Middle cerebral artery infarction after in vitro fertilization: A case report

Authors


  • Conflicts of interest: The authors declare no potential conflict of interest.

Correspondence: Afshin Borhani Haghighi*, Department of Neurology, Shiraz University of Medical Sciences, Motahari Clinic, Namazi Square, Zand Avenue, Shiraz 71835, Fars, Iran.

E-mail: borhanihaghighi@yahoo.com

Dear Editor,

A 33-year-old Iranian woman presented with left-sided weakness. She was a case of primary infertility since four-years prior to admission (PTA) due to polycystic ovary. The patient was given clomide 50 mg daily starting on the first day of menstruation and continuing to the fifth day and Human menopausal gonadotropin (150 IU i.m. daily). After 15 days with oestradiol (E2) level of 3450 pg/ml, 15 follicles were seen in right ovary and 9 in left ovary. Then, 7500 IU recombinant human chorionic gonadotropin (rHCG) was administered as well. Thirty-four hours later 12 oocytes were retrieved from the right ovary, of which 4 were fertilized. Intramuscular progesterone 80 mg/day was also injected on the day of retrieval. The embryo was transferred on luteal day (LD) 3. On LD day 13, she developed right-sided weakness, numbness, and dysarthria and transferred to the neurology department of Namazi Hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, south of Iran. Brain MRI revealed an infarct in the territory of right middle cerebral artery (MCA) (Fig. 1). Brain MRA showed a thrombus in right MCA producing a cut-off sign. Transthoracic and transesophageal echocardiography revealed only mitral valve prolapse but no mural thrombus. Electrocardiography (ECG) and color Doppler sonography of extracranial arteries were unremarkable.

Figure 1.

Axial T2-weighted images showing acute infarct in the territory of right middle cerebral artery (MCA).

Thrombophilia workups including protein C, protein S, antithrombin III, factor V Leiden (resistance to activated protein C), and prothrombin gene mutation (G20210A), antiphospholipid antibodies (IgG and IgM anticardiolipin antibodies and lupus anticoagulant) were all within normal ranges. Vasculitis panel was normal as well. The patient and her family decided to continue the pregnancy.

Aspirin 80 mg daily was prescribed for her. She improved dramatically with physiotherapy and occupational therapy courses but she experienced two episodes of generalized tonic clonic seizures three- and five-months after her stroke. Lamotrigine 100 mg daily was started for her and escalated with therapeutic dose monitoring. The fetus was delivered with cesarean section weighing 2040 gram.

At last follow-up the mother was seizure-free, completely verbal with normal motor strength and the infant reached normal motor and intelligence milestones considering her age.

The incidence of thrombotic events in a series of 2924 in vitro fertilizations has been reported to reach 0·2% [1].However, if the mother has a hypercoagulable condition, the risk of such events would be higher. On the other hand it has been seen that most of the patients having an attack of thromboembolism did not show any evidence of thrombophilia [2]. It has been recommended to screen all patients undergoing IVF [3].On the other hand, the screening tests would result in unnecessary costs [4].Some investigators recommend screening test for the patients with systemic lupus eythematosus, antiphospholipid antibody syndrome, repeated abortions, or family history of thrombosis [5]. Increasing rate of ovarian stimulation for the treatment of infertility necessitates proposing guidelines for screening of the thrombophilic condition for addressing this controversial issue.

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