Towards a Safe Pathway to Biological Parenthood for Pulmonary Arterial Hypertension.

Pulmonary arterial hypertension (PAH) carries a high risk of maternal morbidity and mortality in pregnancy, and current guidelines advise against conception. For women with PAH who wish to have genetically related children, in vitro fertilisation (IVF) combined with gestational surrogacy presents a viable and increasingly safe alternative. Advances in IVF protocols-including gonadotropin-releasing hormone (GnRH) antagonist stimulation, agonist trigger, personalised gonadotropin dosing, and elective embryo cryopreservation-have markedly reduced the risks of ovarian hyperstimulation syndrome and made oocyte retrieval feasible even in high-risk populations. The addition of pre-implantation genetic testing for monogenic disorders (PGT-M) enables the selection of embryos free of heritable PAH-related mutations, while pre-implantation genetic testing for aneuploidy (PGT-A) improves implantation rates and reduces miscarriage. For women who, due to personal, cultural or legal reasons, decline surrogacy and choose to carry a pregnancy themselves, a conservative approach-using natural cycle frozen embryo transfer and single euploid embryos-can reduce, but not eliminate, risk. The risks of pregnancy in this population are acknowledged to be high, and the guidelines continue to mandate against PAH patients becoming pregnant. However, there are alternative strategies developing which may allow biological parenthood without some of the inherent cardiopulmonary risk. This paper reviews the available evidence and proposes a clinical framework for offering IVF safely in this population, while advocating for the development of a dedicated registry and expert consensus to guide future care.