL vs. 115 ng/dL, p = 0.035) which remained statistically significant after correction for age and indications for IVF in multivariable analysis (p = 0.032). One week after r-hCG, the levels of D-dimer were significantly increased both in women with and without a clinical pregnancy with no differences between the groups (748 ng/dL vs. 767 ng/dL, p = 0.88).

Conclusions

D-dimer concentrations seem to predict a higher risk of pregnancy failure in women undergoing IVF. If confirmed in future prospective studies, D-dimer could help identifying a group of patients who could benefit from prophylaxis to increase the pregnancy success rate.

Fibrinolysis alterations in infertile women during controlled ovarian stimulation: influence of BMI and genetic components

INTRODUCTION

Ovarian stimulation protocols have been described to induce prothrombotic phenotype through alterations of both coagulation and fibrinolysis pathways. We investigated fibrinolytic changes during ovarian stimulation through a global test (CLT) and PAI-1 and TAFI concentrations at different times of ovarian stimulation procedure, and the influence of polymorphisms in genes encoding for fibrinogen chains (FGA, FGB, FGG), t-PA (PLAT), TAFI (CBP2), FXIII (FXIIA1, FXIIIB), plasminogen (PLG) and PAI-1 (PAI1) on their intermediate phenotype.

MATERIALS AND METHODS

We evaluated fibrinolytic and genetic parameters in 110 infertile women undergoing ovarian stimulation procedure (in vitro fertilization, IVF or intracytoplasmic sperm injection, ICSI). All women were observed during the mid-luteal phase of cycle (T(0)) and on day 5 (T(1)), 7 (T(2)) and 9 (T(3)) of the ovarian stimulation.

RESULTS

Significant changes in fibrinolytic parameters from T(0) to T(3) of ovarian stimulation were found (CLT p=0.003; TAFI p=0.009 and PAI-1 p=0.003). CLT values, TAFI and PAI-1 concentrations significantly increased from baseline to T(1) (p<0.0001, p=0.01, p=0.005, respectively)(,) and decreased at T(2,) but remained higher than those at T(0). Moreover, at baseline overweight women showed longer CLT, higher TAFI and PAI-1 concentrations than normal weight women, as well as at T(1) two-fold longer CLT and higher PAI-1 concentrations were observed (p=0.001 and p=0.05, respectively). Significant differences of TAFI and PAI-1 concentrations during ovarian stimulation according to TAFI and PAI1 polymorphisms were observed.

CONCLUSIONS

This study shows alterations of fibrinolysis and suggests the contribution of TAFI and PAI1 genes in modulating fibrinolysis changes during the ovarian stimulation cycle.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

[Thrombosis and assisted reproductive techniques (ART)]

Assisted reproductive techniques (ART) concern procedures designed to increase fertility of couples: artificial insemination, in vitro fertilization (IVF), either classical or after intracytoplasmic sperm injection (ICSI), transfer of frozen embryos, or gamete intrafallopian transfer. Their use has greatly increased these last years. They may be associated with severe ovarian hyperstimulation syndrome and one possible major complication is venous or arterial thrombosis. Thromboses are rare but potentially serious with important sequellae. They are mostly observed in unusual sites such as head and neck vessels and the mechanism is still unknown although hypotheses have been proposed. This review is an update of our knowledge and an attempt to consider guidelines for the prevention and treatment of ART-associated thromboses, which frequently occur when the woman is pregnant. Prevention of severe ovarian hyperstimulation by appropriate stimulation procedures, detection of women at risk of hyperstimulation and of women at high risk of thrombosis should allow reduction of the risk of thrombosis, possibly by administration of a thromboprophylaxis at a timing and dose which can be only determined by extrapolation.

Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome

OBJECTIVE

To review the current evidence regarding the relationship between systemic lupus erythematosus (SLE) and antiphospholipid syndrome and female infertility, as well as the risks associated with ovarian stimulation for ovulation induction and IVF. To establish, based on this information, guidelines for safe and successful assisted reproductive technology (ART).

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULT(S)

Systemic lupus erythematosus and antiphospholipid syndrome are not related to infertility, except for cases of amenorrhea accompanying severe flares, renal insufficiency-related hypofertility, and ovarian failure secondary to cyclophosphamide (CTX) therapy. The most threatening conditions in affected women undergoing ovarian stimulation are lupus flares and thrombosis, with the latter being especially associated with the occurrence of an overt ovarian hyperstimulation syndrome (OHSS). Friendly ovarian stimulation, single embryo transfer, avoidance of OHSS, administration of coadjuvant therapy, and use of natural E(2) or P through a nonoral route may constitute the safest approach. Systemic lupus manifested in acute flares, badly controlled arterial hypertension, pulmonary hypertension, advanced renal disease, severe valvulopathy or heart disease, and major previous thrombotic events are situations on which to discourage ART, especially due to the high risk of complications for both mother and fetus during pregnancy and puerperium.

CONCLUSION(S)

Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well-selected women with SLE and antiphospholipid syndrome.

A proteomic analysis of IVF follicular fluid in women <or=32 years old

OBJECTIVE

To address the lack of predictors of IVF success by using proteomic biometrics.

DESIGN

Experimental study of follicular fluid specimens from a prospective cohort of IVF patients.

SETTING

Academic research laboratory and IVF program.

PATIENT(S)

Women <or=32 years old with <11 oocytes retrieved and no pregnancy were matched to women who had >or=11 oocytes and live birth (10 pairs). Year of cycle start and IVF down-regulation protocol were also matched.

INTERVENTION(S)

Follicular fluid was separated by two-dimensional polyacrylamide gel electrophoresis followed by Sypro Ruby staining and comparison with PDQuest software. Logistic regression was incorporated to calculate the likelihood of live birth in relation to the protein spot of interest.

MAIN OUTCOME MEASURE(S)

Protein markers.

RESULT(S)

Liquid chromatography-tandem mass spectrometry and searching of sequence databases revealed 11 potential protein candidates. Haptoglobin alpha, predominantly fetal expressed T1 domain, mitochondrial integrity genome (ATPase), apolipoprotein H (beta-2 glycoprotein I), dihydrolipoyl dehydrogenase, lyzozyme C, fibrinogen alpha-chain, and immunoglobulin heavy chain V-III (region BRO) were found to have increased expression in the live birth group, whereas antithrombin, vitamin D-binding protein, and complement 3 were decreased. An ELISA confirmed a significantly lower level of antithrombin.

CONCLUSION(S)

Proteomic evaluation of follicular fluid is able to identify potential biomarkers of good versus poor responders in matched pairs of IVF patients.

The “ART” of thromboembolism: A review of assisted reproductive technology and thromboembolic complications

Since its development over 25 years ago, the use of assisted reproductive technology (ART) is on the increase. Along with its use, are also reports of thromboembolic complications (TEC); these events could resulted in significant maternal morbidity and even mortality. In this article, we reviewed the general principles of ART. We also performed a search of all published cases of TEC associated with ART, and summarized the results of studies investigating underlying hemostatic changes with ART. The goal of this article is to provide non-fertility specialists an understanding of ART, so as to better manage TEC when they occur in predisposed patients. The most common ART procedure performed today, is in-vitro fertilization-embryo transfer (IVF-ET). The process of IVF involves the use of exogeneous hormones to achieve cycle control, stimulate the ovaries, and support implantation. During this process, supraphysiological estradiol levels can result. One major complication of this intervention, ovarian hyperstimulation syndrome (OHSS), can be associated with both arterial and venous thrombotic complications. These events (especially venous thrombosis) have also been reported to occur weeks after OHSS has resolved; and they can present in unusual sites (upper extremities) resulting in treatment challenges. From current available studies, it is clear that with ovarian stimulation, both the coagulation and fibrinolytic systems are activated. This activation appears to be exaggerated and prolonged with the development of OHSS. Whether these changes are sufficient by themselves to explain the occurrence of TEC is yet unknown. Future studies should be focused on defining the frequency and risk factors of these complications; provide a closer examination of the resultant changes in the coagulation cascade during ART, OHSS and early pregnancy; and investigating the appropriate treatment and thromboprophylaxis for patients undergoing a procedure considered "elective".

Successful management of an extensive intracranial sinus thrombosis in a patient undergoing IVF: case report and review of literature

OBJECTIVE

To report a successfully managed case of extensive intracranial sinus thrombosis that occurred during an IVF cycle, and to review the literature.

DESIGN

Case report and review of literature.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

A 38-year-old nulliparous woman who developed severe ovarian hyperstimulation syndrome on luteal day (LD) 5 during an IVF cycle. Hemoconcentration was corrected, ascitis drained, and heparin prophylaxis started. On LD7, the patient complained of severe headache and neck pain. A magnetic resonance imaging (MRI) study of the head showed extensive cortical vein and dural sinus thrombosis, including the superior sagittal sinus and transverse sinuses.

INTERVENTION(S)

The patient was fully heparinized using low-molecular-weight heparin. On LD15 she was discharged home on warfarin, after confirming a negative pregnancy test. Complete thrombophilia work-up was negative.

MAIN OUTCOME MEASURE(S)

Clinical outcome.

RESULT(S)

Repeat MRI 2 months later revealed patent superior sagittal sinus and transverse sinuses, unremarkable cortical veins, and no evidence of flow obstruction. The patient was asymptomatic, with no neurologic sequelae.

CONCLUSION(S)

Extensive intracranial sinus thrombosis in women undergoing IVF may present with minimal symptoms and can occur in the absence of pregnancy and thrombophilia and despite heparin prophylaxis and correction of hemoconcentration. Medical management was successful and left the patient with no neurologic sequelae.

Exogenous Sex Hormones and Thrombophilia

Worldwide, hundreds of millions of women use exogenous estrogens in contraceptives or for postmenopausal hormone replacement. Exogenous estrogens increase the risk for venous and arterial thrombosis. This article reviews the use of exogenous sex hormones in women with thrombophilia.

Safety of IVF under anticoagulant therapy in patients at risk for thrombo-embolic events

The objective of this study was to assess the safety of induction of ovulation and oocyte retrieval in patients at risk of thrombosis, necessitating treatment with anticoagulants. Twenty-four patients considered as high risk for a thromboembolic event underwent 73 IVF cycles and 68 oocyte retrieval procedures, and were treated concomitantly with anticoagulation therapy (low molecular weight heparin; LMWH). A subgroup of five patients considered at especially high risk for thrombosis was isolated. These patients were prepared for oocyte retrieval using a controlled spontaneous cycle. All these patients were programmed exclusively for surrogacy. Nineteen women underwent 49 cycles of ovulation induction with gonadotrophins. The average peak oestradiol concentration was 1791 +/- 1420 pg/ml with an average of 13.5 +/- 8.4 oocytes retrieved in each cycle. The five patients from the very high risk group underwent 24 cycles: the average peak oestradiol concentration was 163 +/- 98 pg/ml. In 18, an egg was retrieved and in 14, fertilization was achieved. No bleeding or thromboembolic complications were noted during treatment of both groups of patients. It is concluded that during induction of ovulation in patients at risk for thrombosis, the introduction of LMWH as a cycle protective treatment was not associated with any medical complication. The use of a controlled spontaneous cycle with LMWH is suggested in very high risk patients.

Serum P-selectin level during controlled ovarian hyperstimulation--a preliminary report

OBJECTIVE

To measure levels of serum P-selectin in patients undergoing controlled ovarian hyperstimulation (COH) cycles and to determine their possible correlation to COH variables.

SETTING

Large university-based infertility and in vitro fertilization unit.

PATIENTS

Fourteen consecutive patients undergoing our routine COH protocol for unexplained infertility.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Blood was drawn three times during the COH cycle: (1) day 2 or 3 of the menstrual cycle, before gonadotropin treatment (Day-0); (2) day of or prior to human chorionic gonadotropin (hCG) administration (Day-hCG); and (3) day of ovulation (Day-OVU). Serum levels of sex steroids and P-selectin were compared among the three time points. P-selectin was measured with a commercial quantitative sandwich immunoassay technique. To reduce interpatient variability, the percent difference between the Day-0 (non-stimulated, basal) level and the Day-hCG and Day-OVU levels was calculated.

RESULTS

P-selectin level on Day-hCG was significantly higher than on Day-0 (P < 0.05) and non-significantly higher than on Day-OVU (P < 0.12). No significant correlations were observed between serum P-selectin and patient age, amount of gonadotropins used, or estradiol or progesterone level.

CONCLUSION

The increase in serum P-selectin level during COH until peak estradiol suggests that COH may potentiate a state of platelet activation which is substantially attenuated after hCG administration.

Effect of urinary versus recombinant follicle-stimulating hormone on platelet function and other hemostatic variables in controlled ovarian hyperstimulation

OBJECTIVE

To determine the effect of urinary versus recombinant FSH on platelet function and hemostatic variables in women undergoing controlled ovarian hyperstimulation cycles.

DESIGN

Randomized clinical study.

SETTING

Major university-based infertility and in vitro fertilization unit and hemostasis laboratory.

PATIENT(S)

Ten healthy women (in vitro study), and 24 women undergoing routine controlled ovarian hyperstimulation cycles (in vivo study), randomly assigned to receive either urinary (u-FSH) or recombinant gonadotropin (r-FSH).

INTERVENTION(S)

In vitro study: effect of preincubation of plasma with u-FSH or r-FSH, in the presence or absence of estradiol, on platelet function and coagulation parameters. In vivo study: Changes in platelet function and coagulation parameters after treatment with u-FSH or r-FSH during controlled ovarian hyperstimulation cycles.

MAIN OUTCOME MEASURE(S)

Platelet aggregation and ATP release, activated protein C resistance ratio, free protein S.

RESULT(S)

In vitro study: Platelet aggregation and ATP release were significantly inhibited by u-FSH relative to r-FSH in both the presence and absence of estradiol (P=.047). In vivo study: Platelet function was significantly inhibited after treatment with u-FSH (P=.05) but not with r-FSH. In both studies, small changes of minor clinical significance were noted in activated protein C resistance and free protein S levels.

CONCLUSION(S)

The different platelet response to u-FSH and r-FSH may have clinical implications in selected patients, especially those at risk of thromboembolic complications, in decisions regarding the appropriate medication for controlled ovarian hyperstimulation cycles.

Prevalence of thrombophilia in women with severe ovarian hyperstimulation syndrome and cost-effectiveness of screening

OBJECTIVE

To determine the prevalence of markers of thrombophilia in patients with severe ovarian hyperstimulation syndrome (OHSS) and to evaluate the cost-effectiveness of screening for factor V Leiden and prothrombin G20210A mutations in women entering an IVF program.

DESIGN

Case-control study and cost-effectiveness analysis.

SETTING

University teaching hospital.

PATIENT(S)

Women undergoing controlled ovarian hyperstimulation for IVF complicated by severe OHSS (group 1, n = 20), women undergoing controlled ovarian hyperstimulation for IVF without development of severe OHSS (group 2, n = 40), and healthy control subjects (group 3, n = 100).

INTERVENTION(S)

Investigation of markers of thrombophilia. Estimate of number of IVF patients needed to detect a case of severe OHSS and thrombosis associated with thrombophilia genetic mutation was calculated from the available data.

MAIN OUTCOME MEASURE(S)

Blood samples were analyzed for inherited (resistance to activated protein C due to the factor V Leiden mutation; prothrombin G20210A mutation; deficiencies in antithrombin, protein C, and protein S) and acquired (presence of circulating lupus anticoagulants and/or anticardiolipin antibodies; deficiencies of antithrombin and protein S; acquired protein C resistance) markers of thrombophilia. The cost of preventing one thrombotic event in a patient developing severe OHSS after IVF and having factor V Leiden or prothrombin G20210A mutations was calculated.

RESULT(S)

None of the OHSS patients or controls had antithrombin, protein C, or free protein S deficiencies. All of them tested negative for antiphospholipid antibodies. No patient in group 1 had the factor V Leiden or prothrombin G20210A mutations. The prothrombin G20210A mutation was detected in 1 out of 40 patients (2.5%) in group 2. Both factor V Leiden and prothrombin G20210A mutations were detected in two of the control subjects (2%) (group 3). The estimated cost of preventing one thrombotic event arising as a consequence of screening for factor V Leiden and prothrombin G20210A mutation is a minimum of 418,970 dollars and 2,430,000 dollars, respectively.

CONCLUSION(S)

The prevalence of thrombophilia is not increased in women with severe OHSS. Screening for V Leiden and prothrombin G20210A mutation in an IVF general population is not cost-effective.

Bilateral internal jugular venous thrombosis following successful assisted conception in the absence of ovarian hyperstimulation syndrome

The majority of the venous thromboembolic events seen in patient following gonadotropin administration were associated with the development of ovarian hyperstimulation syndrome (OHSS). However, in this case report, a 29-year-old woman that conceived by controlled ovarian hyperstimulation, intracytoplasmic sperm injection and subsequent embryo transfer without conjunction of OHSS was described. Bilateral jugular venous thrombi were detected by duplex Doppler in the 8th week of pregnancy when she was admitted to the emergency room for difficulty in swallowing and bilateral neck pain. She had unremarkable history and negative results for thrombophilia screening. Full anticoagulation with intravenous heparin was initiated and continued subcutaneously throughout pregnancy. She delivered two healthy babies at 36 weeks of pregnancy. Venous thromboembolism should be taken in account in patients undergoing gonadotropin administration for assisted conception with the complaint of extremity pain regardless of having risk factors for thromboembolism.

Hypercoagulability, high tissue factor and low tissue factor pathway inhibitor levels in severe ovarian hyperstimulation syndrome: possible association with clinical outcome

During ovarian gonadotrophin stimulation for ovulation induction or in vitro fertilization, a clinical severe ovarian hyperstimulation syndrome (OHSS) may occur. Only few studies have investigated the mechanism responsible for the alterations of the haemostatic system in women affected by severe OHSS. The aim of the present study was to investigate the correlation between the magnitude of ovarian stimulation and the increase in fibrin formation and degradation in severe OHSS. Twenty-five patients (age range 23-43 years) who were hospitalized for severe OHSS, 25 women undergoing in vitro fertilization who did not develop OHSS (case-control group) and 25 healthy age-matched women (healthy control group) were investigated. On the day of admission a number of haemostatic markers, including D-dimer, thrombin-antithrombin complexes (TAT), prothrombin fragment 1 + 2 (F1 + 2), plasmin-antiplasmin complexes (PAP), tissue factor (TF), tissue factor pathway inhibitor (TFPI) and von Willebrand factor antigen (vWF), were examined. In patients with severe OHSS, TF, D-dimer, TAT, F1 + 2, PAP and vWF antigen plasma levels were significantly higher than those observed both in the case-control group and in healthy controls, whereas TFPI levels were significantly lower (P < 0.005) with respect to both case-controls and healthy controls. D-Dimer levels were related with serum oestradiol levels and oocyte number recovered (r = 0.45, P < 0.001 and r = 0.47, P < 0.001, respectively). D-Dimer and TAT levels were significantly (P < 0.05 and P < 0.005, respectively) higher in OHSS patients with unsuccessful pregnancy outcome (D-dimer, 226.5, 56-1449 ng/ml; TAT, 19.8, 3.1-82.6 microg/l) with respect to those with successful outcome of pregnancy (D-dimer, 145, 29-330 ng/ml; TAT, 5.0, 1.0-19.6 microg/l). Our data indicate that a marked hypercoagulability with alterations of TF and TFPI levels is detectable in patients with severe OHSS and that it is related to the clinical outcome.

In vitro fertilization-induced alterations in coagulation and fibrinolysis as measured by thromboelastography

Supraphysiologic increases in estrogen produced by in vitro fertilization (IVF) promote the expression of hemostatic markers. Although quantitative studies of individual markers have been performed during IVF, their results are conflicting and do not reveal the qualitative effect of each marker on the overall coagulation and fibrinolytic processes. Thrombelastograph (TEG) coagulation analysis, by contrast, provides a global measure of coagulation and fibrinolysis and can indicate the relative contributions of clotting factors, fibrinogen, and platelets to each process. We studied the serum estrogen concentrations and TEG variables in 24 women at the beginning and conclusion of an IVF stimulation cycle. Serum estradiol (E(2)) concentrations (mean +/- SD) increased from 26.9 +/- 8.6 to 2098 +/- 913 pg/mL (P < 0.005) at baseline and oocyte retrieval, respectively. The measured TEG indices demonstrated alterations in coagulation rather than fibrinolysis. Although significant changes were noted in both the clot formation time and the coagulation index (P < 0.005), all TEG values remained within the normal range. In addition, an increased role of fibrinogen in promoting clot strength was observed. These findings may assist in the treatment of IVF patients who ultimately develop thromboembolic complications as a result of ovarian hyperstimulation. IMPLICATIONS. The dramatic changes in estrogen produced by in vitro fertilization therapies result in hemostatic marker alterations. Thrombelastograph coagulation analysis, which provides a global assessment of these changes, demonstrated significant alterations in two coagulation indices (clot formation time, coagulation index), although all variables remained within normal limits. The relative importance of fibrinogen versus platelets in determining clot strength was observed. No significant alterations in fibrinolysis were detected.

[Evolution of homocysteine during ovarian stimulation for IVF or ICSI]

OBJECTIVE

To determine the homocysteine evolution during ovarian stimulation in IVF or ICSI protocols and in, a second time, to evaluate the role of hyperhomocysteine as thrombotic risk factor for the treated patients.

MATERIAL AND METHODS

Plasma homocysteine was determined three times for each of 31 women included in an IVF/ICSI program. Dosages were realised before stimulation, after gonadotrophin-releasing hormone agonist treatment (GnRH) and on the day of hCG injection. Vitamin B12 and folates were determined before stimulation. In case of hyperhomocysteinemia, a research of APCR (Activated Protein C Resistance) was realised.

RESULTS

Five hyperhomocysteinemia cases were discovered (16.12% of studied population). APCR was found in a patient with hyperhomocysteinemia (14 mumol/L, before stimulation). Molecular biology has confirmed an heterozygous mutation of factor V Leiden. During the ovarian stimulation the evolution of homocysteine was independent of the 17 beta oestradiol evolution.

CONCLUSION

The prevalence of hyperhomocysteinemia was not significative according to the limited size of the studied population. The increase of oestradiol during induction protocols is unrelated to the homocysteine level. This work must be continued with largest population to have better knowledge of the prevalence of hyperhomocysteinemia among women included in ovarian stimulation protocols.

Internal jugular vein thrombosis after assisted conception therapy

Superovulation therapy during assisted conception may result in a hypercoagulable state. Five cases of upper extremity venous thrombosis were identified in women who conceived after ovarian stimulation for in vitro fertilization (IVF). They presented between 7 and 10 weeks' gestation with neck pain and swelling. Three had been treated for ovarian hyperstimulation syndrome and two had evidence of inherited thrombophilia. Four patients received thromboprophylaxis before presentation. Although thrombosis is an uncommon complication of IVF, patients should be counselled before treatment. Thrombophilia screening may be considered for 'high-risk' patients, although current regimes for thromboprophylaxis remain suboptimal.

Bilateral jugular venous thromboembolism and pulmonary emboli in a patient with severe ovarian hyperstimulation syndrome

We report here a case of severe ovarian hyperstimulation syndrome with massive ascites in a 25-year-old woman with a history of primary infertility after an IVF-ET cycle. At the 9th gestational week she presented with neck pain and dyspnea and duplex Doppler sonographic examination of the neck veins revealed bilateral jugular venous thrombosis. Despite prompt administration of low-molecular weight heparin, pulmonary emboli developed a few days later.

Low-molecular-weight heparin during pregnancy

Thromboembolism is an infrequent, yet serious cause of both maternal and fetal morbidity and death during pregnancy and the puerperium. Pregnancy itself increases the risk of thromboembolic complications probably owing to a combination of hypercoagulability and venous stasis due to venous dilation. Recent studies have indicated that some serious obstetric complications are correlated with inherited or acquired thrombophilia. The prevalence of venous thromboembolism (VTE) has been extimated to be 1 per 1000-2000 pregnancies in retrospective studies. Anticoagulant treatment and prophylaxis both before and during pregnancy are based on unfractionated heparin (UH), low-molecular-weight heparin (LMWH) and warfarin. Warfarin is teratogenous if administered between the 6th and the 12th week. LMWH is replacing UH in the prevention and treatment of VTE both outside and more recently during pregnancy with the same indications, and also for obstetric complications. This paper assesses the safety and efficacy of heparin therapy during pregnancy and the puerperium. Its cardiovascular and obstetric indications and regimens and maternal and fetal side-effects are also discussed.

[Evaluation of thomboembolic risk before ovarian stimulation: what balance? What prevention?]

The pathophysiology of thrombotic events remains unclear among women undergoing ovulation induction. In this review, present knowledge is summarized from the literature. Prospective studies are needed to determine risk factors and therapeutic approach of these thrombotic complications.

Cortical vein thrombosis misinterpreted as intracranial haemorrhage in severe ovarian hyperstimulation syndrome: case report

A case of cortical vein thrombosis presenting as intracranial haemorrhage is described in a patient with ovarian hyperstimulation syndrome (OHSS) after IVF and embryo transfer. Veno-occlusive disease of the brain could appear as a haemorrhagic lesion on magnetic resonance imaging (MRI) and this made the initial diagnosis of cortical vein thrombosis difficult. The patient developed deep vein thrombosis 2 weeks after the intracranial event and the diagnosis of cortical vein thrombosis was made at that time on MRI study after the resolution of the haemorrhage. This patient actually developed generalized thrombosis as a complication to OHSS. Although the initial MRI picture may be misleading, the diagnosis of thrombosis should always be kept in mind, as it is the commonest cause of intracranial lesions after OHSS.

Thromboembolic complications associated with reproductive endocrinologic procedures

Thromboembolism as a complication of hormonal ovarian stimulation in the context of artificial reproductive techniques is rare and seems to occur when OHS is present. Although accompanied by high serum estrogen concentrations, hCG seems to play a central role in the development of OHS, which has been observed in women with 17,18-desmolase deficiency who have low estrogen levels after induction of ovulation with hGC. Although there is some evidence that hormonal ovarian stimulation with HMG, leading to elevated estrogen levels, and ovulation induction with hCG in preparation for in vitro fertilization are associated with a state of hypercoagulability, the exact role of estrogens, hCG and the physicochemical changes (fluid shift into third spaces) involved in OHS remain to be elucidated.