Chan W S, Dixon M E
Department of Medicine and Obstetrics & Gynecology, Women's College Hospital and Sunnybrook Health Sciences Centre, 76, Grenville Street, Toronto, Ontario, Canada M5S 1B2.
Thromb Res. 2008;121(6):713-26. doi: 10.1016/j.thromres.2007.05.023. Epub 2007 Jul 30.
Since its development over 25 years ago, the use of assisted reproductive technology (ART) is on the increase. Along with its use, are also reports of thromboembolic complications (TEC); these events could resulted in significant maternal morbidity and even mortality. In this article, we reviewed the general principles of ART. We also performed a search of all published cases of TEC associated with ART, and summarized the results of studies investigating underlying hemostatic changes with ART. The goal of this article is to provide non-fertility specialists an understanding of ART, so as to better manage TEC when they occur in predisposed patients. The most common ART procedure performed today, is in-vitro fertilization-embryo transfer (IVF-ET). The process of IVF involves the use of exogeneous hormones to achieve cycle control, stimulate the ovaries, and support implantation. During this process, supraphysiological estradiol levels can result. One major complication of this intervention, ovarian hyperstimulation syndrome (OHSS), can be associated with both arterial and venous thrombotic complications. These events (especially venous thrombosis) have also been reported to occur weeks after OHSS has resolved; and they can present in unusual sites (upper extremities) resulting in treatment challenges. From current available studies, it is clear that with ovarian stimulation, both the coagulation and fibrinolytic systems are activated. This activation appears to be exaggerated and prolonged with the development of OHSS. Whether these changes are sufficient by themselves to explain the occurrence of TEC is yet unknown. Future studies should be focused on defining the frequency and risk factors of these complications; provide a closer examination of the resultant changes in the coagulation cascade during ART, OHSS and early pregnancy; and investigating the appropriate treatment and thromboprophylaxis for patients undergoing a procedure considered "elective".
自25年前辅助生殖技术（ART）问世以来，其使用量一直在增加。随着其应用，也有血栓栓塞并发症（TEC）的报道；这些事件可能导致严重的孕产妇发病甚至死亡。在本文中，我们回顾了ART的一般原则。我们还搜索了所有已发表的与ART相关的TEC病例，并总结了研究ART潜在止血变化的研究结果。本文的目的是让非生殖专家了解ART，以便在易感患者发生TEC时能更好地进行管理。当今最常见的ART程序是体外受精-胚胎移植（IVF-ET）。IVF过程涉及使用外源性激素来实现周期控制、刺激卵巢并支持着床。在此过程中，可能会出现超生理水平的雌二醇。这种干预的一个主要并发症——卵巢过度刺激综合征（OHSS），可能与动脉和静脉血栓形成并发症有关。这些事件（尤其是静脉血栓形成）也有报道在OHSS缓解数周后发生；并且它们可能出现在不寻常的部位（上肢），从而带来治疗挑战。从目前可得的研究来看，很明显在卵巢刺激时，凝血和纤维蛋白溶解系统都会被激活。随着OHSS的发展，这种激活似乎会加剧和延长。这些变化本身是否足以解释TEC的发生尚不清楚。未来的研究应集中于确定这些并发症的发生率和危险因素；更仔细地检查ART、OHSS和早孕期间凝血级联反应的相应变化；以及研究对接受“选择性”手术患者的适当治疗和血栓预防措施。
