Precautions for Beta Thalassemia Patients Undergoing IVF Stimulation
Patients with beta thalassemia undergoing IVF stimulation require careful cardiac assessment and thromboprophylaxis to prevent potentially life-threatening complications.
Cardiac Assessment Before IVF
- Comprehensive cardiac evaluation is essential before starting IVF stimulation, including assessment of heart T2* and cardiac function and dimensions 1
- Annual electrocardiography and echocardiography should be performed to identify pre-clinical cardiac disease that could be exacerbated during IVF 1
- Iron overload status should be evaluated as it may result in cardiac complications during the hormonal changes of IVF stimulation 1
- Patients with severe heart or liver iron overload may require intensified iron chelation therapy before proceeding with IVF 1
Thromboprophylaxis During IVF
- Prophylactic anticoagulation with heparin or low molecular weight heparin (LMWH) is strongly indicated during IVF stimulation due to increased thrombosis risk 1
- Splenectomized beta thalassemia patients have particularly high thrombotic risk and require careful anticoagulation monitoring 1
- LMWH (typically enoxaparin 40 mg daily) should be started at the beginning of ovarian stimulation, withheld 24-36 hours before oocyte retrieval, and resumed following retrieval 1
- Continue anticoagulation until estrogen levels return to near-physiologic levels if no pregnancy occurs 1
Monitoring During IVF Stimulation
- Continuous cardiac monitoring is recommended during IVF stimulation in patients with significant cardiac iron loading 1
- Hemoglobin levels should be maintained around 10 g/dL during the stimulation process to ensure optimal outcomes 1, 2
- Monitor for signs of ovarian hyperstimulation syndrome, which carries additional thrombotic risk in thalassemia patients 1
- Consider ovarian stimulation protocols that yield lower peak serum estrogen levels to reduce thrombosis risk 1
Embryo Transfer Considerations
- Single embryo transfer (SET) is strongly recommended to avoid multiple pregnancies, which significantly increase cardiovascular stress 1
- The decision to perform double embryo transfer instead of single embryo transfer should not be based on endometrial characteristics 1
- Transfer of more than two embryos is not recommended under any circumstances due to high risk of complications 1
Management of Complications
- Have a plan for managing potential cardiac decompensation, which may require specialized care at a center experienced in treating thalassemia patients 1
- Avoid aggressive inotropic therapy if cardiac complications develop, as this can be detrimental in thalassemia patients 1
- Minimum diuretic treatment should be used if needed, as maintaining preload is important in thalassemia patients 1
- Be prepared to manage arrhythmias, which may occur more frequently in patients with cardiac iron loading 1
Special Considerations
- Consider preimplantation genetic testing for monogenic disease (PGT-M) to prevent transmission of beta thalassemia to offspring 3, 4
- Patients with beta thalassemia minor should also be monitored for worsening anemia during potential pregnancy 2
- A multidisciplinary team including a cardiologist with expertise in iron-related cardiac disease should be involved in the care of these patients 1
Post-IVF Care
- If pregnancy is achieved, continue thromboprophylaxis throughout pregnancy for patients with significant iron overload or splenectomy 1
- Monitor cardiac function carefully throughout pregnancy as blood volume and pressure changes may compromise heart function 1
- Be aware that blood consumption may increase during pregnancy, potentially worsening iron overload when combined with interruption of chelation therapy 1