Embryo cryopreservation and preeclampsia risk

OBJECTIVE

To determine whether assisted reproductive technology (ART) cycles involving cryopreserved-warmed embryos are associated with the development of preeclampsia.

DESIGN

Retrospective cohort study.

SETTING

IVF clinics and hospitals.

PATIENT(S)

A total of 15,937 births from ART: 9,417 singleton and 6,520 twin.

INTERVENTION(S)

We used linked ART surveillance, birth certificate, and maternal hospitalization discharge data, considering resident singleton and twin births from autologous or donor eggs from 2005-2010.

MAIN OUTCOME MEASURE(S)

We compared the frequency of preeclampsia diagnosis for cryopreserved-warmed versus fresh ET and used multivariable logistic regression to adjust for confounders.

RESULT(S)

Among pregnancies conceived with autologous eggs resulting in singletons, preeclampsia was greater after cryopreserved-warmed versus fresh ET (7.51% vs. 4.29%, adjusted odds ratio = 2.17 [95% CI 1.67-2.82]). Preeclampsia without and with severe features, preeclampsia with preterm delivery, and chronic hypertension with superimposed preeclampsia were more frequent after cryopreserved-warmed versus fresh ET (3.99% vs. 2.55%; 2.95% vs. 1.41%; 2.76 vs. 1.48%; and 0.95% vs. 0.43%, respectively). Among pregnancies from autologous eggs resulting in twins, the frequency of preeclampsia with severe features (9.26% vs. 5.70%) and preeclampsia with preterm delivery (14.81% vs. 11.74%) was higher after cryopreserved versus fresh transfers. Among donor egg pregnancies, rates of preeclampsia did not differ significantly between cryopreserved-warmed and fresh ET (10.78% vs. 12.13% for singletons and 28.0% vs. 25.15% for twins).

CONCLUSION(S)

Among ART pregnancies conceived using autologous eggs resulting in live births, those involving transfer of cryopreserved-warmed embryos, as compared with fresh ETs, had increased risk for preeclampsia with severe features and preeclampsia with preterm delivery.

Placental imprinting variation associated with assisted reproductive technologies and subfertility

Infertility affects one in 6 couples in developed nations, resulting in an increasing use of assisted reproductive technologies (ART). Both ART and subfertility appear to be linked to lower birth weight outcomes, setting infants up for poor long-term health. Prenatal growth is, in part, regulated via epigenetically-controlled imprinted genes in the placenta. Although differences in DNA methylation between ART and control infants have been found, it remains unclear whether these differences are due to the ART procedures or to the underlying parental subfertility and how these methylation differences affect imprinted gene expression. In this study, we examined the expression of 108 imprinted genes in placental tissues from infants born to subfertile parents (n = 79), matched naturally-conceived controls (n = 158), and infants conceived using in vitro fertilization (IVF, n = 18). Forty-five genes were identified as having significantly different expression between the subfertile infants and controls, whereas no significant differences were identified between the IVF and control groups. The expression of 4 genes-IGF2, NAPIL5, PAX8-AS1, and TUBGCP5-was significantly downregulated in the IVF compared with the subfertile group. Three of the 45 genes significantly dysregulated between subfertile and control placentae-GRB10, NDN, and CD44 -were found to have a significant positive correlation between expression and birth weight. Methylation levels for these 3 genes and 4 others-MKRN3, WRB, DHCR24, and CYR61-were significantly correlated with expression. Our findings indicate that epigenetic differences in placentas resulting from IVF pregnancies may be related to the underlying subfertility in parents using IVF rather than the IVF procedure itself.

Kisspeptin as a promising oocyte maturation trigger for in vitro fertilisation in humans

The aim of this review is to analyse the effectiveness of exogenous kisspeptin administration as a novel alternative of triggering oocyte maturation, instead of currently used triggers such as human chorionic gonadotropin (hCG) or gonadotropin releasing hormone (GnRH) agonist, in women undergoing in vitro fertilisation (IVF) treatment. Kisspeptin has been considered a master regulator of two modes of GnRH and hence gonadotropin secretion, pulses and surges. Administration of kisspeptin-10 and kisspeptin-54 induces the luteinising hormone (LH) surge required for egg maturation and ovulation in animal investigations and LH release during the preovulatory phase of the menstrual cycle and hypothalamic amenorrhoea in humans. Exogenous kisspeptin-54 has been successfully administered as a promising method of triggering oocyte maturation, following ovarian stimulation with gonadotropins and GnRH antagonists in women undergoing IVF, due to its efficacy considering achieved pregnancy rates compared to hCG and GnRH agonists. Also, its safety in patients at high risk of developing ovarian hyperstimulation syndrome is noteworthy. Nevertheless, further studies would be desirable to establish the optimal trigger of egg maturation and to improve the reproductive outcome for women undergoing IVF treatment.

What is the best predictor of severe ovarian hyperstimulation syndrome in IVF? A cohort study

PURPOSE

The purpose of the present study is to study what is the best predictor of severe ovarian hyperstimulation syndrome (OHSS) in IVF.

METHODS

This is a retrospective analysis of all consecutive IVF/intracytoplasmic injection cycles performed during a 5-year period (2009-2014) in a single university fertility centre. All fresh IVF cycles where ovarian stimulation was performed with gonadotrophins and GnRH agonists or antagonists and triggering of final oocyte maturation was induced with the administration of urinary or recombinant hCG were analyzed (2982 patients undergoing 5493 cycles). Because some patients contributed more than one cycle, the analysis of the data was performed with the use of generalized estimating equation (GEE).

RESULTS

Severe OHSS was diagnosed in 20 cycles (0.36%, 95% CI 0.20-0.52). The number of follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles. The cutoff in the number of follicles ≥10 mm with the best capacity to discriminate between women that will and will not develop severe OHSS was ≥15.

CONCLUSION

The presence of more than 15 follicles ≥10 mm on the day of triggering final oocyte maturation represents the best predictor of severe OHSS in IVF cycles.

[COMPLICATIONS OF PREGNANCY, RESULTING FROM ASSISTED REPRODUCTIVE TECHNOLOGY]

When pregnancy occurs as a result of assisted reproductive technologies (ART), there are more chances of developing complications and adverse outcomes for the mother and fetus compared to spontaneous pregnancies. Taking into account the noted features, the purpose of our study was to determine the nature of the complications of induced pregnancy and their frequency, depending on the causes of infertility. Under our supervision were 86 women with induced single-pregnancy. Two clinical groups were formed depending on the causes of infertility: group I was represented by 53 observations, in which infertility of endocrine genesis took place; Group II included 33 women with tubal peritoneal infertility. Pregnancy, resulting from ART, should be attributed to the group at high risk of complications of pregnancy. Among the causes of female infertility, the tubal peritoneal factor is the least dangerous in terms of the complicated course of the gestational process, and the endocrine factors that can cause a two-fold increase in the frequency of the threat of abortion and pre-eclampsia are more dangerous. In turn, the cause of endocrine infertility are various factors that need to be determined when predicting the course of induced pregnancy. A special feature of maintaining this category of pregnant women is the constant observation and correction of dyshormonal disorders, which not only cause anovulation, but can also negatively affect the course of pregnancy.

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.

Obstetric and neonatal complications in pregnancies conceived after oocyte donation: a systematic review and meta-analysis

BACKGROUND

Approximately 50 000 oocyte donation (OD) treatment cycles are now performed annually in Europe and the US.

OBJECTIVES

To ascertain whether the risk of adverse obstetric and perinatal/neonatal outcomes is higher in pregnancies conceived by OD than in pregnancies conceived by conventional in-vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) or spontaneously.

SEARCH STRATEGY

A systematic search was performed in the PubMed, Cochrane and Embase databases from 1982-2016. Primary outcomes were hypertensive disorders of pregnancy, pre-eclampsia (PE), gestational diabetes mellitus, postpartum haemorrhage, caesarean section, preterm birth, low birthweight and small for gestational age.

SELECTION CRITERIA

Inclusion criteria were original studies including at least five OD pregnancies with a control group of pregnancies conceived by conventional IVF/ICSI or spontaneous conception, and case series with >500 cases reporting one or more of the selected complications. Studies not adjusting for plurality were excluded.

DATA COLLECTION AND ANALYSIS

Thirty-five studies met the inclusion criteria. A random-effects model was used for the meta-analyses.

MAIN RESULTS

For OD pregnancies versus conventional IVF/ICSI pregnancies the risk of PE was adjusted odds ratio (AOR) 2.11 (95% CI, 1.42-3.15) in singleton and AOR 3.31 (95% CI, 1.61-6.80) in multiple pregnancies. The risks of preterm birth and low birthweight in singletons were AOR 1.75 (95% CI, 1.39-2.20) and 1.53 (95% CI, 1.16-2.01), respectively.

CONCLUSIONS

OD conceptions are associated with adverse obstetric and neonatal outcomes. To avoid the additional increase in risk from multiplicity, single-embryo transfer should be the choice of option in OD cycles.

TWEETABLE ABSTRACT

Oocyte donation pregnancies have increased risk of a range of obstetric and neonatal complications.

Optimal euploid embryo transfer strategy, fresh versus frozen, after preimplantation genetic screening with next generation sequencing: a randomized controlled trial

OBJECTIVE

To compare two commonly used protocols (fresh vs. vitrified) used to transfer euploid blastocysts after IVF with preimplantation genetic screening.

DESIGN

Randomized controlled trial.

SETTING

Private assisted reproduction center.

PATIENT(S)

A total of 179 patients undergoing IVF treatment using preimplantation genetic screening.

INTERVENTION(S)

Patients were randomized at the time of hCG administration to either a freeze-all cycle or a fresh day 6 ET during the stimulated cycle.

MAIN OUTCOME MEASURE(S)

Implantation rates (sac/embryo transferred), ongoing pregnancy rates (PRs) (beyond 8 weeks), and live birth rate per ET in the primary transfer cycle.

RESULT(S)

Implantation rate per embryo transferred showed an improvement in the frozen group compared with the fresh group, but not significantly (75% vs. 67%). The ongoing PR (80% vs. 61%) and live birth rates (77% vs. 59%) were significantly higher in the frozen group compared with the fresh group.

CONCLUSION(S)

Either treatment protocol investigated in the present study can be a reasonable option for patients. Freezing all embryos allows for inclusion of all blastocysts in the cohort of embryos available for transfer, which also results in a higher proportion of patients reaching ET. These findings suggest a trend toward favoring the freeze-all option as a preferred transfer strategy when using known euploid embryos.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02000349.

Reduced Ectopic Pregnancy Rate on Day 5 Embryo Transfer Compared with Day 3: A Meta-Analysis

OBJECTIVE

To compare the risk of ectopic pregnancy (EP) after embryo transfer on day 3(D3-ET) and day 5(D5-ET).

DESIGN

Meta-analysis.

PATIENTS

Women with pregnancy resulting from in vitro undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

RESULT(S)

Twenty-two studies were identified through research conducted using the PubMed, Embase, and Cochrane databases and ClinicalTrials.gov. All studies were conducted prior to October 2016. Adding the reproductive data from our center, a total of 143 643 pregnancies were reviewed(D3-ET: n = 62027,D5-ET:n = 81616). A lower EP rate was found in women undergoing D5-ET than in those undergoing D3-ET [relative risk (RR), 0.67;95% confidence interval (CI), 0.54-0.85;143643 pregnancies in 23 studies; I2 = 67%]. These results were validated in subgroups of fresh embryo-transfer (Fre-ET) cycles [RR, 0.78; 95%CI, 0.69-0.88; 91 871 pregnancies in 21 studies; I2 = 29%] and frozen-thawed embryo-transfer (Fro-ET) cycles [RR, 0.43; 95%CI, 0.36-0.51; 51 772 pregnancies in 10 studies; I2 = 33%]. After separating out the randomized controlled trials (RCTs), a significant difference was found in the retrospective studies in both subgroups [both Fre-ET (RR,0.78;95% CI 0.69-0.88);91182 pregnancies in 14 studies; I2 = 45%] and Fro-ET(RR,0.43;95% CI 0.36-0.51; 51751pregnancies in 9 studies;I2 = 33%)], while the RCTs showed no statistical significance for Fre-ET cycles[RR,0.86;95% CI 0.32-2.26); 689 pregnancies in 7 studies; I2 = 0%].

CONCLUSION(S)

The present study indicates that D5-ET reduces the risk for EP in cycles that use IVF or ICSI, compared with D3-ET. It suggests that D5-ET may be a better choice for decreasing the EP rate in assisted reproductive technology. Further high-quality randomized controlled trials are anticipated.

[The reference ranges for min parameters of clinical blood analysis in dynamics of physiological pregnancy. A comparative analysis with pregnancy after extra corporal fertilization and embryo transfer into uterine cavity]

The article presents the results of examination of 1140 women with spontaneous monocyesis occurred and 307 women with monocyesis occurred as a result of implementation of program of extra-corporeal fertilization and transfer of embryos into uterus. The female patients were distributed to 6 subgroups depending on gestation period (4-8, 9-134, 14-20, 21-27, 28-34, 35-40 weeks). The 16 main hematologic indices were analyzed. The reference intervals (2.5 and 97.5 percentiles) for various periods of physiological pregnancy were calculated according IFSS guidelines concerning statistical processing of reference values. It is demonstrated that at evaluation of results of clinical analysis of blood in pregnant women it is necessary to apply special reference intervals. The comparative analysis of hematologic indices in dynamics of pregnancy of healthy women and in female patients of the program of extra-corporeal fertilization and transfer of embryos into uterus demonstrated that interpretation of results of examination in both groups of female patients can be implemented using reference intervals derived for spontaneous pregnancy. The exclusion of this rule included total number of leukocytes and number of thrombocytes in period of 4-8 weeks.

Extremities of body mass index and their association with pregnancy outcomes in women undergoing in vitro fertilization in the United States

OBJECTIVE

To investigate the associations among underweight body mass index (BMI), pregnancy, and obstetric outcomes among women using assisted reproductive technology (ART).

DESIGN

Retrospective cohort study using national data and log binomial regression.

SETTING

Not applicable.

PATIENT(S)

Women undergoing IVF in the United States from 2008 to 2013.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy outcomes (intrauterine pregnancy, live birth rates) per transfer, miscarriage rate per pregnancy, and low birth weight and preterm delivery rates among singleton and twin pregnancies.

RESULT(S)

For all fresh autologous in vitro fertilization (IVF) cycles in the United States from 2008 to 2013 (n = 494,097 cycles, n = 402,742 transfers, n = 180,855 pregnancies) reported to the national ART Surveillance System, compared with normal weight women, underweight women had a statistically significant decreased chance of intrauterine pregnancy (adjusted risk ratio [aRR] 0.97; 95% confidence interval [CI], 0.96-0.99) and live birth (aRR 0.95; 95% CI, 0.93-0.98) per transfer. Obese women also had a statistically decreased likelihood of both (aRR 0.94; 95% CI, 0.94-0.95; aRR 0.87; 95% CI, 0.86-0.88, respectively). Among cycles resulting in singleton pregnancy, both underweight and obese statuses were associated with increased risk of low birth weight (aRR 1.39; 95% CI, 1.25-1.54, aRR 1.26; 95% CI, 1.20-1.33, respectively) and preterm delivery (aRR 1.12; 95% CI, 1.01-1.23, aRR 1.42; 95% CI, 1.36-1.48, respectively). The association between underweight status and miscarriage was not statistically significant (aRR 1.04; 95% CI, 0.98-1.11). In contrast, obesity was associated with a statistically significantly increased miscarriage risk (aRR 1.23; 95% CI, 1.20-1.26).

CONCLUSION(S)

Among women undergoing IVF, prepregnancy BMI affects pregnancy and obstetric outcomes. Underweight status may have a limited impact on pregnancy and live-birth rates, but it is associated with increased preterm and low-birth-weight delivery risk. Obesity negatively impacts all ART and obstetric outcomes investigated.

Critical Ovarian Hyperstimulation Syndrome After In Vitro Fertilization Treatment in a Renal Transplant Recipient: A Case Report

OBJECTIVE

The study sought to describe a case of critical ovarian hyperstimulation syndrome (OHSS) after in vitro fertilization treatment in a renal transplant recipient.

PATIENT

A 35-year-old woman with a 5-year history of renal transplantation underwent in vitro fertilization treatment with a midluteal pituitary downregulation regimen.

RESULT

There are only 7 cases published regarding successful pregnancies outcomes after in vitro fertilization treatment in renal transplant recipients. In the most of the case reports, there was no deterioration of graft function. However, our patient developed critical OHSS. After effective treatment, her serum creatinine level decreased from 668 μmol/L to baseline.

CONCLUSIONS

Our case demonstrates that the highly specialized care and close cooperation of transplantation and perinatology teams are required when undergoing in vitro fertilization treatment in renal transplant recipients.

Type of chromosome abnormality affects embryo morphology dynamics

OBJECTIVE

To study the differences in the cleavage time between types of embryo chromosomal abnormalities and elaborate algorithm to exclude aneuploid embryos according to the likelihood to be euploid.

DESIGN

Retrospective cohort study.

SETTING

University affiliated private center.

PATIENT(S)

Preimplantational genetic screening patients (n = 112) including cases of advanced maternal age, repeated implantation failure, and recurrent miscarriage. A total of 485 embryos were analyzed.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

All biopsied embryos were cultured in an incubator with time-lapse technology, cleavage timing from insemination to day 3 and all kinetic parameters that have been described in previous studies by our group.

RESULT(S)

Logistic regression analysis were used to identify morphokinetic parameters and some were strongly associated with complex aneuploid embryos; t3 (odds ratio = 0.590, 95% confidence interval 0.359-0.971) and t5-t2 (odds ratio = 0.151, 95% confidence interval 0.082-0.278).

CONCLUSION(S)

Embryo morphokinetics are affected by chromosome aneuploidy and further analysis of the chromosome content reveals higher differences when the complexity in the chromosome disorders is increased. The use of time-lapse monitoring, although not able to detect an abnormal embryo, may be potentially useful to discard those embryos with high risk of complex chromosomal abnormalities.

The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance

BACKGROUND

Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS).

OBJECTIVE AND RATIONALE

The aim of this paper was to present an evidence base for the management of anovulatory PCOS.

SEARCH METHODS

The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus.

OUTCOMES

Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is ≥35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed.

WIDER IMPLICATIONS

This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.

Abdominal ectopic pregnancy after in vitro fertilization and single embryo transfer: a case report and systematic review

BACKGROUND

Ectopic pregnancy is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with assisted-reproductive technology (ART), occurring in approximately 1.5-2.1 % of patients undergoing in-vitro fertilization (IVF). Abdominal ectopic pregnancy is a rare yet clinically significant form of ectopic pregnancy due to potentially high maternal morbidity. While risk factors for ectopic pregnancy after IVF have been studied, very little is known about risk factors specific for abdominal ectopic pregnancy. We present a case of a 30 year-old woman who had an abdominal ectopic pregnancy following IVF and elective single embryo transfer, which was diagnosed and managed by laparoscopy. We performed a systematic literature search to identify case reports of abdominal or heterotopic abdominal ectopic pregnancies after IVF. A total of 28 cases were identified.

RESULTS

Patients' ages ranged from 23 to 38 (Mean 33.2, S.D. = 3.2). Infertility causes included tubal factor (46 %), endometriosis (14 %), male factor (14 %), pelvic adhesive disease (7 %), structural/DES exposure (7 %), and unexplained infertility (14 %). A history of ectopic pregnancy was identified in 39 % of cases. A history of tubal surgery was identified in 50 % of cases, 32 % cases having had bilateral salpingectomy. Transfer of two embryos or more (79 %) and fresh embryo transfer (71 %) were reported in the majority of cases. Heterotopic abdominal pregnancy occurred in 46 % of cases while 54 % were abdominal ectopic pregnancies.

CONCLUSIONS

Our systematic review has revealed several trends in reported cases of abdominal ectopic pregnancy after IVF including tubal factor infertility, history of tubal ectopic and tubal surgery, higher number of embryos transferred, and fresh embryo transfers. These are consistent with known risk factors for ectopic pregnancy following IVF. Further research focusing on more homogenous population may help in better characterizing this rare IVF complication and its risks.

Fertility treatment and dichorionic discordant twins - are they related?

OBJECTIVE

This prospective cohort study evaluated the relationship between fertility treatments and the prevalence and outcomes of dichorionic discordant twins. This issue has gained importance due to twin gestations resulting from fertility treatments.

STUDY DESIGN

Mothers of dichorionic twin pregnancies achieved in a single fertility clinic by assisted reproduction techniques, who had completed the first trimester of the pregnancy, were prospectively enrolled. Pregnancies with major fetal anomalies were excluded. Data regarding concordant and discordant twins based on the fertility treatments given to achieve the pregnancies were analyzed to determine the prevalence of discordance and pregnancy outcomes.

RESULTS

A total of 571 dichorionic twin pregnancies were available for evaluation. Fertility treatments modalities, sperm quality and implantation of cultured and thawed embryos did not influence the rate and severity of discordant twins. Increased hospitalization rates were found among discordant (n=108) compared to concordant (n=463) twins (47.2% vs. 31.3%, P<0.0001) and higher rates of betamethasone treatment (65.7% vs. 28.9%, P<0.0001). Secondary analysis of discordant pregnancies with a growth restricted twin, revealed the same results. We found no association between various fertility treatments and twin discordance.

CONCLUSIONS

Our data suggest that fertility treatments do not play a major role in the pervasiveness and outcome of discordant twin pregnancies.

Ectopic pregnancy following in vitro fertilization: meta-analysis and single-center experience during 6 years

BACKGROUND

Ectopic pregnancy (EP) has been reported to occur in 1.4-5.4% of all clinical pregnancies resulting from in vitro fertilization (IVF) and embryo transfer (ET). Data on factors associated with abnormal embryo implantation following assisted conception are limited.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed to determine whether there is an association between the day (cleavage-stage, D3, versus blastocyst, D5) or the type (fresh versus frozen/thawed) of ET and EP rate. Risk factors for EP were evaluated in a retrospective study of 1194 women, who achieved pregnancy at our IVF unit between 2010 and 2016.

RESULTS

Sixteen papers were considered for the meta-analysis. EP rate did not differ between D3 and D5 fresh ET groups (RR = 0.99, 95%CI: 0.76-1.30) and was higher after fresh versus frozen ET (RR = 1.56, 95%CI: 1.25-1.95). At our clinic, 21 (1.76%) pregnancies were documented as ectopic. The risk of EP was associated with tubal pathology (OR = 3.37, 95%CI: 1.39-8.2), previous appendectomy and past chlamydial infection.

CONCLUSIONS

Present meta-analysis suggests that EP rate is similar following fresh blastocyst and cleavage ETs, but is significantly reduced after frozen compared with fresh ET. Our own findings demonstrate that tubal pathology has the major impact on EP occurrence following assisted conception.

Elective single embryo transfer in women less than age 38 years reduces multiple birth rates, but not live birth rates, in United States fertility clinics

OBJECTIVE

To determine the effect of elective single ET (eSET) on live birth and multiple birth rates by a cycle-level and clinic-level analysis.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Patient ages <35 and 35-37 years old.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinics were divided into groups based on eSET rate for each age group and aggregate rates of live birth per ET and multiple birth per delivery were calculated. A cycle-level analysis comparing eSET and double ET (DET) live birth and multiple birth rates was also performed, stratified based on total number (2, 3, or 4+) of embryos available, embryo stage, and patient age.

RESULT(S)

There was a linear decrease in multiple birth rate with increasing eSET rate and no significant difference in clinic-level live birth rates for each age group. Cycle-level analysis found slightly higher live birth rates with double ET, but this was mainly observed in women aged 35-37 years or with four or more embryos available for transfer, and confirmed the marked reduction in multiple births with eSET.

CONCLUSION(S)

Our study showed a marked and linear reduction in multiple birth rates, and important, little to no effect on clinic-level live birth rates with increasing rates of eSET supporting the growing evidence that eSET is effective in decreasing the high multiple birth rates associated with IVF and suggests that eSET should be used more frequently than is currently practiced.

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.

Prevalences and pregnancy outcome of vanishing twin pregnancies achieved by in vitro fertilization versus natural conception

OBJECTIVE

To evaluate whether vanishing twin (VT) pregnancies achieved by in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) had a more adverse perinatal outcome than those after natural conception.

DESIGN

Longitudinal, retrospective cohort study.

SETTING

Tertiary university hospital.

PATIENT(S)

Three hundred and six (78 after IVF-ICSI and 228 after natural conception) VT pregnancies over a 22-year period, with VT cases matched to primarily singleton controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Obstetric and neonatal outcome data.

RESULT(S)

The incidence of VT was statistically significantly higher after natural conception (18.2% of twins) than after IVF-ICSI (12.6% of twins). The odds of VT in pregnancies complicated with pregestational or gestational diabetes were disproportionally higher in IVF-ICSI cases than in spontaneously conceived VT pregnancies (adjusted odds ratio [AOR]: 0.80 vs. 3.10 and 1.00 vs. 1.07, respectively). Previous induced abortion (AOR 1.34) or second-trimester fetal loss (AOR 3.3) increased the risk of VT pregnancies after spontaneous conception. Gestational diabetes mellitus in both the previous (AOR 5.41) and the present (AOR 2.3) pregnancy as well as chronic maternal diseases (AOR 3.5) and placentation anomalies all represented independent risk factors for VT after IVF-ICSI.

CONCLUSION(S)

Vanishing twin pregnancies had a lower prevalence and a worse perinatal outcome after IVF-ICSI as compared with those of their spontaneously conceived counterparts.

Proof of concept: preimplantation genetic screening without embryo biopsy through analysis of cell-free DNA in spent embryo culture media

OBJECTIVE

To assess whether preimplantation genetic screening (PGS) is possible by testing for free embryonic DNA in spent IVF media from embryos undergoing trophectoderm biopsy.

DESIGN

Prospective cohort analysis.

SETTING

Academic fertility center.

PATIENT(S)

Seven patients undergoing IVF and 57 embryos undergoing trophectoderm biopsy for PGS.

INTERVENTION(S)

On day 3 of development, each embryo was placed in a separate media droplet. All biopsied embryos received a PGS result by array comparative genomic hybridization. Preimplantation genetic screening was performed on amplified DNA extracted from media and results were compared with PGS results for the corresponding biopsy.

MAIN OUTCOME MEASURE(S)

[1] Presence of DNA in spent IVF culture media. [2] Correlation between genetic screening result from spent media and corresponding biopsy.

RESULT(S)

Fifty-five samples had detectable DNA ranging from 2-642 ng/μL after a 2-hour amplification. Six samples with the highest DNA levels underwent PGS, rendering one result with a derivative log ratio SD (DLRSD) of <0.85 (a quality control metric of oligonucleotide array comparative genomic hybridization). The fluid sample and trophectoderm results were identical demonstrating (45XY, -13). Three samples were reamplified 1 hour later and tested showing improving DLRSD. One of the three samples with a DLRSD of 0.85 demonstrated (46XY), consistent with the biopsy. Overnight DNA amplification showed DNA in all samples.

CONCLUSION(S)

We demonstrate two novel findings: the presence of free embryonic DNA in spent media and a result that is consistent with trophectoderm biopsy. Improvements in DNA collection, amplification, and testing may allow for PGS without biopsy in the future.

Ovarian Stimulation for In Vitro Fertilization and Long-term Risk of Breast Cancer

IMPORTANCE

Previous studies of breast cancer risk after in vitro fertilization (IVF) treatment were inconclusive due to limited follow-up.

OBJECTIVE

To assess long-term risk of breast cancer after ovarian stimulation for IVF.

DESIGN, SETTING, AND PARTICIPANTS

Historical cohort (OMEGA study) with complete follow-up through December 2013 for 96% of the cohort. The cohort included 19,158 women who started IVF treatment between 1983 and 1995 (IVF group) and 5950 women starting other fertility treatments between 1980 and 1995 (non-IVF group) from all 12 IVF clinics in the Netherlands. The median age at end of follow-up was 53.8 years for the IVF group and 55.3 years for the non-IVF group.

EXPOSURES

Information on ovarian stimulation for IVF, other fertility treatments, and potential confounders was collected from medical records and through mailed questionnaires.

MAIN OUTCOMES AND MEASURES

Incidence of invasive and in situ breast cancers in women who underwent fertility treatments was obtained through linkage with the Netherlands Cancer Registry (1989-2013). Breast cancer risk in the IVF group was compared with risks in the general population (standardized incidence ratios [SIRs]) and the non-IVF group (hazard ratios [HRs]).

RESULTS

Among 25,108 women (mean age at baseline, 32.8 years; mean number of IVF cycles, 3.6), 839 cases of invasive breast cancer and 109 cases of in situ breast cancer occurred after a median follow-up of 21.1 years. Breast cancer risk in IVF-treated women was not significantly different from that in the general population (SIR, 1.01 [95% CI, 0.93-1.09]) and from the risk in the non-IVF group (HR, 1.01 [95% CI, 0.86-1.19]). The cumulative incidences of breast cancer at age 55 were 3.0% for the IVF group and 2.9% for the non-IVF group (P = .85). The SIR did not increase with longer time since treatment (≥20 years) in the IVF group (0.92 [95% CI, 0.73-1.15]) or in the non-IVF group (1.03 [95% CI, 0.82-1.29]). Risk was significantly lower for those who underwent 7 or more IVF cycles (HR, 0.55 [95% CI, 0.39-0.77]) vs 1 to 2 IVF cycles and after poor response to the first IVF cycle (HR, 0.77 [95% CI, 0.61-0.96] for <4 vs ≥4 collected oocytes).

CONCLUSIONS AND RELEVANCE

Among women undergoing fertility treatment in the Netherlands between 1980 and 1995, IVF treatment compared with non-IVF treatment was not associated with increased risk of breast cancer after a median follow-up of 21 years. Breast cancer risk among IVF-treated women was also not significantly different from that in the general population. These findings are consistent with absence of a significant increase in long-term risk of breast cancer among IVF-treated women.

Cost Implications for Subsequent Perinatal Outcomes After IVF Stratified by Number of Embryos Transferred: A Five Year Analysis of Vermont Data

BACKGROUND

In states in the USA without in vitro fertilzation coverage (IVF) insurance coverage, more embryos are transferred per cycle leading to higher risks of multi-fetal pregnancies and adverse pregnancy outcomes.

OBJECTIVE

To determine frequency and cost of selected adverse perinatal complications based on number of embryos transferred during IVF, and calculate incremental cost per IVF live birth.

METHODS

Medical records of patients who conceived with IVF (n = 116) and delivered at >20 weeks gestational age between 2007 and 2011 were evaluated. Gestational age at delivery, low birth weight (LBW) term births, and delivery mode were tabulated. Healthcare costs per cohort, extrapolated costs assuming 100 patients per cohort, and incremental costs per infant delivered were calculated.

RESULTS

The highest prematurity and cesarean section rates were recorded after double embryo transfers (DET), while the lowest rates were found in single embryo transfers (SET). Premature singleton deliveries increased directly with number of transferred embryos [6.3 % (SET), 9.1 % (DET) and 10.0 % for ≥3 embryos transferred]. This trend was also noted for rate of cesarean delivery [26.7 % (SET), 36.6 % (DET), and 47.1 % for ≥3 embryos transferred]. The proportion of LBW infants among deliveries after DET and for ≥3 embryos transferred was 3.9 and 9.1 %, respectively. Extrapolated costs per cohort were US$718,616, US$1,713,470 and US$1,227,396 for SET, DET, and ≥3 embryos transferred, respectively.

CONCLUSION

Attempting to improve IVF pregnancy rates by permitting multiple embryo transfers results in sharply increased rates of multiple gestation and preterm delivery. This practice yields a greater frequency of adverse perinatal outcomes and substantially increased healthcare spending. Better efforts to encourage SET are necessary to normalize healthcare expenditures considering the frequency of very high cost sequela associated with IVF where multiple embryo transfers occur.

How Many Embryos should be Transferred? The Relevance of Parity and Obstetric History

BACKGROUND

Fertility treatments are responsible for the rise in high order pregnancies in recent decades and their associated complications. Reducing the number of embryos returned to the uterus will reduce the rate of high order pregnancies.

OBJECTIVES

To explore whether obstetric history and parity have a role in the clinician's decision making regarding the number of embryos transferred to the uterus during in vitro fertilization (IVF).

METHODS

In a retrospective study for the period August 2005 to March 2012, data of twin deliveries > 24 weeks were collected, including parity, mode of conception (IVF vs. spontaneous), gestational age at delivery, preeclampsia, birth weight, admission to the neonatal intensive care unit (NICU), and Apgar scores.

RESULTS

A total of 1651 twin deliveries > 24 weeks were record- ed, of which 959 (58%) were at term (> 37 weeks). The early preterm delivery (PTD) rate (< 32 weeks) was significantly lower with increased parity (12.6%, 8.5%, and 5.6%, in women with 0, 1, and ≥ 2 previous term deliveries, respectively). Risks for PTD (< 37 weeks), preeclampsia and NICU admission were significantly higher in primiparous women compared to those who had one or more previous term deliveries. Primiparity and preeclampsia, but not IVF, were significant risk factors for PTD.

CONCLUSIONS

The risk for PTD in twin pregnancies is significantly lower in women who had a previous term delivery and decreases further after two or more previous term deliveries. This finding should be considered when deciding on the number of embryos to be transferred in IV.

The serum brain-derived neurotrophic factor concentration prior to initiation of an in vitro fertilization cycle predicts outcome

Our objective was to determine if the concentration of circulating brain-derived neurotrophic factor (BDNF) prior to cycle initiation predicts outcome in women undergoing in vitro fertilization (IVF). Stored serum samples from 226 women - 54 with a live birth, 45 with a spontaneous abortion, 38 with a biochemical pregnancy, 54 who did not become pregnant and 35 with an ectopic pregnancy- were retrospectively blindly tested for BDNF by ELISA. The median serum concentration of BDNF was highest in women with an extrauterine ectopic pregnancy (7.3ng/ml), intermediate in women whose embryos did not implant (5.5ng/ml) and lowest in women with a spontaneous abortion (4.2ng/ml), biochemical pregnancy (3.8ng/ml) or a live birth (3.6ng/ml) (P<0.0001). Among women with a positive pregnancy test an elevated BDNF level predicted an ectopic pregnancy with a sensitivity of 0.853 (0.689, 0.950) and a specificity of 0.949 (0.897, 0.979). We conclude that elevated BDNF in serum obtained before IVF cycle initiation is predictive of an extrauterine pregnancy.

Having a child together in lesbian families: combining gestation and genetics

The increasing acceptance of lesbian couples in medically assisted reproduction has led to new, unusual requests. This paper discusses the request for egg transfer from one partner to the other. In the first part, different analogies (egg donation, embryo donation, surrogacy and mitochondrial replacement) are made in order to find out whether one of these can help us determine whether this procedure is acceptable. It is shown that there are major difficulties with all analogies. In the second part, two balances are developed between the medical risks and costs of in vitro fertilisation (IVF) and intrauterine insemination on the one hand and the medical risks of IVF and the psychosocial benefits on the other hand. The final conclusion is that the disadvantages of the procedure can be compensated by the psychosocial advantages and thus can be accepted.

First trimester pregnancy loss after fresh and frozen in vitro fertilization cycles

OBJECTIVE

To characterize risks for early pregnancy loss after fresh and frozen IVF cycles and to investigate whether risk is modified by infertility diagnoses or transfer of embryos in fresh versus frozen cycles.

DESIGN

Retrospective cohort study using data from the National Assisted Reproductive Technology (ART) Surveillance System.

SETTING

Fertility centers.

PATIENT(S)

Clinical pregnancies achieved with fresh and frozen IVF cycles between 2007 and 2012 (N = 249,630).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

First trimester pregnancy loss.

RESULT(S)

A diagnosis of uterine factor was associated with an increased risk of loss in women aged 40 years and younger (<30 years: adjusted risk ratio (aRR) = 1.24, 95% confidence interval (CI) 1.04-1.48; 30-34 years: aRR = 1.27, 95% CI 1.17-1.38; 35-37 years: aRR = 1.12, 95% CI 1.03-1.21; 38-40 years: aRR = 1.08, 95% CI 1.01-1.17). There was an increased risk of loss in women with diminished ovarian reserve aged 30-34 years (aRR = 1.08, 95% CI 1.01-1.15) and in women with ovulatory dysfunction younger than 35 years (<30 years: aRR = 1.12, 95% CI 1.05-1.19; 30-34 years: aRR = 1.07, 95% CI 1.02-1.13). There was an increased risk of loss after frozen ETs versus fresh among women younger than 38 years, but this remained significant in the subanalysis of similar quality embryos only in women younger than 30 years (aRR = 1.16, 95% CI 1.04-1.32).

CONCLUSION(S)

Uterine factor had the largest increased risk of loss among infertility diagnoses, although the magnitudes of all risks were small. When transferring embryos of similar quality, the risks of loss were similar between fresh and frozen cycles.

Does the addition of growth hormone to the in vitro fertilization/intracytoplasmic sperm injection antagonist protocol improve outcomes in poor responders? A randomized, controlled trial

OBJECTIVE

To evaluate the effectiveness of the addition of growth hormone (GH) to the antagonist protocol in IVF/intracytoplasmic sperm injection cycles in poor responders.

DESIGN

Parallel randomized, controlled, open-label trial.

SETTING

University hospital.

PATIENT(S)

A total of 141 patients (GH, n = 68; gonadotropins only, n = 73) were enrolled. Twenty-five patients had their cycles cancelled. Analysis was performed per cycle start as well as per ET.

INTERVENTION(S)

Patients received the antagonist protocol with or without GH supplementation.

MAIN OUTCOME MEASURE(S)

Mean number of cumulus complexes, metaphase II oocytes retrieved and fertilized, chemical and clinical pregnancy rates, early miscarriage rate, ongoing pregnancy and live birth rates.

RESULT(S)

The addition of GH significantly lowered duration of hMG treatment, duration of GnRH antagonist treatment, and dose of gonadotropin. It significantly increased mean E2 levels on the day of hCG administration, number of collected oocytes (7.58 ± 1.40 vs. 4.90 ± 1.78 [mean ± SD]), number of metaphase II oocytes (4.53 ± 1.29 vs. 2.53 ± 1.18), number of fertilized oocytes (4.04 ± 0.96 vs. 2.42 ± 1.03), and number of transferred embryos (2.89 ± 0.45 vs. 2.03 ± 0.81). There was no significant difference in the clinical pregnancy rate per cycle (22.1% vs. 15.1%) or live birth rate per cycle (14.7% vs. 10.9%).

CONCLUSION(S)

Growth hormone as an adjuvant treatment in IVF/intracytoplasmic sperm injection cycles for poor responders should be cautiously used with the antagonist protocol, because there is still no identified impact on pregnancy outcomes. However, evaluation of the clinical pregnancy and live birth rates in our data was limited by low statistical power.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT02195947.

A Comprehensive Analysis of Body Mass Index Effect on in Vitro Fertilization Outcomes

The effect of a raised body mass index (BMI) on the outcome of assisted reproduction technology (ART) still represents a controversial issue. Even less clear is whether BMI acts with a potential detrimental effect on IVF outcomes via a deleterious effect on innate quality of oocytes or on the environmental milieu within the uterus. With the aim to better understand the mechanisms underlying the potential deleterious effect of an increased BMI on IVF outcomes, we have evaluated the effects of female BMI on number and quality of retrieved oocytes, fertilization rate, embryo score and incidences of ongoing pregnancy and live births among couples undergoing IVF in an Italian population. Data from 1602 women who underwent their first IVF cycle were retrospectively analyzed. A significantly reduced percentage of mature oocytes when comparing obese (BMI ≥ 30 kg/m²) and normal-weight patients (BMI = 18.50–24.99 kg/m²) was found. After adjusting for maternal age and other confounders, odds for ongoing pregnancy rate showed no differences across different BMI categories. However, a significant increased odds ratio (OR) could be observed for miscarriage rate in patients with BMI ≥ 25 (OR = 2.5; p = 0.04). These results should be taken into account in order to define optimal strategies for overweight and obese patients referring to ART procedures.

In vitro fertilization represents a risk factor for vasa praevia

Vasa praevia is a rare but very dangerous obstetrical condition. The purpose of our article is to evaluate data available in literature that indicate in vitro fertilization as a risk factor for vasa praevia. PubMed Library and Cochrane Database were searched using the keywords vasa praevia, in vitro fertilization, velamentous cord insertion, placenta praevia. The conditions related to in vitro fertilization that increase the risk of vasa praevia formation were identified and discussed. Also, the diagnosis and management options were reviewed. In vitro fertilization represents a risk factor for vasa praevia and all such pregnancies should be screened by transvaginal ultrasound for vasa praevia.

[ASSISTED REPRODUCTIVE TECHNOLOGIES AND OVARIAN CANCEROGENESIS]

Development of assisted reproductive technologies (ART) for treatment of infertility poses many questions about potential involvement of the drugs used in ART in the process of ovarian carcinogenesis. The presence of other etiological factors makes the assessment of risks implied by administering these drugs rather difficult. The results obtained in the study are controversial and inconclusive, yet theoretical and epidemiological data suggest that caution is needed in IVF patients, receiving such drug therapy.

[Successful treatment of a cervical heterotopic pregnancy following an in vitro fertilization procedure]

A 37-year-old nulligravida infertile female had a cervical heterotopic pregnancy following an in vitro fertilization procedure. Early intervention on the 6th week of gestation with a manual vacuum aspirator reached to remove the cervical pregnancy. Ligation of the descending cervical branches of the uterine arteries and a cervical cerclage, were placed before the aspiration, for prevention of possible hemorrhage. Successful removal of the cervical pregnancy was achieved with only mild bleeding. An intrauterine pregnancy progressed to viability without complications, resulting in a vaginal delivery of a preterm live-birth at 35.4 weeks, of a male that weighted 2740 g.

The MOSART database: linking the SART CORS clinical database to the population-based Massachusetts PELL reproductive public health data system

Although Assisted Reproductive Technology (ART) births make up 1.6 % of births in the US, the impact of ART on subsequent infant and maternal health is not well understood. Clinical ART treatment records linked to population data would be a powerful tool to study long term outcomes among those treated or not by ART. This paper describes the development of a database intended to accomplish this task. We constructed the Massachusetts Outcomes Study of Assisted Reproductive Technology (MOSART) database by linking the Society of Assisted Reproductive Technologies Clinical Outcomes Reporting System (SART CORS) and the Massachusetts (MA) Pregnancy to Early Life Longitudinal (PELL) data systems for children born to MA resident women at MA hospitals between July 2004 and December 2008. PELL data representing 282,971 individual women and their 334,152 deliveries and 342,035 total births were linked with 48,578 cycles of ART treatment in SART CORS delivered to MA residents or women receiving treatment in MA clinics, representing 18,439 eligible women of whom 9,326 had 10,138 deliveries in this time period. A deterministic five phase linkage algorithm methodology was employed. Linkage results, accuracy, and concordance analyses were examined. We linked 9,092 (89.7 %) SART CORS outcome records to PELL delivery records overall, including 95.0 % among known MA residents treated in MA clinics; 70.8 % with full exact matches. There were minimal differences between matched and unmatched delivery records, except for unknown residency and out-of-state ART site. There was very low concordance of reported use of ART treatment between SART CORS and PELL (birth certificate) data. A total of 3.4 % of MA children (11,729) were identified from ART assisted pregnancies (6,556 singletons; 5,173 multiples). The MOSART linked database provides a strong basis for further longitudinal ART outcomes studies and supports the continued development of potentially powerful linked clinical-public health databases.

Expression of CD11c+HLA-DR+dendritic cells and related cytokines in the follicular fluid might be related to pathogenesis of ovarian hyperstimulation syndrome

OBJECTIVE

To explore the expressions of CD11c+HLA-DR+dentritic cells in the follicular fluid of patients with OHSS and their significances.

SUBJECTS

100 individuals.

TREATMENT

embryos were observed. The distribution of dentritic cells in follicular fluid and the levels of IL-10, IL-12, IL-18 and IL-23 in follicular fluid were detected.

METHODS

There were ovarian hyperstimulation syndrome (OHSS) group and control group in this study. The OHSS group consisted of 50 patients with OHSS and the control group consisted of 50 patients who underwent in vitro fertilization-embryo transfer (IVF-ET) only due to male factors. The statuses of embryos were compared between the two groups. The distribution of dentritic cells in follicular fluid was determined with flow cytometry, and the levels of IL-10, IL-12, IL-18 and IL-23 in follicular fluid were detected with enzyme-linked immunosorbent assay (ELISA) in all patients.

RESULTS

The two-pronuclear (2PN) fertility rate, high-quality embryo rate and available embryo rate were all significantly lower in OHSS group than in control group (all P<0.05). The number of CD11c+HLA-DR+dentritic cells (P<0.05) and the levels of IL-10, IL-12, IL-18 and IL-23 were all significantly higher in OHSS group than in control group (all P<0.01).

CONCLUSION

The follicular fluid of the patients with OHSS is in an inflammatory status, the inflammatory status may be involved in OHSS and the microenvironment of follicular fluid may affects oocyte quality and embryo development.

Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization

This study investigated the risk factors and early predictors for heterotopic pregnancy (HP) after in vitro fertilization and embryo transfer (IVF-ET). From January 2008 to January 2013, 41 cases of HP and 72 cases of intrauterine twin pregnancy after IVF-ET were recruited and retrospectively analyzed. Compared with intrauterine twin pregnancy group, the HP group had a lower basal luteinizing hormone (LH) level (P = 0.005) and more cases had a history of hydrosalpinx (P = 0.008). After 14 days of IVF-ET, the serum β-HCG (β-human chorionic gonadotropin), E2 (Estradiol) and P (Progesterone) levels were lower in HP group (P<0.001, respectively). Moreover, vaginal bleeding and abdominal pain were the significant features of HP before diagnosis (P<0.001, respectively). Further by logistic regression, serum β-hCG, P levels on the 14th day after ET, and vaginal bleeding were identified as the independent factors of HP. These results indicate that when two or more embryos transferred in IVF procedure, β-hCG, P levels on the 14th day after ET, and vaginal bleeding could be taken as predictors for HP.

[Association of fertilization strategy and embryo transfer time with the incidence of ectopic pregnancy]

OBJECTIVE

To investigate the correlation of the fertilization strategy and embryo transfer (ET) time with the incidence of ectopic pregnancy.

METHODS

We selected 3,331 fresh and 2,706 frozen-thawed ET cycles for the patients undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). The fresh transfers included 2 546 IVF-ET and 785 ICSI-ET cycles and 2,220 day-3 embryo and 1,111 day-5 blastocyst transfers, while the frozen-thawed transfers included 2,080 IVF-ET and 626 ICSI-ET cycles and 741 day-3 embryo and 1 965 day-5 or -6 blastocyst transfers. We compared the incidence rate of ectopic pregnancy associated with different fertilization strategies and ET time.

RESULTS

The incidence rate of ectopic pregnancy was 1. 41% (36/2 546) in the IVF-ET cycles and 3.44% (27/785) in the ICSI-ET cycles of the fresh transfers, significantly lower in the IVF-ET than in the ICSI-ET cycles (P < 0.01), and it was 1.01% (21/2,080) in the IVF-ET cycles and 0.80% (5/626) in the ICSI-ET cycles of the frozen-thawed transfers, with no remarkable difference between the two groups (P > 0.05). The IVF-ET and ICSI-ET cycles included 2,220 fresh day-3 (F-D3) embryos, 1,111 F-D5 blastocysts, 741 frozen-thawed day-3 (T-D3) embryos, and 1,965 T-D5/6 blastocysts. The incidence rate of ectopic pregnancy was 1.71% (n = 38) in the F-D3, 2.25% (n = 25) in the F-D5, 1.35% (n = 10) in the T-D3, and 0.81% (n = 16) in the T-D5/6 group, respectively, significantly lower in the T-D5/6 than in the other three groups (P < 0.05).

CONCLUSION

The incidence rate of ectopic pregnancy is associated with fertilization strategies, which is significantly lower in frozen-thawed than in fresh embryo transfers.

Adverse pregnancy outcomes after in vitro fertilization: effect of number of embryos transferred and plurality at conception

OBJECTIVE

To evaluate risks for adverse pregnancy outcomes by number of embryos transferred (ET) and fetal heartbeats (FHB) in assisted reproductive technology-conceived singleton live births.

DESIGN

Longitudinal cohort using cycles reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System between 2004 and 2008 among women who were treated and gave birth in Massachusetts.

SETTING

Not applicable.

PATIENT(S)

Assisted reproductive technology data on 6,073 births between 2004 and 2008 were linked to vital records and hospital data. Likelihood of ET ≥3 vs. 1-2, FHB >1 vs. 1, and risks of preterm birth (PTB, <37 weeks' gestation), low birth weight (LBW, <2,500 g), and small-for-gestational-age birth weight (SGA, <10th percentile) with FHB >1 were modeled with binary logistic regression using a backward-stepping algorithm, and presented as adjusted odds ratios (95% confidence intervals).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

ET ≥3, FHB >1, PTB, LBW, and SGA.

RESULT(S)

Higher ET was significantly more likely with older maternal age, intracytoplasmic sperm injection, assisted hatching, cleavage-stage embryos, and thawed embryos. The likelihood of FHB >1 with ≥3 ET vs. 1-2 ET was 2.04 (1.68-2.48). Risks of PTB and LBW with FHB >1 were 1.63 (1.27-2.09) and 1.81 (1.36-2.39), respectively; the risk of SGA was not significant. Nulliparity was associated with higher risks of PTB (1.34 [1.12-1.59]), LBW (1.48 [1.20-1.83]), and SGA (2.17 [1.69-2.78]).

CONCLUSION(S)

Number of embryos transferred was strongly associated with FHBs, with twice the risk of FHB >1 with ≥3 ET vs. 1-2 ET. Increasing FHBs were associated with significantly greater risks for PTB and LBW outcomes.

Ovarian hyperstimulation syndrome: a clinical report on 4894 consecutive ART treatment cycles

BACKGROUND

Although a large number of studies have been dedicated to ovarian hyperstimulation syndrome (OHSS) none gave full embryological and clinical outcomes comparing oocyte trigger with human chorionic gonadotrophin (HCG) versus with a gonadotrophin-releasing hormone (GnRH) agonist (Buserelin) in cases with suspicious OHSS. The aim of the present study was thus to analyze 4894 consecutive assisted reproductive treatment cycles to undercover associated risk factors for development of OHSS, and the effects of the use of Buserelin as ovulation trigger on embryological and clinical outcomes.

METHODS

In the 51 cases that developed OHSS, ovulation trigger was performed with HCG as indicators were not suspicious for OHSS. These were compared against two types of groups: 71 cases where Buserelin was used for ovulation induction due to suspicious development of OHSS; and those remaining 4772 cases where ovulation trigger was currently performed with HCG (control).

RESULTS

Of the cases treated with Buserelin the oocyte maturation rate and the ongoing pregnancy rate were significantly lower, with higher rates of ectopic pregnancy and newborn malformations, but none developed OHSS. Of the OHSS cases, 23 needed hospitalization, with no major complications.

CONCLUSIONS

Young age, lower time of infertility, lower basal follicle stimulating hormone levels, higher number of cases with female factor and polycystic ovarian syndrome, high number of follicles and higher estradiol concentrations were the risk factors found associated with OHSS. Cases with OHSS also presented higher follicle count but the estradiol levels were within the normal range. It thus remains to develop more strict criteria to avoid all cases with OHSS.

Mitochondrial DNA content as a viability score in human euploid embryos: less is better

OBJECTIVE

To investigate the clinical relevance of mitochondrial DNA (mtDNA) content as a viability score in human euploid embryos.

DESIGN

Retrospective analysis of mtDNA content of transferred euploid embryos.

SETTING

Reproductive genetics laboratory.

PATIENT(S)

Single-embryo transfer in 270 patients who underwent preimplantation genetic screening (205 day-3 blastomere biopsies, and 65 day-5 trophectoderm biopsies), and 10 patients with double-embryo transfer (male-female).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Normalized mtDNA content versus nuclear DNA (nDNA) from transferred euploid embryos.

RESULT(S)

A high mtDNA copy number in euploid embryos is indicative of lower embryo viability and implantation. Using the normalized mtDNA content, we created the mitochondrial score or Mitoscore (Ms). Day-3 embryos with <34 (MsA) had an implantation rate (IR) of 59% (n = 51); those with 34-52 (MsB) had an IR of 44% (n = 52); those with 52-97 (MsC) had an IR of 42% (n = 50); and those with >97 (MsD) had an IR of 25% (n = 52). Embryos with Ms >160 (n = 22) never implanted. Day-5 embryos with <18.19 (MsA) had an IR of 81%; those with 18.19-24.15 (MsB) had an IR of 50% (n = 16); those with 24.15-50.58 (MsC) had an IR of 62% (n = 16); and those with levels >50.58 (MsD) had an IR of 18% (n = 17). Embryos with levels >60 (n = 7) never implanted.

CONCLUSION(S)

An increased amount of mtDNA in euploid embryos is related to poor implantation potential and may be indicative of reduced metabolic fuel during oocyte maturation. We are implementing Ms in our preimplantation genetic screening platform to prospectively analyze its clinical relevance.

Utrogestan as an effective oral alternative for preventing premature luteinizing hormone surges in women undergoing controlled ovarian hyperstimulation for in vitro fertilization

A major cause of cycle cancellation during controlled ovarian hyperstimulation (COH) in women undergoing in vitro fertilization (IVF) is the occurrence of premature luteinizing hormone (LH) surges. Steroidal preparations can modulate the secretion of gonadotropins (Gn); however, few studies using progesterone to inhibit the premature LH surges in COH have been published. The purpose of the study was to evaluate the oral delivery of progesterone soft capsules (Utrogestan) to prevent LH surges from the follicular phase and to compare cycle characteristics as well as to evaluate pregnancy outcomes in subsequent frozen-thawed embryo transfer (FET) cycles. A total of 374 patients were enrolled in this retrospective study, among which 187 patients were simultaneously administered Utrogestan and human menopausal gonadotrophin (hMG) from cycle day 3 until the trigger day. A short protocol including 187 controls with comparable age, body mass index (BMI), infertility duration, and antral follicle count was also used. GnRH agonist (0.1 mg) or hCG (3000 IU) was used for a trigger when the dominant follicles matured. Viable embryos were cryopreserved for later transfer in both groups. The primary outcome was the number of oocytes retrieved. The secondary outcomes included the number of mature oocytes, incidence of premature LH surge, and clinical pregnancy outcomes from FET cycles. Consistent LH suppression was achieved during COH, with a range of 0.07 to 8.9 IU/L, and no premature LH surge was detected. The number of oocytes retrieved in the Utrogestan and hMG protocol was comparable with that in the short protocol (10.92 ± 5.74 vs 10.6 ± 6.22, P > 0.05), and the dose of hMG was higher than that used in the short protocol (1884.22 ± 439.47 IU vs 1446.26 ± 550.48 IU, P < 0.05). No significant between-group difference was observed in the mature oocyte rate (88.88% vs 90.12%), cleavage rate (96.58% vs 96.58%), clinical pregnancy rate (54.27% vs 51.65%), or implantation rate (33.59% vs 34.02%). The study shows that Utrogestan is an effective oral alternative for preventing premature LH surges in women undergoing COH, which will help to establish a convenient user regimen in combination with FET.

[Neonatal complications and birth defects in infants conceived by in vitro fertilization]

OBJECTIVE

To investigate the survival quality of infants conceived by in vitro fertilization (IVF) and to identify the factors that cause birth defects and neonatal complications in IVF infants.

METHODS

The study included 150 IVF infants (IVF group) and 200 naturally conceived infants (control group). Indicators such as birth situation, gestational disease, birth defects, and neonatal complications were compared between groups. The influencing factors for birth defects and neonatal complications were analyzed by non-conditional logistic regression analysis.

RESULTS

Compared with the control group, the IVF group had increased incidences of twin pregnancy and low birth weight (P<0.01) but decreased average birth weight (P<0.05). In the IVF group, the mother's age was elder, with higher incidence of cesarean section, premature rupture of membranes, and pregnancy complications, as compared with the control group (P<0.05). There was no significant difference in the incidence of birth defects between the two groups (P>0.05). The IVF group had higher incidence rates of low birth weight and neonatal scleroderma (P<0.05), with a longer hospital stay (P<0.01), as compared with the control group. The non-conditional logistic regression analysis indicated that IVF, prematurity, twin pregnancy, and pregnancy complications were risk factors for low birth weight (P<0.05).

CONCLUSIONS

There is no significant difference in the incidence of birth defects between IVF and naturally conceived infants. However, IVF infants have higher incidences of twin pregnancy and low birth weight, with a longer hospital stay, as compared with naturally conceived infants. Natural conceiving, avoiding prematurity, twin pregnancy, and pregnancy complications will reduce the incidence of low birth weight.

The periconceptional environment and cardiovascular disease: does in vitro embryo culture and transfer influence cardiovascular development and health?

Assisted Reproductive Technologies (ARTs) have revolutionised reproductive medicine; however, reports assessing the effects of ARTs have raised concerns about the immediate and long-term health outcomes of the children conceived through ARTs. ARTs include manipulations during the periconceptional period, which coincides with an environmentally sensitive period of gamete/embryo development and as such may alter cardiovascular development and health of the offspring in postnatal life. In order to identify the association between ARTs and cardiovascular health outcomes, it is important to understand the events that occur during the periconceptional period and how they are affected by procedures involved in ARTs. This review will highlight the emerging evidence implicating adverse cardiovascular outcomes before and after birth in offspring conceived through ARTs in both human and animal studies. In addition, it will identify the potential underlying causes and molecular mechanisms responsible for the congenital and adult cardiovascular dysfunctions in offspring whom were conceived through ARTs.

Association of assisted reproductive technology (ART) treatment and parental infertility diagnosis with autism in ART-conceived children

STUDY QUESTION

Are assisted reproductive technology (ART) treatment factors or infertility diagnoses associated with autism among ART-conceived children?

SUMMARY ANSWER

Our study suggests that the incidence of autism diagnosis in ART-conceived children during the first 5 years of life was higher when intracytoplasmic sperm injection (ICSI) was used compared with conventional IVF, and lower when parents had unexplained infertility (among singletons) or tubal factor infertility (among multiples) compared with other types of infertility.

WHAT IS KNOWN ALREADY

Some studies found an increased risk of autism among ART-conceived infants compared with spontaneously-conceived infants. However, few studies, and none in the USA, have examined the associations between types of ART procedures and parental infertility diagnoses with autism among ART-conceived children.

STUDY DESIGN, SIZE, DURATION

Population-based retrospective cohort study using linkages between National ART Surveillance System (NASS) data for 1996-2006, California Birth Certificate data for 1997-2006, and California Department of Developmental Services (DDS) Autism Caseload data for 1997-2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All live born ART-conceived infants born in California in 1997-2006 (n = 42 383) with 5-year observation period were included in the study. We assessed the annual incidence of autism diagnosis documented in DDS, which includes information on the vast majority of persons with autism in California, and the association of autism diagnosis with ART treatment factors and infertility diagnoses.

MAIN RESULTS AND THE ROLE OF CHANCE

Among ART-conceived singletons born in California between 1997 and 2006, the incidence of autism diagnosis remained at ∼0.8% (P for trend 0.19) and was lower with parental diagnosis of unexplained infertility (adjusted hazard risk ratio [aHRR]; 95% confidence interval: 0.38; 0.15-0.94) and higher when ICSI was used (aHRR 1.65; 1.08-2.52), when compared with cases without these patient and treatment characteristics. Among ART-conceived multiples, the incidence of autism diagnosis between 1997 and 2006 remained at ∼1.2% (P for trend 0.93) and was lower with parental diagnosis of tubal factor infertility (aHRR 0.56; 0.35-0.90) and higher when ICSI was used (aHRR 1.71; 1.10-2.66).

LIMITATIONS, REASONS FOR CAUTION

Study limitations include imperfect data linkages, lack of data on embryo quality and possible underestimation of autism diagnosis cases. Limitations of the observational study design could affect the analysis by the possibility of residual confounders. Since information about ICSI use was missing for most frozen/thawed embryo transfer cycles, our findings of association of ICSI use and autism diagnosis can only be generalizable to fresh embryo transfer cycles.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides additional evidence of the association between some types of ART procedures with autism diagnosis. Additional research is required to explain the increased risk of autism diagnosis with ICSI use, as well as studies on the effectiveness and safety of ICSI.

Freeze-all policy: is it time for that?

PURPOSE

This publication will evaluate the available evidence in the literature comparing fresh embryo transfer (ET) and elective frozen-thawed embryo transfer (FET) regarding the possible interference of controlled ovarian stimulation (COS) in implantation and endometrial receptivity, IVF safety, and obstetric and perinatal outcomes.

METHODS

We performed a review in the literature of the available evidence comparing fresh to elective FET (freeze-all policy).

RESULTS

The improvements made in cryopreservation techniques have led to few or no detrimental effects to the embryo and have resulted in no consequences to the offspring when compared to fresh embryos; this has allowed reproductive practitioners to create the freeze-all policy (when all viable embryos are electively cryopreserved in the fresh cycle and transferred in a posterior cycle). There are increasing concerns about the adverse effects associated with COS over the endometrial and uterine environments, as well as with the safety of COS in pregnancies that have originated from fresh ET during in vitro fertilization (IVF) treatments. COS may contribute to modifications in the endometrium, which might be related to poorer outcomes when fresh ET is performed. It has been suggested that obstetric and perinatal outcomes in pregnancies resulting from fresh ET are poorer when compared with those that occur after FET. In cycles with fresh ET, there is still a risk of ovarian hyperstimulation syndrome (OHSS).

CONCLUSION

There is growing evidence in the literature suggesting better IVF outcomes, and decreased obstetric and perinatal morbidity when adopting the freeze-all policy instead of fresh ET.

Germline Manipulation and Our Future Worlds

Two genetic technologies capable of making heritable changes to the human genome have revived interest in, and in some quarters a very familiar panic concerning, so-called germline interventions. These technologies are: most recently the use of CRISPR/Cas9 to edit genes in non-viable IVF zygotes and Mitochondrial Replacement Therapy (MRT) the use of which was approved in principle in a landmark vote earlier this year by the United Kingdom Parliament. The possibility of using either of these techniques in humans has encountered the most violent hostility and suspicion. However it is important to be aware that much of this hostility dates back to the fears associated with In Vitro Fertilization (IVF) and other reproductive technologies and by cloning; fears which were baseless at the time concerning both IVF and cloning the use of both of which have proved to be highly beneficial to humanity and which have been effectively regulated and controlled. This paper argues that CRISPR should by pursued through researh until it is safe enough for use in humans but there is no reason to suppose at this stage that such use will be unsafe or unethical (Collins 2015).

The Impact of Psycho-Education on in Vitro Fertilisation Treatment Efficiency

AIM

The aim of the study was to examine the efficiency of psycho-education of candidates for the IVF in stress, anxiety and depression decreasing, and the impact of the psycho educative techniques on the successfulness of the treatment.

METHOD

A random sample of 64 candidates for IVF treatment is divided in two groups: control group without psycho-education (32 candidates) and intervention group of 32 candidates included in psycho-education. Depression, anxiety and stress scale (DASS) was used as a psychometric test. It's a multiple choice, self-reported inventory for measuring the levels of stress, anxiety and severity of depression. For statistic evaluation SPSS software was used.

RESULTS

The study shows that the intervention group included in psycho-education has a signifycantly lower scores on stress (t = 3.201, p < 0.05) and anxiety (t = 2.311, p < 0.05). The scale of depression did not show differences in the two compared groups. However, the success of the IVF treatment is more common among candidates that were included in psycho-education.

CONCLUSION

In our country, psycho-education of candidates for in vitro fertilization is not systematically integrated in the treatment. The study showed the efficiency of psycho-education in anxiety and stress decreasing, as well as significant impact in the successfulness of the treatment. It was pointed out that psychological support of candidates for IVF is important for the lessening of the negative emotional reactions of candidates as well as for the successfulness of the treatment.