Hardly a month goes by without reading or hearing a media report of some or other catastrophe that a woman undergoing IVF has experienced. It was not long ago following the tragic death of the Saturday Night Live star Gilda Radner from ovarian cancer and the concern that it was her use of fertility drugs that caused or contributed to the disease. Then there were the numerous reports suggesting that babies born following IVF are at an increased risk of birth defects and of developing autism. Other reports have suggested that women receiving fertility drugs as part of an IVF procedure are invariably at serious risk of ovarian hyperstimulation with its sometimes life endangering complications. Most recently there was a report suggesting that the performance of intracytoplasmic sperm injection (ICSI) causes an increased risk of birth defects. Patients/couples seeking IVF treatment are highly vulnerable to alarmist reports, which in many cases, turn out to be “much ado about nothing.” Nevertheless, it is well to recognize that almost all patients/couples destined to undergo IVF will pose the question as to whether the process itself is safe for them and for their prospective offspring.

To start with, it is important to recognize that no medical intervention is totally devoid of risk. IVF is no exception to this rule. However, any decision regarding whether to proceed with a medical treatment must take the risk/benefit ratio into account. When it comes to IVF, the risks are not the same for all cases. Some patients/couples are at very low risk while others may be at higher risk. As with all medical procedures, it is essential to provide patients/couples with sufficient information with which to make an informed decision. Consider the following:

On average, women trying to conceive through IVF tend to be older. Accordingly, these women are thus more likely to have diseases such as hypertension and diabetes mellitus when they conceive. Both of these conditions can add a significant risk in any ensuing pregnancy. In addition, older women are more likely to have an anatomical reproductive disease such as uterine fibroids and/or endometriosis. Obviously, the greater the anatomical distortion, the more difficult it would be to access the ovaries or perform an embryo transfer, and accordingly, the greater the likelihood of causing bleeding and infection. Finally, there is the fact that babies born to older women are more at risk of chromosomal birth defects such as Down’s syndrome and of autism.

There is no doubt that the proliferation of IVF has been accompanied by a significant increase in the incidence of IVF multiple births, especially high-order multiples (triplets or greater) which in turn, leads to a much higher rate of premature births. These often have serious risks and consequences to the offspring as well as for the families.

Very young women and women who do not ovulate or who ovulate irregularly, are at a much greater risk of developing severe ovarian hyperstimulation syndrome following the administration of fertility drugs in preparation for IVF. Such complications can be life endangering if not managed expeditiously and properly.

Certain women are at an increased risk of developing blood clots during pregnancy as a result of an underlying condition known as thrombophilia. These clots can affect the placenta and so compromise growth and development of the baby. Sometimes clotting occurs in the deep veins of the lower limbs or pelvis. Such clots, should they become dislodged, can travel to the lung or brain with serious or even lethal consequences.

One important risk associated with IVF that is often overlooked is the fact that in some women, it causes such a degree of emotional destabilization as to unmask serious and often persistent psychological problems.

The question of course is whether such risks can be mitigated through preemptive prevention, evaluation, and management.

The performance of preimplantation genetic diagnosis can be used to assess the chromosomal genetic integrity of the woman’s eggs/embryos and can allow for the selective transfer of embryos that are free of chromosomal abnormalities. Once pregnant, timely performance of prenatal genetic testing through chorionic villus sampling (CVS) in the first trimester and amniocentesis early in the second trimester can detect chromosomal abnormalities that would warrant consideration of pregnancy termination. Unfortunately there is no prenatal test that can predict the subsequent occurrence of autism in the offspring, but this risk is small. It should, however, be discussed with older women who contemplate IVF.

Pregnancy induced complications such as preeclampsia and gestational diabetes are often predictable. Women that are markedly overweight, have a family history of diabetes, have polycystic ovarian syndrome (PCOS), etc., are more at risk of developing such complications during pregnancy. The performance of certain tests will go a long way towards identifying those women most at risk for developing such conditions. These include but are not limited to EKG, blood chemistry and a glucose tolerance test. The absence of any such predisposition in older woman significantly reduces there level of risk during pregnancy. In some cases, preemptive treatment, while not totally eliminating the risk of pregnancy-induced complications, can minimize it.

There is no doubt that IVF has caused a virtual explosion in the incidence of multiple births and that this represents the biggest risk associated with undergoing the procedure. Multiple births, especially high order multiples (triplets or greater) often times result in preterm deliveries. Premature babies in turn have a much higher mortality rate, and a large percentage of those that do survive arduous, prolonged and expensive treatment in neonatal intensive care units are left with long-term health problems that impact the quality of their lives, the lives of their caregivers, and society as a whole.

The main reason for high-order multiple IVF births is the transfer of multiple embryos at one time. Such practice (as evidenced by the recent “Octomom” experience) is irresponsible and inexcusable, given newer methods for identifying “competent” embryos. Newer genetic techniques such as the use of comparative genomic hybridization (CGH) to identify those embryos that are most likely to make a baby, now allow for fewer embryos to be transferred without compromising the chance of success. BUT it will take a long time for this new technology to gain a strong foothold – especially since it involves the additional cost associated with sophisticated genetic testing.

Severe ovarian hyperstimulation can be avoided through the use of a procedure known as “prolonged coasting” (see elsewhere) which completely eliminates the associated life-endangering risks.

Thrombophilia can be diagnosed through blood testing prior to the initiation of IVF. Appropriate treatment with high dosage folic acid and/or heparin (e.g. Lovenox, Clexane) starting as soon as pregnancy is diagnosed and continuing throughout gestation, will go a long way towards preventing related complications.

Finally, it is important not to ignore the emotional/psychological risks associated with IVF. It is my opinion that all patients need psychological support prior to and during IVF. While in most cases such support can be provided by a seasoned and well trained medical team of physicians and nurses, it is essential at all times to be on the lookout for those patients whose demeanor and behavior suggests severe emotional vulnerability. They should be referred for appropriate psychological counseling (and in some cases psychiatric treatment) prior to proceeding with IVF.

I wish to re-emphasize that IVF will never be a totally risk-free procedure. However, it is important to recognize that not all reports by sensationalistic media are necessarily valid. Often times the risks and complications that occur with IVF are related to the woman’s underlying health rather than to the process of IVF itself. As an example, after the Gilda Radner debacle, a large retrospective study undertaken and reported on in a highly prestigious medical journal concluded that fertility drugs increased the risk of ovarian cancer. This evoked such a degree of alarm that subsequently and for at least a decade, virtually every patient undergoing IVF required detailed advanced counseling and many IVF physicians even required that their patients sign a release form, exonerating them from any risk should ovarian cancer develop in the future.

Ultimately, after a few well conducted prospective studies showed that there was no association between the use of injectable fertility drugs and the subsequent development of ovarian cancer, things returned to normal. More recently, a similar alarmist publication suggested there was a link between the performance of ICSI and birth defects. Subsequent multicenter studies showed that it was not the performance of ICSI itself that caused the problem, but rather the underlying sperm dysfunction that mandated the treatment in the first place. These are but two of numerous examples that demonstrate how and why it is so important not to overreact when there is a media report of an adverse consequence associated with IVF.