{"doi":"10.1111/epi.17862","title":"Letter regarding “Seizure control in women with epilepsy undergoing assisted reproductive technology”","abstract":"To the Editors: We commend Abdulrazaq et al. on their important work, “Seizure Control in Women With Epilepsy Undergoing Assisted Reproductive Technology.”1 This retrospective case series contributes to limited literature regarding assisted reproductive technology (ART) use in people with epilepsy (PWE) desiring pregnancy, and importantly highlights that seizure control may be maintained despite the use of exogenous hormones. In vitro fertilization (IVF) is the mainstay treatment for infertility, contributing to >2% of all live births in the United States.2 One study demonstrated that ART is effective in PWE,3 but the effect on seizure control is understudied. One case series described seizure worsening in two PWE undergoing ART. In this report, one patient had a seizure cluster after gonadotrophin use resulting in estrogen rise, and another patient on lamotrigine experienced breakthrough seizures while taking estradiol valerate for embryo transfer preparation.4 Abdulrazaq et al. offer necessary reassurance that PWE may undergo successful ART without seizure worsening. This cohort, however, was mostly comprised of patients with well-controlled or resolved epilepsy and only one with drug-resistant epilepsy. Five of 12 patients were not on antiseizure medication (ASM), and only three were on ASMs potentially affected by estrogen (valproic acid or lamotrigine).5, 6 Two patients underwent medication serum concentration monitoring and dosing adjustments during ART. One patient was on levetiracetam. It would be interesting to know the concentrations and dose adjustments in this patient. The other patient had lamotrigine increased while on estrogen-containing pills for cycle synchronization. The authors present a detailed graphic of changes for this patient during ART, pregnancy, and postpartum. This type of analysis will be needed in more patients with active epilepsy to understand how to best manage ASMs during ART. One of the challenges in understanding the effect of IVF on ASM clearance and seizure control is that techniques can significantly vary by location, patient, and between pregnancies. Accessing the care plan and specialty-to-specialty communication can be difficult, especially because many fertility treatments are offered outside of centers where patients receive their neurological care. Several key stages of ART may have implications for PWE (see Table 1), namely, those that result in high levels of endogenous estrogen or involve prescription exogenous estrogens. For example, frozen embryo transfer protocols typically require prescription of estrogen for endometrial preparation. It is vital that patients, reproductive endocrinology and infertility (REI) experts, and neurologists understand potential areas where fertility treatments and seizure management intersect. ASM concentrations are ideally at the lowest level necessary for seizure control prior to pregnancy; thus, decreases in concentrations may result in seizure exacerbation for some PWE.7, 8 This impact will be more significant for a patient with active epilepsy. It is critical to know the effect of ART regimens on ASM concentrations. Studying factors that may predict breakthrough seizures (e.g., specific protocols, follicular development, estrogen rise) will be invaluable, along with defining optimal approaches to ASM serum monitoring and dose adjustments. This is a call for interdisciplinary collaboration and further research efforts that will be crucial to optimizing care for PWE in planning REI protocols. Daily FSH + LH combination Assess maturing follicles with ultrasound (goal of ~8–12 oocytes; 250–300 pg/mL per oocyte) and estradiol levels (peak <5000 pg/mL to avoid ovarian hyperstimulation syndrome) 1. Depending on endogenous estrogen levels, which may vary considerably based on number of follicles developed, ASM levels (particularly lamotrigine) may decreaseb 2. It is unclear whether increased endogenous estradiol or estrogen to progesterone ratios at t","journal":"Epilepsia","year":2023,"id":415043,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9568,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":408556,"name":"Heidi M. Munger Clary","orcid":"0000-0002-9889-8351","position":1,"is_corresponding":false},{"id":1022977,"name":"Manisha Holmes","orcid":"0000-0002-4262-0764","position":2,"is_corresponding":false},{"id":661349,"name":"Abrar Al‐Faraj","orcid":"0000-0002-9446-4134","position":3,"is_corresponding":false},{"id":419887,"name":"Behnaz Esmaeili","orcid":"0000-0003-2547-0853","position":4,"is_corresponding":false},{"id":1196901,"name":"Genna Waldman","orcid":"0009-0002-3114-7796","position":5,"is_corresponding":false},{"id":662204,"name":"Danielle A. Becker","orcid":"0000-0002-4792-8055","position":6,"is_corresponding":false},{"id":1197215,"name":"Julia V. Johnson","orcid":null,"position":7,"is_corresponding":false},{"id":1036957,"name":"P. Emanuela Voinescu","orcid":"0000-0001-5216-2018","position":8,"is_corresponding":false},{"id":426502,"name":"Elizabeth E. Gerard","orcid":"0000-0003-3062-8360","position":9,"is_corresponding":false},{"id":449193,"name":"Barbara Decker","orcid":"0000-0002-8084-7353","position":0,"is_corresponding":true}],"reference_count":12,"raw_metadata":null,"created_at":"2026-07-19T01:22:08.814145Z","pmid":"38098189","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}