Update. 2008; 14(6):553–61.20 20 Chen H, Xiao L, Li J, Cui L, Huang W. Adjuvant gonadotropin‐releasing hormone analogues for the prevention of chemotherapy‐induced premature ovarian failure in premenopausal women. Cochrane Database of Syst Rev. March 2019.
21 21 Dohle GR. Male infertility in cancer patients: review of the literature. Int J Urol. 2010; 17(4):327–31.
22 22 Oktay K, Cil AP, Bang H. Efficiency of oocyte cryopreservation: a meta‐analysis. Fertil Steril. 2006; 86:70–80.
23 23 The Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of the American Society for Reproductive Medicine. Essential elements of informed consent for elective oocyte cryopresevation: a Practice Committee opinion. Fertil Steril. 2008;90:134–5.
24 24 Goldman RH, Racowsky C, Farland LV, Munné S, Ribustello L, Fox JH. Predicting the likelihood of live birth for elective oocyte cryo‐ preservation: a counseling tool for physicians and patients. Hum Reprod. 2017; 32:853–9.
25 25 Aflatoonian N, Pourmasumi S, Aflatoonian A, Eftekhar M. Duration of storage does not influence pregnancy outcome in cryopreserved human embryos. Iran J Reprod Med. 2013; 11(10):843–6.
26 26 Turkgeldi L, Cutner A, Turkgeldi E, Al Chami A, Cassoni A, Macdonald N, Mould T, Nichol A, Olaitan A, Saridogan E. Laparoscopic ovarian transposition and ovariopexy for fertility preservation in patients treated with pelvic radiotherapy with or without chemotherapy. Facts Views Vis Obgyn. 2019; 11(3):235–42.
27 27 Terenziani M, Piva L, Meazza C, Gandola L, Cefalo G, Merola M. Oophoropexy: a relevant role in preservation of ovarian function after pelvic irradiation. Fertil Steril. 2009; 91(3):15–6.
28 28 Morice P, Thiam‐Ba R, Castaigne D, Haie‐Meder C, Gerbaulet A, Pautier P, Duvillard P, Michel G. Fertility results after ovarian transposition for pelvic malignancies treated by external irradiation or brachytherapy. Hum Reprod. 1998; 13(3):660–3.
11 The patient with heart disease
Anna S. Herrey1 and Catherine Nelson-Piercy2
1 Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
2 Department of Women’s Health, Guy’s and St Thomas’ Foundation Trust, London, UK
Case History 1: A 42‐year‐old woman is being assessed for IVF treatment. She smokes 20 cigarettes per day and has chronic hypertension and diet‐controlled type 2 diabetes mellitus. Her body mass index (BMI) is 33 kg/m2. She takes ramipril 10 mg once a day and simvastatin 20 mg once a day. Because of her increased risk of ischemic heart disease, she is advised to undergo ischemia testing before receiving infertility treatment.
Case History 2: A 27‐year‐old patient is attending with her partner to discuss IVF. She has had a mechanical mitral valve replacement 2 years previously for rheumatic mitral valve stenosis and is currently taking 7 mg/day warfarin. She reports normal exercise tolerance. Appropriate preconception counseling is provided, including a discussion about the choice of anticoagulant (vitamin K antagonist or low‐molecular weight heparin with anti X‐a monitoring) as well as the high risk of thromboembolic and bleeding complications she is taking (direct oral anticoagulants are ineffective in mechanical heart valves and contraindicated in pregnancy).
Case History 3: A 53‐year‐old woman with a previous medical history of breast cancer treated with chemotherapy and severe left ventricular (LV) impairment presents to the obstetric service at 14 weeks gestation. She had received IVF with oocyte donation in another country and had no preconception counseling or cardiac risk assessment prior to pregnancy. She had been advised to discontinue all her cardiac medications including ramipril and bisoprolol. The woman undergoes preconception counseling alerting her to the risk of LV function deterioration, arrhythmia and increased risk of cardiac events and possible poor fetal outcome. She is restarted on betablocker, with the plan of keeping her on this drug throughout the pregnancy (ACE‐inhibitors are contraindicated in pregnancy but not while breastfeeding).
Background
Cardiovascular disease complicates approximately 1–4% of all pregnancies and remains the leading cause of maternal death in the Western World [1,2]. The Registry of Pregnancy and Cardiac Disease (ROPAC) recognizes that structural heart disease significantly increases maternal morbidity and mortality [3]. Preexisting cardiovascular disease may deteriorate as a result of increased cardiac workload during pregnancy, and previously undiagnosed cardiac disease may be unmasked. In addition, there is an increasing cohort of older women with multiple cardiac risk factors wishing to receive fertility treatment. These women should be counseled prior to conception by a cardiologist, an obstetric physician or a high‐risk obstetrician [1].
Management options
Any cardiovascular condition which could impact on the mother’s ability to increase cardiac output and tolerate intravascular volume expansion can lead to problems in pregnancy. Data from the ROPAC registry suggest that structural heart disease significantly increases maternal risk [4]. Therefore, all women with cardiovascular disease wishing to embark on pregnancy should receive preconception counseling [5]. Assisted reproduction techniques (ART) may add to risk in this patient population: superovulation increases the pro‐thrombotic state of pregnancy, which is particularly relevant to patients at risk of thrombotic complications, e.g. those with mechanical heart valves, certain types of congenital and inherited cardiac conditions etc. Ovarian hyperstimulation syndrome (OHSS) can lead to significant fluid shifts, which may not be tolerated by women with brittle cardiovascular disease, and single embryo transfer is preferable in any woman with cardiovascular disease undergoing fertility treatment.
According to the 2018 European Society of Gynecology (ESG) guidelines on management of cardiovascular disease in pregnancy, IVF is contraindicated in any women considered to be in WHO class IV, and those in class III and/or on anticoagulation are at high risk from superovulation so that alternative methods such as natural cycle IVF should be considered [6].
Ischemic heart disease
A meta‐analysis of myocardial infarction in pregnancy, including 66,470,100 pregnancies from high income countries, found the pooled incidence of myocardial infarction in pregnancy was 3.34 per 100,000 (95% CI 2.09–4.58) with a maternal fatality rate of around 5% [7]. Currently in the UK, approximately a quarter of all cardiovascular deaths in pregnancy are due to myocardial ischemia. With increasing prevalence of obesity, type 2 diabetes and advanced female age, the incidence of acute coronary syndromes in pregnancy is likely to rise, and with every year of increasing maternal age, the risk of myocardial infarction rises by 20% [8]. Therefore, women with multiple risk factors for coronary disease such as hypertension, diabetes, smoking, dyslipidemia and older reproductive age should have a cardiac assessment prior to undergoing ART.
A high index of suspicion is needed to diagnose acute coronary syndrome (ACS) in a young pregnant or postpartum patient. As in the nonpregnant patient, there is often a history of chest pain, palpitations and breathlessness. However, presentation may be atypical with dizziness, nausea or epigastric pain without chest pain. Interpretation of the ECG may be challenging with T‐wave inversion and ST shift frequently seen in the pregnant population in the absence of coronary ischemia. ST elevation, however, is always abnormal, and elevated troponin levels, even in the presence of preeclampsia, should trigger
