Successful implantation after reducing matrix metalloproteinase activity in the uterine cavity

BACKGROUND

Recently, the concept of recurrent implantation failure (RIF) in assisted reproductive technology has been enlarged. Chronic uterine inflammation is a known cause of implantation failure and is associated with high matrix metalloproteinase (MMP) activity in uterine cavity flushing. MMP activity of women with RIF has been reported to be higher than that of fertile women. In the present retrospective study we evaluated the efficacy of treatment for high MMP activity in the uterine cavity of patients with RIF.

METHODS

Of the 597 patients recruited to the study, 360 patients underwent MMP measurements and 237 patients did not (control group). All patients had failed to become pregnant, despite at least two transfers of good-quality embryos. Gelatinase MMP-2 and MMP-9 activity in uterine flushing fluid was detected by enzymology (MMP test). All samples were classified into two groups (positive or negative) based on the intensity of the bands on the enzyme zymogram, which represents the degree of MMP activity. Patients who tested positive on the initial test were treated for 2 weeks with a quinolone antibiotic and a corticosteroid, and subsequently underwent a second MMP test. Negative results on the second MMP tests after treatment and subsequent rates of pregnancy and miscarriage were used to evaluate the efficacy of treatment. Data were analyzed by the Mann-Whitney U-test and the chi-square test.

RESULTS

Of the patients who underwent the MMP test, 15.6% had positive results (high MMP activity). After treatment, 89.3% of patients had negative results on the second MMP test. These patients had a significantly better pregnancy rate (42.0%) than the control group (26.6%), as well as a lower miscarriage rate (28.5% vs 36.5%, respectively).

CONCLUSIONS

A 2-week course of antibiotics and corticosteroids effectively improves the uterine environment underlying RIF by reducing MMP activity.

Long-term follow-up of children conceived through assisted reproductive technology

Children conceived via assisted reproductive technologies (ART) are nowadays a substantial proportion of the population. It is important to follow up these children and evaluate whether they have elevated health risks compared to naturally conceived (NC) children. In recent years there has been a lot of work in this field. This review will summarize what is known about the health of ART-conceived children, encompassing neonatal outcomes, birth defects, growth and gonadal developments, physical health, neurological and neurodevelopmental outcomes, psychosocial developments, risk for cancer, and epigenetic abnormalities. Most of the children conceived after ART are normal. However, there is increasing evidence that ART-conceived children are at higher risk of poor perinatal outcome, birth defects, and epigenetic disorders, and the mechanism(s) leading to these changes have not been elucidated. Continuous follow-up of children after ART is of great importance as they progress through adolescence into adulthood, and new ART techniques are constantly being introduced.

Probabilistic linkage of assisted reproductive technology information with vital records, Massachusetts 1997-2000

To assess the validity of probabilistic linkage (PL) in combining national surveillance data on assisted reproductive technology (ART) with Massachusetts birth and infant death data, for the purpose of monitoring maternal and child health outcomes of ART. A study conducted in 2006 utilized direct identifiers to match Massachusetts birth records with records on ART procedures performed to Massachusetts residents in fertility clinics located in Massachusetts and Rhode Island, achieving a linkage rate of 87.5%. The present study employed PL using the program Link Plus, without access to direct identifiers. The primary linking variables were maternal and infant dates of birth, and plurality. Ancillary variables such as maternal ZIP code and gravidity helped resolve duplicate matches and capture additional matches. PL linked 5,390 (87.8%) of 6,139 deliveries, correctly identifying 96.4% of the matches previously obtained using deterministic linkage methods. PL yielded a high linkage rate with satisfactory validity; this method may be applied in other states to help monitor the maternal and child health outcomes of ART.

What is the best treatment option for infertile women aged 40 and over?

PURPOSE

To summarise the causes of decreased fecundity with age and review chronological vs biological ovarian ageing. To explore the clinician's means of assessing a woman's ovarian reserve. To review the recent literature on the effectiveness of different assisted reproductive technology (ART) techniques for women aged 40 and over and offer a single best treatment option.

METHODS

Pubmed and google scholar were searched for relevant articles using key words. Data were extracted based on authors, year, aims, sample and results.

RESULTS

Success rates for women aged 40 or over with clomiphene, IUI, IUI with FSH are all extremely low, at less than 1% live birth per cycle. However, IVF offers a success rate of around 13.7% per cycle.

CONCLUSION

An exploration of the effectiveness of available treatment options for older infertile women using their own gametes suggests that IVF offers the best prospects of success. Attempting treatments other than IVF will delay conception unnecessarily.

Very advanced maternal age and morbidity in Victoria, Australia: a population based study

BACKGROUND

In Australia, approximately 0.1% of births occur to women 45 years or older and this rate has been increasing in recent years. There are however, few population based studies examining perinatal outcomes among this age group. The aim of this study was to determine the maternal and perinatal outcomes of pregnancies in women aged 45 years or older compared to women aged 30-34 years.

METHODS

Data on births at 20 or more weeks' gestation were obtained from the Victorian Perinatal Data Collection for the years 2005 and 2006. We examined selected maternal and perinatal outcomes for women of very advanced maternal age (VAMA) aged 45 years or older (n = 217) and compared them to women aged 30-34 years (n = 48,909). Data were summarised using numbers and percentages. Categorical data were analysed by Chi-square tests and Fisher's exact test. Comparisons are presented using unadjusted odds ratios, 95 percent confidence intervals (CIs) and p-values.

RESULTS

Women aged 45 years and older had higher odds of gestational diabetes (OR 2.05; 95% CI 1.3-3.3); antepartum haemorrhage (OR 1.89; 95% CI 1.01-3.5), and placenta praevia (OR 4.88; 95% CI 2.4-9.5). The older age-group also had higher odds of preterm birth between 32-36 weeks (OR 2.61; 95% CI 1.8-3.8); low birth-weight (<2,500 gr) (OR 2.22; 95% CI 1.5-3.3) and small for gestational age (OR 1.53; 95% CI 1.0-2.3). Stratified analysis revealed that VAMA was most strongly associated with caesarean section in primiparous women (OR 8.24; 95% CI 4.5, 15.4) and those using ART (OR 5.75; 95% CI 2.5, 13.3), but the relationship persisted regardless of parity, ART use and plurality. Low birthweight was associated with VAMA only in first births (OR 3.90; 95% CI 2.3, 6.6), while preterm birth was more common in older women for both first (OR 3.13; 95% CI 1.8, 5.3) and subsequent (OR 2.08; 95% CI 1.2, 3.5) births, and for those having singleton births (OR 2.11; 95% CI 1.3, 3.4), and those who did not use ART (OR 2.10; 95% CI 1.3, 3.4). Preterm birth was very common in multiple births and following ART use, regardless of maternal age.

CONCLUSIONS

This study demonstrates that women aged 45 years and older, in Victoria, Australia, have higher rates of pregnancy and perinatal complications, compared to women aged 30-34 years.

Assisted reproductive technologies and perinatal morbidity: interrogating the association

Interrogating the association between assisted reproductive technologies (ART) and perinatal outcome is complicated but very important. This is an introduction to a series of articles that review this potential association with an eye toward etiology of risk, and what aspects of in vitro fertilization (IVF) can be modified to reduce this risk. When an association is not due to chance (i.e., statistically significant), one must also consider how the association may be affected due to bias or confounding. Despite lack of the perfect study, perinatal consequences of ART are apparent, even though the vast majority of children conceived with ART are healthy. Pregnancy after IVF is altered as evidenced by risk of preterm delivery, low birth weight among infants, and an alerted prevalence of preeclampsia. The long-term clinical implications of ART, such as childhood development and metabolism, have not been established and ongoing study is proceeding. The risk attributed to multiple births is iatrogenic and needs to be minimized. Optimizing the environment at the time a woman conceives will likely have an effect on gestation as well as the health of children. Reproduction effects health and health effects reproduction.

Cardiometabolic health of children conceived by assisted reproductive technologies

The cardiometabolic health of children conceived by assisted reproductive technologies (ART) compared with children conceived without medical assistance is unclear. Although the majority of published studies evaluating height, weight, and body mass index have not found differences by method of conception, some studies have indicated differences in adiposity by more direct measures such as skinfolds and dual X-ray absorptiometry. Far fewer studies have investigated other cardiometabolic characteristics, such as blood pressure and measures of lipid and glucose metabolism. Of these studies, some indications of increased blood pressure and recent findings of vascular dysfunction among children conceived by ART compared with children conceived without ART warrant further investigation. Epigenetic differences may be the global mechanism at work, resulting from different aspects of ART treatment, such as ovarian stimulation, in vitro culture, and manipulation of sperm, among other considerations. Fetal growth and placental development may serve as mediators of these effects. Future studies should consider recruiting sufficient numbers of ART and non-ART conceived multiples and collect information on indicators of cardiometabolic health in the parents. Despite some advantages of sibling cohorts in developmental origins research, its feasibility and utility for investigating health of children conceived by ART remains debatable.

Assisted reproductive technologies in Italy, 2005-2007: results from the Italian Assisted Reproductive Technologies Register

AIM

The aim of this study was to assess the quantitative and qualitative outcomes of assisted reproductive technologies in Italy, from 2005 to 2007, collected by the Italian Assisted Reproductive Technologies Register (IARTR).

METHODS

We analyzed, retrospectively, 121,708 ART treatments performed by Italian assisted reproductive technologies (ART) centres from 2005 to 2007.

RESULTS

In the study period ART Italian centers were reporting data to the IARTR. Number of total cycles (all homologous) reported was 121,708 including 110,074 fresh (FRESH), 8682 frozen/thawed oocytes (FO) and 2952 frozen embryo (FER). Pregnancy rates per cycle with respect to FRESH, FO and FER treatments were 19.1%, 10.2% and 15%, respectively. Delivery rate per cycle with at least one live birth was 10.8%, 5.8% and 8.4%, respectively, per type of procedure. Twin and "triplet or more" birth rate per delivery was 21% and 2.8%; 12% and 0.4%; 14.9% and 0.8%, respectively. During the study period 15923 ART infants were born (0.95% of all newborn in Italy).

CONCLUSION

From 2005 to 2007 we registered a strong increase in ART procedures concomitantly with a qualitative improvement leading to increased pregnancy and live birth rates per cycles. Remarkably, pregnancy loss to follow-up decreased drastically during the three years study-period.

Management of infertility in HIV infected couples: a review

The HIV epidemic has continued to grow and remains a major challenge to mankind. In the past, ethical considerations about the resulting child and risks of sexual, vertical and nosocomial transmission of HIV prevented practitioners from offering fertility services to people living with HIV. In recent times however, the use of highly active antiretroviral therapy (HAART), has not only improved the life expectancy and quality of life of those infected but also reduced the risk of HIV transmission. The need for fertility services in the HIV-positive population has thus increased and may be employed for management of infertility and protection from transmission or acquisition of HIV infection. As such, preconception counseling, sexual health and fertility screening have become routine in the management of HIV-positive couples. The option of care include adoption, self insemination with husband sperm, embryo donation from couples who have been verified to be HIV negative, insemination with donor sperm, timed unprotected intercourse (TUI) and sperm washing combined with intrauterine insemination (IUI) and assisted reproductive technology (ART) including in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Access to these fertility services by HIV-positive clients should be facilitated as part of efforts to promote their reproductive health and rights.

Obesity, assisted reproductive technology, and early preterm birth--Florida, 2004-2006

Florida resident birth certificates for 2004-2006 were linked to the Centers for Disease Control and Prevention's National ART Surveillance System and were used to investigate 1) whether the association of assisted reproductive technology (ART) with preterm birth varies by prepregnancy body mass index and 2) whether the association varies by plurality. Preterm birth was defined as early preterm birth (gestation <34 weeks) and late preterm birth (gestation 34-36 weeks). Descriptive statistics and multinomial logistic regression were used to explore maternal and infant differences by ART status and plurality. Of 581,403 women included in the study, 24.0% were overweight, 18.6% were obese, 7.3% had late preterm birth, 2.6% had early preterm birth, and 0.67% conceived through ART. Among singleton births, ART was associated with increased early preterm birth risk among underweight (odds ratio (OR) = 2.94, 95% confidence interval (CI): 1.27, 6.81), overweight (OR = 1.75, 95% CI: 1.12, 2.72), and obese (OR = 2.37, 95% CI: 1.51, 3.71) women. Among twins, ART was significantly associated with increased risk among overweight (OR = 1.61, 95% CI: 1.12, 2.32) and obese (OR = 1.85, 95% CI: 1.18, 2.90) women. Differences in the associations between ART and early preterm birth by body mass index and plurality warrant further investigation.

Assisted reproductive technology surveillance--United States, 2009

PROBLEM/CONDITION

Since the birth of the first U.S. infant conceived with Assisted Reproductive Technology (ART) in 1981, use of advanced technologies to overcome the problem of infertility has increased steadily, as has the number of fertility clinics providing ART services in the United States. ART includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Women who undergo ART procedures are more likely to deliver multiple-birth infants than those who conceive naturally. Multiple births pose substantial risks to both mothers and infants, including pregnancy complications, preterm delivery, and low birthweight infants. This report presents the most recent data on ART use and birth outcomes for U.S. states and territories.

REPORTING PERIOD COVERED

2009.

DESCRIPTION OF SYSTEM

In 1996, CDC began collecting data on all ART procedures performed in the United States, as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). ART data for 1995-2003 were obtained from the Society of Assisted Reproductive Technology (SART) through its proprietary Clinical Outcomes Reporting System data base (SART CORS). Since 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from fertility clinics in the United States through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC.

RESULTS

In 2009, a total of 146,244 ART procedures were reported to CDC. These procedures resulted in 45,870 live-birth deliveries and 60,190 infants. The largest numbers of ART procedures were performed among residents of California (18,405), New York (14,539), Illinois (10,192), Massachusetts (9,845), New Jersey (9,146), and Texas (8,244). Together, these six states reported the highest number of live-birth deliveries as a result of ART and accounted for 48% of all ART procedures initiated, 46% of all infants born from ART, and 45% of all ART multiple-birth deliveries but only 34% of all births in the United States. Nationally, the average number of ART procedures performed per 1 million women of reproductive age (15-44 years), which is a proxy indicator of ART utilization, was 2,361. In four states (Massachusetts, New York, New Jersey, and Connecticut) and the District of Columbia, this proxy measure of ART use exceeded twice the national average. Nationally, the average number of embryos transferred was 2.1 among women aged <35 years, 2.5 among women aged 35-40 years, and 3.0 among women aged >40 years (and varied most in this age group from 1.7 in Maine to 3.5 in Missouri). Age-specific elective single-embryo transfer (eSET) rates were approximately 7% among women aged <35 years, 3% among women aged 35-40 years, and 0.5% among women aged >40 years. The highest rates of eSET were observed among women aged <35 years (41% in Delaware, 20% in Iowa, and 17% Massachusetts). Overall, ART contributed to 1.4% of U.S. births (ranging from 0.2% in Puerto Rico to 4.3 % in Massachusetts). The proportion of ART to total infants born in the state or territory, which is another measure of ART utilization, was highest in Massachusetts (>4%) with high rates also observed in New Jersey, New York, Connecticut, and the District of Columbia (>3% of all infants born). Infants conceived with ART accounted for 20% of all multiple-birth infants (ranging from 4% in Maine to 41% in New York), 19% of all twin births (ranging from 4% in Maine to 42% in New York) and 34% of triplet or higher order births (ranging from 0 in several states to 61.5% in New Jersey). Among infants conceived with ART, 47% were born as multiple-birth infants (ranging from 35% in Delaware to 60.8% in Wyoming), compared with only 3% of infants among the general birth population (ranging from 1% in New York to 5% in Connecticut). Nationally, infants conceived with ART contributed to approximately 6% of all low birthweight (<2,500 grams) infants, ranging from 1.3% in Mississippi to 15% in Massachusetts and to 6% of all very low birthweight (<1,500 grams) infants, ranging from 1% in Alaska to 15% in New Jersey. Overall, among ART-conceived infants, 32% were low birthweight (ranging from 20% in Alaska to 48% in Puerto Rico), compared with 8% among the general birth population (ranging from 5.8% in South Dakota to 12.2% in Mississippi), and 6% of ART infants were very low birthweight (ranging from 1.5% in Alaska to 13% in South Dakota), compared with 1% among the general birth population (ranging from 1% in Alaska to 2% in Mississippi and District of Columbia). Finally, ART-conceived infants accounted for 3.9% of all preterm (<37 weeks; range: 0.5% in Puerto Rico to 11.1% in Massachusetts) and 4.5% of all very preterm births (<32 weeks; range: 0.5% in Puerto Rico to 12% in New York). Overall, among infants conceived with ART, 33.4% were born preterm (ranging from 21.3% in Vermont to 47.1% in Wyoming), compared with 12.2% of the general birth population (ranging from 9.3% in Vermont to 18.0% in Mississippi), and 6.1% of ART infants were very preterm births (ranging from 1.5% in Alaska to 14.7% in South Dakota), compared with 2% among the general birth population (ranging from 1.4% in Alaska, Oregon, Utah, and Washington to 3% in Mississippi).

INTERPRETATION

The proportion of births from ART varied considerably by state and territory (ranging from 0.2% to 4.3%) with substantial impact on perinatal outcomes in some states. In most states, multiple births from ART accounted for substantial proportions of twins and triplets and higher order infants, and the rates of low birthweight and preterm births were disproportionately higher among ART infants than in the general birth population. More than one embryo was transferred per procedure in most states and territories for all age groups, influencing the overall multiple birth rates in the United States. ART use was represented disproportionately in the United States, with only 13 states having above-average ART use. High rates of ART utilization were observed in Massachusetts and New Jersey, which have comprehensive statewide-mandated health insurance coverage for ART procedures. Insurance mandates might influence ART utilization and ART-related birth outcomes.

PUBLIC HEALTH ACTIONS

Promotion of single-embryo transfer, where feasible, is needed to reduce multiple births and related adverse consequences of ART. Nevertheless, because ART accounts for a relatively small fraction of total births in most states and territories, the overall prevalence of low birthweight and preterm births cannot be explained solely by the use of ART, and therefore non-ART causes of these adverse outcomes must be examined. Monitoring the use of non-ART infertility treatments (e.g., ovulation stimulation medications without ART) in the general population might be useful because these treatments also might be associated with high rates of multiple births and adverse outcomes such as preterm delivery and infants born with low birthweight.

Diagnosis and treatment of diminished ovarian reserve in assisted reproductive technology cycles of women up to age 40 years: the role of insurance mandates

OBJECTIVE

To explore correlates of diminished ovarian reserve (DOR) and predictors of assisted reproductive technologies (ART) treatment outcome in DOR cycles using the Society for Assisted Reproductive Technologies-Clinical Outcomes Reporting System (SART-CORS) database; we hypothesized that mandated state insurance coverage for ART is associated with the prevalence of DOR diagnosis in ART cycles and with treatment outcomes in DOR cycles.

DESIGN

Cross-sectional study using ART cycles between 2004 and 2007.

SETTING

Not applicable.

PATIENT(S)

A total of 182,779 fresh, nondonor, initial ART cycles in women up to age 40 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of DOR and elevated FSH, odds ratio of DOR and elevated FSH in ART mandated vs. nonmandated states, live birth rates.

RESULT(S)

Compared with cycles performed in states with mandated ART coverage, cycles in states with no ART mandate were more likely to have DOR (adjusted odds ratio 1.43, 95% confidence interval 1.37-1.5) or elevated FSH (adjusted odds ratio 1.69, 95% confidence interval 1.56-1.85) as the sole reason for treatment. Lack of mandated ART coverage was associated with increased live birth rates in cycles diagnosed as DOR, but not in cycles characterized only by an elevated FSH.

CONCLUSION(S)

A significant association was observed between lack of mandated insurance for ART and the proportion of cycles treating DOR or elevated FSH. The presence or absence of state-mandated ART coverage could impact access to care and the mix of patients that pursue and initiate ART cycles in ways that influence these proportions. Additional studies are needed that consider the coalescence of insurance mandates, patient and provider factors, and state-level variables on the odds of specific infertility diagnoses and treatment prognosis.

[The prognosis for children born after assisted reproduction]

Children who are born after assisted reproduction (ART) have a slightly increased risk of being born preterm, of having low birthweight and a higher perinatal mortality than spontaneously conceived children. The higher rate of multiple births among women having had ART can to some extent explain this. However, adverse outcomes persist even in ART singletons. The characteristics of the infertile parents have negative effects on the outcome, but also the hormone stimulation and the in vitro techniques are thought to play a role. A milder hormone stimulation and elective single embryo transfer, which reduces the number of multiples after ART, have improved the overall health of children born as a result of ART.

[Fertility treatment in Denmark--development and challenges]

In Denmark, a total of 31,000 assisted reproductive technology (ART) and intrauterine insemination treatments yearly results in the delivery of around 6,300 children, which represents 9% of the Danish birth cohort. The delivery rate following ART (in vitro fertilization/intracytoplasmatic sperm injection, frozen embryo replacement and oocyte donation) has been stable around 20% per cycle initiated during the last decade, despite the transfer of fewer embryos. The future challenges are the increasing age of women seeking fertility treatment, the development of biomarkers of embryonic implantation potential as well as the improvement of embryo culture, and embryo freezing techniques.

Assessment of assisted reproductive technology use questions: Pregnancy Risk Assessment Monitoring System Survey, 2004

OBJECTIVE

Women who conceive with the assistance of fertility treatments are at increased risk for multiple-gestation pregnancies and accompanying adverse pregnancy outcomes. The Pregnancy Risk Assessment Monitoring System (PRAMS) can be used to assess outcomes associated with fertility treatments, but a previous study suggested that PRAMS questions about fertility treatments overestimated use of assisted reproductive technology (ART) by 2.6 times. These PRAMS ART questions were revised in 2004. We compared prevalence estimates based on revised questions with counts from the National ART Surveillance System (NASS), the standard for describing ART prevalence.

METHODS

We compared weighted PRAMS prevalence estimates of births conceived by using ART with corresponding counts from NASS for three states (Florida, Maryland, and Utah) for 2004. We also compared these data by age, parity, plurality, and infant birthweight.

RESULTS

Estimated ART births determined from PRAMS totaled 3,672 (95% confidence interval 2,210, 5,134), compared with 2,939 ART births reported to NASS. PRAMS estimates and NASS counts differed by maternal age (p=0.02) and parity (p<0.01). For example, PRAMS responses from women aged ≥ 40 years overestimated ART use by 70% (27.9% vs. 16.5%, p<0.01).

CONCLUSIONS

Revised PRAMS questions better estimate numbers of ART births than earlier PRAMS questions. PRAMS data are useful to describe behaviors and outcomes associated with ART use.

The effects of insurance mandates on choices and outcomes in infertility treatment markets

For the 10% to 15% of American married couples who experience reproductive problems, in vitro fertilization (IVF) is the leading technologically advanced treatment procedure. However, IVF's expense may prevent many couples from receiving treatment, and those who are treated may take an overly aggressive approach to reduce the probability of failure. Aggressive treatment, which occurs through an increase in the number of embryos transferred during IVF, can lead to medically dangerous multiple births. We evaluated the principle policy proposal-insurance mandates-for improving IVF access and outcomes. We used data from US markets during 1995-2003 to show that broad insurance mandates for IVF result in not only large increases in treatment access but also significantly less aggressive treatment. More limited insurance mandates, which may apply to a subset of insurers or provide weaker guidelines for insurer behavior, generally have little effect on IVF markets.

Subfertility treatment in women with systemic lupus erythematosus

This study comprised of 65 infertile patients with systemic lupus erythematosus (SLE). The aim was to study causes and different modalities used for the management of subfertile patients with SLE. All patients were diagnosed to have SLE according to the standard criteria of diagnosis. All patients were scheduled to expectant treatment, ovulation induction and timed intercourse, intrauterine insemination (IUI), intracytoplasmic sperm injection (ICSI). Anovulation was in 20 patients (20%), due to PCOS in 10 cases and due to other causes in three patients. A total of 28 patients (43.1%) needed laparoscopy for their work-up of infertility. Male factor for infertility was present in nine couples (16.7%). Ovulation induction and timed intercourse was adopted for a maximum 6 cycles and IUI for 3 cycles. In vitro fertilisation (IVF)/ICSI was needed in five cases using standard long agonist protocol. Four cases were complicated by significant ovarian hyperstimulation syndrome after conventional ovarian stimulation and cycles were cancelled. Pregnancy occurred in 20 women. Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well selected women with non-complicated SLE.

Mode of conception of triplets and high order multiple pregnancies

A retrospective audit was performed of all high order multiple pregnancies (HOMPs) delivered in three maternity hospitals in Dublin between 1999 and 2008. The mode of conception for each pregnancy was established with a view to determining means of reducing their incidence. A total of 101 HOMPs occurred, 93 triplet, 7 quadruplet and 1 quintuplet. Information regarding the mode of conception was available for 78 (81%) pregnancies. Twenty eight (27.7%) were spontaneous, 34 (33.7%) followedlVF/ICSI/FET treatment (in-vitro fertilisation, intracytoplasmic sperm injection, frozen embryo transfer), 16 (15.8%) resulted from Clomiphene Citrate treatment and 6 (6%) followed ovulation induction with gonadotrophins. Triplet and HOMPs are a major cause of maternal, feta land neonatal morbidity. Many are iatrogenic, arising from fertility treatments including Clomiphene. Reducing the numbers of embryos transferred will address IVF/ICSI/FET-related multiple pregnancy rates and this is currently happening in Ireland. Clomiphene and gonadotrophins should only be prescribed when appropriate resources are available to monitor patients adequately.

Multiple Maternities and Neighborhood Income

This study aimed to examine differences in multiple maternities by neighborhood-income levels in Toronto, Canada. Hospital records were used to perform secondary analysis of 144,731 maternities resulting in single or multiple infants live-born to mothers residing in the City of Toronto 1996 to 2001. The independent variable was neighborhood income, defined as mean household neighborhoodincome quintiles. Multiple logistic regression analysis was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Differences by income levels were found in twin maternities but not in higher order maternities. Twin maternities were more likely to occur in the richest neighborhood-income quintile compared to the rest of the population (AOR: 1.25, 95% CI: 1.10-1.41), after adjustment for potential confounders. The positive association between high neighborhood income and twin maternities found in this study suggests that the richest neighborhoods select families whose characteristics pose them at increased risk of having twins. Further studies are needed to clarify the underlying mechanisms leading to socioeconomic differences in multiple births.

Regional Variations in Trends for Multiple Births: A Population-Based Evaluation in France, 1972–2003

The aim of the study was to assess, using population-based data, trends and regional variations in multiple births during the period of increasing use and changes in practice patterns for infertility treatments. National data for 24,554,977 births (live births and stillbirths) were used, including 569,423 twins during the period 1972 to 2003, and 14,599 triplets for 1984 to 2003. Statistical analyses included age-adjusted hierarchical logistic regression models for twin births and separate analyses for triple, same-sex, and different-sex twin births. Due to confidentiality considerations, the only variable available for adjustment was maternal age. Regionallevel variations were estimated using median odds ratios based on random-intercept hierarchical logistic regression models. Overall, twin births increased from 18.1 per 1000 births (95% confidence interval [CI] 17.9–18.2) in 1972 to 1975 to 29.9 per 1000 (95% CI 29.7–30.1) in 2000 to 2003. Twin births increased progressively across all regions, whereas triple births reached a peak in the early 1990s and decreased thereafter. Trends for both twin and triple births varied significantly across regions. Both trends and regional variations were greater for different-sex as compared with same-sex twin births. Regional variations in the proportion of multiple births increased in the case of twin births and decreased for triple births. Differences in multiple births at the regional level in France were comparable to country-level differences observed across several western and northern European countries. Regional differences in multiple births need to be monitored and used to inform policies aimed at regulating the use of infertility treatments.

Utilization of infertility treatments: the effects of insurance mandates

Over the last several decades, both delay of childbearing and fertility problems have become increasingly common among women in developed countries. At the same time, technological changes have made many more options available to individuals experiencing fertility problems. However, these technologies are expensive, and only 25% of health insurance plans in the United States cover infertility treatment. As a result of these high costs, legislation has been passed in 15 states that mandates insurance coverage of infertility treatment in private insurance plans. In this article, we examine whether mandated insurance coverage for infertility treatment affects utilization. We allow utilization effects to differ by age and education, since previous research suggests that older, more-educated women should be more likely to be directly affected by the mandates than younger women and less-educated women, both because they are at higher risk of fertility problems and because they are more likely to have private health insurance, which is subject to the mandate. We find robust evidence that the mandates do have a significant effect on utilization for older, more-educated women that is larger than the effects found for other groups. These effects are largest for the use of ovulation-inducing drugs and artificial insemination.

Using a genetically informative design to examine the relationship between breastfeeding and childhood conduct problems

A number of public health interventions aimed at increasing the uptake of breastfeeding are in place in the United States and other Western countries. While the physical health and nutritional benefits of breastfeeding for the mother and child are relatively well established, the evidence for psychological effects is less clear. This study aimed to examine whether there is an association between breastfeeding and later conduct problems in children. It also considered the extent to which any relationship is attributable to maternally-provided inherited characteristics that influence both likelihood of breastfeeding and child conduct problems. A prenatal cross-fostering design with a sample of 870 families with a child aged 4-11 years was used. Mothers were genetically related or unrelated to their child as a result of assisted reproductive technologies. The relationship between breastfeeding and conduct problems was assessed while controlling for theorised measured confounders by multivariate regression (e.g. maternal smoking, education, and antisocial behaviour), and for unmeasured inherited factors by testing associations separately for related and unrelated mother-child pairs. Breastfeeding was associated with lower levels of conduct disorder symptoms in offspring in middle childhood. Breastfeeding was associated with lower levels of conduct problems even after controlling for observed confounders in the genetically related group, but not in the genetically unrelated group. In contrast, maternal antisocial behaviour showed robust associations with child conduct problems after controlling for measured and inherited confounders. These findings highlight the importance of using genetically sensitive designs in order to test causal environmental influences.

Estimation of the contribution of assisted and non-assisted reproductive technology fertility treatments to multiple births during the past 30 years in Japan: 1979-2008

The effect of assisted reproductive technology (ART) and non-ART ovulation stimulation fertility treatment on the number and rate of multiple live births from 1979-2008 in Japan was estimated using two independent data sources, ART statistics and vital statistics. Japanese ART statistics presented by the Japan Society of Obstetrics and Gynecology between 1989 and 2008 were gathered and reanalyzed. The number and rates of ART between 1984 and 1988 were interpolated using an approximation formula, using the values from 1983, when the first ART baby was born in Japan, and the 1989-1992 values. The number of ART multiples between 1979-1982 was set as equal to zero. The minimum (or maximum) number of non-ART iatrogenic multiple births was estimated by subtracting the maximum (or minimum) ART multiples from the total iatrogenic multiples, which was estimated by vital statistics assuming that spontaneous multiple-birth rates according to maternal age class would be constant. There was an overall increase in the non-ART multiple births during the 30-year period, whereas ART multiples tended to increase from 1983 to 2005, and then rapidly decreased thereafter. The number or percentage of ART multiples was almost consistently lower than that of non-ART multiples. The percentage of non-ART multiples (33%) among the total multiples was estimated to be about three times more than the ART multiples (11-12%) in 2008. Given the medical and social impact of multiple births, it is imperative to construct a hospital-based monitoring system for fertility treatments, specially non-ART fertility treatments and multiple births.