MO170: Systematic Review of Patients with Chronic Kidney Disease Undergoing Fertility Treatment

Abstract

Abstract BACKGROUND AND AIMS The prevalence of chronic kidney disease (CKD) in women of reproductive age continues to rise and reduced fertility is recognized even with mild disease. A greater proportion of women with CKD are seeking assisted reproductive technology (ART) treatment; however, our understanding of treatment success and adverse outcomes is limited. Our aim was to perform a systematic review to describe pregnancy and kidney outcomes and complications of pregnancies in women with CKD following ART. METHOD The systematic review was performed with reference to the Cochrane Handbook for Systematic Reviews of Interventions and reported with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched from 1946 to May 2021: (1) Cochrane Central Register of Controlled Trials (CENTRAL), (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (3) Embase and (4) MEDLINE. Relevant review articles were also searched for additional studies. RESULTS The database search identified 3520 records, of which 35 publications were suitable for analysis. A total of 95 fertility treatment cycles were analysed in 74 women with CKD who had ART. The median age of women with CKD at the time of pregnancy was 32.0 years (IQR 29.0, 34.0 years). The majority of women had in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) (56/74; 75.7%). One woman had an autotransplant of cryopreserved ovarian tissue which led to a spontaneous pregnancy, one woman had a medicated frozen embryo transfer cycle, one woman used donor eggs and five women used gestational surrogates. Of the 95 cycles, 11 women (15%) did not have a clinical pregnancy; there were 66 clinical pregnancies from 63 women (69%). There were 81 live births in total, with 21 multifetal live births (26%). There was 1 ectopic pregnancy, 13 miscarriages and 2 still births. Seven cycles in seven women were complicated by ovarian hyperstimulation syndrome (OHSS) (7%) which were all associated with AKI. Full recovery of kidney function occurred in six women; one woman had progression of her CKD. Hypertensive disorders of pregnancy including pre-eclampsia complicated 27 pregnancies (41%). The most common mode of delivery was caesarean section (42/74, 57%). Preterm delivery (<37 weeks’ gestation) occurred in 25 (34%) births. Low birth weight (<2500 g) was present in 46 (79%) of live births and 6 (20%) of birthweights were under the 10th centile. Twelve (15%) neonates required admission to a neonatal intensive care unit (NICU). A total of 7/12 children had normal development at up to 10 years of follow-up. When comparing women with CKD requiring ART to those with natural conception, rates of preterm delivery and caesarean section were similar; however, rates of pre-eclampsia (P = .001) and multifetal deliveries were significantly higher (P < .001) in the ART cohort. CONCLUSION To our knowledge, this systematic review represents the most comprehensive assessment of fertility outcomes in patients with CKD who have assisted conception. Limitations include reporting bias due to a high reported live birth rate. Patient selection for fertility treatment and identification of risk factors remains crucial in order to maximize patient safety, screen for adverse events and optimise fertility outcomes.