GRASPing the risk: Managing complex patients in IVF

In recent years, the rise of women with underlying health conditions seeking fertility treatment has become a significant concern. As a fertility practitioner, I've observed first-hand how advances in medical care enable women with chronic conditions to pursue motherhood. However, these advances bring new challenges – specifically, how we manage the risks associated with these complex cases.

UK maternal health statistics paint a stark picture: pre-existing medical conditions are now the most common cause of maternal death. As a result, there has been a renewed emphasis on risk assessment and the need for continuity of care throughout a woman's fertility journey, from preconception to postnatal care.

NHS England's Maternal Medicine Networks, launched in 2021, aim to address these needs. However, the implementation of these networks has been inconsistent across the country. This patchiness in coverage creates a gap in care for women with complex conditions who require specialised support before and during pregnancy.

The reality of handling complex cases in IVF

Women with chronic medical conditions – whether it's heart disease, diabetes, or autoimmune disorders – desire to conceive just as much as anyone else. Yet, many fertility specialists are unprepared for the complexities these patients bring. The rise in maternal age and BMI among IVF patients has only added to the challenge (see BioNews 1248).

While the risks of pregnancy for women with medical conditions are well-documented, there is limited research on the IVF-specific risks these women face. This knowledge gap leaves specialists without solid guidelines, forcing us to rely on individual clinical judgment in what can be high-stakes situations.

GRASP: A new mnemonic for risk assessment

The GRASP framework I proposed in my recent review article published in the Journal of Assisted Reproduction and Genetics helps address this challenge. By focusing on five key aspects – Genetics, Retrieval, Anaesthetics, Stimulation, and Pregnancy – fertility specialists can systematically assess risks throughout the IVF process.

For instance, under 'Genetics', it's essential to revisit the potential hereditary risks of a patient's condition, even if it was diagnosed years earlier. Rapid advancements in genetics may offer new insights or even options for pre-implantation genetic testing for monogenic disorders. In cases where a patient's condition has a known genetic component, pre-treatment counselling can help guide decisions about whether IVF is the best route, or whether genetic testing can help prevent transmission of a disease.

In the 'Retrieval' phase, women with pelvic pathology, such as endometriosis, or systemic blood conditions may be at higher risk of complications like pelvic infection or bleeding during oocyte retrieval. Careful planning is required to avoid such risks, including the use of prophylactic antibiotics in select cases.

'Anaesthetics' pose their own challenges, especially in patients with significant cardiovascular or respiratory conditions. While oocyte retrieval is typically performed under sedation, medically complex patients may require more careful monitoring, not only during the procedure but also in recovery. In stand-alone clinics, where anaesthetic resources may be limited, coordinating care with hospitals is crucial to avoid life-threatening complications. Some complex patients may not be suitable to be treated in stand-alone clinics.

The 'Stimulation' phase also carries risks, particularly for women with cardiovascular or renal conditions, as ovarian stimulation can cause hemodynamic changes. Preventing ovarian hyperstimulation syndrome is critical in these cases, especially for patients prone to fluid imbalances or thromboembolism. The use of antagonist protocols and freeze-all strategies can mitigate these risks but must be tailored to the patient’s health profile.

Finally, in the 'Pregnancy' phase, women who conceive via IVF face higher risks of pre-eclampsia, gestational diabetes, and preterm birth. For those using donor eggs, these risks increase further, particularly regarding severe pre-eclampsia. Fertility specialists must be proactive in promoting single embryo transfers to reduce the likelihood of multiple pregnancies, which can further exacerbate these complications.

The NHS-private divide: A challenge for complex cases

One of the greatest challenges we face is the disconnection between private IVF clinics and NHS services. Maternal Medicine Networks play a vital role for NHS patients, but private patients may not have access to these networks during preconception. This leaves many women without the necessary pre-pregnancy care they need to safely undergo IVF.

This gap raises questions about how we ensure continuity of care for women who begin their fertility journey in private clinics. Should these patients be allowed to access before conception? While there's a strong argument for providing equal access, we also need to consider the burden this places on the NHS, particularly in regions where networks are already overstretched.

It is also worth noting that many of these private patients will subsequently have their maternity care under the NHS. If they have been able to access the NHS Maternal Medicine Networks pre-conceptionally, they will have received the best possible continuity of care, since the same professional team who helped optimise their health before pregnancy is also the one that looks after them during pregnancy.

Having access to an NHS Maternal Medicine network comes with another distinct advantage: the doctors have ready access to the patient's comprehensive medical history. This allows them to have personalised discussions and draft highly individualised plans. Private doctors, on the other hand, do not have ready access to NHS records and have to communicate with NHS services to obtain the necessary clinical information, to make a complete risk assessment.

Taking ownership: The role of fertility specialists

Traditionally, maternal medicine specialists have coordinated care for women with complex medical conditions. However, for patients undergoing IVF, fertility specialists must take on a more central role, particularly before conception. After all, it is during the IVF process where many of the medical interventions occur, and specialists need to be well-versed in the associated risks.

This shift in responsibility requires a cultural change within fertility clinics, where specialists need to take ownership of medically complex cases. By integrating multidisciplinary teams and strengthening collaboration with NHS networks, fertility clinics can provide better support for these patients.

Educating specialists for the future

A major gap in care is the lack of training for fertility specialists in managing medically complex patients. While the GRASP framework offers a structured approach, it is crucial that we invest in educating fertility professionals on the broader healthcare infrastructure and risks these patients face.

In addition, more research is needed on IVF-specific risks in complex cases. Without this data, we are left to make difficult decisions with incomplete information. National registries and larger cohort studies could help fill this gap and provide the evidence base needed to develop better guidelines.

Moving Forward: Collaboration and Change

Collaboration between fertility clinics, NHS Maternal Medicine Networks, and other healthcare providers is essential. We must bridge the gap between private and NHS care to ensure that all women – regardless of where they begin their fertility journey – have access to safe, comprehensive care.

As more women with underlying health conditions seek IVF, it is imperative that fertility specialists take a central role in managing their care. By educating ourselves, improving collaboration, and advocating for better integration between private and NHS services, we can ensure that these women have the opportunity to pursue motherhood safely.