Concurrent reciprocal IVF and risk of pre-eclampsia

Background

Reciprocal IVF is an established method for lesbian couples to have a child to whom they both have a biological connection. It involves one partner being the genetic parent by providing the oocytes which following fertilisation are then implanted in the other partner’s womb who then acts as the gestational parent (Marina et al. 2010).

Pregnancy from donated oocytes is a significant risk factor for pre-eclampsia (Giannakou et al. 2018) but NICE guidelines do not currently recommend antenatal low dose aspirin prophylaxis in this group (National Institute for Health and Care Excellence (NICE) 2019).

Angiogenic markers such as PLGF provide a new diagnostic test for pre-eclampsia in patients at risk (Duhig et al. 2019).

We report a case where both partners in a lesbian couple underwent concurrent reciprocal IVF and a PLGF test diagnosed a high risk of pre-eclampsia in one partner.

Case report

Before undergoing Reciprocal IVF neither partner was informed about the increased pre-eclampsia risk.

At our unit, we follow NICE risk-based guidance for the screening of pre-eclampsia, like most UK units, and do not implement the Foetal Medicine Foundation screening algorithm, nor perform routine uterine artery dopplers at the time of the dating or anomaly scan.

Partner A aged 39 conceived first. She was at high risk of pre-eclampsia according to NICE guidance so she was prescribed low dose aspirin in early pregnancy and asked to self-monitor her blood pressure. Her blood pressure was normal throughout her pregnancy and she did not develop pre-eclampsia. She delivered via emergency c-section after admission with PPROM at 35 weeks. The baby was 2040 g and was transferred to NICU following poor feeding and weight loss at 24 hours. Mother and baby were discharged well, 2 weeks later.

Partner B aged 38 conceived 15 weeks later and no additional management was instigated initially as she was not deemed high risk for pre-eclampsia according to NICE guidance. At 20 weeks’ she was referred to the foetal medicine unit due to a FL <3^rd centile. She had a negative TORCH screen and a low risk NIPT for foetal aneuploidy.

At 24 + 6 weeks it was determined that she had IUGR with the FL <3^rd centile with an estimated foetal weight on the 7^th centile without clinical signs of preeclampsia. At 28 + 6 weeks she was diagnosed with gestational hypertension without proteinuria. In view of her symptoms, a PLGF test was performed which was <12 mg/ml.

At 33 + 5 weeks she was admitted with a blood pressure of 152/98, significant proteinuria, and diagnosed with PET. She delivered at 34 + 0 weeks via emergency c-section due to worsening hypertension and raised pulsatility index in the foetal umbilical artery doppler. A 1560 g (3^rd centile) baby was born in good condition and discharged after 3 weeks in the NICU. Partner B was normotensive at 8 weeks without requirement for antihypertensive treatment.

Discussion

Pre-eclampsia develops in around 5% of pregnancies worldwide (Schwarze et al. 2018) and early diagnosis is key to reducing adverse maternal and foetal complications. Current NICE guidelines for pre-eclampsia screening use a combination of maternal risk factors, blood pressure measurements and urinalysis. However, this detects less than 30% of women who will develop pre-eclampsia (Karin et al. 2011).

Our experience, highlighted by this case report, suggests that patients considering Reciprocal IVF are properly counselled about the significantly increased pre-eclampsia risk and the possible maternal and foetal complications that may arise as a result, along with alternative options.

PLGF is a diagnostic tool that can improve maternal outcomes in women at high risk of pre-eclampsia by early detection thereby allowing for appropriate antenatal surveillance and timing of delivery (Duhig et al. 2019).

PLGF levels are often abnormally low both in women with pre-eclampsia and in women who will likely develop pre-eclampsia (Chau et al. 2017). The varied clinical presentation of pre-eclampsia means PLGF levels can be very valuable as a result <12 can confirm placental dysfunction and allow risk assessment of women who do not yet meet all diagnostic criteria. Furthermore, incorporating PLGF testing into care for women with suspected pre-eclampsia has the potential to save £532 per woman tested (Duckworth et al. 2016). PLGF was a useful predictor for pre-eclampsia in Partner B and enabled closer monitoring for PET signs.

Daily low-dose aspirin has been found to significantly decrease the risk of developing pre-eclampsia in high-risk women provided it is started before 16 weeks (Roberge et al. 2018) and reduces the risk of having an SGA baby by 16% (Duley et al. 2019). It is notable that Partner A was prescribed low-dose aspirin early and did not develop pre-eclampsia.

Undergoing IVF using donor oocytes has been found to be a significant risk factor for pre-eclampsia as it results in at least a 4 fold increase risk of developing the condition in comparison to IVF using autologous oocytes, independent of age and parity (Schwarze et al. 2018).

If Reciprocal IVF or donor oocytes are the chosen assisted reproductive technique, we recommend consideration of low-dose aspirin in early pregnancy. PLGF levels may also allow prompt detection of risk and appropriate antenatal scheduling. We suggest that ‘pregnancy from donated oocytes’ becomes a documented risk factor for pre-eclampsia under NICE guidelines.

Patient consent

Written informed consent of both participants was given to be included in this case report, ethics committee approval was unnecessary due to the nature of the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).