RISKS AND SIDE EFFECTS OF DRUG TREATMENTS AND SURGERY ASSOCIATED WITH ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

There are risks associated with everyday living and all of us unconsciously calculate these in undertaking daily activities (eg. car accident, falling down stairs). We also suffer side effects as a result of daily exposure to most things we come into contact with (eg. hay fever, sunburn).

You must now understand the risks and side effects that may occur with drugs we might suggest you take, and the surgical treatment possibly required for ART ie. IVF, GIFT etc. You must decide whether these risks are worth taking and whether the side effects are worth tolerating.

SURGERY

Oocyte (eggs) collection is undertaken using either Laparoscopy or Transvaginal Ultrasound.

The following complications of surgery have been described:

General

Bleeding: From the ovary or from adjacent pelvic structures. Bleeding usually settles by itself but very rarely the “bleeding point” must be tied off requiring surgery.

Pelvic Infection: Some Concept patients take antibiotics before and during treatment to help prevent this occurring but the possibility still exists.

Anaesthesia: Risks include allergic rashes, temporary paralysis, vomiting and even, in more extreme cases, death. With young, fit, healthy women these risks are lower than for general surgery patients.

Laparoscopy: Laparoscopy requires deeper anaesthesia than for Transvaginal Aspiration which may be carried out under sedation with local anaesthesia.

Accidental bowel injury: Patients who have had previous surgery (and this applies to many requiring ART) may have bowel adhesions. This increases the risk of injury to the bowel. Any injury must be repaired immediately to avoid peritonitis (infection of the abdomen).

Superficial haemorrhage: Some bruising around the puncture marks or abdominal wall is common.

Retained gas: The carbon dioxide gas which is placed into the abdomen during laparoscopy may not all be expelled at the end of the operation; again this is more usual in patients with adhesions. This may provide some discomfort under the ribs or in the shoulder. It does not usually last longer than twenty four hours.

Transvaginal Ultrasound Aspiration

Unrecognised bleeding. Symptoms should be noted within six hours and this is the basis of our requirement that nursing observation be carried out for this period of time.

MEDICATIONS

It is neither possible nor useful to list all the possible reactions to medication. All drugs produce some side effects. These can be one or more of the following;

Allergic reactions: These are bizarre responses peculiar to some individuals and not to others (eg. Penicillin can produce lumpy rashes or sudden fluid retention and, if this occurs within the larynx, some obstruction to breathing is possible).

Exaggerated side effects: These are the effects of medication which in some degree are common to many patients taking drugs but some people have an exaggerated reaction (eg. Pethidine produces relief of pain but commonly "queasiness" or light headed feelings).

The specific medications which are used in ART are as follows:

Lucrin/Synarel

This medication is used to suppress the natural menstrual cycle to allow greater control over the response by the ovaries to gonadotrophins eg. Humagon/Pergonal and Gonal F/Puregon.

It will produce similar effects to the menopause. It does not produce an early menopause. The main side effects are hot flushes and mood swings.

Stopping the drug will allow the pituitary to recover (similar to the effect of oral contraceptives). Hence the normal menstrual cycle may be delayed.

Gonadotrophin (Puregon/Gonal F/Humagon)

These are the injectable drugs which directly stimulate the ovaries to produce more oocytes (eggs). The side effects are very similar to the menopause since these medications are exactly the same hormones as menopausal women have in their own bodies. Patients may notice weariness, mood changes, hot flushes, nausea and headaches. These are temporary and cease as soon as the medications are stopped.

As the ovaries will swell to accommodate the follicles, some patients may notice an increased pelvic pressure. If the ovaries are bound down by adhesions the pressure may be felt as pain. This pressure may continue into the second half of the cycle (luteal phase) and if pregnant, for up to three (3) months.

Very rarely, the ovary may rotate and twist or may bleed. These may produce severe pelvic pain and lead to a requirement for further surgery.

Human Chorionic Gonadotrophin (Hcg/Profasi/Pregnyl)

This medication causes the final maturing of the oocyte before aspiration. It may be a slightly more uncomfortable injection than the others.

Clomiphene (Clomid/Serophene)

This oral drug is used to stimulate the pituitary to stimulate the production of extra oocytes.

Occasionally side effects like headache, weariness, occasional visual disturbance and hot flushes may be noticed after a few days on this drug. These cease as soon as patients stop taking it..

Some patients who have used Clomiphene have suffered breast and ovarian cancers in later life but there is no proven association between the use of Clomiphene and cancer. (*NOTE: women who delay child bearing until later in life or those who do not have children also have a higher incidence of breast and ovarian cancer in later life and Clomiphene users are in these groups).

For further information try Infertility and Drugs.

MISCELLANEOUS

      Disappointment

Infertility itself creates a feeling of intense hurt and disappointment. The opportunity of an ART treatment and thus the possibility of a pregnancy offers hope. However, the effort put into undergoing ART procedures will not be rewarded in every cycle. Success is achievable for most couples, as long as a number of attempts are tried.

It is also likely that your parents, relations or friends will not appreciate what you have been through. They cannot really know. You may feel lonely yet become irritated by sympathy; angry, but not sure who or what with or why. Do not be afraid or ashamed to ask for help. For more information try Emotional responses to infertility.

      Multiple Pregnancy

There is an increased pregnancy rate with an increase in the number of oocytes or embryos replaced but there is also an increased risk of multiple pregnancies.

One or two oocytes or embryos are currently replaced but, depending upon age, cause of infertility and previous outcomes three may be replaced.

This will be discussed with you before the oocytes or embryos are replaced.

With two embryos or two oocytes replaced the chances of twins are about one in five.

There are some possible disadvantages in multiple pregnancies.

Medical (Maternal)

Obstetrically, carrying two babies places greater pressures on the pregnant women. There is an increased risk of miscarriage, obstetrical complications, premature deliveries and birth complications. Please discuss these with your gynaecologist.

Medical (Babies)

Babies born from a multiple birth have a greater risk of prematurity which may or may not then require neonatal intensive care. These babies are also at greater risk of cerebral palsy although delivery methods may contribute to this. Please discuss this further with your obstetrician.

Social (Babies)

Babies born from a multiple birth need to compete for the attention and care provided by the parents. This may cause greater social problems in due course. Please discuss this with your gynaecologist.

      Ectopic Pregnancy

(i.e. implanting, and growing in the Fallopian tube and not in the uterus.) It is easy to understand that this can happen in GIFT procedures but placing embryos into the uterine cavity can also result in this situation. However, iIn the majority of cases the embryo will stay in the uterus. Some embryos, however, may move into the fallopian tubes and implant ectopically.

A tubal pregnancy can grow, rupture and lead to a surgical emergency. If recognised early measures can be taken to avoid such emergency situations. It is important that all screening procedures be followed to ensure that no patient suffer from an unrecognised ectopic pregnancy.

A patient diagnosed as pregnant following IVF or GIFT should have an ultrasound carried out at such time that an intra-uterine pregnancy can be identified. This is possible from three weeks after ovulation or when the QHCG level reaches 3000 units or more.

That patients assumed not pregnant have this confirmed by a negative QHCG at two weeks (14 days) after ovulation. A period can occur with an ectopic pregnancy and is not sufficient reasurrance.

These precautions are most important for patients, who live a long way from medical attention, as an ectopic pregnancy far from medical help could be disastrous.

LABORATORY MATERIALS

      Sperm Treatments

In some cases where reduced sperm motility or numbers indicate that normal fertilisation rates might not be attainable, the use of a stimulant on the sperm will be recommended.

This stimulant may be Pentoxyfilline. This agent acts by removing some of the excess oxygen compounds from the sperm and eliminating some of the damaging effects of these compounds. The result is that sperm are more capable of swimming faster and have an increased fertilizing potential. Some other chemical agents are used to improve the sperm recruitment procedures. These include Percoll, Nycodens and Isolate.

These agents have been in use routinely, to improve the fertilizing capacity of sperm, for a number of years.

There has been no evidence, that these agents have any damaging effect on the developing embryo or baby. None of these agents were developed or registered for these specific uses but have been used in these ART treatments since the early 1980's.

      Culture Medium

The normally used culture fluids for A.R.T. procedures utilise inert salt solutions.

A number of other materials such as Propylene Glycol, Hepes and D.M.S.O. are also used in the culture and in the freezing of sperm and embryos. None of these agents were developed or registered for the specific uses but have been used in ART culture treatments since the early 1980's.

Antibiotics are also included in the culture medium but in such minute quantities that even women who have penicillin allergies have not noticed any effects. Some other human blood products may be used and although they are made from plasma which has been screened or tested for known transmissible agents such as HIV (AIDS), hepatitis B and hepatitis C, there may be possible contamination with these or other unknown agents. Chemical processing and virus inactivation stages included in the manufacture of these products are believed to render them safe from the risk of infection. Nevertheless the possibility of transmitting these agents must always be considered.