It’s okay I if isogenic yes the answer is I if isogenic yes IVF increases absolute risk of Ven thomism uh this risk rang in the difference St between 0.8 and about 1% and this risk is this risk is ex exactly similar to the woman using the combined oral contraceptive
PS uh the risk uh the risk of Veno thrm all occurs during the different stages of IVF even in the ABS of pregnancy or other predisposing factors the risk the risk during stimulation is exactly similar to that of pregancy unfortunately if the woman developed ovarian hyper stimulation
Syndrome and I should stress any form or any degree of ovarian hyper stimulation syndrome will increases the risk of develop Vena thrombo aism uh to about 100 fold more than uh the more than normal the second question whether pregnancy following IVF in particular increases the risk of developing ven Veno
Thomism and unfortunately the answer is yes yes the answer is true yes the uh risk is much higher if pregnancy occur and if we have confir yes sir if we have compared the natural pregnancy to that of pregnancy following IVF we found that the risk of tromo ulis is much higher during the
Pregnancy after IVF when compared with the natural pregnancy yes sir uh and this risk during pregnancy is highest during the first trimester then it will will start to decrease gradually till the end of pregnancy this is conditioned and the condition is that there should be no other predisposing
Factors in the presence of other risk factors the risk of venoth ulis will increases as pregnancy advances and these informations and this data has have been documented in many systematic reviews and meta analysis not only that not only the RIS the risk is high during the pregnancy but also
Yes the risk increases the risk persist throughout the postpartum period yes and a woman a woman with who develop thrombo ulis during pregnancy following IVF it carries a risk of tromo ulis till about 10 weeks post partum once again the risk of developing Thro ulis during the postpartum period is
Much higher in pregnancy following I when compared to the Natural pregnancy the third question whe there is any peculiar or specific RIS risk factor during your pregnancy following IVF which increases the risk of thomism or not the answer is definitely sure yes first of all I will discuss that the
IVF itself is a risk factor but the fresh Cycles no sorry sorry again again backward backward please backward yes the risk of FR Cycles is much higher than the Frozen Cycles in developable for empolis yes the number of pregnancies Market affects the risk of Thro ulis where multi pregnancy are associated with a
Much higher risk of Veno thomism when compared to the sangon pregnancy how how does IVF increases the risk of Thro empolis by many mechanism the first and is a Strang gon tropins themselves induce a h changes particularly high estrad level and all of us know that the estrad has a
Thropogenic effect which exactly similar to pregnancy no backward please backward yes it’s you should keep in mind that the urinary FSH associated with a much higher risk and this is particularly due to hhcg content next please yes the HCG you should always keep in mind
Is that the HCG is the main trigger for the coagulation Cascade and it is uncommon for thrombosis to occur before uh the woman receive HCG yes next despite all of these data and information you should be cautious and many things that you keep in mind mind
Is that the risk of Thro impol during stimulation is uncommon and the predisposing factors are usually needed and one of you may say that or ask me that you jumbled us or you have complicated the situation no I didn’t complicate it and this data indicate this data indicate that
Yes the multi-hit nature of Vena Thro impm for thomism to occur one or more risk factors are usually necessary so yes the stimulation itself carries a risk but this risk is very high in the presence of other uh risk or other predisposing factors the next question whether the clinical presentation of thrombo impm
Following IVF is is is exactly typical to the conventional thrombosis or not the answer is no yes and the the Veno Thro blism following IVF is totally different from the conventional thr impis in that it’s there is unusual and surprising predilection for upper uh upper extremities and nck
Fiction when compared to the lower LM and s in the conventional thr imp pois and always you should keep in mind that if a woman after IVF develop something in the neck or or pain in the upper LMS you should not ignore and you should not be ignore the complaint of the patient
But why why this is unusual a presentation of trompo anolis yes all of us know that the many drainage of the peronal cavity is through lymphatic through the thoracic duct which will drain into the subclavian vein yes and it has been postulated that drainage of the peronal fluid particularly following ovarian hyp
Stimulation syndrome which is very rich in inflammatory mediator will go through the the thoracic duct into Subic leavian veins and these inflammatory mediators will initiate the coagulation G get there and this is one of the theories which is explain why there is a special or particular predilection of the neck
And the upper uh lamps yes risk factors during pregnancy itself yes which increase the risk of uh Venus Thro embolism the first and the most important ovarian hyper stimulation syndrome and I will any degree of ovarian hyper stimulation syndrome the second is is the high estal level the
Third is the HCG which is the most important trigger for the process of coagulation Cascade the next is pregnancy whether single or multiple and lastly the use of synthetic estradiol for Frozen cycle preparation yes with all of us know that prevention is better than cure whether there is any
Way that can Will prevent the occurrence of this uh catastrophic event yes definitely the the implementation of what’s called ovarian H ohhs free Cycles will decrease the risk dramatically the second is single Embry transfer because many studies show that the risk is much higher in uh multiple pregnancy when
Compared with a single singl pregnancy natural cycle Frozen Embry transfer to avoid the use of the synthetic exogenous estrogen if artificial cycle is uh chosen or if the natural cycle is not possible we should always use natural estrad and if this natural estrad is not available no please we should please
Yes we should use a prophylactic and coagulant but always remember that this should not be in all cycles that that should be implemented only in the presence of other risk factor this means frozen embryo transfer with other predosing factors so you should use a prophylactic anti coagulant yes whether
There is any guidelines for the prevention of Thro ulis during pregnancy yes the only available guidelines is uh elaborated from by the Swedish Society of obric and Gynecology in 2015 yes and these guidelines the first step in preventing uh the Veno embolism is start by a preconceptional risk assessment adequate history taking adequate
Investigations should be and adequate family history in order to assess the risk of acquiring trolis during pregnancy this is very important and the second there are certain risk factors that should be kept in mind which put the woman at the highest risk of of developing Vena Thro impul the first yes
The first is the ovarian hyp stimulation Sy the second is recurrent or previous history of Vena thomism the third is antiphospholipid syndrome with Venus rism and the most important and and the most dangerous is anti-mine deficiency antipin deficiency will put the woman at the highest risk of development Veno
Throm on poisin during pregnancy or during the course of IVF itself yes the guidelines STS that routine prophylaxis or the routine use of anarine is not indicated in a patient without risk factor so if there is no risk factor hyper is not indicated however if the woman developed ovarian hyp stimulation syndrome should
She should pass through through this algorithm if she was not pregnant the anoar should contined for four weeks after resolution of the manifestation of ovarian hypers stimulation and I this again not for four weeks four weeks after resolution of the manifestation on the other hand if the patient was
Pregnant the management will be totally different this will depend upon the risk assessment if there is not any other risk factor this hin this anticoagulation should contain till the end of the first triester however in the presence of other risk factor the management will depend upon the continuation of anexar will depend upon
Your risk assessment that has been conducted before starting the I unfortunately about yes sir about 10% of patient with severe ovarian hyper stimulation syndrome develop Vena thromboembolism despite of full anticoagulation so please this patient requires an additional additional care particularly in the IC with a very extensive investigation order to detect
Any early stes of the coagulation abnormalities all of us know that the timing is very important yes when to start this Co anticoagulation it’s very important to start early the presence of any other risk factors before the start of the synthesis of the clo you should start
The inoar with the onset of your stimulation you can omit it on the day of o despite that not so essential then restart it again yes what about the amount of an exoin the woman should receive it’s variable but according to the risk assessment and this is yes one table
Which simplify according to the body weight the amount of he that’s needed a normal body with about 40 mgram per day but and but again again this is in the absence of other predisposing Factor the presence of any other predisposing Factor will change this amount if the
Woman is opas she can receive at least 80 mgram uh bir day of an exper yes sir lastly I should close this presentation with a PR storming in order to revise and take home message we should take some to our home yes if you have supposed
Confronted with a 27 years old lady she had Primal infertility six years her her Cycles were totally irregular she was obese and with the previous history of um cerebral sign of thosis yes she was treated with herin and now she was on oral antant for six months her thrombophilia scan was normal
The she was diagnosed as typical polycystic ovarian disease and has her husband was uh suffering of oo teratospermia she was allocated into an ex trial yes so the first question which protocol yes this woman is PCO definitely you will select the antagonist protocol yes the type the dosage of gonadotropin yes definitely
The recumbant FSH in this lady in particular is much much safe than the urinary FSH you want to get red of the HCG and Mild stimulation protocol is advisable in order to decrease the possibility of ovarian hyper stimulation syndrome in a woman with PCO yes whether she will receive anticoagulation or not
This lady yes definitely she is opas she has polyes ovarian disease with increased risk of uh ovan hypers stimulation syndrome not only that she has a previous history of cerebral vinus sinos thrombosis all these factors culminate in putting the woman at the highest risk for developing
Thro embolism so the those will be at least 120 milligram per day of an Exar at least yes on day 10 she had 17 uh she had 11 follicles and the E2 was about 3,000 yes now she’s ready for trigger yes I think the answer you will know it you
Will trigger it by the GnRH analog not by the HCG yes she didn’t develop manifestation of aan hyper stimulation unfortunately and she yielded four good quality uh plas system so your next plan in this lady in particular will be fresh or frozen cycle yes once again this woman is very high
Risk for developing ovarian hyper stimulation syndrome so we should implement the policy of freeze o okay with single en transfer in the naked cycle yes Frozen cycle preparation yes how you’ll prepare as we mentioned before natural cycle in this woman is possible or not yes it’s definitely not
Possible to prepare the woman using the natural cycle because her Cycles were were totally irregular so hormonal or artificial cycle is necessary so which type of estrogen you will use okay the by far the best is a transdermal estrogen which is natural estrogen which has less impact on the coagul
Cascade okay single plasto was transferred in the netive Frozen cycle unfortunately the patient was conceived the patient conceived so what’s your next plan in this woman in particular definitely you should use an exop parin throughout pregnancy the woman had three risk factors not only throughout pregnancy but at least 10 weeks post part
Yes take home message yes please you should avoid and I wait for this slide to come down yes sir yes please give this slide sometime you should avoid what’s called Hein I’m intentionally doing that in order not to for for get it you should avoid heing paradox heing paradox it
Mean that the he or Anar is used when not necessary and it is not used when is that it should be used yes and this and I am always closing my presentation with this Immortal statement life is finite while knowledge is infinite and thank you dear chair and Dear Professor that I
Have skied my uh allocated time thank you