ASD Device Closure (7.5 months ago) + IVF Embryo Transfer: Clinical Assessment

Short Answer

1. Her Cardiac Risk Category (WHO mWHO I)

• No detectable increased risk of maternal mortality
• Only mild or no increase in morbidity
• Maternal cardiac event rate: ~2.5%-5.9%
• Requires only 1-2 cardiology visits during the entire pregnancy

2. What the Textbooks Say About Repaired ASD and Pregnancy/Reproduction

"Women with successful closure of isolated left-to-right shunts are at low risk for complications during pregnancy. In the absence of other risk factors such as cardiac arrhythmias, cardiac events after closure, systemic ventricular dysfunction, or pulmonary hypertension, women with repaired shunts can deliver at their local hospital."

3. IVF-Specific Considerations

a. Ovarian Hyperstimulation Syndrome (OHSS)

• OHSS causes fluid shifts, hemoconcentration, and a hypercoagulable state - all of which increase thrombotic risk.
• In a patient with a well-closed ASD with no residual shunt, paradoxical embolism risk is minimal, but thromboprophylaxis should still be discussed with the fertility team, particularly if OHSS occurs.
• The fertility team should be briefed on the prior ASD closure so that anticoagulation protocols are appropriate.

b. Antiplatelet Therapy Timing

• Standard post-ASD-device-closure protocol requires aspirin for 6 months (some centers extend to 12 months) and clopidogrel/antiplatelet for ~3-6 months post-procedure to allow endothelialization.
• At 7.5 months, she is likely either still on aspirin or has just completed her antiplatelet course. This must be clarified before the egg transfer, because:
  • If still on aspirin: most fertility centers are comfortable with low-dose aspirin (81 mg) - it is sometimes even beneficial in IVF (endometrial blood flow). No issue.
  • If dual antiplatelet (aspirin + clopidogrel) is still ongoing: the fertility specialist and cardiologist should coordinate, as this is sometimes adjusted peri-transfer.

c. Embryo Transfer Itself

• Frozen embryo transfer (FET) is a very low-stress procedure - no general anesthesia, minimal hemodynamic change, very brief. No cardiac concern.
• Fresh transfer (after stimulation) carries the OHSS risk mentioned above.

d. No Antibiotic Prophylaxis Needed

• From Creasy & Resnik's: "Those who underwent a device closure do not routinely require antibiotic prophylaxis" for cardiac purposes.

4. When Device Closure Was Done (7.5 Months Ago)

5. Practical Recommendations Before Proceeding

6. Supporting Evidence

Bottom Line

1. Get a formal cardiology clearance letter confirming stable device, no residual shunt, normal cardiac function.
2. Confirm the antiplatelet/anticoagulation status with the cardiologist before the transfer cycle begins.
3. The fertility team should have a OHSS prevention strategy in place.
4. Plan for fetal cardiac echo at ~20 weeks if she achieves pregnancy (small hereditary risk of CHD).

Important note: This is clinical guidance based on established textbook principles and published evidence. The final decision must involve her cardiologist, reproductive endocrinologist, and ideally a maternal-fetal medicine (MFM) specialist working as a multidisciplinary team.

Does Progesterone in IVF Affect a Patient with Prior ASD Device Closure?

The Short Answer

How Progesterone Affects the Cardiovascular System

1. Progesterone Has Vasodilatory / Anti-hypertensive Effects

• Progesterone relaxes smooth muscle in blood vessels, causing peripheral vasodilation and reduced systemic vascular resistance.
• This is actually protective rather than harmful for most cardiac conditions - it reduces cardiac afterload slightly.
• In the context of a well-repaired ASD (mWHO Class I), this is not a concern.

2. Natural (Micronized) Progesterone - Very Safe Profile

• Studies have consistently shown that micronized progesterone (oral or vaginal) does NOT increase the risk of venous thromboembolism (VTE) or arterial events.
• A systematic review on micronized progesterone cardiovascular impact (PMID 35112635) found that VTE risk was not altered by micronized progesterone - in contrast to synthetic progestogens (norpregnane derivatives), which do carry thrombotic risk.
• D-dimer, blood pressure, heart rate, and Framingham risk scores were all unchanged vs. placebo in controlled trials.

3. Synthetic Progestogens - More Caution Needed

• Dydrogesterone, norethisterone, and other synthetic progestins carry more variable cardiovascular profiles.
• One PMC review on luteal phase support specifically noted that dydrogesterone may have epigenetic effects including relation to congenital heart disease - this is still under investigation.
• For a cardiac patient, vaginal micronized progesterone (e.g., Crinone gel, Utrogestan pessaries) is preferred over synthetic progestins.

The Real IVF Cardiovascular Risk - Estrogen, Not Progesterone

• If she is doing a frozen embryo transfer (FET) - which is the most common protocol now - the VTE and cardiac stress are minimal.
• If a fresh transfer, the estrogen-driven thrombotic risk is real and needs proactive thromboprophylaxis planning.

Specific Impact on Her ASD Device

Practical Recommendations for Her Team

1. Prefer vaginal micronized progesterone (e.g., Utrogestan 200 mg vaginally, or Crinone gel) over synthetic progestins - safer cardiovascular profile.
2. Prefer frozen embryo transfer (FET) over fresh transfer to minimize the estrogen-driven VTE risk.
3. If fresh transfer is needed: discuss low molecular weight heparin (LMWH) thromboprophylaxis with her cardiologist - especially given the prior cardiac procedure.
4. The progesterone luteal support itself (at standard IVF doses) does not interact with her ASD device, residual cardiac anatomy, or prior antiplatelet therapy in any clinically significant way.
5. Continue aspirin if still prescribed by her cardiologist - low-dose aspirin is compatible with IVF and may even slightly improve implantation rates.

Bottom Line