Risk Assessment for Patients Considering Assisted Reproductive Technology

Publications highlighting risk assessment for individuals with cardiovascular disease during pregnancy and the postpartum, as well as those addressing longer term cardiovascular risk profiles in individuals affected by adverse pregnancy outcomes have contributed to the evolution of the cardio-obstetric space.^1-4 More recently, preconception and contraception counseling have been identified as topics on which to focus for the cardiology community.⁵ The AHA scientific statement entitled ‘Assessing and Addressing Cardiovascular and Obstetrical Risks in Patients Undergoing Assisted Reproductive Technology' comprehensively provides guidance to cardiology providers regarding risk counseling ahead of, and during, the process of building a family by focusing on fertility treatment, specifically in vitro fertilization (IVF), a form of assisted reproductive technology (ART). The statement summarizes the current literature regarding risks of ART in individuals with cardiovascular disease and possible adverse cardiovascular outcomes related to ART. It outlines a suggested approach to the evaluation of patients with CVD seeking fertility treatment, as well as modifications to therapy that can be discussed in concert with a reproductive endocrinology and infertility (REI) specialist to minimize known risks. This guidance is inclusive of psychological health support during ART. Lastly, it highlights knowledge gaps and future research directions.

What is ART, and what are the intersections of cardiovascular care and ART?

Assisted reproductive technology is defined as the in vitro handling of oocytes, embryos or both. In 2020, greater than 326,000 ART cycles were performed at 449 clinics in the United States reporting data, which yielded 79,942 live born infants.⁶ Depending on the cause of infertility, various treatment options including ovulation induction and ovarian stimulation for superovulation, which involves the use of pharmacologic treatments to induce ovulation in the former, or induce multiple mature ovarian follicles in the latter. Ovulation induction and superovulation can be coupled with timed intercourse or intrauterine insemination (IUI), non-ART procedures, in situations in which the fallopian tubes are patent and the semen parameters are above a certain threshold. In vitro fertilization (IVF), on the other hand, involves superovulation, oocyte retrieval, and fertilization in an embryology lab with subsequent embryo transfer to a uterus.^7-8

As more and more individuals and couples are requiring fertility services, the proportion of individuals with underlying cardiac disease who need either IUI or IVF are increasing.⁹

Why is ART an important topic to understand for cardiology providers?

Given the demographic trends of the US birthing population, it is increasingly important for cardiovascular providers to be aware of nuanced risk assessment surrounding ART. As of May 2024, according to the CDC, the average birthing person was 27.5 years at the time of their first child's birth – a record high in our country. This is attributable to several factors, including decline in the teen birth rate¹⁰, prioritization of higher education and career development, financial concerns (childcare, rising cost of living)¹¹. As well, more states are now mandating that private insurance companies cover fertility treatment, allowing the process to be more financially accessible. Between 2021 and 2022, the birth rate among women ages 40 to 44 rose 4%, according to a CDC report. During the same period, the birth rate rose 12% for women 45 and older. As such, more women with a higher cardiovascular risk profile are incorporating ART along their pathway to parenthood. As important as it is to understand the influence of cardiometabolic risk factors on the outcomes of ART and pregnancies arising thereof, we recall that there are now more adults living with congenital heart conditions than there are children. Also key is the personalized risk assessment for these adults desiring pregnancy, and/or for those who may consider ART.

The challenge of personalizing and communicating risk

As the authors have provided an excellent summary of current evidence regarding cardiovascular outcomes related to ART. It is now our cardiovascular community's role to recognize the outlined risk factors and to assess individual risk. Communicating that risk to patients may be a unique challenge as patients face various paths to build their family. As is true for communication of risk more broadly, clear communication, acknowledging areas where science is uncertain, are foundational pillars to guide the conversation. Contextualizing risk, discussing preventative measures, encouraging questions, providing written materials while providing anonymized anecdotal examples of how other patients have managed risk, all with an empathetic approach, have been helpful at engaging patients in shared decision making conversations.^12-14

Future research directions

The authors highlight the paucity of data as it relates to outcomes after ART in patients with cardiovascular disease; as is intuitive, this is especially true for people with under-access to fertility care. Though available data suggest a relatively lower short-term risk for (many, but not all) individuals with cardiovascular conditions using ART, the authors rightly recommend multi-center prospective studies and large databases to explicitly examine the influence of ART on cardiovascular conditions, both short and long term.

Conclusion

ART is increasingly incorporated as part of our patients' pathway to parenthood. It is important to recognize and communicate risk surrounding ART as a component of our comprehensive preconception counseling.