Yarışılabilir Olmayan Talebin Kaldıraç Olarak Kullanılması

TERMO DE CONSENTIMENTO LIVRE E ESCLARECIDO

“Avaliação da Pressão Arterial e da Filtração Glomerular Estimada em Pacientes Submetidas à Estimulação Ovariana para Fertilização in Vitro”

Você está sendo convidada a participar de uma pesquisa de Mestrado do Programa de Pós-Graduação em Medicina do Hospital São Lucas da PUCRS que tem como objetivo principal avaliar a pressão arterial e o funcionamento renal das pacientes que serão submetidas à fertilização in vitro – FIV (união do óvulo ao espermatozóide para formação de um embrião em laboratório, com sua posterior transferência para o útero).

O trabalho está sendo realizado pela ginecologista Roberta Soletti Musachio, sob a orientação dos professores Dr Ivan Carlos Ferreira Antonello e da Dra Mariangela Badalotti. Você será submetida à coleta de sangue e urina em dois momentos: no primeiro dia do processo de estimulação ovariana e no dia em que os folículos atingirem determinado tamanho (em torno do 6º dia do ciclo menstrual), visualizados por ecografia transvaginal.

O estudo não trará riscos além daqueles já relacionados ao tratamento empregado, como gravidez múltipla, sangramento vaginal ou risco anestésico no momento da punção dos ovários.

Dentre os benefícios, podemos citar a oportunidade de conhecermos melhor a variação da pressão arterial e do funcionamento dos rins das pacientes em estimulação dos ovários para FIV.

Ressaltamos que a concordância em participar deste estudo não implica necessariamente em qualquer modificação no tratamento a que você está sendo submetida. Da mesma forma, a não concordância em participar deste estudo não alterará de maneira nenhuma o tratamento já estabelecido.

__________________________ ________________________ Rubrica da pesquisadora Rubrica da paciente

Eu, _______________________ (paciente ou responsável) fui informada a respeito dos objetivos da pesquisa acima de maneira clara e detalhada. Recebi informação a respeito do tratamento recebido e esclareci minhas dúvidas. Sei que em qualquer momento poderei solicitar novas informações e modificar minha decisão se assim eu o desejar. A Dra Roberta Soletti Musachio certificou-me de que todos os dados desta pesquisa serão confidenciais, bem como do fato de que o meu tratamento não será alterado em função deste estudo. Fui informada de que, caso haja danos à minha saúde, causados diretamente pela pesquisa, terei direito a tratamento médico e indenização conforme estabelece a lei. Também sei que, caso existam gastos adicionais, estes serão absorvidos pelo orçamento da pesquisa. Caso tiver novas perguntas sobre este estudo, possa ligar para Dra Roberta Soletti Musachio no telefone (51) 33361715. Declaro que recebi cópia do presente Termo de Consentimento.

______________________ ___________________________ ___________ Assinatura da Paciente Nome Data

______________________ ___________________________ ___________

Assinatura da Pesquisadora Nome Data

Este formulário foi lido para _______________________________ (paciente) em ___/___/____ pela Dra Roberta Soletti Musachio enquanto eu estava presente.

______________________ ___________________________ ___________ Assinatura de testemunha Nome Data

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Anexo 4 - Artigo Original em Inglês.

BLOOD PRESSURE, HEART RATE AND RENAL FUNCTION IN OVARIANSTIMULATION TOIN VITRO FERTILIZATION

ROBERTA SOLETTI MUSACHIO1, MARIANGELA BADALOTTI2, IVAN CARLOS FERREIRA ANTONELLO,1,3,

1

Medicine Pos Graduation Program at Medicine School of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Avenida Ipiranga, 6690, CEP 90610- 000,Porto Alegre, RS, Brazil. E-mail: [email protected]

2

Gynecology Service at Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Avenida Ipiranga, 6690, CEP 90610-000,Porto Alegre, RS, Brazil. E-mail: [email protected]

3

Nephrology Service at Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Avenida Ipiranga, 6690, CEP 90610-000,Porto Alegre, RS, Brazil. E-mail: [email protected]

Running tittle: BLOOD PRESSURE, KIDNEY AND IN VITRO FERTILIZATION

Correspondence to:

Roberta Soletti Musachio Avenida Ipiranga, 6690/201

CEP: 90.610-000 - Porto Alegre, RS, Brasil Tel: +55 51 33361715

ABSTRACT

OBJECTIVE: To evaluate blood pressure (BP), heart rate (HR), albuminuria (AL), and glomerular filtration rate (GFR) of patients undergoing ovarian stimulation to in vitro fertilization (IVF).

METHODS: From March to September 2013 this quasi-experimental design analyzed the variation of baseline and after BP levels, HR, AL, and GFR from 75 subjects. Blood pressure was measured after a five minutes at rest. Glomerular filtration was estimated by CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. Follicular growth was assessed using serial ultrasound scans.

RESULTS: Median patient age was 36,89 years. Thirty-three (44%) women got pregnant, and 9 (12%) cycles were complicated by ovarian hyperstimulation. No statistically significant associations were found between systolic BP levels (P=0,945), diastolic BP levels (P=0,802), and GFR (P=0,301) before and after ovarian stimulation. However, this study found a statistically significant correlation of HR (P=0,012) and AL (P=0,002) with ovarian stimulation. There was no statistically significant difference in the modification of variables before and after stimulation between patients who got pregnant from those who did not pregnant, as well as the group who developed ovarian hyperstimulation compared with group that developed the expected number of follicles. Three patients developed acute kidney injury.

CONCLUSION: Ovarian stimulation to IVF does not change the BP levels, and GFR of patients undergoing it. There is statistically significant increasing of HR and AL, but without clinical relevance. Pregnancy and ovarian hyperstimulation does not alter the pattern of the study variables.

Keywords: Arterial blood pressure, renal function, ovarian stimulation, in vitro fertilization, pregnancy.

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INTRODUCTION

Worldwide more than 70 million couples are infertile (1). Infertility is the absence of clinically detected pregnancy after twelve months of regular sexual life without the use of contraception (2). Due to the choice of delaying motherhood, nowadays, and the increasing prevalence of the disease, the techniques of assisted reproduction occupy large space in medical care to infertile couples (3).

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of assisted reproduction technology (4).The mild form, which has little clinical consequence, occurs in about 25% of in vitro fertilization (IVF) cycles. There are changes related to stimulation, particularly in the ovarian hyperstimulation, which increase vascular permeability and activate the renin-angiotensin-aldosterone system (5), as well as a straight correlation between plasma renin activity and OHSS severity. Follicular fluid and ascetic angiotensin II concentration is higher than the one found in the plasma (6). It’s unknown if patients undergoing IVF cycles have hemodynamic changes or renal damage previous to pregnancy considering the knowledge of hemodynamic and renal physiology pattern owned to pregnancy onset.

Due to rising searches for treatments in reproductive medicine and toward the best understanding of renal and hemodynamic pattern in this situation, the study assessed BP, HR, and AL of patients undergoing controlled ovarian stimulation to IVF. Italso evaluates this variable pattern in accordance with chronological age comparing its evolution to pregnancy or absence of pregnancy as well as physiologic stimulation or ovarian hyperstimulation.

MATERIAL AND METHODS

Study Design

This quasi-experimental design analyzed the variation of baseline and after BP levels, HR, AL, and GFR from infertile patients seen in the Clínica Fertilitat - Reproductive Medicine Center, from March to September 2013.

This study included women undergoing ovarian stimulation to IVF. Exclusion criteria were arterial systemic hypertension (ASH), previous chronic kidney disease (CKD), use of drugs that could change BP or serum creatinine, and poor ovarian response to hormonal stimulation.

ASH includes previous arterial hypertension, use of antihypertensive drugs, two blood pressure measurements showing systolic BP ≥140 mmHg or diastolic BP ≥90

mmHg obtained on first visit. We considered CKD (7) the presence of hematuria,

increased AL levels or GFR <60 ml/min per 1.73 m².

It is thought poor ovarian response to hormonal stimulation controlled by not producing ovarian follicles with a mean diameter greater than 10 mm until Day 8 of the menstrual cycle.

This study was approved by the Ethics and Research Committee of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil. All patients signed an informed consent term to participate in the study.

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Treatment Protocol

The patients underwent controlled ovarian hyperstimulation using gonadotropin- releasing hormone (GnRH) antagonist. Ovarian maturation was achieved by the

administration of recombinant follicle-stimulating hormone (rFSH) and/or human menopausal gonadotropin (hMG) until at least 3 follicles reached a mean diameter of 18 mm, and then recombinant human chorionic gonadotropin (hCG) was administered for oocyte maturation. Follicle puncture was performed 36 hours after hCG injection.

Measurement of study variables

Baseline creatinine and AL levels were measured. Creatinine was measured by an automated Jaffé reaction; AL was determinated by turbidimetric immunoassay. On day 2 or 3 of the menstrual cycle, BP and HR were measured and the first vaginal ultrasound scan was performed.

BP was measured using an aneroid sphygmomanometer after the participants

had rested for 5 minutes in a sitting position. The lower end of the blood pressure cuff

was placed two to three centimeters above the left arm’s antecubital fossa. It was told that they did not smoke, eat or practice physical exercises for at least 30 minutes before measurements. We obtained two measures separated by one or two minutes and it was used the second one for record. The per minute HR verification was performed after the BP measurement, using the pulse of radial artery by counting over 30 seconds and doubling the result.

GFR was estimated from serum creatinine, sex, age, and race using the CKD- EPI equation (9, 10). This equation was developed to provide a more accurate estimate of GFR, especially when it’s higher than 60 mL/min per 1.73 m2.

The patients were followed up using serial ultrasound scans (every 3 or 4 days) to visualize the growing follicle. When the ovarian follicles are judged to be mature, we proceeded to oocyte retrieval, it was measures BP, HR, creatinine, and AL for the second time. Use of vaginal progesterone for luteal phase support was initiated on the day of oocyte retrieval. Embryo transfer was performed about 72 hours after egg retrieval.

Pregnancy outcome was defined as a positive beta-hCG test and an ultrasound scan showing a gestational sac and a live embryo. Ovarian hyperstimulation included a large number of small follicles (8 to 12 mm) seen on ultrasound scans (11).

Statistical analysis

The study data were analyzed using the Statistical Package for the Social

Sciences (SPSS) for windows (version 16).Continuous variables were expressed as

means with standard deviations. We use Student t-test for comparing the means of two samples. Categorical variables were expressed as proportions. The level of significance was established at P< 0.05.

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RESULTS

The study began with 84 participants undergoing ovarian stimulation. Of these, nine were excluded, leaving 75. An algorithm, including exclusions, is shown in Figure

1.

Median patient age ± standard deviation was 36.89 ± 3.9 years. One patient (0,75 %) was african american, and everyone else were caucasian women. Thirty-three (44%) women got pregnant, and 9 (12%) cycles were complicated by ovarian hyperstimulation. This data are available in Table 1.

Table 1: Patients undergoing in vitro fertilization included in study (n=75).

Variables Médian+ Standard

Deviation orAbsolute Number and Percentage Age 36,89 + 3,9 Ethnic 74 (99,25%) Pregnancy 33 (44%) OvarianHyperstimulation 9 (12%)

Pregnancy + Ovarian Hyperstimulation 6 (8%)

Non Pregnancy + Ovarian

Hyperstimulation

3 (4%)

Prior the start of the study, the mean systolic BP was 110,23 mm Hg (95 to 125), the mean diastolic BP was 69,53 mm Hg (53 to 82), the mean HR was 69,17bpm (60 to 84), the mean AL was 4,47 mg/dl (0,7 to 27,5), the mean creatinine was 63,64µmol/L (35,36 to 97,24), and the mean estimated GFR was 103,48 ml/min/1,73m² (64 to 144).

55

On the other hand, after the ovarian stimulation, the mean systolic BP was 110,10 mm Hg (92 to 130), the mean diastolic BP was 69,17 mm Hg (56 to 85), the mean HR was 71,42bpm (60 to 84), the mean AL was 6,57 mg/dl (0,7 to 18,4), the mean creatinine was 66,30µmol/L (59,04 to 97,24), and the mean estimated GFR was 100,98 ml/min/1,73m² (64 to 120).

No statistically significant associations were found between systolic BP levels, diastolic BP levels, and GFR before and after ovarian stimulation. However, this study found a statistically significant correlation of HR and AL with ovarian stimulation, with no clinical relevance. This data are shown in Table 2.

Table 2: Variation of systolic blood pressure, diastolic blood pressure, heart rate, albuminuria, creatinine, and e estimated glomerular filtration of patients before and after ovarian stimulation (n=75).

Variables Beforestimulation Afterstimulation P

Median SBP*(mmHg) 110,23+ 7,93 110,10+ 8,22 0,945 Median DBP** (mmHg) 69,53+ 5,68 69,17+ 6,74 0,802 Median HR*** (bpm) 69,17+ 6,08 71,42+ 6,78 0,012 MedianAlbuminuria (mg/dL) 4,47+ 4,38 6,57+ 4,92 0,002 Creatinine (µµµµmol/L) 63,64+12,37 66,30+10,60 0,202 Median EGFR**** (mL/min/1,73m²) 103,48 + 17,00 100,98 + 15,19 0,301

*Systolic Blood Pressure; **Diastolic Blood Pressure; *** Heart Rate; **** Estimated Glomerular Filtration Rate

Considering analysis adjusted for age, our study found a statistically significant correlation of rise of HR and AL with increase of age. Systolic BP, diastolic BP, and creatinine levels does not change with age as seen in Table 3.

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Table 3: Variation of systolic blood pressure, diastolic blood pressure, heart rate, albuminuria, creatinine, and e estimated glomerular filtration of patients before and after ovarian stimulation adjusted by age (n=75).

VARIABLES MEDIAN

RATES

LOWER LIMIT UPPER LIMIT P

SBP 1,00 0,97 1,02 0,933 DBP 0,99 0,96 1,02 0,744 HR 1,03 1,00 1,05 0,015 Albuminuria 1,46 1,14 1,88 0,003 Creatinine 1,03 0,98 1,08 0,125 EGFR 1,01 0,88 1,03 0,201

Three patients (2,25%) developed acute kidney injury according criterion of international guideline group KDIGO (Kidney Disease Improvement Global

Outcomes).As isolated group, they did not show statistical significant difference in

others variables.

Nine patients (12%) developed ovarian hyperstimulation. In this group, the variables pattern showed no statistical significant difference before and after ovarian stimulation.

During the ovarian stimulation, there was no statistical significant difference in systolic BP levels, diastolic BP levels, HR, AL, and estimated GFR of the patients who got pregnant from those who did not.

When we separate the group who got pregnant and developed ovarian hyperstimulation versus those got pregnant and obtained expected number of follicles, there was also no statistical significant difference.

DISCUSSION

Table 1 provides profile of patients. There is high average of age considering intention to pregnancy, but clearly show that women are seeking in vitro fertilization after previous difficulties and unsuccessful attempt pregnancy. It is also evident that the group of patients reflects the social stratum to discover that, of 84 possible patients for the study, only one was african american.

Our results expressed in Tables 2 and 3 reinforce the few data in the scientific

literature that ovarian stimulation does not change systolic and diastolic BP levels, creatinine, and estimated GFR of patients undergoing in vitro fertilization (12, 13).

Regarding HR and AL, the study found a statistically significant correlation after ovarian stimulation. However, it is possible this data does not have clinical relevance because the variation is small in absolute numbers. The statistical difference occurs because of large number of patients included in study.

In addition, since the start of ovarian stimulation occurs in the first days of the menstrual cycle and menstrual bleeding can engender false positive rates in a

AL (14), we chose to obtain AL sample until six months previous to research.

The well-documented decline of female fertility with ageing has been associated with decreases in oocyte number and quality. Fertility decline starts at 30 years of age

59

and accelerates after 35 (15). As we can see in Figure 1, 42 patients (56% of 75 patients undergoing ovarian stimulation) did not get pregnant. Women with higher age showed increased levels of HR and AL compared to their baseline levels after undergoing ovarian stimulation with statistical significance. On the other hand, our findings did not reveal any association between age and systolic BP, diastolic BP, creatinine, and estimated GFR.

It is well documented that age is an important risk factor for ASH in pregnancy. In the same way, arterial hypertension is associated with increased risk of higher levels of AL (16). Maybe data are more related to age than pregnancy or ovarian hyperstimulation.

When we compare woman who got pregnant from those who did not, we found

no significant associations of variables levels before and after ovarian stimulation.

However, we know systolic and diastolic BP levels and HR change during pregnancy (17).There is a small difference in systolic BP, and diastolic BP increases 5-10 mm Hg

by the middle of the second trimester as well as a 20% increase in maternal HR. There

are known pregnancy findings and, as we can see, it starts even after the beginning of pregnancy and it seems to be absent during ovarian stimulation to fertilization.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of supraphysiologic ovarian stimulation, almost exclusively associated with exogenous gonadotropin therapy, which is dependent on several risk factors such as polycystic ovaries syndrome and past history of polycystic ovaries syndrome (18).We sought to identify pattern of variables in pregnancy during ovarian stimulation identified by ultrasound imaging. There was no statistically significant difference in the modification of variables among participants who developed ovarian hyperstimulation compared with

group that developed the expected number of follicles. Similarly, no statistically significant difference was seen of variables before and after ovarian stimulation among pregnant who developed ovarian hyperstimulation compared with pregnant who developed the expected number of follicles.

Limitations of these data should be considered as absence of one or more intermediate moments among measurements of systolic and diastolic BP, HR, AL, and creatinine before and after ovarian stimulation in order to detect a possible change of their levels in these intervals. In addition, we do not know if the results obtained in this study can be applied in spontaneous pregnancies once they are related to assisted reproduction techniques.

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