can be resolved in the absence of pregnancy. in moderate cases, ovaries swell and fluid accumulated in the abdominal cavities and may have symptoms of heartburn, gas, nausea or loss of appetite. in severe cases patients have sudden excess abdominal pain, nausea, vomiting and will result in hospitalisation. during egg retrieval, there exists a small chance of bleeding, infection, and damage to surrounding structures such as bowel and bladder (transvaginal ultrasound aspiration) as well as difficulty in breathing, chest infection, allergic reactions to medication, or nerve damage (laparoscopy). ectopic pregnancy may also occur if a fertilised egg develops outside the uterus, usually in the fallopian tubes and requires immediate destruction of the fetus. ivf does not seem to be associated with an elevated risk of cervical cancer, nor with ovarian cancer or endometrial cancer when neutralising the confounder of infertility itself. nor does it seem to impart any increased risk for breast cancer. regardless of pregnancy result, ivf treatment is usually stressful for patients. neuroticism and the use of escapist coping strategies are associated with a higher degree of distress, while the presence of social support has a relieving effect. a negative pregnancy test after ivf is associated with an increased risk for depression in women, but not with any increased risk of developing anxiety disorders. pregnancy test results do not seem to be a risk factor for depression or anxiety among men. studies show that there is an increased risk of venous thrombosis or pulmonary embolism during the first trimester of ivf. when looking at long-term studies comparing women who received or did not receive ivf, there seems to be no correlation with increased risk of cardiac events. there are more ongoing studies to solidify this. spontaneous pregnancy has occurred after successful and unsuccessful ivf treatments. within 2 years of delivering an infant conceived through ivf, subfertile couples had a conception rate of 18%. birth defects a review in 2013 came to the result that infants resulting from ivf (with or without icsi) have a relative risk of birth defects of 1.32 (95% confidence interval 1.24–1.42) compared to naturally conceived infants. in 2008, an analysis of the data of the national birth defects study in the us found that certain birth defects were significantly more common in infants conceived through ivf, notably septal heart defects, cleft lip with or without cleft palate, esophageal atresia, and anorectal atresia; the mechanism of causality is unclear. however, in a population-wide cohort study of 308,974 births (with 6,163 using assisted reproductive technology and following children from birth to age five) researchers found: "the increased risk of birth defects associated with ivf was no longer significant after adjustment for parental factors." parental factors included known independent risks for birth defects such as maternal age, smoking status, etc. multivariate correction did not remove the significance of the association of birth defects and icsi (corrected odds ratio 1.57), although the authors speculate that underlying male infertility factors (which would be associated with the use of icsi) may contribute to this observation and were not able to correct for these confounders. the authors also found that a history of infertility elevated risk itself in the absence of any treatment (odds ratio 1.29), consistent with a danish national registry study and "implicates patient factors in this increased risk." the authors of the danish national registry study speculate: "our results suggest that the reported increased prevalence of congenital malformations seen in singletons born after assisted reproductive technology is partly due to the underlying infertility or its determinants." risk in singleton pregnancies resulting from ivf (with or without icsi) conditionrelative risk95% confidence interval beckwith–wiedemann syndrome3-4 congenital anomalies1.671.33–2.09 ante-partum haemorrhage2.492.30–2.69 hypertensive disorders of pregnancy1.491.39–1.59 preterm rupture of membranes1.161.07–1.26 caesarean section1.561.51–1.60 gestational diabetes1.481.33–1.66 induction of labour1.181.10–1.28 small for gestational age1.391.27–1.53 preterm birth1.541.47–1.62 low birthweight1.651.56–1.75 perinatal mortality1.871.48–2.37 other risks to the offspring if the underlying infertility is related to abnormalities in spermatogenesis, it is plausible, but too early to examine that male offspring are at higher risk for sperm abnormalities. ivf does not seem to confer any risks regarding cognitive development, school performance, social functioning, and behaviour. also, ivf infants are known to be as securely attached to their parents as those who were naturally conceived, and ivf adolescents are as well-adjusted as those who have been naturally conceived. limited long-term follow-up data suggest that ivf may be associated with an increased incidence of hypertension, impaired fasting glucose, increase in total body fat composition, advancement of bone age, subclinical thyroid disorder, early adulthood clinical depression and binge drinking in the offspring. it is not known, however, whether these potential associations are caused by the ivf procedure in itself, by adverse obstetric outcomes associated with ivf, by the genetic origin of the children or by yet unknown ivf-associated causes. increases in embryo manipulation during ivf result in more deviant fetal growth curves, but birth weight does not seem to be a reliable marker of fetal stress. ivf, including icsi, is associated with an increased risk of imprinting disorders (including prader-willi syndrome and angelman syndrome), with an odds ratio of 3.7 (95% confidence interval 1.4 to 9.7). an ivf-associated incidence of cerebral palsy and neurodevelopmental delay are believed to be related to the confounders of prematurity and low birthweight. similarly, an ivf-associated incidence of autism and attention-deficit disorder are believed to be related to confounders of maternal and obstetric factors. overall, ivf does not cause an increased risk of childhood cancer. studies have shown a decrease in the risk of certain cancers and an increased risks of certain others including retinoblastoma, hepatoblastoma and rhabdomyosarcoma. ethics mix-ups in some cases, laboratory mix-ups (misidentified gametes, transfer of wrong embryos) have occurred, leading to legal action against the ivf provider and complex paternity suits. an example is the case of a woman in california who received the embryo of another couple and was notified of this mistake after the birth of her son. this has led to many authorities and individual clinics implementing procedures to minimise the risk of such mix-ups. the hfea, for example, requires clinics to use a double witnessing system, the identity of specimens is checked by two people at each point at which specimens are transferred. alternatively, technological solutions are gaining favour, to reduce the manpower cost of manual double witnessing, and to further reduce risks with uniquely numbered rfid tags which can be identified by readers connected to a computer. the computer tracks specimens throughout the process and alerts the embryologist if non-matching specimens are identified. although the use of rfid tracking has expanded in the us, it is still not widely adopted. preimplantation genetic diagnosis or screening pre-implantation genetic diagnosis (pgd) is criticized for giving select demographic groups disproportionate access to a means of creating a child possessing characteristics that they consider "ideal". many fertile couples now demand equal access to embryonic screening so that their child can be just as healthy as one created through ivf. mass use of pgd, especially as a means of population control or in the presence of legal measures related to population or demographic control, can lead to intentional or unintentional demographic effects such as the skewed live-birth sex ratios seen in china following implementation of its one-child policy. while pgd was originally designed to screen for embryos carrying hereditary genetic diseases, the method has been applied to select features that are unrelated to diseases, thus raising ethical questions. examples of such cases include the selection of embryos based on histocompatibility (hla) for the donation of tissues to a sick family member, the diagnosis of genetic susceptibility to disease, and sex selection. these examples raise ethical issues because of the morality of eugenics. it becomes frowned upon because of the advantage of being able to eliminate unwanted traits and selecting desired traits. by using pgd, individuals are given the opportunity to create a human life unethically and rely on science and not by natural selection. for example, a deaf british couple, tom and paula lichy, have petitioned to create a deaf baby using ivf. some medical ethicists have been very critical of this approach. jacob m. appel wrote that "intentionally culling out blind or deaf embryos might prevent considerable future suffering, while a policy that allowed deaf or blind parents to select for such traits intentionally would be far more troublesome." profit desire of the industry in 2008, a california physician transferred 12 embryos to a woman who gave birth to octuplets (suleman octuplets). this led to accusations that a doctor is willing to endanger the health and even life of people in order to gain money. robert winston, professor of fertility studies at imperial college london, had called the industry "corrupt" and "greedy" stating that "one of the major problems facing us in healthcare is that ivf has become a massive commercial industry," and that "what has happened, of course, is that money is corrupting this whole technology", and accused authorities of failing to protect couples from exploitation: "the regulatory authority has done a consistently bad job. it's not prevented the exploitation of people, it's not put out very good information to couples, it's not limited the number of unscientific treatments people have access to". the ivf industry has been described as a market-driven construction of health, medicine and the human body. in the us, the copyright clause provides innovators with a temporary monopoly over their respective work. as a result, ivf is prohibitively expensive for patients as providers have to also cover the costs of patents. for example, 23andme has patented a process used to calculate the probability of gene inheritance. the industry has been accused of making unscientific claims, and distorting facts relating to infertility, in particular through widely exaggerated claims about how common infertility is in society, in an attempt to get as many couples as possible and as soon as possible to try treatments (rather than trying to conceive naturally for a longer time). this risks removing infertility from its social context and reducing the experience to a simple biological malfunction, which not only can be treated through bio-medical procedures, but should be treated by them. indeed, there are serious concerns about the overuse of treatments, for instance sami david, a fertility specialist, has expressed disappointment over the current state of the industry, and said many procedures are unnecessary; he said: "it's being the first choice of treatment rather than the last choice. when it was first opening up in late 1970s, early 80s, it was meant to be the last resort. now it's a first resort. i think that it can harm women in the long run." ivf thus raises ethical issues concerning the abuse of bio-medical facts to 'sell' corrective procedures and treatments for conditions that deviate from a constructed ideal of the 'healthy' or 'normal' body i.e., fertile females and males with reproductive systems capable of co-producing offspring. older patients all pregnancies can be risky, but there are greater risk for women who are older and are over the age of 40. the older the woman the riskier the pregnancy. as women get older, they are more likely to develop conditions such as gestational diabetes and pre-eclampsia. if older women do conceive over the age of 40, their offspring may be of lower birth weight, and more likely to requires intensive care. because of this, the increased risk is a sufficient cause for concern. the high incidence of caesarean in older mothers is commonly regarded as a risk. women conceiving at 40 have a greater risk of gestational hypertension and premature birth. the offspring is at risk when being born from older mothers, and the risks associated with being conceived through ivf. normal vaginal canal vs menopause adriana iliescu held the record for a while as the oldest woman to give birth using ivf and a donor egg, when she gave birth in 2004 at the age of 66. in september 2019, a 74-year-old woman became the oldest-ever to give birth after she delivered twins at a hospital in guntur, andhra pradesh. pregnancy after menopause although menopause is a natural barrier to further conception, ivf has allowed women to be pregnant in their fifties and sixties. women whose uteruses have been appropriately prepared receive embryos that originated from an egg of an egg donor. therefore, although