What is an intermittent ectopic beat?

Ectopic pregnancy with additional twin pregnancy in uterus

• One week ago I was had an ectopic pregnancy in the left fallopian tube at the same time a normal twin pregnancy (8 weeks into gestation with an ultrasound scan a few hours prior to surgery confirmed these facts) in the uterus. Bleeding and abdominal pain increasingly presented for two weeks prior to surgery. Emergency surgery (3-hour surgery started as a 1-hour laproscopic procedure but ultimately required an abdominal incision for access to all damaged areas)resulted in the removal of the ruptured fallopian tube, associated blood clot in the abdominal cavity and loss of one twin (one day after surgery). Two days after surgery an ultrasound scan showed normal heart-beat for the surviving twin. I have had no prior pregnancies, abdominal surgeries and no history of ectopic pregnancy in my family. My questions are: (1) What is the probability of this condition (ectopic plus uteran pregnancy) occuring at the same time? (2) What is the probability that the surviving twin will not survive to birth? (3) What is the probability that the surviving twin will have been damaged due to drugs administered during and after surgery, surgical process, etc? How can this damage, if any, be determined? Thank you. PS: Please, no lectures or answers that tell me to just "ask my doctor".

• Answer:

  Hello monsterthecat-ga, My heart goes out to you wishing you well for carrying your pregnancy to term and having the baby you long for. You?ve asked very specific questions and I?ve collected a selection of authoritative resources that should give you sufficient information to draw your own conclusions. Above all, it?s important that you consult your own doctors for medical guidance in your own case. I am not a doctor and cannot give you medical advice. I will give yoU a short summary of my findings and then you can explore each topic in depth with the websites I?ve listed. (1) What is the probability of this condition (ectopic plus uteran pregnancy) occuring at the same time? The probability of heterotopic pregnancy was estimated to be 1/30,000 until the late 1940s. Data in the 1980s showed an increase to 1/10,000 and more recent estimates have shown the range to be 1/4,000-7,000. In the case of assisted reproduction, the rate of heterotopic pregnancies is shown as 1-8/100 depending on the study. As you can see, the rate of heterotopic pregnancy for women receiving IVF treatments is very high. Please see the articles below for up-to-date information. (2) What is the probability that the surviving twin will not survive to birth? I?m very sorry to tell you that this is a very high risk pregnancy. It is difficult to give you a numerical estimate of the probability for this twin surviving to birth because there are so many unknown factors involved regarding your specific situation. I will give you the general findings from my research but you will have to apply the information I?ve collected and apply it to yourself using the guidance of your own doctors. There are some small studies of successful births after laparoscopic surgery for ectopic pregnancy concurrent with intrauterine pregnancy. These studies show healthy births in 67-78% of the cases studied. There is a major caveat to take into account along with these studies. This is the issue of the consideration of your age in reaching a successful delivery of your surviving twin. In your clarification you explained that you?re 47 years old, that you used 6 frozen embryos in you IVF procedure, and that you had ?numerous IVF/IUI failures.? All of these factors add a lot of risk to the pregnancy. I?ve included lots of resources to help you understand how these conditions impact the likelihood of a successful pregnancy. I especially call your attention to a very recent study that directly addresses your question. "One Last Chance for Pregnancy: A Review of 2,705 In Vitro Fertilization Cycles Initiated in Women Age 40 Years and Above" concludes that the probability of a woman over 45 having a baby using her own eggs is extremely slim. This conclusion is reached even without the complicating factor of the ectopic pregnancy and the loss of one twin. I am terribly sorry to be the conveyor of such bad news. (3) What is the probability that the surviving twin will have been damaged due to drugs administered during and after surgery, surgical process, etc? How can this damage, if any, be determined? What neonatal testing would be recommended above and beyond the traditional tests to check for fetal development problems? The description of your treatment seems normal and appropriate for your situation. The surviving twin is likely to have suffered some stress but this is not the major issue in the likelihood of survival. I?ve collected a variety of resources for evaluating what kind of neonatal testing you should consider because of your advanced age for childbirth. The rate of miscarriage for women over 45 is very high. Because the quality of a woman?s eggs declines with age, the probability of genetic conditions that might result in early miscarriage are high. The articles I?ve collected will give you a good overview of the issues involved and the common testing guidelines for high risk pregnancies. I suggest that you discuss your continuing concerns about further testing with your obstetrician. Dear monsterthecat-ga, I?m very sorry that most of the information I?ve found for you is not encouraging. I?m sure you had good reason for deciding to attempt to have a child at this time so there might be factors that provide more optimistic indicators for you. I wish you the fulfillment of your dreams with all my heart. ~ czh ~ ========================================================= PROBABILITY CONCURRENT ECTOPIC AND INTRAUTERINE PREGNANCY ========================================================= http://www.advancedfertility.com/ectopic.htm Heterotopic pregnancy: Combined intra- and extra-uterine pregnancy Old (1940's) literature says the rate is 1/30,000 pregnancies. Current rate is about 1/4000 pregnancies. Rate is increased with the use of ovarian stimulation. With IVF, rate is about 1/35-1/100 clinical pregnancies. ------------------------------------------------- http://www.hypertension-consult.com/Secure/textbookarticles/Primary_Care_Book/112.htm Ectopic Pregnancy: Part I An especially problematic and high risk variation of EP is the heterotopic pregnancy. In this case, a normal uterine pregnancy coexists with an EP. In 1948, this was a very rare condition and was reported in only 1 in 30,000 pregnancies.26 However, the ED physician should be aware that the heterotopic pregnancy is becoming increasingly common. In this regard, data from the 1980s show a rate of 1 in 10,000 pregnancies, and the most recent estimates vary from 1 in 3889 to 1 in 6778 pregnancies.27-29 However, in the case of assisted reproduction, the heterotopic pregnancy rate soars to a staggering 1-8 per 100 pregnancies.27 ------------------------------------------------- http://medstat.med.utah.edu/kw/human_reprod/lectures/clin_radiology/ First Trimester Ultrasounds Ectopic Pregnancy The most reassuring sign that an ectopic pregnancy is not present is the sonographic demonstration of a normal intrauterine pregnancy. The presence of an intrauterine pregnancy decreases the risk of a concurrent ectopic pregnancy to 1 in 30,000 for a low risk patient and 1 in 5,000 for a high risk patient (history of pelvic inflammatory disease (PID), previous ectopic, infertility, tubal surgery). Transvaginal ultrasound, with a reported accuracy of greater than 90%, should routinely be used in the evaluation for ectopic pregnancy. ------------------------------------------------- http://www.aafp.org/afp/20000215/1080.html American Family Physician, February 2000 Ectopic Pregnancy Heterotopic Pregnancy Any discussion of ectopic pregnancy would be incomplete without mention of heterotopic pregnancy (coexistence of intrauterine and ectopic pregnancies). In Europe and the United States, this condition occurs in one of 2,600 pregnancies.34 With fertility treatments, the incidence of heterotopic pregnancy increases to as high as 3 percent.34 Heterotopic pregnancy is extremely difficult to diagnose, and 50 percent of cases are identified only after tubal rupture. If retention of the intrauterine gestation is desired, the ectopic pregnancy must be treated surgically.1,12 ------------------------------------------------ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11155422&dopt=Abstract Mayo Clin Proc. 2001 Jan;76(1):90-2. Interstitial heterotopic pregnancy in a woman conceiving by in vitro fertilization after bilateral salpingectomy. Heterotopic pregnancy, defined as the coexistence of an intrauterine pregnancy and an ectopic pregnancy, occurs in approximately 1 in 100 pregnancies conceived by in vitro fertilization (IVF), particularly when multiple embryos are transferred into the uterus. The ectopic gestation of the combined pregnancy usually occurs within the ampulla of the fallopian tube. If it implants within the interstitial portion of the fallopian tube, however, the resulting interstitial pregnancy eventually can rupture through the uterus, leading to sudden, severe hemorrhage and maternal death. This article describes the rupture of an interstitial heterotopic pregnancy in a 37-year-old woman conceiving by IVF after bilateral salpingectomy. The interstitial pregnancy was removed by laparotomy to protect the intrauterine pregnancy from damage. Physicians should consider interstitial ectopic pregnancy as a cause of abdominal pain, even when a viable pregnancy occurs by IVF after salpingectomy. PMID: 11155422 [PubMed - indexed for MEDLINE] =============================================================== PROBABILITY OF SURVIVAL OF INTRAUTERINE PREGNANCY AFTER SURGERY =============================================================== http://www.ingentaconnect.com/content/repro/rebi/2002/00000005/00000003/art00016 Heterotopic triplet pregnancy: report and video of a case of a ruptured tubal implantation with living embryo concurrent with an intrauterine twin gestation Abstract: This report presents a case of triplet heterotopic gestation after intracytoplasmic sperm injection (ICSI)-IVF treatment, with a left ruptured ectopic tubal implantation with a living embryo and successful outcome of the concurrent intrauterine twin gestation. A couple whose infertility was caused by oligoasthenozoospermia was referred for ICSI treatment. Three good quality embryos were transferred at the request of the patient. Early gestational control was performed by ultrasound at weeks 5 and 7 of gestation. The patient reported to the centre during week 7 with severe abdominal pain and with signs of peritoneal irritation. Transvaginal ultrasound revealed an extra-uterine ruptured implantantion. During the concomitantly performed laparoscopic procedure, a living embryo was observed after opening the extra-uterine embryonic sac. Heartbeat activity was present and lasted for 5 min after surgical resection of the tubal implantation. The patient was discharged from hospital without complications. The intrauterine twin gestation was not affected and two healthy infants were born at week 38 of gestation. ------------------------------------------------- http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10438980&dopt=Abstract Conservative medical and surgical management of interstitial ectopic pregnancy. There were nine cases of heterotopic interstitial pregnancy. Seven patients were managed with potassium chloride injected into the ectopic pregnancy, and two patients were treated by laparoscopy. Overall, 67% of the coexisting intrauterine pregnancies resulted in successful deliveries and the remainder ended in spontaneous abortions. ------------------------------------------------- http://www.rscbayarea.com/articles/ectopic_pregnancy.html Ectopic Pregnancy Surgical vs. Medical Therapy Current Evidence-Based Review of the Medical Literature Introduction Any pregnancy located outside of the uterine cavity is defined as an Ectopic Pregnancy (EP). The vast majority (99%) of EP's occur in the fallopian tube ("tube") and ectopics currently account for 1-2% of all pregnancies. Ectopic pregnancies are potentially life-threatening, and more than 100,000 cases occur annually in the United States 1. The incidence of EP continues to increase yearly due to the occurrence of sexually transmitted diseases, prior salpingitis (tubal infections), IUD use, pelvic adhesions and other causes. The death rate from EP is about 0.3% 2. Heterotopic Pregnancy As mentioned above, the presence of both an intrauterine pregnancy and an ectopic pregnancy at the same time is termed a heterotopic pregnancy. Because most of these occur with ART procedures, an ultrasound exam of the woman's uterus should be done before surgery for removal of the ectopic pregnancy. This will result in a 67% term delivery rate of the normal intrauterine pregnancy 19. MTX therapy cannot be used with heterotopic pregnancies as it will terminate both gestations. ------------------------------------------------- http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11048410&dopt=Abstract [Heterotopic pregnancy and its occurrence in assisted reproduction] [Article in Czech] Hulvert J, Mardesic T, Voboril J, Muller P. Sanatorium Pronatal, Praha. OBJECTIVE: To assess the incidence of heterotopic pregnancy after infertility treatment using the technology of assisted reproduction. DESIGN: A prospective study of 618 women who became clinically pregnant following assisted reproduction technology (ART) procedures. SETTING: Sanatorium Pronatal, Na dlouhe mezi 4/12, 147 00 Praha 4-Hodkovicky. METHODS: Study group consists of clinical pregnancies conceived after ART procedures within the period from January 1, 1997 until June 30, 1998. A condition to be included in survey group was that there was a gestation sac detected by ultrasound or histological confirmation of ectopic pregnancy. RESULTS: Six-hundred-eighteen clinical pregnancies resulted and 23 of the pregnancies were ectopic gestations (3.7%). Seven out of the 23 (30.5%) ectopic pregnancies were heterotopic. Thus heterotopic pregnancy rate after ART was, 1.14% (1 in 88). CONCLUSION: The incidence of heterotopic pregnancy following assisted reproduction technique is relatively frequent. This condition represents a live-threatening complications of pregnancy. The prognosis for intrauterine gestation in case of heterotopic pregnancy is usually good. About 78% delivered living child at term. ------------------------------------------------- http://www.liebertonline.com/doi/abs/10.1089/104240603763487186?journalCode=gyn Journal of Gynecologic Surgery Laparoscopic Treatment of Heterotopic Pregnancy Mar 2003, Vol. 19, No. 1: 49-52 Savvas Efkarpidis, MD, Evangelos Alexopoulos, MD, PhD, MRCOG, Panayiota Antoniadou, MD, David Liu, MD, FRCOG Heterotopic pregnancy poses difficulty for diagnosis and for management. The challenge is to treat the ectopic component without risking the mother and ensuring the intrauterine conception progresses safely to full term. There are no studies comparing the various treatment modalities and their outcomes. The authors present a case of laparoscopic treatment of heterotopic pregnancy and literature review. ------------------------------------------------- http://www.obgmanagement.com/content/obg_featurexml.asp?file=2002/10/obg_1002_00036.xml Volume 14, No. 10 October 2002 Heterotopic pregnancy: an emerging diagnostic challenge Due in part to rising rates of in vitro fertilization, heterotopic pregnancy isn?t nearly as rare a condition as it was in times past. Here, the authors detail protocols for diagnosing and treating this challenging disorder. Final thoughts It is important to note that one-third of intrauterine pregnancies accompanying heterotopic pregnancy miscarry in the first (89%) and second trimesters (8.5%). Miscarriage beyond the second trimester is rare, though preterm delivery may occur-particularly when heterotopic pregnancy is accompanied by multiple births. Still, a full two-thirds of intrauterine pregnancies accompanying heterotopic pregnancy do survive to term. ------------------------------------------------- http://eastcoastivf.com/Super_Ovulation.html Superovulation/Ovulation Induction POTENTIAL RISKS AND DISADVANTAGES The development of a pregnancy following ovulation induction treatment is dependent on many factors, some of which include: the age of the woman, the diagnosis, the number of previous cycles of treatment, the number and quality of the eggs and the quality of the semen sample. There are many complex and sometimes unknown factors which may prevent the establishment of pregnancy. ====== LUPRON ====== http://www.stronghealth.com/services/womenshealth/ivf/currentpatients/ovulationinduction/lupron.cfm Lupron Description GnRh agonist Purpose Lupron is used to prepare the ovaries for stimulation with fertility medications. Lupron temporarily shuts down the messages from the brain to the pituitary gland, which then shuts down FSH and LH production. Without the production of these hormones, the ovaries can?t produce the necessary hormones to make eggs. When fertility medications are added Lupron allows the ovaries to grow multiple eggs and suppresses the selection process that only permits one egg a month to ovulate. It also prevents ovulation from occurring before the egg retrieval. ------------------------------------------------- http://www.havingbabies.com/fertility-drugs-lupron.html Lupron (leuprolide acetate) ------------------------------------------------- http://www.advancedfertility.com/ivfstim.htm Ovarian Stimulation for IVF ------------------------------------------------- http://www.fertilitynetwork.com/articles/articles-ivf.htm In Vitro Fertilization (IVF) ------------------------------------------------- http://www.rxlist.com/cgi/generic/leuprolide_wcp.htm LUPRON (leuprolide acetate) Pregnancy, Teratogenic Effects: Pregnancy Category X. (see CONTRAINDICATIONS section). When administered on day 6 of pregnancy at test dosages of 0.00024, 0.0024, and 0.024 mg/kg (1/600 to 1/6 the human dose) to rabbits, LUPRON produced a dose-related increase in major fetal abnormalities. Similar studies in rats failed to demonstrate an increase in major fetal malformations. There was increased fetal mortality and decreased fetal weights with the two higher doses of LUPRON in rabbits and with the highest dose in rats. The effects on fetal mortality are expected consequences of the alterations in hormonal levels brought about by this drug. Therefore, the possibility exists that spontaneous abortion may occur if the drug is administered during pregnancy. If this drug is administered during pregnancy or if the patient becomes pregnant while taking any formulation of LUPRON, the patient should be apprised of the potential hazard to the fetus. ------------------------------------------------- http://www.drugs.com/lupron.html Lupron leuprolide (LOO pro lide) Eligard, Lupron, Viadur What is Lupron? -- Lupron is related to a naturally occurring hormone called gonadotropin-releasing hormone (GnRH). GnRH influences the release of the hormones testosterone and estrogen in the body. -- Lupron is used to reduce the amount of testosterone or estrogen in the body. It is used for conditions such as cancer of the prostate, endometriosis (growth of uterine lining outside of the womb), uterine fibroids, and early puberty (before 8 years of age in females and 9 years of age in males). -- Lupron may also be used for purposes other than those listed in this medication guide. What should I discuss with my healthcare provider before using Lupron? -- Lupron is in the FDA pregnancy category X. This means that Lupron is known to cause birth defects in an unborn baby. Do not use this medication if you are pregnant or could become pregnant during treatment. ------------------------------------------------- http://www.fda.gov/cder/foi/nda/2001/20-011S021_Lupron.htm Lupron Depot (Leuprolide Acetate) Company: TAP Pharmaceuticals Products, Inc. Application No.: 20-011/S021 Approval Date: 9/21/01 ------------------------------------------------- http://www.medicinenet.com/leuprolide/article.htm PREGNANCY: Leuprolide should not be administered to pregnant women because there is a high chance of harm to the fetus. =============================================================== PRECAUTIONS FOR MAINTAINING INTRAUTERINE PREGNANCY AFTER AGE 40 =============================================================== http://www.send2press.com/newswire/2005-08-0831-008.shtml One Last Chance for Pregnancy: A Review of 2,705 In Vitro Fertilization Cycles Initiated in Women Age 40 Years and Above Published: Wed, 31 Aug 2005, 04:56 EDT HOFFMAN ESTATES, Ill. - August 31 (SEND2PRESS NEWSWIRE) -- Karande & Associates today announces the recently published article by Sigal Klipstein, MD in Fertility and Sterility entitled: "One last chance for pregnancy: a review of 2,705 in vitro fertilization cycles initiated in women age 40 years and above." This investigation is the largest and most detailed ever published to look at fertility success rates within this population. The study shows that, as women are waiting longer and longer to attempt pregnancy, they face a significant risk of infertility. While pregnancy rates in women aged 40-43 remain reasonable, success drops precipitously from age 44 years and on. By the end of the 45th year, there are virtually no in vitro fertilization pregnancies. ------------------------------------------------- http://www.karandeivf.com/Over40.pdf http://www.karandeivf.com/Over40_PressRelease.pdf August 2005 One last chance for pregnancy: a review of 2,705 in vitro fertilization cycles initiated in women age 40 years and above. Sigal Klipstein, MD Full length article (PDF) | WebMD review by Salynn Boyles | Press release (PDF) ***** The full-length article is 11 pages and includes full details illustrated with tables and graphs. ------------------------------------------------- http://my.webmd.com/content/article/110/109758.htm After Age 44, Fertility Successes Are Few High-Tech Infertility Rx 'Reasonable' Until Mid-40s By Salynn Boyles WebMD Medical News ------------------------------------------------- http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16084887&dopt=Citation Fertil Steril. 2005 Aug;84(2):435-45. One last chance for pregnancy: a review of 2,705 in vitro fertilization cycles initiated in women age 40 years and above. Klipstein S, Regan M, Ryley DA, Goldman MB, Alper MM, Reindollar RH. Boston IVF, Waltham, Massachusetts, USA. [email protected] OBJECTIVE: To describe live birth rates and predictors of success in 1-year age increments for women > or =40 years when initiating assisted reproductive technologies (ART). DESIGN: Retrospective database analysis. SETTING: A large university-affiliated infertility center. PATIENT(S): One thousand two hundred sixty-three women undergoing 2,705 ART cycles at age 40 or above. INTERVENTION(S): Couples undergoing ART. MAIN OUTCOME MEASURE(S): Pregnancy and live birth rates per cycle start were determined based on 1-year increments in women aged > or =40. Predictors of success, including number of embryos transferred, number of fetal heartbeats, availability of embryos for cryopreservation, and cycle day 3 FSH levels, were analyzed. RESULT(S): The overall live birth rate per cycle start was 9.7%. Cumulative live birth rates in women ranged from 28.4% if starting ART at age 40 to 0 by age 46. The overall spontaneous abortion rate was 32.6% (range, 23.9%-66.7%). Higher pregnancy rates were predicted by the greater number of embryos available for transfer, by the availability of excess embryos for cryopreservation, and by the presence of two fetal heartbeats on ultrasound. The outcome of the first IVF cycle did not predict the outcome of subsequent cycles. CONCLUSION(S): Assisted reproductive technology has a reasonable chance for success (>5%) up until the end of the forty-third year. Twins on initial ultrasound, large numbers of embryos available for transfer, and the presence of excess embryos for cryopreservation predict higher live birth rates. PMID: 16084887 [PubMed - in process] ------------------------------------------------- http://www.fertilityneighborhood.com/content/in_the_news/archive_1263.aspx Is There Still Hope After 40? 08-24-05 In what's being touted as the largest study to date of assisted reproductive success in women over 40, doctors have concluded there's still a "reasonable" chance of success in their efforts to achieve a pregnancy.1 "The biggest obstacle most women over 40 face is two-fold: diminishing ovarian reserve coupled with poor embryo quality," explained the study's first author, reproductive endocrinologist Sigal Klipstein, MD, who practices at Karande & Associates, a fertility clinic near Chicago. This in turn, boosts the risk of miscarriage, the investigators pointed out. Examining ART Results But the research team wanted to know if those challenging prospects should preclude women over age 40 from undergoing assisted reproductive technologies (ART). To better clarify this, the investigators pulled patient records related to more than 2,700 cycles involving women over 40 using in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI) between 1999 and 2002. The team performed a second analysis, pulling records of a smaller group of patients whose first IVF or ICSI occurred after age 40, during the same period. This was done to determine any differences in outcome between women who started using assisted reproductive technologies (ART) before age 40, then continued past their 40th birthday, and those who began ART for the first time in their 40s. While pregnancy rates weren't much different in those aged 41 through 43, the number of successful outcomes dropped off significantly starting with women aged 44 and above. In those aged 45, only one healthy birth resulted, and no births occurred in women beyond that age. By comparison, in the smaller group of women who began ART for the first time after age 40, the trend was the same. About 28 percent of those aged 40 gave birth (73 of 257 women), but that number slowly declined with age. By age 44, only one in 62 women had successfully given birth. Successful outcomes weren't much different for those aged 40 through 42, but were significantly lower in older women. Setting the Record Straight Otherwise, "reasonable" success using ART can be expected for women in their early 40s, they concluded. "Although rare pregnancies will occur at age 44 years and beyond, women in this age group should be strongly advised to consider other options, including egg donation and adoption, as the rates of success quickly fall from below 3% per cycle at age 44 years, to well below 1% within 1 to 2 years," the researchers wrote. ------------------------------------------------- http://cumc.columbia.edu/dept/obgyn/rightbar/newsletters/summer02.html The Center for Women?s Reproductive Care at Columbia University What are the success rates for women over 40? Birth after 40 is rare, but receives much press. You may be surprised to learn that just 2% of babies born each year in the U.S. are born to women over 40. And 75% of these are born to 40-year-olds. Why is it so difficult to conceive at 40 or 45? Difficulty is normal when trying to conceive after 40. The main obstacle is the biology of the human egg. Most eggs retrieved for IVF after 40 are abnormal and don?t lead to pregnancy. How much does IVF improve success rates? IVF dramatically improves your chances after 40. Women who are infertile at age 40 have a less than 1% chance of spontaneous conception each month. But they achieve a birth following embryo transfer 15% of the time. Using donated eggs from younger women improves this success rate to roughly 50%. What?s the upper age limit for donor egg treatment? Women up to age 55 can get pregnant at the same rate as younger women using donated eggs. After age 45, patients undergo screening for high risk factors. ------------------------------------------------- http://health.yahoo.com/ency/healthwise/hw227379 In vitro fertilization for infertility How Well It Works The number of women who give birth to a live infant after in vitro fertilization varies depending on the cause of infertility. The average success rate for IVF is about 25%. 1 However, IVF success varies widely depending mostly on the woman's age, the cause of the couple's infertility, and pregnancy history. The aging of the egg supply has a powerful effect on the chances that an assisted reproductive technology (ART) procedure will result in pregnancy and a healthy baby. Many women over age 40 choose to use donor eggs, which greatly improves their chances of giving birth to a healthy child. Age. Per year, birth rates resulting from embryo transfer using women's own eggs are about: 2 35% for women age 34 and younger. 28% for women age 35 to 37. 20% for women age 38 to 40. 10% for women age 41 to 42. 4% for women 43 and older. Own eggs versus donor eggs. Birth rates are affected by whether ART procedures use a woman's own eggs or donor eggs. Per embryo transfer: 2 Using her own eggs, a woman's chances of having a live birth decline from about 40% in her late 20s, to about 30% at age 37, to about 10% by age 42. Live birth rates are the same among younger and older women using donor eggs. At age 30 and at age 45, the average donor egg birth rate using fresh (not frozen) embryos is 47%. Frozen IVF embryos that are thawed and transferred to the uterus are less likely to result in a live birth (average 23% success) than are newly fertilized IVF embryos (average 33% success). However, frozen embryos are less expensive and less invasive for a woman, because superovulation and egg retrieval aren't necessary. 2 ------------------------------------------------- http://www.hypertension-consult.com/Secure/textbookarticles/Primary_Care_Book/113.htm Ectopic Pregnancy: Part II Spontaneous Miscarriage Up to 20% of pregnant women will experience vaginal bleeding during the first weeks of pregnancy, and as many as 50% of them will progress to miscarriage.35 The risk of miscarriage varies greatly with age. For patients younger than 20 years, the risk averages only 12%, whereas in patients older than 45 years it approaches 50%.36 Pathophysiology. Spontaneous miscarriage may result from abnormal embryo development or from maternal factors. Up to 50% of women with spotting or cramping early in pregnancy will have an abnormal intrauterine pregnancy on initial ultrasound, with many of these embryos being morphologically abnormal.39 Approximately 33% of miscarried specimens lost before 9 weeks are due to anembryonic development, termed a ?blighted ovum.?40 In this case, only an empty gestational sac is seen on ultrasound. The significant percentage of embryonic abnormalities represents a natural process that eliminates almost 95% of cytogenetic defects before birth. The rate of identified chromosome defects in miscarried embryos from the first trimester approaches 60%, and falls to 7% by the end of the 24th week.34 Threatened Miscarriage Up to 95% of pregnancies will continue to live birth if a normal fetal heart rate is found at 8 weeks gestation.46 The rate of pregnancy loss is only 1% when a live fetus is present at 14-16 weeks gestation.44 To date there is no convincing evidence that any treatment will change the outcome in patients diagnosed with threatened miscarriage. ------------------------------------------------- http://www.extenza-eps.com/RCOG/doi/full/10.1576/toag.2002.4.3.124?cookieSet=1 Complications of assisted reproduction EARLY PREGNANCY LOSS Miscarriage Several authors have concluded that the incidence of miscarriage is higher with IVF pregnancies than natural conceptions. ? The fact that miscarriage rates in IVF pregnancies are high, regardless of the cause of infertility, suggests a possible relationship to gonadotrophin therapy or multiple ovulation. ? Therefore, the apparent increase in miscarriage associated with IVF appears to be multifactorial with infertility itself, regardless of cause, being of major significance.30 Ectopic pregnancy The ectopic pregnancy rate varies between 2?11% in reported series of IVF pregnancies.31 Ectopic pregnancy rates in the general population are around 2.5%. The aetiology of ectopic pregnancy after IVF and embryo transfer is multifactorial with tubal disease being the main factor. Damaged tubes, unlike normal tubes, may not be able to propel an embryo that has migrated into the tube back into the uterine cavity.32 Reverse migration of the embryos may also be associated with the high concentration of oestradiol or an altered oestrogen: progesterone ratio.33 In addition to numbers of embryos transferred the technique of embryo transfer may contribute to the increased risk of ectopic pregnancy, by forcing the embryos through the tubal ostia by hydrostatic pressure.34 This could arise if a large volume of transfer fluid is used or if the embryo transfer catheter was placed either beyond the mid-cavity of the uterus or into the tube itself. Heterotopic pregnancy is estimated to occur in 1% of IVF pregnancies compared with an incidence of 1 in 3889?4778 spontaneous conceptions.35 OBSTETRIC OUTCOME Women who become pregnant after IVF or GIFT are at increased risk of multiple pregnancy, preterm labour, low infant birthweight and perinatal death.28,37,38, However, of these the major complication is multiple pregnancy. Dhont et al47 reported that the perinatal mortality rate in assisted reproduction singleton pregnancies, even when matched for age, parity and fetal sex, was more than twice that in control pregnancies (13.4% vs 5.9%). The incidence of congenital malformations was also significantly higher (3.1% vs 1.7% in the general population). This may, however, reflect the older age of women who conceive with IVF as the difference was lost after matching for age. ------------------------------------------------- http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8828432&dopt=Abstract Am J Obstet Gynecol. 1996 Sep;175(3 Pt 1):668-74. Very advanced maternal age: pregnancy after age 45. OBJECTIVE: Our purpose was to describe the maternal and fetal outcomes of pregnancies in women > or = 45 years old at delivery. STUDY DESIGN: A retrospective review of in-hospital deliveries after 20 weeks of gestation was performed in four Utah tertiary care hospitals for the 10-year period between 1985 and 1994. RESULTS: Seventy-nine cases were identified among 126,500 births, with an incidence of 0.63 per 1000 births. Maternal ages were 45 (n = 44), 46 (n = 21), and > or = 47 (n = 14) years. Three of the conceptions were assisted, including both twin gestations. Thirty-seven (46.8%) had obstetric complications during pregnancy; the most frequent complications were gestational diabetes (12.7%) and preeclampsia (10.1%). Median (range) gestational age at delivery was 39 (22.9 to 41.7) weeks; 12 (15.2%) deliveries occurred before 37 weeks. Eight (9.9%) karyotype abnormalities were diagnosed. The cesarean section rate was 31.7%; the most frequent indications were abnormal lie (n = 9), fetal distress (n = 5), and previous cesarean delivery (n = 5). There were no maternal deaths. Median (range) birth weight was 3466 (397 to 5085) gm; 14 (17.3%) were < 2500 gm and 16 (19.8%) were > 4000 gm. Twelve (14.8%) infants were admitted to the neonatal intensive care unit. The corrected perinatal mortality rate was 1.3% (1/78). CONCLUSIONS: In women > 45 years old at delivery maternal and fetal outcomes were generally good, but there was a high incidence of pregestational (chronic hypertension, hypothyroidism) and gestational (karyotype abnormalities, gestational diabetes, cesarean section, macrosomia) complications. This information may be helpful for counseling women between 45 and 50 years old who are considering pregnancy. PMID: 8828432 [PubMed - indexed for MEDLINE] ------------------------------------------------- http://www.marchofdimes.com/professionals/681_1155.asp Pregnancy After 35 What is the risk of birth defects in babies of women over 35? The risk of bearing a child with certain chromosomal disorders increases as a woman ages. The most common of these disorders is Down syndrome, a combination of mental retardation and physical abnormalities caused by the presence of an extra chromosome 21 (humans have 23 pairs of chromosomes). At age 25, a woman has about a 1-in-1,250 chance of having a baby with Down syndrome; at age 30, a 1-in-1,000 chance; at age 35, a 1-in-400 chance; at age 40, a 1-in-100 chance; and at 45, a 1-in-30 chance. What is the risk of miscarriage as a woman gets older? Most miscarriages occur in the first trimester for women of all ages. The rate of miscarriage in older women is significantly greater than that in younger women. A 2000 Danish study found that about 9 percent of recognized pregnancies for women aged 20 to 24 ended in miscarriage. The risk rose to about 20 percent at age 35 to 39, and more than 50 percent by age 42. The increased incidence of chromosomal abnormalities contributes to the agerelated risk of miscarriage. Does the risk of pregnancy complications and adverse pregnancy outcomes increase after age 35? While women in their late 30s and 40s are likely to have a healthy baby, they do face more complications along the way. =============== SEARCH STRATEGY =============== concurrent ectopic uterine pregnancy Heterotopic pregnancy heterotopic pregnancy rate heterotopic pregnancy successful birth heterotopic pregnancy survival rate intrauterine ivf after age 45 pregnancy after 45