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8 The patient with thrombophilia
Yorain Sri Ranjan and Ying C. Cheong
Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK; Complete Fertility Centre, Princess Anne Hospital, Southampton, UK
Case History: A 35‐year‐old solicitor with a 3‐year history of unexplained subfertility presented for IVF treatment. She had a deep venous thrombosis (DVT) when she was 22 years old whilst taking the oral contraceptive pill. All investigations for thrombophilia were then negative. She is fit and well. Her body mass index (BMI) is 35; she is a nonsmoker and only drinks alcohol socially. Her partner is 34 years old and is fit and well. He has a normal semen analysis. The patient and her husband have come for a consultation regarding their IVF treatment but are concerned about the risks associated with her previous DVT.
Background
Thromboembolism is a rare complication of ovarian stimulation for IVF. The incidence has been estimated to be 1.6 per 100,000 cycles [1], and the majority of cases of thromboembolism reported in the literature are associated with the presence of risk factors for thromboembolic disease [2]. A 2017 systematic review has demonstrated that the frequency of venous thromboembolism (VTE) during pregnancy in patients after IVF, with or without ovarian hyperstimulation syndrome (OHSS), varies between 0.8 and 25 per 1,000 cycles (cf. 0.17–2.5 per 1,000 for natural pregnancies) [3]. Furthermore, in women who experience OHSS in fresh IVF cycles, there is almost a 100‐fold increased risk of VTE in the first trimester, as compared with natural conception [4]. It is therefore important to identify women at increased risk of this complication in order to provide appropriate counseling and management, and to allow preventative steps to be taken where necessary. Venous thrombosis is a potentially serious disorder which may often lead to post‐thrombotic syndrome causing chronic morbidity. Because women undergoing IVF are generally young and active, this may afflict their lives for many years.
The pathogenesis of venous thrombosis is complex and not completely understood. Ovarian stimulation results in a hyperestrogenic state, which has been thought to be associated with hypercoagulability and increased risk of deep venous thrombosis (DVT).
