As with all medical treatments, there are some risks and complications that may arise during fertility treatment.
Risks associated with the Medication
The most common and harmless side effects of fertility drugs are:
-Local inflammation at the injection site
-Bloating and tiredness in the stomach
-Headache
-Migraine
-Hot flashes
However, there is another complication, Ovarian Hyperstimulation Syndrome (OHSS), which occurs very rarely but can be serious enough. OHSS is a medical condition that occurs when the ovaries overreact to daily stimulation injections. However, it is not the stimulation drug itself that causes OHSS. The stimulation injections can cause the ovaries to become swollen and painful. The drug that can trigger OHSS is the last injection 36 hours before egg retrieval (the triggering injection – usually Ovitrelle) (see IVF-ICSI chapter)
Of course, this does not mean that all women undergoing fertility treatment are at risk of OHSS. As a rule, they are young, slim patients with a very good ovarian reserve (high AMH and high AFC) and patients with polycystic ovary syndrome (PCOS) have a higher risk of OHSS.
There are 3 degrees of hyperstimulation syndrome (OHSS)
Mild OHSS
In this case, the ovaries become enlarged and cysts may form due to the remains of the follicles after egg retrieval. Symptoms may include mild to moderate abdominal pain. Pain in the abdomen, bloating and swelling and tenderness in the ovary area. Mild OHSS is not serious and treatment includes rest, taking common painkillers such as acetaminophen, and eating a diet rich in protein and fluids.
Moderate OHSS
In moderate OHSS, the ovaries become larger and abdominal discomfort and pain are more intense. Nausea, vomiting and even diarrhea may occur and body weight may increase. Treatment is the same as for mild OHSS, although close monitoring is required in case it progresses to severe OHSS.
Severe OHSS
Severe hyperstimulation is the most dangerous, but at the same time it is very rare, occurring in less than 1% of cases. The abdominal discomfort and pain are severe mainly because of fluid accumulation in the abdominal cavity.
The fluid can also build up in the chest, causing difficulty breathing and shortness of breath. Changes in blood counts can lead to the formation of blood clots, which can be life-threatening. Treatment includes hospitalization, intravenous fluids and medications, and possibly drainage of the fluid that collects in the abdomen and chest.
Risks associated with fertility treatment
1. No response to fertility medications
Unfortunately, there is a group of patients called “poor responders” who do not respond to fertility medications even when given the highest dose. These are usually women of advanced age, with high FSH and very low AMH and AFC. For these patients, specific protocols are available and are helpful.
2. Failure of fertilization
Even if the couple has a good number of eggs and normal sperm after egg retrieval, fertilization failure can still occur. This means that the eggs are not fertilized by the sperm. In this case, additional investigations are required for the couple, usually genetic testing, to determine the reason for the failed fertilization.
3. Multiple pregnancy
Multiple pregnancy is a potential risk with all types of fertility treatments (see “Fertility Treatment” chapter). One in ten pregnancies following IVF treatment results in the birth of twins. This is almost seven times higher than the twin rate from natural conception.
Unfortunately, the health risks for twins or triplets are significantly increased, especially because twins are more prone to premature births and being underweight. The risk for the mothers is also high during pregnancy as they have several serious problems like pre-eclampsia and eclampsia, gestational diabetes etc.
To avoid multiple pregnancies after IVF and increase the risks of serious health problems for both the mothers and the babies reduce the number of embryos that can be inserted. In Greece, the number of embryos that can be transferred depends on the age of the mother and her ability to achieve a multiple pregnancy.
4. Miscarriages
In the general population, at least one in four pregnancies ends in miscarriage, and unfortunately pregnancies following fertility treatment are no exception. The first 12 weeks of pregnancy are the most critical, and as a rule, the pregnancies that can reach this stage usually end in a live birth.
5. Ectopic and heterotopic pregnancies
Normally the fertilized egg implants itself in the lining of the uterus (see chapter “How does the reproductive system work”)
An ectopic pregnancy occurs when the fertilized egg implants outside the uterine cavity and the pregnancy therefore develops outside the uterus, usually in the fallopian tubes.
Heterotopic pregnancy is when there are multiple pregnancies, but one of them is normal and present in the uterine cavity and the other is outside the uterus, most often in the fallopian tube and less often in the cervix or ovary. Heterotopic pregnancies are generally very rare, 1/30,000 in spontaneous pregnancies and 1/4000-5000 after IVF treatment.
Unfortunately, in both cases the ectopic pregnancy must be terminated. In heterotopic pregnancies, the survival rate for intrauterine pregnancy is 60-70%.
6. Implantation failure
Unfortunately, the success rate of fertility treatment is not 100%. It is 45% in young couples with a high ovarian reserve and completely normal sperm. As people get older, not only the number but also the quality of the genetic material (i.e. eggs for the female partner and sperm for the male partner) deteriorates and the success rate of fertility treatment becomes lower and lower.
The limiting parameter of fertility treatment is implantation. Implantation is the stage in which the embryo is implanted in the uterine cavity after the embryo transfer (see chapter “IVF/ICSI”). Implantation is a very complicated and almost unknown process that takes place in the woman’s body and depends on numerous chemical, biological and other factors that fertility treatment cannot influence. Fertility treatment can facilitate implantation, but cannot force implantation.
7. Long-term effects of fertility drugs
Recent research has raised the question of whether the drugs, and particularly the stimulation injection, used for fertility treatment may increase the risk of ovarian and breast tumors. This connection has not yet been proven. As long as fertility medications are used sensibly and prudently, there is no additional risk to patients. In addition, the same drugs are used by oncology patients to preserve fertility.
Risks associated with ICSI
Because the intracytoplasmic sperm injection (ICSI) technique is a relatively new treatment (it was introduced in 1992), there are many questions about the safety and possible long-term consequences for children of using this technique in the laboratory.
There is no doubt that children born through ICSI are absolutely healthy. If there is a problem, it is not related to the ICSI technique itself, but to the couple’s genetic material.
This means that the problem can occur even if you conceive naturally. Sometimes infertility is related to underlying genetic problems that are completely unknown but can be passed on to offspring.
Risks associated with egg retrieval
Egg retrieval is a surgical procedure (see chapter “IVF/ICSI”) and as with all surgical procedures, even the smaller ones, there are some risks:
-Pain – can usually be controlled with common painkillers such as paracetamol.
-Bleeding – usually occurs in the first few hours after the procedure.
-Pelvic infection – the risk is extremely low, but additional antibiotics are given to eliminate the risk.
-Hematomas – usually insignificant small hematomas. 1/100 of hematomas could be larger and closer monitoring is required.
-Injury to surrounding organs – such as bladder, intestines, uterus and vessels. This is an extremely rare complication requiring surgical laparoscopy and hospitalization.
-The eggs cannot be retrieved – if the ovaries are completely inaccessible and there is an obvious risk of damaging the surrounding organs, or if eggs cannot be collected in the follicles.