Obstetrical and perinatal morbidity and mortality among in-vitro fertilization pregnancies: a population-based study

PURPOSE

To compare patient characteristics and obstetrical/neonatal outcomes of in-vitro fertilization (IVF) and spontaneously conceived pregnancies.

METHODS

Using the Nationwide Inpatient Sample, we conducted a retrospective cohort study from 2008 to 2011 comparing IVF conceptions to spontaneous ones. Patient characteristics were descriptively compared, and after adjusting for baseline characteristics with logistic regression, obstetrical/neonatal outcomes were also compared.

RESULTS

Among 3,315,764 pregnancies, 5773 (0.17%) were a result of IVF. These patients were more often older, wealthier, Caucasian, non-smokers, and more likely to carry a higher order pregnancy. IVF was strongly associated with pre-eclampsia (OR 1.48, 95% CI 1.32-1.62), gestational diabetes (OR 1.27, 95% CI 1.17-1.38), antepartum hemorrhage (OR 2.04, 95% CI 1.79-2.32), placenta previa (OR 3.14, 95% CI 2.71-3.64), pre-term premature rupture of membranes (OR 1.49, 95% CI 1.30-1.70), chorioamnionitis (OR 1.52, 1.29-1.79), and cesarean section (OR 1.60, 95% CI 1.51-1.70). There was a significantly increased risk of post-partum hemorrhage (OR 2.95, 95% CI 2.29-3.80) and hysterectomy (OR 1.73, 95% CI 1.12-2.69), as well as disseminated intravascular coagulopathy (OR 2.23, 95% CI 1.24-3.99), transfusion (OR 1.78, 95% CI 1.53-2.07), prolonged hospitalization (OR 1.96, 95% CI 1.80-2.14), intrauterine growth restriction (OR 1.81, 95% CI 1.63-2.02), and pre-term birth (OR 1.31, 95% CI 1.22-1.41).

CONCLUSION

IVF is still primarily used by only a subset of the population, and is associated with increased obstetrical and perinatal morbidity and mortality. These patients may benefit from more vigilant antenatal surveillance and delivery in a tertiary care center.

CDC-reported assisted reproductive technology live-birth rates may mislead the public

The Centre for Disease Control and Prevention (CDC) publicly reports assisted reproductive technology live-birth rates (LBR) for each US fertility clinic under legal mandate. The 2014 CDC report excluded 35,406 of 184,527 (19.2%) autologous assisted reproductive technology cycles that involved embryo or oocyte banking from LBR calculations. This study calculated 2014 total clinic LBR for all patients utilizing autologous oocytes two ways: including all initiated assisted reproductive technology cycles or excluding banking cycles, as done by the CDC. The main limitation of this analysis is the CDC report did not differentiate between cycles involving long-term banking of embryos or oocytes for fertility preservation from cycles involving short-term embryo banking. Twenty-seven of 458 (6%) clinics reported over 40% of autologous cycles involved banking, collectively performing 12% of all US assisted reproductive technology cycles. LBR in these outlier clinics calculated by the CDC method, was higher than the other 94% of clinics (33.1% versus 31.1%). However, recalculated LBR including banking cycles in the outlier clinics was lower than the other 94% of clinics (15.5% versus 26.6%). LBR calculated by the two methods increasingly diverged based on proportion of banking cycles performed by each clinic reaching 4.5-fold, thereby, potentially misleading the public.

Fresh and Frozen-Thawed Embryo Transfer Compared to Natural Conception: Differences in Perinatal Outcome

BACKGROUND/AIM

To compare the pregnancy outcome of singletons conceived after transfer of cryopreserved and thawed embryos (frozen embryo transfer [FET]) to singletons conceived after fresh embryo transfer (fresh ET) and natural conceived singletons.

METHODS

Using a retrospective data analysis on a study population consisting of 1,261 singletons born after FET and 2,519 singletons born after fresh ET between 2006 and 2015. The control group consisted of singletons born after natural conception. Main outcome measures consisted of birth weight (in grams), gestational age, preterm birth (<37 weeks of gestation), being large for gestational age (LGA, above 90th weight percentile adjusted for gestational age) and Apgar scores.

RESULTS

Babies born after FET had an increased risk of high birth weight (adjusted OR [AOR]) 2.92; 1.503-3.482) and being LGA (AOR fresh ET vs. FET 1.47; 1.210-1.787) compared to singletons born after fresh ET, as well as higher birth weights compared to natural conceived children.

CONCLUSIONS

Singletons born after FET have a higher risk of high birth weight and being LGA compared to singletons after fresh ET and compared to natural conceived singletons. We assume that the freezing process might be the underlying cause.

Male and female alcohol consumption and live birth after assisted reproductive technology treatment: a nationwide register-based cohort study

The objective was to assess the potential association between female and male alcohol consumption and probability of achieving a live birth after assisted reproductive treatment. From a nationwide Danish register-based cohort information on alcohol consumption at assisted reproductive treatment initiation was linked to information on births and abortions. From 1 January 2006 to 30 September 2010, 12,981 women and their partners went through 29,834 treatment cycles. Of these, 22.4% and 20.4% led to a live birth for female abstainers and heavy consumers (>7 drinks/week), respectively. Concerning men, 22.6% and 20.2% of cycles resulted in a live birth for abstainers and heavy consumers (>14 drinks/week), respectively. No statistically significant associations between alcohol consumption and live birth were observed. Adjusted odds ratios from trend analyses were 1.00 (95% confidence interval (CI) 0.99-1.01) and 0.99 (95% CI 0.97-1.01) for every one-unit increase in female and male weekly alcohol consumption at assisted reproductive treatment initiation, respectively. In conclusion, this study did not show significant associations between male or female alcohol consumption and odds of live birth after assisted reproductive treatment.

Epidemiology of Candida albicans and non-C.albicans of neonatal candidemia at a tertiary care hospital in western China

BACKGROUND

Although the majority of Candida infections occur in the developing world, candidemia epidemiology is poorly understood in these countries. The aim of this study was to investigate the epidemiology of non-Candida albicans (non-C. albicans) candidemia among neonates at Liuzhou Maternity and Child Healthcare Hospital in China.

METHODS

A retrospective review of all positive blood culture about Candida species in neonatal intensive care unit was conducted between January 2012 and November 2015. Information about demographics, risk factors and outcome of candidemia were collected. Univariate and multivariate logistic regression models were used to identify the risk factors associated with the development of non-C.albicans candidemia.

RESULTS

The prevalence of candidemia in infants was 1.4%. Non-C.albicans was responsible for 56.5% of neonatal candidemia. The predisposing factors for development of non-C.albicans candidemia among infants included mechanical ventilation [odds ratio (OR), 95% confidence interval (95%CI) = 3.13, 1.07-9.14; P = 0.037] and use of assisted reproductive technology (OR, 95%CI = 4.52, 1.39-14.77; P = 0.012). The overall mortality rate of candidemia was 8.7% and non-C.albicans attributed to 83.3% of all mortalities.

CONCLUSIONS

Non-C.albicans species are the major cause of candidemia in local neonatal group. The study highlights the urgent needs to evaluate the possibility of development of non-C.albicans candidemia in neonates exposed to these risk factors and much emphasis must be laid on the early implementation of medical intervention to reduce the incidences of candidemia in neonates.

[Does fertility treatment increase the risk of breast cancer? Current knowledge and meta-analysis]

OBJECTIVE

The objective of this review was to assess the level of risk of breast cancer for women exposed to ovulation-inducing therapy (OIT).

METHODS

The 25 selected studies were extracted from the PUBMED database from January 2000 until March 2016 with the following key-words: "fertility agents", "infertility treatments", "clomiphene citrate", "buserelin", "ovarian stimulation", "assisted reproductive technology" and "breast cancer". Our meta-analysis was performed using Review Manager software, Cochrane Collaboration, 2014. The results were calculated by type of OIT, as well as globally.

RESULTS

The analysis of these published epidemiological studies confirms that exposition to OIT is not a breast cancer risk factor, but the results are contradictory. Two studies have shown a significantly increased risk of breast cancer in a population of infertile women, while two others have found a significant decrease of this risk. The twenty others did not show any impact of IOT over this risk. Our meta-analysis of 20 selected studies has not identified a significant association between exposition to OIT and breast cancer risk (relative risk=0,96; IC 95: (0,81-1,14) for cohort studies and odds ratio=0,94; IC 95% (0,81-1,10) for case-control studies).

CONCLUSION

Exposition to OIT is not an identified risk factor for breast cancer. A message reassuring about a possible risk of OIT-related breast cancer should be given to these women. Exposition to OIT is therefore not an indication of increased breast surveillance.

Revealing the secret life of pre-implantation embryos by time-lapse monitoring: A review

High implantation success following in vitro fertilization cycles are achieved via the transfer of embryos with the highest developmental competence. Multiple pregnancies as a result of the transfer of several embryos per cycle accompany with various complication. Thus, single-embryo transfer (SET) is the preferred practice in assisted reproductive technique (ART) treatment. In order to improve the pregnancy rate for SET, embryologists need reliable biomarkers to aid their selection of embryos with the highest developmental potential. Time-lapse technology is a noninvasive alternative conventional microscopic assessment. It provides uninterrupted and continues the survey of embryo development to transfer day. Today, there are four time-lapse systems that are commercially available for ART centers. In world and Iran, the first time lapse babies were born in 2010 and 2015, respectively, conceived by SET. Here, we review the use of time-lapse monitoring in the observation of embryogenesis as well as its role in SET. Although, the findings from our review support common use of time-lapse monitoring in ART centers; but, future large studies assessing this system in well-designed trials are necessary.

In vitro fertilization when men, women, or both partners are positive for HIV: a case-control study

PURPOSE

The aim of this study was to compare the outcomes of in vitro fertilization (IVF) for couples where one or both partners were positive for the human immunodeficiency virus (HIV) to matched control couples.

METHODS

A matched case-control retrospective study was performed. Data for 104 couples where the woman was HIV-positive; for 90 couples where the man was HIV-positive; and for 33 couples where both partners were HIV-positive were prospectively analyzed in comparison to matched controls treated in our center during the same period. The main outcomes were clinical pregnancy and live birth rates.

RESULTS

For couples involving an HIV-positive man, clinical outcomes were comparable to controls and resulted in the birth of 18 healthy babies after 90 cycles. When the woman was affected, cycle cancelation, number of retrieved oocytes, and on-going clinical pregnancy rates per transfer were statistically reduced. Implantation rates were comparable to those of non-affected controls. Seven healthy babies for 104 cycles were obtained. For a couple in which both partners were HIV-positive, only one healthy birth occurred after 33 cycles. Pregnancy rates were systematically reduced though not significantly probably due to sample size.

CONCLUSIONS

Our data suggest that IVF outcomes were similar to controls when men were HIV-positive and remain acceptable when women were HIV-positive. IVF outcomes were severely reduced in our sero-concordant couples; however, many patients had severe HIV disease previously, and therefore, these results should be reassessed in patients treated early in their disease.

Omphalocele and Gastroschisis in Newborns: Over 16 Years of Experience from a Single Clinic

Infants born with potentially life-threatening conditions of omphalocele and gastroschisis may require long-term hospitalization. We aimed to compare the outcomes of these two conditions occurring over a 16-year period (2001-16). It is a retrospective study of 19 newborns undergoing surgery for these two abdominal wall defects (8 patients with omphalocele and 11 cases of gastroschisis). The average birth weights for the newborns with omphaloceles and gastroschisis were 2554.5 g and 2248.6 g respectively. Associated anomalies included trisomy 18, Beckwith-Wiedemann syndrome, congenital heart disease, Meckel’s diverticulum, inguinal hernias, renal deformities, limb deformities, cryptorchidism, body stalk anomalies, and closed gastroschisis. The average hospital stay for the newborns with omphaloceles and gastroschisis were 42.6 days 50.2 days respectively. The time to the start of postoperative nutritional supplementation for the newborns with omphaloceles and gastroschisis were 4.3 days for the infants with omphaloceles and 7.3 days for respectively. The survival rates for the newborns with omphaloceles and gastroschisis were similar, 87.5% and 81.8% respectively. Survival rates in omphalocele correlated negatively with associated anomalies. In gastroschisis cases, strict care is necessary when intestinal dilation is observed via fetal sonography.

First Successful Conception Induced by a Male Cystinosis Patient

Cystinosis is a rare autosomal recessive lysosomal storage disease characterized by multi-organ cystine accumulation, leading to renal failure and extra-renal organ dysfunction. Azoospermia of unknown origin is the main cause of infertility in all male cystinosis patients. Although spermatogenesis has shown to be intact at the testicular level in some patients, no male cystinosis patient has been reported yet to have successfully induced conception.We present the first successful conception ever reported, induced by a 27-year-old male renal transplant infantile nephropathic cystinosis patient through percutaneous epididymal sperm aspiration (PESA) followed by intracytoplasmatic sperm injection (ICSI). After 36 weeks and 6 days of an uncomplicated pregnancy, a dichorial diamniotic (DCDA) twin was born with an appropriate weight for gestational age and in an apparently healthy status. Moreover, we demonstrate that the sperm of epididymal origin in selected male cystinosis patients can be viable for inducing successful conception.Our observation opens a new perspective in life for many male cystinosis patients whom nowadays have become adults, by showing that despite azoospermia fathering a child can be realized. In addition, our findings raise questions about the possibility of sperm cryopreservation at a young age in these patients.

A retrospective study of the effect of increasing age on success rates of assisted reproductive technology

OBJECTIVE

To demonstrate the effect of increasing age on the outcome of assisted reproductive technology, particularly among women aged 40 years or older.

METHODS

A retrospective analysis was conducted using prospectively collected data for all in vitro fertilization and intracytoplasmic sperm injection cycles among women aged 30-35 years or 40-44 years conducted at Merrion Fertility Clinic, Dublin, Ireland, between January 1, 2010, and December 31, 2014. The relationship between age and treatment outcome was assessed.

RESULTS

Among women aged 30-35 years, 726 cycles led to 281 (38.7%) clinical pregnancies and 242 (33.3%) live births. By contrast, among women aged 40-44 years, 433 cycles led to 102 (23.6%) clinical pregnancies and 64 (14.8%) live births (both P<0.001). The live birth rate was particularly low after cycles among the women aged 42 years (5/89 [5.6%]) or 43 years (2/30 [6.7%]).

CONCLUSION

The success rates of assisted reproductive technology are decreased among women aged older than 40 years. Fertility clinics have a responsibility to fully inform this group about the limitations of assisted reproductive technology.

Vitrified-warmed single-embryo transfers may be associated with increased maternal complications compared with fresh single-embryo transfers

Cryopreservation of embryos allows single-embryo transfer and storage of supernumerary embryos, maximizing cumulative pregnancy rates. The purpose of this retrospective cohort study was to compare pregnancy outcome in singletons born after fresh or vitrified-warmed single blastocyst transfer (SBT). Singleton live births resulting from SBT of fresh or vitrified-warmed embryos were compared. Primary outcomes were perinatal outcomes including small for gestational age (SGA), low birthweight, preterm deliveries (PTD), large for gestational age (LGA) and congenital malformations. Maternal complications included pre-eclampsia, placenta previa, placental abruption, gestational diabetes mellitus (GDM) and chorioamnionitis. Adjustment for confounding factors was performed. Of 1886 fresh SBTs and 1200 vitrified-warmed SBTs during the study period, vitrified-warmed SBTs compared with fresh SBTs resulted in significantly lower clinical pregnancy rate (P < 0.0001). Live birth and miscarriage rates calculated only for pregnancy with known outcome revealed lower live birth rates and higher miscarriage rates for the vitrified-warmed group. Perinatal complications were calculated for clinical pregnancies with known outcomes (12.9% catchment failure was excluded from analysis). The vitrified-warmed group showed a trend toward higher rates of pre-eclampsia, GDM, Caesarean delivery and LGA neonates. Rates of PTD and SGA were comparable. In conclusion, vitrified-warmed SBT might be associated with increased feto-maternal complications.

Effects and safety of GnRH-a as a luteal support in women undertaking assisted reproductive technology procedures: follow-up results for pregnancy, delivery, and neonates

PURPOSE

To investigate the effects and safety of gonadotropin releasing hormone analogue (GnRH-a) as an addition to progesterone luteal support in women who underwent in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) and achieved a clinical pregnancy.

METHODS

A retrospective analysis was conducted on 214 patients who underwent IVF/ICSI-ET procedures with standard long mid-luteal protocol, of which 123 received GnRH-a-free protocol and 91 received GnRH-a-added protocol. The patients' pregnancy and delivery course, and their neonates' status at birth and growth/development after birth were statistically compared.

RESULTS

There was no significant difference between both study groups regarding embryo risks and maternal complications during early pregnancy. as well as fetal risks during the middle and late stages and neonate risks during birth, except that the twin pregnancies of the GnRH-a-added group had a considerably greater male/female ratio, and a significantly higher rate of premature delivery and low birth weight than those of the GnRH-a-free group. In addition, there was no significant difference in neonate risks within 2 years after birth between both cohorts.

CONCLUSION

With precautions taken to control the number of implanted embryos and reduce the incidence of twinning pregnancy, the addition of GnRH-a to luteal support is relatively safe and effective.

Perinatal outcomes among singletons after assisted reproductive technology with single-embryo or double-embryo transfer versus no assisted reproductive technology

OBJECTIVE

To examine outcomes of singleton pregnancies conceived without assisted reproductive technology (non-ART) compared with singletons conceived with ART by elective single-embryo transfer (eSET), nonelective single-embryo transfer (non-eSET), and double-embryo transfer with the establishment of 1 (DET -1) or ≥2 (DET ≥2) early fetal heartbeats.

DESIGN

Retrospective cohort using linked ART surveillance data and vital records from Florida, Massachusetts, Michigan, and Connecticut.

SETTING

Not applicable.

PATIENT(S)

Singleton live-born infants.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Preterm birth (PTB <37 weeks), very preterm birth (VPTB <32 weeks), small for gestational age birth weight (<10th percentile), low birth weight (LBW <2,500 g), very low birth weight (VLBW <1,500 g), 5-minute Apgar score <7, and neonatal intensive care unit (NICU) admission.

RESULT(S)

After controlling for maternal characteristics and employing a weighted propensity score approach, we found that singletons conceived after eSET were less likely to have a 5-minute Apgar <7 (adjusted odds ratio [aOR] 0.33; 95% CI, 0.15-0.69) compared with non-ART singletons. There were no differences among outcomes between non-ART and non-eSET infants. We found that PTB, VPTB, LBW, and VLBW were more likely among DET -1 and DET ≥2 compared with non-ART infants, with the odds being higher for DET ≥2 (PTB aOR 1.58; 95% CI, 1.09-2.29; VPTB aOR 2.46; 95% CI, 1.20-5.04; LBW aOR 2.17; 95% CI, 1.24-3.79; VLBW aOR 3.67; 95% CI, 1.38-9.77).

CONCLUSION(S)

Compared with non-ART singletons, singletons born after eSET and non-eSET did not have increased risks whereas DET -1 and DET ≥2 singletons were more likely to have adverse perinatal outcomes.

The Clinical Characteristics of Acute Cerebrovascular Accidents Resulting from Ovarian Hyperstimulation Syndrome

BACKGROUND AND PURPOSE

Ovarian hyperstimulation syndrome (OHSS) is a serious complication that occurs after the ovarian-induction treatment. Acute cerebrovascular accident is one of the most dangerous manifestations of the syndrome. However, the characteristics of stroke resulting from OHSS have so far not been well summarised in any study.

METHODS

We reported 2 cases of acute cerebrovascular accidents secondary to OHSS. And then we performed a literature search for reports on this type of stroke, and summarised their characteristics.

RESULTS

Thirty-six published cases of this type of stroke were reviewed. Thirty two out of 36 (88.9%) of the women were 35 years old or younger. Stroke in 28 out of 36 (77.8%) of these cases was caused by arterial thrombosis. In 17 out of 28 cases, the involved cerebral vascular branches were mainly middle cerebral artery (MCA) and internal carotid artery (ICA). The acute cerebrovascular accidents happened 7 and 9.25 days after embryo transplantation or 8 and 8.33 days after last human chorionic gonadotropin treatment respectively. The prognosis of patients was relatively good after anticoagulation and some supportive treatments.

CONCLUSION

The MCA and ICA are easily involved in stroke resulting from OHSS. The young age may be a risk factor for developing stroke secondary to OHSS. Once thromboembolism develops, administering appropriate therapy is crucial.

The effect of gentamicin on sperm motility and bacterial abundance during chilled sperm storage in the Booroolong frog

Antibiotics can inhibit bacterial contamination and extend sperm longevity during storage; a primary goal of captive facilities conducting biobanking and artificial fertilisation (AF). This study evaluated the effects of gentamicin on the short-term storage of Booroolong frog sperm. Sperm suspensions were obtained via either testis maceration, or as spermic urine, following hormonal induction of sperm-release. The effect of 0, 1, 2, 3 or 4mgmL^-1 gentamicin on bacterial abundance (CFUmL^-1) was determined and sperm motility assessed. In both testis macerate samples and spermic urine samples, gentamicin administered at intermediate-to-high doses (2, 3 & 4mgmL^-1) eliminated, or significantly reduced, bacterial abundance. Sperm samples obtained via testis maceration exhibited significantly lower sperm motility at the highest doses (3 & 4mgmL^-1). All remaining treatments (0, 1 & 2mgmL^-1) were statistically similar and maintained sperm motility >55%. Sperm samples obtained as spermic urine exhibited no difference in sperm motility or velocity when treated with gentamicin at any dose. While antibiotic treatment did not improve sperm longevity as predicted, this is the first study to demonstrate that antibiotic treatment can reduce bacterial abundance without compromising sperm motility in an anuran amphibian. Antibiotic supplementation may be an important tool for reducing pathogen transmission where sperm samples are transferred between captive institutions for biobanking and AF.

The Human Oocyte Preservation Experience (HOPE) Registry: evaluation of cryopreservation techniques and oocyte source on outcomes

BACKGROUND

This prospective, Phase IV, multicenter, observational registry of assisted reproductive technology clinics in the USA studied outcomes of first cycles using thawed/warmed cryopreserved (by slow-freezing/vitrification) oocytes (autologous or donor).

METHODS

Patients were followed up through implantation, clinical pregnancy, and birth outcomes. The main outcome measure was live birth rate (LBR), defined as the ratio of live births to oocytes thawed/warmed minus the number of embryos cryopreserved for each cycle, averaged over all thawing cycles. Clinical pregnancy rate (CPR) was also evaluated, and was defined as the presence of a fetal sac with heart activity, as detected by ultrasound scan performed on Day 35-42 after embryo transfer.

RESULTS

A total of 16 centers enrolled 204 patients; data from 193 patients were available for analyses. For donor oocytes, in the slow-freezing (n = 40) versus vitrification (n = 94) groups, respectively, CPR and LBR were significantly different: 32.4% versus 62.6%, and 25.0% versus 52.1%; outcomes from Day 3 transfers did not differ significantly. For vitrified oocytes, in the autologous (n = 46) versus donor (n = 94) group, respectively, CPR and LBR were significantly different: 30.0% versus 62.6% and 17.4% versus 52.1%. This was largely due to a significant difference in CPR with Day 5/6 transfers.

CONCLUSIONS

In two subgroup data analyses, in women who received cryopreserved oocytes from donors, CPR and LBR were significantly higher in cycles using oocytes cryopreserved via vitrification versus slow-freezing, reflecting differences in methodologies and more Day 5/6 transfers; in women who received vitrified oocytes, CPR and LBR were significantly higher in cycles using donor versus autologous oocytes with Day 5/6 transfers.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00699400 . Registered June 13, 2008.

Morbidity and mortality among very preterm singletons following fertility treatment in Australia and New Zealand, a population cohort study

BACKGROUND

Due to high rates of multiple birth and preterm birth following fertility treatment, the rates of mortality and morbidity among births following fertility treatment were higher than those conceived spontaneously. However, it is unclear whether the rates of adverse neonatal outcomes remain higher for very preterm (<32 weeks gestational age) singletons born after fertility treatment. This study aims to compare adverse neonatal outcomes among very preterm singletons born after fertility treatment including assisted reproductive technology (ART) hyper-ovulution (HO) and artificial insemination (AI) to those following spontaneous conception.

METHODS

The population cohort study included 24069 liveborn very preterm singletons who were admitted to Neonatal Intensive Care Unit (NICU) in Australia and New Zealand from 2000 to 2010. The in-hospital neonatal mortality and morbidity among 21753 liveborn very preterm singletons were compared by maternal mode of conceptions: spontaneous conception, HO, ART and AI. Univariate and multivariate binary logistic regression analysis was used to examine the association between mode of conception and various outcome factors. Odds ratio (OR) and adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated.

RESULTS

The rate of small for gestational age was significantly higher in HO group (AOR 1.52, 95% CI 1.02-2.67) and AI group (AOR 2.98, 95% CI 1.53-5.81) than spontaneous group. The rate of birth defect was significantly higher in ART group (AOR 1.71, 95% CI 1.36-2.16) and AI group (AOR 3.01, 95% CI 1.47-6.19) compared to spontaneous group. Singletons following ART had 43% increased odds of necrotizing enterocolitis (AOR 1.43, 95% CI 1.04-1.97) and 71% increased odds of major surgery (AOR 1.71, 95% CI 1.37-2.13) compared to singletons conceived spontaneously. Other birth and NICU outcomes were not different among the comparison groups.

CONCLUSIONS

Compared to the spontaneous conception group, risk of congenital abnormality significantly increases after ART and AI; the risk of morbidities increases after ART, HO and AI. Preconception planning should include comprehensive information about the benefits and risks of fertility treatment on the neonatal outcomes.

DNA methyltransferase 3A promoter polymorphism is associated with the risk of human spontaneous abortion after assisted reproduction techniques and natural conception

PURPOSE

The aim of this study was to explore the association of the DNA-methyltransferase (DNMT)-3A and DNMT3B promoter polymorphisms with the risk of human spontaneous abortion after assisted reproduction techniques (ARTs) and natural conception.

METHODS

We collected tissues from women who underwent abortion procedures: (a) chorionic villus samples (CVS) and muscle samples (MS) from spontaneous abortions conceived by ART and natural cycle (study group), n = 152; and (b) CVS and MS from normal early pregnancy and second trimester (control group), n = 155. The single-nucleotide polymorphism (SNP) -448A > G in the DNMT3A promoter region and -149C/T polymorphism of DNMT3B were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and confirmed by sequencing.

RESULTS

The allele frequency of -448A among pregnancy loss group and control group was 34.2 % vs. 16.5 %, respectively. Compared with GG carriers, the DNMT3A -448AA homozygotes had an about 16-fold increased risk of spontaneous abortion [odds ratio (OR) = 16.130, 95 % confidence interval (CI), 3.665-70.984], and AG heterozygotes had an OR of 2.027 (95 % CI, 1.247-3.293). However, the distribution of -448A > G in individuals derived from ART pregnancies was not statistically significantly compared with those derived from spontaneous pregnancies (P = 0.661). For DNMT3B, we observed genotype frequencies of 100 % (TT) in the study group and the control group.

CONCLUSIONS

The DNMT3A -448A > G polymorphism may be a novel functional SNP and contribute to its genetic susceptibility to spontaneous abortion in Chinese women, and ART may not affect the distribution of -448A > G in pregnancy loss and normal pregnancy. The observed TT genotype of DMNT3B suggests that this is the predominant genotype of this population. The findings provide new insights into the etiology of human spontaneous abortion.

Increased incidence of post-term delivery and Cesarean section after frozen-thawed embryo transfer during a hormone replacement cycle

PURPOSE

This study aimed to clarify the risks of adverse pregnancy outcomes in patients who conceive singletons after frozen embryo transfer (FET) during a hormone replacement cycle and their offspring.

METHODS

A retrospective cohort study was conducted in patients who conceived after FET, based on the Japanese-assisted reproductive technology registry for 2013. The perinatal outcomes in cases with live-born singletons achieved through natural ovulatory cycle FET (NC-FET) (n = 6287) or hormone replacement cycle FET (HRC-FET) (n = 10,235) were compared. Multiple logistic regression analyses were performed to determine the potential confounding factors.

RESULTS

The frequencies of macrosomia (1.1% in NC-FET and 1.4% in HRC-FET; P = 0.058) were comparable between patients after NC-FET and HRC-FET. The proportions of post-term delivery (0.2% in NC-FET and 1.3% in HRC-FET; P < 0.001) and Cesarean section (33.6% in NC-FET and 43.0% in HRC-FET; P < 0.001) were higher in patients after HRC-FET than in patients after NC-FET. The risks of post-term delivery (adjusted odds ratio (AOR) 5.68, 95% confidence interval (CI) 3.30-9.80) and Cesarean section (AOR 1.64, 95% CI 1.52-1.76) were also higher in patients after HRC-FET than in patients after NC-FET.

CONCLUSIONS

Patients who conceived singletons after HRC-FET were at increased risk of post-term delivery and Cesarean section compared with those who conceived after NC-FET.

Systematic review of worldwide trends in assisted reproductive technology 2004-2013

BACKGROUND

Assisted Reproductive Technology (ART) has undergone considerable changes over the last decade, with consequences on ART outcomes in different regions of the world being unknown.

METHODS

We conducted a systematic review of published national and regional ART registry data to assess how changes in clinical practice between 2004 and 2013 have impacted outcomes in Australia and New Zealand, Canada, Continental Europe, the United Kingdom (U.K.), Japan, Latin America, and the United States (U.S.). The data reflect 7,079,145 total ART cycles utilizing both fresh and previously cryopreserved embryos from autologous oocytes that resulted in 1,454,724 live births. This review focused on the following measures: ART cycle volume, use of cryopreserved embryos, single embryo transfer (SET), live birth rates in fresh and frozen-thawed cycles, and perinatal outcomes in recent years.

RESULTS

SETs and utilization of frozen-thawed embryos increased worldwide over the study period. In 2012 SET utilization in all ART cycles was highest in Japan and Australia/New Zealand (82.6% and 76.3% respectively) and lowest in Latin America (16.0%). While gradual improvements in live birth rates were observed in most regions, some demonstrated declines. By 2012-2013, fresh cycle live birth rates were highest in the U.S. (29%) and lowest in Japan (5%). In Japan, the observed decline in fresh cycle live birth rate coincided with transition to minimal stimulation protocols, transfer of frozen-thawed rather than fresh embryos, and implementation of an SET policy. Similarly, implementation of an SET policy in parts of Canada was followed by a decline in fresh cycle live birth rate. Increasing live birth rates in frozen-thawed embryo cycles, seen all over the world, partially compensated for declines in fresh ART cycles. During 2012-2013 Australia/New Zealand and Japan reported the lowest multiple delivery rates of 5.6 and 4% respectively while the US had the highest of 27%. In recent years, preterm delivery rates in all regions ranged between 9.0 to 16.6% for singletons, 53.9 to 67.3% for twins, and 91.4 to 100% for triplets and higher order multiples. Inconsistencies in the way perinatal outcome data are presented by various registries, made comparison between regions difficult.

CONCLUSIONS

ART practices are characterized by outcome differences between regions. International consensus on the definition of ART success, which accounts for perinatal outcomes, may help to standardize worldwide ART practice and improve outcomes.

TRIAL REGISTRATION

PROSPERO ( CRD42016033011 ).

Gap junctional connexin messenger RNA expression in the ovine uterus and placenta: effects of estradiol-17β-treatment, early pregnancy stages, and embryo origin

Gap junctions play a major role in direct, contact-dependent cell-cell communication, and they have been implicated in the regulation of cellular metabolism and the coordination of cellular functions during growth and differentiation of organs and tissues. Gap junctional channels, composed of connexin (Cx) proteins, have been detected and shown to be influenced by hormones (eg, estrogen and progesterone) in uterine and placental tissues in several species. We hypothesized that (1) the messenger RNA (mRNA) for Cx26, Cx32, Cx37, and Cx43 is expressed in the uterus of ovariectomized sheep treated with estradiol-17β (E2) and in ovine placenta during early pregnancy, (2) E2-treatment of ovariectomized ewes would cause time-specific changes in Cx26, Cx32, Cx37, and Cx43 mRNA expression (experiment 1), and (3) expression of these 4 Cx would vary across the days of early pregnancy (experiment 2) and will be affected by embryo origin (ie, after application of assisted reproductive technologies [ARTs]; experiment 3). Thus, we collected uterine tissues at 0 to 24 h after E2 treatments (experiment 1), and placental tissues during days 14 to 30 of early pregnancy after natural (NAT) breeding (experiment 2) and on day 22 of early pregnancy established after transfer of embryos generated through natural breeding (NAT-ET), in vitro fertilization (IVF), or in vitro activation (IVA, parthenotes; experiment 3). In experiment 1, the expression of Cx26, Cx37, and Cx43 mRNA increased (P < 0.05) and Cx32 mRNA decreased (P < 0.06) in both caruncular and intercaruncular tissues after E2 treatment. In experiment 2, during early pregnancy, there were significant changes (P < 0.01) across days in the expression of Cx26, Cx37, and Cx43 mRNA in the maternal placenta, accompanied by changes (P < 0.001) in Cx37 and Cx43 mRNA in the fetal placenta. In experiment 3, in maternal placenta, Cx32 mRNA expression was decreased (P < 0.001) in NAT-ET, IVF, and IVA groups compared to the NAT group; but in fetal placenta, Cx32 mRNA expression was increased (P < 0.05) in NAT-ET, IVF and IVF groups, and Cx26 mRNA expression was increased (P < 0.05) in IVA compared to NAT group. These data suggest that Cx26, Cx32, Cx37, and Cx43 play specific roles in E2-regulated uterine function and in placental development during early gestation both after natural mating and with application of ART.

Embryo wastage rates remain high in assisted reproductive technology (ART): a look at the trends from 2004-2013 in the USA

This work examined the trend in "embryo wastage" rates after ART in USA and its relationship to the number of embryos transferred, live born infants delivered across patient age, and the yearly percentage of embryos wasted. The data were obtained from the US-clinics SART databank for the years 2004-2013. A total of 1,808,082 non-donor embryos were transferred in 748,394 fresh cycles resulting in 358,214 liveborn. During the years of analysis, the mean number of embryos transferred has progressively decreased leading to an overall significant decrease in Embryo Wastage rates (83.2 to 76.5%, p < 0.001) while the percentage of transfers leading to a live born increased (24.8 to 27.8%, p = 0.002). Embryo Wastage negatively correlated with percentage of transfers resulting in live birth (p = 0.001), and the average number of embryos transferred positively correlated with the percentage of embryos wasted (p < 0.001). The overwhelming majority of embryos transferred still do not result into a live birth confirming that only few embryos per ART cycle are competent. The overall "Embryo Wastage" rates have consistently decreased from a high of 90% in 1995 to a rate of 76.5% in 2013. Transferring fewer embryos particularly at the blastocyst-stage and improved methods of embryo selection may further decrease "Embryo Wastage" rates.

Effects of maternal age on embryo quality and pregnancy outcomes using testicular sperm with intracytoplasmic sperm injection

Objective

The aim of this study was to evaluate the influence of maternal age on fertilization, embryo quality, and clinical pregnancy in patients undergoing intracytoplasmic sperm injection (ICSI) using testicular sperm from partners with azoospermia.

Methods

A total of 416 ICSI cycles using testicular spermatozoa from partners with obstructive azoospermia (OA, n=301) and non-obstructive azoospermia (NOA, n=115) were analyzed. Female patients were divided into the following age groups: 27 to 31 years, 32 to 36 years, and 37 to 41 years. The rates of fertilization, high-quality embryos, clinical pregnancy, and delivery were compared across maternal age groups between the OA and NOA groups.

Results

The rates of fertilization and high-quality embryos were not significantly different among the maternal age groups. Similarly, the clinical pregnancy and delivery rates were not significantly different. The fertilization rate was significantly higher in the OA group than in the NOA group (p<0.05). Age-group analysis revealed that the fertilization and high-quality embryo rates were significantly different between the OA and NOA groups in patients aged 27 to 31 years old, but not for the other age groups. Although the clinical pregnancy and delivery rates differed between the OA and NOA groups across all age groups, significant differences were not observed.

Conclusion

In couples using testicular sperm from male partners with azoospermia, pregnancy and delivery outcomes were not affected by maternal age. However, women older than 37 years using testicular sperm from partners with azoospermia should be advised of the increased incidence of pregnancy failure.

Sexual satisfaction among involuntarily childless women: A cross-cultural study in Italy and Brazil

Infertility has been negatively associated with sexual satisfaction. This study aimed to estimate the relation of infertility to sexual satisfaction from a cross-cultural perspective, comparing Italian and Brazilian women. Between June 2012 and January 2013, 528 women seeking assisted reproduction technology (ART) treatment in Italy (39%) or Brazil (61%) completed self-reports of sexual satisfaction (ISS) and infertility-related stress in the marital domain (IRS). IRS was the same across countries. ISS differed, with 34.31% of the Italians and 43.52% of the Brazilians being sexually dissatisfied at a clinical level (ISS score >30). Multiple logistic regression models showed that being sexually dissatisfied at a clinical level was associated with lower education and higher IRS among Italian women, regardless of having a diagnosed cause of infertility. It was instead associated with higher IRS only among the Brazilian women who had a diagnosed cause of infertility. These findings suggest that, regardless of nationality, sexual satisfaction and infertility-related stress need to be addressed in the treatment of infertile women turning to ART. However, as factors associated with these dimensions vary across countries, interventions to promote sexual satisfaction among infertile women should be adapted to their specific socio-cultural context.

Clinical outcomes for couples containing a reciprocal chromosome translocation carrier without preimplantation genetic diagnosis

OBJECTIVE

To evaluate the pregnancy outcomes of couples containing a carrier of a reciprocal chromosome translocation (RCT) after assisted reproductive technology without preimplantation genetic diagnosis.

METHODS

A retrospective study was performed using data for couples with an RCT carrier and control couples with a normal karyotype (1:4 ratio) who underwent assisted reproductive technology cycles at a Chinese fertility center in 2010-2011. The embryos were fertilized via in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Only the first pick-up cycles were used for analysis. Clinical variables were compared.

RESULTS

Compared with the control group (n=164), the RCT group (n=41) had a marginally lower clinical pregnancy rate (46.3% [19/41] vs 54.3% [89/164]), implantation rate (21.7% [23/106] vs 26.9% [118/438]), multiple-gestation pregnancy rate (21.1% [4/19] vs 32.6% [29/89]), and delivery rate (36.6% [15/41] vs 47.6% [78/164]), whereas the spontaneous abortion rate was slightly higher (21.1% [4/19] vs 12.4% [11/89]). However, none of these differences were significant.

CONCLUSION

The clinical outcomes for RCT carriers were acceptable after IVF/ICSI without performing preimplantation genetic diagnosis, indicating that this approach might comprise a feasible alternative fertility treatment for RCT carriers.

Increased risk of large-for-gestational age birthweight in singleton siblings conceived with in vitro fertilization in frozen versus fresh cycles

BACKGROUND

Children born from fresh in vitro fertilization (IVF) cycles are at greater risk of being born smaller and earlier, even when limited to singletons; those born from frozen cycles have an increased risk of large-for-gestational age (LGA) birthweight (z-score ≥1.28). This analysis sought to overcome limitations in other studies by using pairs of siblings, and accounting for prior cycle outcomes, maternal characteristics, and embryo state and stage.

METHODS

Pairs of singleton births conceived with IVF and born between 2004 and 2013 were identified from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database, matched for embryo stage (blastocyst versus non-blastocyst) and infant gender, categorized by embryo state (fresh versus frozen) in 1st and 2nd births (four groups).

RESULTS

The data included 7795 singleton pairs. Birthweight z-scores were 0.00-0.04 and 0.24-0.26 in 1st and 2nd births in fresh cycles, and 0.25-0.34 and 0.50-0.55 in frozen cycles, respectively. LGA was 9.2-9.8 and 14.2-15.4% in 1st and 2nd births in fresh cycles, and 13.1-15.8 and 20.8-21.0% in 1st and 2nd births in frozen cycles. The risk of LGA was increased in frozen cycles (1st births, adjusted odds ratios (AOR) 1.74, 95% CI 1.45, 2.08; and in 2nd births when the 1st birth was not LGA, AOR 1.70, 95% CI 1.46, 1.98 for fresh/frozen and 1.40, 1.11, 1.78 for frozen/frozen).

CONCLUSIONS

Our results with siblings indicate that frozen embryo state is associated with an increased risk for LGA. The implications of these findings for childhood health and risk of obesity are unclear, and warrant further investigation.

Does adding endometrial scratching to diagnostic hysteroscopy improve pregnancy rates in women with recurrent in-vitro fertilization failure?

OBJECTIVE

To investigate the effect of additional endometrial scratching procedure during hysteroscopy on assisted reproductive technology (ART) cycle outcomes in repeated implantation failure (RIF) patients without endometrial or uterine abnormalities on hysteroscopic evaluation.

MATERIALS AND METHODS

Three hundred and forty-five RIF patients who underwent ART at a university-based infertility clinic between January 2011 and June 2015 were recruited in this retrospective cohort study. Uterine cavities of all included patients were evaluated by diagnostic hysteroscopy 7-14 days prior to the subsequent ART cycle. Women without endometrial abnormalities were allocated into two groups; the scratching group was consisted of patients who underwent endometrial scratching by using monopolar electric energy with needle forceps during hysteroscopy, and the control group was consisted of patients who underwent only diagnostic hysteroscopy.

RESULTS

The implantation rate was significantly higher in the scratching group than the control group (37.7% versus 24.5%; p = 0.04). Clinical and ongoing pregnancy rates were also found to be significantly higher in the scratching group than the control group (37.7% versus 27.6%; p = 0.03; and 33.3% versus 23%; p = 0.03, respectively).

CONCLUSION

Endometrial scratching during diagnostic hysteroscopy seems to enhance implantation and as well pregnancy rates in comparison to diagnostic hysteroscopy alone.

Fertility-preservation in endometrial cancer: is it safe? Review of the literature

Almost 5% of women with endometrial cancer are under age 40, and they often have well-differentiated endometrioid estrogen-dependent tumors. Cancer survival rates have improved over the last decades so strategies to avoid or reduce the reproductive damage caused by oncologic treatment are needed. We reviewed the published literature to find evidence to answer the following questions: How should we manage women in reproductive age with endometrial cancer? How safe is fertility preservation in endometrial cancer? Can pregnancy influence endometrial cancer recurrence? What are the fertility sparing options available? Progestins may be prescribed after careful evaluation and counseling. Suitable patients should be selected using imaging methods and endometrial sampling since surgical staging will not be performed. Conservative treatment should only be offered to patients with grade 1 well-differentiated tumors, absence of lymph vascular space invasion, no evidence of myometrial invasion, metastatic disease or suspicious adnexal masses, and expression of progesterone receptors in the endometrium. The presence of co-existing ovarian metastatic of synchronous cancer should be investigated and ruled out before the decision to preserve the ovaries. The availability of Assisted Reproductive Technology (ART) has made it possible for women with endometrial cancer to give birth to a child without compromising their prognoses. Gamete, embryo or ovarian tissue cryopreservation techniques can be employed, although the latter remains experimental. Unfortunately, fertility preservation is rarely considered. Current recommendations for conservative management are based on the overall favorable prognosis of grade 1 minimally invasive tumors. Selected patients with endometrial cancer may be candidates to a safe fertility-preserving management.

Prognostic factors for patients undergoing vitrified-warmed human embryo transfer cycles: a retrospective cohort study

We examined the prognostic factors for pregnancy in 210 vitrified-warmed embryo transfer (ET) cycles in 121 patients. The univariate analysis showed that age, gravida, the number of cycles associated with infertility caused by endometriosis, the number of previous assisted reproductive technology (ART) treatment cycles, and the number of ICSI procedures were significantly lower in pregnant cycles compared with non-pregnant cycles. The percentages of ET using at least one intact embryo and of ET using at least one embryo that had developed further after warming were significantly higher in pregnant cycles compared with non-pregnant cycles. Multivariate logistic regression analysis showed that previous ART treatment cycles, ET with at least one intact embryo, and ET using at least one embryo that had developed further were independent prognostic factors for pregnancy in vitrified-warmed ET cycles. We conclude that fewer previous ART treatment cycles, ET using at least one intact embryo, and ET with embryos that have developed further after warming might be favourable prognostic factors for pregnancy in vitrified-warmed ET cycles.

Buying and selling human eggs: infertility providers' ethical and other concerns regarding egg donor agencies

Background

Egg donor agencies are increasingly being used as part of IVF in the US, but are essentially unregulated, posing critical ethical and policy questions concerning how providers view and use them, and what the implications might be.

Methods

Thirty-seven in-depth interviews of approximately 1 h were conducted – with 27 IVF providers and 10 patients.

Results

Clinicians vary in their views and interactions concerning egg donor agencies, ranging widely in whether and how often they use agencies. Agencies may offer egg recipients increased choices, but raise ethical and other concerns regarding respect for donors as individuals (e.g., adequacy of informed consent), potential harms, justice (e.g., concerns about possible eugenics – by encouraging and facilitating selection and marketing of facts for offspring), and donors constituting a vulnerable group. The quality of agencies appears to vary considerably, from acceptable to problematic. Agencies’ medical and psychological screenings of donors can range, and be minimal. Not all agencies adequately track donors’ prior numbers of donations, or share the relevant records with clinics. Clinics may find that potential donors have genetic mutations and medical problems about which they were unaware. Yet agencies and clinics do not provide care for such donors, generating stress. Dissemination of donors’ personal data can potentially threaten confidentiality. Questions emerge of whether increased monitoring/oversight of agencies may be beneficial.

Conclusions

These data, the first to examine providers’ views and interactions regarding egg donor agencies, suggest wide variations in quality and use of agencies, and have critical implications for practice, policy, education and research. Given the potential limitations of the current model of self-regulation of agencies, the present data suggest needs to consider stronger professional guidelines or possible governmental regulations to establish, require and enforce higher standards for agencies to follow, regarding advertising to potential donors and recipients, arranging for appropriate informed consent concerning risks and benefits involved, and for quality control. Appropriate informed consent should be obtained from potential egg donors, including the fact that they may learn about mutations or medical problems about which they were unaware, but for which they will not receive treatment as part of this process. Enhancing understanding among the public-at-large about what egg donation entails may also be helpful.

Electronic supplementary material

The online version of this article (doi:10.1186/s12910-016-0151-z) contains supplementary material, which is available to authorized users.

Fertility treatment and childhood type 1 diabetes mellitus: a nationwide cohort study of 565,116 live births

OBJECTIVE

To investigate the association between specific types of fertility treatment and childhood type 1 diabetes mellitus.

DESIGN

Nationwide birth cohort study.

SETTING

Not applicable.

PATIENT(S)

All pregnancies resulting in a live-born singleton child in Denmark from 1995 to 2003.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Childhood type 1 diabetes mellitus identified from redeemed prescriptions for insulin until 2013.

RESULT(S)

The study included 565,116 singleton pregnancies. A total of 14,985 children were conceived by ovulation induction or intrauterine insemination, and 8,490 children were conceived by in vitro fertilization or intracytoplasmic sperm injection. During the follow-up period, 2,011 (0.4%) children developed type 1 diabetes mellitus. The primary analyses showed no association between fertility treatment and childhood type 1 diabetes mellitus. In secondary analyses, ovulation induction or intrauterine insemination with follicle-stimulating hormone was associated with an increased risk of type 1 diabetes mellitus (hazard ratio 3.22; 95% confidence interval 1.20 to 8.64). No clear associations were seen with other types of fertility treatment or with specific treatment indications.

CONCLUSION(S)

No association between fertility treatment and childhood type 1 diabetes mellitus was found. Ovulation induction or intrauterine insemination with follicle-stimulating hormone may be associated with an increased risk of childhood type 1 diabetes mellitus. However, this finding may be due to chance or to confounding by indication and thus requires further investigation.

Impact of DNA mismatch repair system alterations on human fertility and related treatments

DNA mismatch repair (MMR) is one of the biological pathways, which plays a critical role in DNA homeostasis, primarily by repairing base-pair mismatches and insertion/deletion loops that occur during DNA replication. MMR also takes part in other metabolic pathways and regulates cell cycle arrest. Defects in MMR are associated with genomic instability, predisposition to certain types of cancers and resistance to certain therapeutic drugs. Moreover, genetic and epigenetic alterations in the MMR system demonstrate a significant relationship with human fertility and related treatments, which helps us to understand the etiology and susceptibility of human infertility. Alterations in the MMR system may also influence the health of offspring conceived by assisted reproductive technology in humans. However, further studies are needed to explore the specific mechanisms by which the MMR system may affect human infertility. This review addresses the physiological mechanisms of the MMR system and associations between alterations of the MMR system and human fertility and related treatments, and potential effects on the next generation.

Risk of Preeclampsia in Pregnancies After Assisted Reproductive Technology and Ovarian Stimulation

Objective To compare the risk of preeclampsia among spontaneously conceived pregnancies to those after hyperestrogenic ovarian stimulation (hyperestrogenic OS) with and without assisted reproductive technology (ART), and stimulation with non-hyperestrogenic aromatase inhibitor stimulation (non-hyperestrogenic OS). Methods Live-born singleton deliveries among women 20-49 years were identified in the 2004-2012 Truven Health MarketScan Commercial Claims and Encounters Databases using ICD-9 and CPT codes. Maternal characteristics were compared using Chi squared and Fisher exact tests. We performed multilevel multivariable logistic regression, controlling for maternal age, parity, comorbid conditions, and region of delivery, and calculated adjusted odds ratios (aOR) and 95 % confidence intervals for mild and severe preeclampsia. Results 1,014,526 spontaneously conceived, 6881 hyperestrogenic OS with ART, 27,516 hyperestrogenic OS without ART, and 2117 non-hyperestrogenic OS pregnancies were identified. The adjusted odds of developing preeclampsia were increased for deliveries after hyperestrogenic OS with ART (mild preeclampsia aOR 1.42, 1.24-1.62; severe preeclampsia aOR 1.83, 1.59-2.11) and without ART (mild preeclampsia aOR 1.32, 1.24-1.42; severe preeclampsia aOR 1.53, 1.41-1.66). Adjusted odds of preeclampsia were similar between spontaneously conceived and non-hyperestrogenic OS pregnancies. Conclusions for Practice Risk of preeclampsia after ART may in part be related to supraphysiologic estrogen associated with hyperestrogenic OS.

Risk factors vary early preterm birth and perinatal complications after assisted reproductive technology

We conducted a study of markers of endothelial dysfunction and angiogenesis regulation, as well as the identification of the main lymphocyte populations, activated CD3 ⁺ CD95⁺-cells and cytokine-producing CD4 ⁺ IFN-γ⁺-, CD4 ⁺ IL-4⁺-lymphocytes in the 1st trimester of gestation in women with ART-induced pregnancy and spontaneous pregnancy. We used the same indicators to assess the immune status of ELBW infants at birth and at the post-conceptual age of 38-40 weeks. It was determined that the risk factors of very early preterm delivery are: threatened miscarriage, chronic placental insufficiency, endothelial dysfunction, increased spontaneous production of intracellular cytokines. Adverse perinatal outcomes in ELBW infants from ART-induced pregnancy are associated with lower anthropometric measures, low Apgar scores high level of inflammatory infections (pneumonia), grade II intraventricular hemorrhage, movement disorders in the form of lower paraparesis. Immune status of those infants is characterized by the increase in the number of CD8⁺- and CD3^-CD16 ⁺ CD56⁺-lymphocytes, the expression level of Fas-receptor by T-cells, and the increased production of intracellular and serum IFNγ against the decrease in the number of CD4⁺-cells, which indicates enhancing of cytotoxic effector potential and proinflammatory orientation of cell responses.

Pregnancy outcome following frozen embryo transfer after artificial cycle or treatment by clomiphene citrate

The optimal method to prepare endometrium before frozen embryo transfer (FET) is not yet established. We retrospectively studied 4496 FET and detailed pregnancy and miscarriage rates in three groups of patients according to the endometrium preparation they have followed before their successive FET: clomifene citrate (CC, group 1), artificial cycle (AC, group 2) or switch between CC and AC (group 3). The overall pregnancy rates per transfer were 24.3, 20.8 and 17.3% while the miscarriage rates reached 23.2, 29.8 and 42.5%, respectively. Group 1 experienced the highest ongoing pregnancy rate (18.6%), the lowest being observed in group 3 (10.0%, p < 0.001). Here we propose several alternatives to improve our AC protocol (group 2) that seemed less effective than CC (group 1) and we consider the use of a gonadotrophin-stimulated treatment for patients with the lowest reproductive outcomes (group 3).

Congenital heart disease in twins: The contribution of type of conception and chorionicity

BACKGROUND

Increased incidence of congenital heart disease (CHD) has been reported in the offspring of monochorionic twin gestations. Assisted reproductive technology (ART), which is related to increased rates of twinning, has also been associated with higher risk of birth defects. We studied the incidence of CHD in a cohort of twins to clarify the contribution of type of conception and chorionicity.

METHODS

Data concerning 874 live-born twins of which at least one was admitted in our Neonatal Unit during 1995-2012 were analysed. Forty-five % (N=197) of the gestations resulted from ART (in vitro fertilisation or intracytoplasmic sperm insertion).

RESULTS

In the ART group 32/389 (8.2%) had CHD compared to 21/485 (4.3%) infants conceived naturally (OR 1.90, 95%CI 1.08-3.34, p=0.024). Spontaneous-conception gestations had higher incidence of monochorionic placentation (47/245 versus 4/197, p<0.001), and included younger mothers (29.1±5.2 versus 33.9±5.5years, p<0.001) who had higher parity (median 2 [range 1-7] versus 1 Pinborg (2005), Blondel and Kaminski (2002), Knopman et al. (2014), Kyvik and Derom (2006) ; p<0.001). Multivariable logistic regression analysis showed that ART (OR 2.60, 95% CI 1.24-5.45) and monochorionicity (OR 3.49, 95% CI 1.57-7.77) were significant determinants of CHD, independently of maternal age, parity, and the gender of the offspring.

CONCLUSIONS

We confirmed that monochorionic twins have increased risk of CHD and we documented a higher incidence of CHD in ART twins independently of chorionicity. We suggest improvement of echocardiographic skills of health care professionals involved in prenatal screening and foetal cardiology referral of ART dichorionic twins with suspicious findings at screening, in addition to all monochorionic gestations.

Perinatal outcomes of singleton siblings: the effects of changing maternal fertility status

PURPOSE

The objective of this study was to evaluate the effect of changing fertility status on perinatal outcomes of singleton siblings, conceived with and without assisted reproductive technology (ART).

METHOD

A longitudinal cohort study of Massachusetts resident women having two consecutive singleton births during 2004-2010 was performed. Women were classified as ART (A), subfertile (S), or fertile (F) and categorized by their fertility status in each birth as A-A, A-S, S-A, S-S, F-A, F-S, and F-F. Within categories, adjusted mean birthweights, gestations, and birthweight Z scores were estimated with linear generalized estimating equations. Risks of low birthweight (LBW, <2500 g), preterm birth (PTB, <37 weeks), and placental complications were modeled using logistic regression by fertility status as adjusted odds ratios (AORs) and 95 % confidence intervals (CIs).

RESULTS

Birthweights in second pregnancies averaged 74-155 g higher, except for births to F-A women, who averaged -16 g lower. Most women had a reduction in length of gestation in their second pregnancies, with F-A women having the largest decline (-0.5 weeks). In first birth models, the risks for LBW and placental complications were increased for subfertile (AOR 1.39 [1.07-1.81] and 1.97 [1.33-2.93], respectively) and ART women (AOR 1.58 [1.29-1.93] and 3.40 [2.64-4.37], respectively). Second birth models showed increased risks for ART births of LBW (AOR 3.13 [2.19-4.48]) and placental complications (AOR 2.45 [1.56-3.86]) and greater risks of PTB for both ART (AOR 2.37 [1.74-3.23]) and subfertile women (AOR 1.47 [1.02-2.13]).

CONCLUSIONS

Declining fertility status, with and without assisted reproductive technology treatment, is associated with increasing risks for adverse outcomes, greatest for women whose fertility status declined the most.

Area under curve of temporal estradiol measurements for prediction of the detrimental effect of estrogen exposure on implantation

OBJECTIVE

To assess whether the area under the curve of temporal estradiol measurements (AUCEM) during cycles of assisted reproductive technology (ART) can be used to predict failure of implantation and clinical pregnancy.

METHODS

In a prospective study, women aged 24-39years undergoing ART at a center in Turkey were enrolled between January and December 2014. Eligible patients had a regular menstrual cycle, normal levels of serum prolactin, and no hormone treatment within the past 3months. The area under the curve of the time course of estradiol measurements was calculated for each participant, and assessed for its ability to predict successful implantation.

RESULTS

Among 282 participants, 109 (38.6%) women had successful implantation. There was a significant difference between the two groups of women in AUCEM, estradiol per day (AUCEM divided by duration of stimulation), and endometrial thickness on the day of human chorionic gonadotropin administration (P<0.05 for all).

CONCLUSION

The area under the curve of estradiol measurements during ART cycles might be useful for predicting failure of implantation and clinical pregnancy.

The impact of FMR1 gene mutations on human reproduction and development: a systematic review

PURPOSE

This is a comprehensive review of the literature in this field attempting to put the FMR1 gene and its evaluation into context, both in general and for the reproductive health audience.

METHODS

Online database search of publications with systematic review of all papers relevant to ovarian reserve and assisted reproduction was done.

RESULTS

Relevant papers were identified and assessed, and an attempt was made to understand, rationalize and explain the divergent views in this field of study. Seminal and original illustrations were employed.

CONCLUSIONS

FMR1 is a highly conserved gene whose interpretation and effect on outcomes remains controversial in the reproductive health setting. Recent re-evaluations of the commonly accepted normal range have yielded interesting tools for possibly explaining unexpected outcomes in assisted reproduction. Fragile X investigations should perhaps become more routinely assessed in the reproductive health setting, particularly following a failed treatment cycle where oocyte quality is thought to be a contributing factor, or in the presence of a surprise finding of diminished ovarian reserve in a young patient.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study

OBJECTIVES

Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART.

METHODS

A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time.

RESULTS

MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]).

CONCLUSIONS

It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Risk of peripartum hysterectomy in births after assisted reproductive technology

OBJECTIVE

To investigate whether women who conceive after assisted reproductive technology (ART) are at higher risk for emergency peripartum hysterectomy.

DESIGN

A case-control study using a prospectively maintained institutional database.

SETTING

A tertiary referral university teaching maternity hospital.

PATIENT(S)

Thirty-one women who underwent peripartum hysterectomy for management of hemorrhage, and 19,902 control women.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Association between potential predictors and peripartum hysterectomy.

RESULT(S)

The incidence of peripartum hysterectomy was 1.7 cases per 1,000 births (95% confidence interval [CI] 1.2-2.4). After adjustment for maternal age and twin pregnancy, placenta previa (odds ratio [OR] 50.78, 95% CI 23.30-110.68), prior cesarean delivery (OR 6.72, 95% CI 2.99-15.09 for one cesarean; OR 6.80, 95% CI 1.45-31.90 for two or more cesareans), previous myomectomy (OR 24.59, 95% CI 6.70-90.19), and ART conception (OR 5.98, 95% CI 2.18-16.40) were all antenatal predictors for peripartum hysterectomy. In women having a peripartum hysterectomy, 13.4% of the risk is attributable to mode of conception.

CONCLUSION(S)

A history of ART increases the likelihood of needing a peripartum hysterectomy to control hemorrhage. Further investigation is needed to determine whether ART conception should be included in algorithms of risk stratification for emergency cesarean hysterectomy and plan of care be modified accordingly.

The effect on pregnancy and multiples of transferring 1-3 embryos in women at least 40 years old

PURPOSE "CAPSULE" IS MANDATORY. PLEASE PROVIDE.SINGLE EMRBYO TRANSFER (SET) IN WOMEN ≥40 YEARS OLD APPEARS TO LOWER THE CHANCE OF A PREGNANCY. HOWEVER, IT MINIMIZES THE RISK OF MULTIPLE PREGNANCIES EVEN IN WOMEN OF ADVANCED MATERNAL AGE. THEREFORE, WOMEN 40 YEARS OF AGE OR OLDER SHOULD BE OFFERED (SET).: This study was performed to investigate the multiple pregnancies and live birth rates when 1-3 embryos are transferred at this age in women at least 40 years of age.

METHOD

A retrospective analysis of data which included 631 women aged 40 to 46 years, who underwent 901 cycles of IVF, from August 2010 to June 2012 was undertaken. These women underwent embryo transfer of 1-3 non-donor fresh embryo(s).

RESULTS

Results suggested that the average pregnancy rate when up to three embryos were transferred was 25 % for women 40 years old, 20 % for women 41 years old, 16 % for women 42 years old, 17 % for women 43 years old, 8 % for women 44 years old, 6 % for women 45 years old, and 0 % for women 46 years old. No live births occurred in women treated after their 44th birthday, and only patients younger than 42 years of age receiving double embryo transfer had a live birth of twins. Live birth rates increased as more embryos were transferred for 40- and 42-year-old subjects (p = 0.01 and 0.05, respectively).

CONCLUSIONS

From these results, it was concluded that SET in women ≥40 years old appears to lower the chance of a pregnancy. However, it minimizes the risk of multiple pregnancies even in women of advanced maternal age. Women 40 years of age or older should be offered single-embryo transfer. Further studies are needed to determine risk of multiple pregnancies in women 42 years of age or older when few embryos are transferred. Decisions on the number of embryos to transfer should be on a case by case basis, in discussion with the patient.

Assisted reproductive technology and perinatal outcomes: conventional versus discordant-sibling design

OBJECTIVE

To compare risks of adverse perinatal outcomes between assisted reproductive technology (ART) and naturally conceived singleton births using a dual design approach.

DESIGN

Discordant-sibling and conventional cross-sectional general population comparison.

SETTING

Not applicable.

PATIENT(S)

All singleton live births, conceived naturally or via ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Birth weight, gestational age, low birth weight, preterm delivery, small for gestational age (SGA), low Apgar score.

RESULT(S)

A total of 32,762 (0.8%) of 3,896,242 singleton live births in the three states were conceived via ART. In 6,458 sibling pairs, ART-conceived singletons were 33 g lighter (adjusted β = -33.40, 95% confidence interval [CI], -48.60, -18.21) and born half a day sooner (β = -0.58, 95% CI, -1.02, -0.14) than singletons conceived naturally. The absolute risk of low birth weight and preterm birth was 6.8% and 9.7%, respectively, in the ART group and 4.9% and 7.9%, respectively, in the non-ART group. The odds of low birth weight were 33% higher (adjusted odds ratio [aOR] = 1.33; 95% CI, 1.13, 1.56) and 20% higher for preterm birth (aOR = 1.20; 95% CI, 1.07, 1.34). The odds of SGA and low Apgar score were not significantly different in both groups (aOR = 1.22; 95% CI, 0.88, 1.68; and aOR = 0.75; 95% CI, 0.54, 1.05, respectively). Results of conventional analyses were similar, although the magnitude of risk was higher for preterm birth (aOR, 1.51; 95% CI 1.46, 1.56).

CONCLUSION(S)

Despite some inflated risks in the general population comparison, ART remained associated with an increased likelihood of low birth weight and preterm birth when underlying maternal factors were kept constant using discordant-sibling comparison.

Assisted reproductive techniques in Latin America: The Latin American Registry, 2013

Multinational data on assisted reproduction techniques undertaken in 2013 were collected from 158 institutions in 15 Latin American countries. Individualized cycle-based data included 57,456 initiated cycles. Treatments included autologous IVF and intracytoplasmic sperm injection (ICSI), frozen embryo transfers, oocyte donations. In autologous reproduction, 29.22% of women were younger than 35 years, 40.1% were 35-39 years and 30.6% were 40 years or older. Overall delivery rate per oocyte retrieval was 20.6% for ICSI and 25.4% for IVF. Multiple births included 20.7% for twins and 1.1% for triplets and over. In oocyte donations, twins reached 30% and triplets 1.4%. In singletons, pre-term births were 7.5%: 36.58% in twins and 65.52% in triplets. The relative risk for prematurity was 4.9 (95% CI 4.5 to 5.3) in twins and 8.7 (95% CI 7.6 to 10.0) in triplets and above. Perinatal mortality was 29.4 per 1000 in singletons, 39.9 per 1000 in twins and 71.6 per 1000 in high order multiples. Elective single embryo transfer represented only 2% of cycles, with delivery rate of 39.1% in women aged 34 years or less. Given the effect of multiple births and prematurity, it is mandatory to reduce the number of embryos transferred in the region.

The Mahabharata and reproductive endocrinology

This communication approaches the Mahabharata through the prism of reproductive endocrinology. Descriptions of episodes related to reproduction are listed here, to provide fodder for the endocrinologically minded brain. The cases described here are perhaps, the first documented observations of fetal orgasm, pseudocyesis and assisted reproductive technology, including assisted insemination by donor, induction of ovulation, and in vitro fertilization as well as precocious growth and intersex. We do not presume to offer a definite explanation for these interesting episodes from the Mahabharata. We do, however, hope to stimulate interest in ancient Indian literature, and encourage a literary "forensic endocrine" analysis of events relevant to our specialty.

The endometrium in assisted reproductive technology: How thin is thin?

A thin endometrium is encountered infrequently (2.4%) in assisted reproductive technology cycles. When it does occur it is a cause of concern as it is associated with lower implantation rate and pregnancy rate. Though pregnancies have been reported at 4 and 5 mm it is apparent that an endometrial thickness <6 mm is associated with a trend toward lower probability of pregnancy. Hormone replacement therapy – frozen embryo transfer (FET) cycles appear to give better results due to an improvement in endometrial receptivity (ER). The etiology of thin endometrium plays a significant part in its receptivity. A number of treatments have been tried to improve endometrial growth, but none has been validated so far. Confirming ER of a thin endometrium by an ER array test before FET offers reassurance.

Testicular versus ejaculated spermatozoa in ICSI cycles of normozoospermic men with high sperm DNA fragmentation and previous ART failures

As a part of male assessment, conventional sperm parameters including morphologic features have been dedicated as major factors influencing fertilisation and pregnancy rates in assisted reproductive technology (ART). Genomic integrity of spermatozoa has also been found to influence fertility prognosis, and hence, sperm DNA fragmentation index (DFI) has been adopted by many centres to document this entity. Despite several suggested approaches, there is lack of universal consensus on optimising fertility outcomes in males with high sperm DFI. In this context, the results from cycles using testicular spermatozoa (TESA) obtained by aspiration were compared with those of ejaculated spermatozoa (EJ) in normozoospermic subjects with high sperm DFI and previous ART failures. Clinical (41.9% versus 20%) and ongoing pregnancy rates (38.7% versus 15%) were significantly better and miscarriages were lower in TESA group when compared to EJ group. Sperm DFI should be a part of male partner's evaluation following unsuccessful ART attempts. When high DFI is detected (>30%), ICSI using testicular spermatozoa obtained by TESA seems an effective option particularly for those with repeated ART failures in terms of clinical, ongoing pregnancies and miscarriages even though conventional sperm parameters are within normal range.

Efficacy and safety of frozen-thawed embryo transfer in women aged 35 to 42 years from the PURSUE randomized clinical trial

OBJECTIVE

To examine the efficacy and safety of frozen-thawed embryo transfer (FTET) cycles with supernumerary embryos cryopreserved during a randomized clinical trial (PURSUE).

DESIGN

Follow-up clinical study.

SETTING

In vitro fertilization (IVF) centers.

PATIENT(S)

Infertile women 35 to 42 years of age.

INTERVENTION(S)

In PURSUE, women were randomized to a single injection of 150 μg of corifollitropin alfa (n = 694) or daily 300 IU of recombinant follicle-stimulating hormone (recombinant FSH; n = 696) for the first 7 days of controlled ovarian stimulation (COS) in a gonadotropin-releasing hormone (GnRH) antagonist protocol.

MAIN OUTCOME MEASURE(S)

Cumulative vital pregnancy rate per-patient by treatment group, cumulative live-birth rate per-patient by treatment group, and occurrence of adverse events in (pregnant) women and their fetuses/infants and the incidence of congenital malformations in the infants.

RESULT(S)

Of the 1,390 treated women in PURSUE, 307 were enrolled in the FTET study. In PURSUE or a subsequent FTET cycle, the cumulative vital pregnancy rate (per patient) was 31.1% (95% confidence interval [CI], 27.7%; 34.7%) with corifollitropin alfa versus 33.0% (95% CI: 29.6%; 36.7%) with recombinant FSH; treatment difference, -1.8% (95% CI, -6.5%; 3.0%), and the cumulative live-birth rate (per patient) was 28.2% (95% CI, 24.9%; 31.8%) with corifollitropin alfa versus 29.5% (95% CI, 26.1%; 33.0%) with recombinant FSH; treatment difference, -1.2% (95% CI, -5.7%; 3.4%). There were no clinically relevant differences in safety outcomes collected from pregnant women or their infants after transfer of cryopreserved embryos obtained by treatment with corifollitropin alfa or recombinant FSH.

CONCLUSION(S)

The cumulative vital pregnancy and live-birth rates (from fresh cycles and FTET) were similar in women treated with corifollitropin alfa and recombinant FSH. No new safety signals were detected in this follow-up FTET study.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01146418.

In Vitro fertilization (IVF) treatments in Maccabi Healthcare Services 2007-2014

BACKGROUND

Israel reports the world's highest IVF cycles per capita. However, clinical outcome data of these treatments are scarce. In a previous publication, we summarized IVF results among Maccabi Healthcare Services members for the years 2007-2010. The main findings included an increase in mean patients' age over the period studied, a 50 % increase in cycle numbers during this time, and a decrease in success rate (live birth) from 18.8 % in 2007 to 14.8 % in 2010. The purpose of the current publication is to summarize IVF outcome for the years 2011-2014, and to explore possible changes in the trends we reported previously.

METHODS

IVF and live births data were collected from Maccabi Healthcare Services' fertility treatments registry. Analyses were conducted by treatment year and patients' age at the initiation of treatment cycles. Autologous cycles, were included (ovum donation cycles and frozen-thaw cycles were excluded). A successful cycle was defined if a live birth was recorded within 10 months of its initiation.

RESULTS

In accordance with previous data for the years 2007-2010, mean patients' age continued to rise (from 36.2 in 2011 to 37.1 in 2014). In contrast to previous years, during which a continued increase in treatment cycles was recorded, we found that treatment number decreased from a peak of 9,751 in 2011 to 8,623 in 2014. Contrary to that trend, the number of patients over 40 years of age increased from 3,204 in 2011 to 3,648 in 2014. Success rate fluctuated between 14.4 % in 2014 to 16.4 % in 2013. The majority (78 %) of treatment cycles were conducted in four private medical centers.

CONCLUSIONS

The decrease in treatment cycles in recent years notwithstanding, Israel is still leading the world with IVF treatments relative to population. Success rate is relatively low compared to international data. Given the steady increase in patients' mean age, and particularly, the increase in patients over 40 years of age, we maintain that the low success rate reflects a growing number of treatments that a priori have a low chance of success.