Are there subtle genome-wide epigenetic alterations in normal offspring conceived by assisted reproductive technologies?

OBJECTIVE

To review recent data regarding subtle, but widespread, epigenetic alterations in phenotypically normal offspring conceived by assisted reproductive technologies (ART) compared with offspring conceived in vivo.

DESIGN

A PubMed computer search was performed to identify relevant articles.

SETTING

Research institution.

PATIENT(S)

Not applicable.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULT(S)

Studies in animals indicate that in vitro culture may be associated with widespread alterations in imprinted genes compared with in vivo-conceived offspring. Recently, studies in humans have likewise demonstrated widespread changes in DNA methylation, including genes linked to adipocyte development, insulin signaling, and obesity in offspring conceived by ART compared with in vivo-conceived children. Changes in multiple imprinted genes after ART also were noted in additional studies, which suggested that the diagnosis of infertility may explain the differences between in vivo-conceived and ART offspring.

CONCLUSION(S)

These data suggest that ART is associated with widespread epigenetic modifications in phenotypically normal children, and that these modifications may increase the risk of adverse cardiometabolic outcomes. Further research is needed to elucidate the possible relationship between ART, genome-wide alterations in imprinted genes, and their potential relevance to subtle cardiometabolic consequences reported in ART offspring.

Assisted reproductive technology and risk for autism spectrum disorder

Epidemiologic studies on maternal and pregnancy risk factors for autism spectrum disorder (ASD), including use of assisted reproductive technology (ART), found conflicting results. This study included the following aims: to assess frequencies of ART in a large ASD group; to examine confounding birth and familial risk factors in the ASD with ART group; to examine possible relationships between ART and autism severity, adaptive skills and developmental trajectory. The study included 624 participants, 507 diagnosed with ASD. Autism severity and adaptive skills were assessed using standardized tests. Extensive medical, familial and developmental histories were obtained. The rate of ART in the ASD group was significantly higher (10.7%) than in a large Israeli population (3.06%). Parental age's distribution did not differ in both ASD groups, with and without ART. Although maternal age was more advanced in the ASD group, the frequency of ART in young mothers (<29 years) was still significantly high (8.7%). The frequencies of gestational age <36 weeks and low birth weight (<2500 g) in the ASD with ART singleton group and in the Israeli population were not significantly different. None of the ASD with ART group and 14.7% in the ASD without ART group had a relative with ASD. Autism severity, adaptive skills and developmental regression were not significantly different in the ASD with and without ART groups. This pilot study points to the role of assisted conception as a risk factor for ASD. However, this group of ASD with ART does not represent a separate clinical phenotype in ASD.

[Medical treatment of diabetic patients in high risk pregnancy clinic improves glycemic control prior to fertility treatment]

INTRODUCTION

Diabetic women are at increased risk for spontaneous abortions and congenital anomalies. Preconception care can improve pregnancy outcome.

AIM

To evaluate glycemic control in diabetic women undergoing fertility treatment, and compare between women who were treated in high risk pregnancy (HRP) clinics prior to fertility treatment and those who received usuaL care.

METHODS

Retrospective study on diabetic women undergoing fertility treatment during 2008-2009 in Haifa and Western Galilee District of Clalit Health Services (CHS). Data on fertility treatments, prescription fillings, HBA1C Levels and demographic data was extracted from CHS computer Data on medical treatment in HRP clinic was retrieved from visits in the researcher clinic. We evaluated measurement and Level of HBA1C within 3 months of fertility treatment; and compared it between the two groups.

RESULTS

There were 230 fertility treatment cycles in 83 diabetic women; 10 women were treated in the HRP clinic. Median HBA C was significantly lower 6.1% in the HRP group compared to 7.1% in women who received usual care (P < 0.05]. HBA1C Level was recorded within 3 months of fertility treatment in 84.2% of cycles in the HRP group compared to 52.6% of cycles in the usual care group (P < 0.05). Furthermore, HBA1C < 7.0% was found in 68.4% of cycles in women in the HRP clinic compared to only 24.0% of cycles in the other group [P < 0.05).

CONCLUSIONS

The medical care of diabetic women undergoing fertility treatment needs improvement. Many women undergo fertility treatment despite poor glycemic control. Referral to HRP clinic improves diabetic control and can improve pregnancy outcome.

Risk of adverse pregnancy outcomes in women with polycystic ovary syndrome: population based cohort study

OBJECTIVE

To study the risk of adverse pregnancy outcomes in women with polycystic ovary syndrome, taking into account maternal characteristics and assisted reproductive technology.

DESIGN

Population based cohort study.

SETTING

Singleton births registered in the Swedish medical birth register between 1995 and 2007.

PARTICIPANTS

By linkage with the Swedish patient register, 3787 births among women with a diagnosis of polycystic ovary syndrome and 1,191,336 births among women without such a diagnosis.

MAIN OUTCOME MEASURES

Risk of adverse pregnancy outcomes (gestational diabetes, pre-eclampsia, preterm birth, stillbirth, neonatal death, low Apgar score (<7 at five minutes), meconium aspiration, large for gestational age, macrosomia, small for gestational age), adjusted for maternal characteristics (body mass index, age), socioeconomic factors (educational level, and cohabitating with infant's father), and assisted reproductive technology.

RESULTS

Women with polycystic ovary syndrome were more often obese and more commonly used assisted reproductive technology than women without such a diagnosis (60.6% v 34.8% and 13.7% v 1.5%). Polycystic ovary syndrome was strongly associated with pre-eclampsia (adjusted odds ratio 1.45, 95% confidence interval 1.24 to 1.69) and very preterm birth (2.21, 1.69 to 2.90) and the risk of gestational diabetes was more than doubled (2.32, 1.88 to 2.88). Infants born to mothers with polycystic ovary syndrome were more prone to be large for gestational age (1.39, 1.19 to 1.62) and were at increased risk of meconium aspiration (2.02, 1.13 to 3.61) and having a low Apgar score (<7) at five minutes (1.41, 1.09 to 1.83).

CONCLUSIONS

Women with polycystic ovary syndrome are at increased risk of adverse pregnancy and birth outcomes that cannot be explained by assisted reproductive technology. These women may need increased surveillance during pregnancy and parturition.

Prevalence of uterine anomalies and their impact on early pregnancy in women conceiving after assisted reproduction treatment

OBJECTIVE

To estimate the prevalence of congenital uterine anomalies in subfertile women and to evaluate their influence on early pregnancy following assisted reproduction treatment (ART).

METHODS

We prospectively recruited 1402 subjects undergoing ART over a period of 5 years from 2005 to 2009. Three-dimensional transvaginal sonography was performed in the early follicular phase of the menstrual cycle (days 2-5) and repeated in the late follicular phase (days 10-14) if the shape of the uterine cavity could not be assessed at the first scan. All subjects who conceived following ART were followed up to 12 weeks' gestation. Chi-square test was used to compare the pregnancy rates and miscarriage rates between women shown to have uterine anomalies and those with a normal uterus.

RESULTS

One thousand three hundred and eighty-five subjects were included for final analysis after excluding 17 subjects in whom a definitive diagnosis could not be made. While 1201 (86.7%) subjects had a normal uterine cavity, uterine anomalies were demonstrated in 184 (13.3%) subjects. Arcuate uteri represented the commonest anomaly (n = 164 (11.8%)) followed by septate (n = 7 (0.5%)), unicornuate (n = 6 (0.4%)), subseptate (n = 5 (0.4%)), bicornuate (n = 1 (0.1%)) and T-shaped uteri (n = 1 (0.1%)). A total of 440 subjects who underwent ART were followed up. The pregnancy rates in women with arcuate uteri (36/66 (54.5%)) and major uterine anomalies (7/10 (70.0%)) were statistically similar (P = 0.09 and P = 0.11, respectively) to that of the matched controls with normal uteri (158/364 (43.4%)). While first-trimester miscarriage rates were similar (P = 0.81) between the control group (20/158 (12.7%)) and women with arcuate uteri (5/36 (13.9%)), women with major uterine anomalies experienced a higher miscarriage rate (3/7 (42.9%); P = 0.05).

CONCLUSIONS

Women who are referred for ART have a high prevalence of congenital uterine anomalies, the most common anomaly being an arcuate uterus. These anomalies are not associated with a reduction in pregnancy rates following ART. However, while the arcuate uterus was not associated with an increase in first-trimester miscarriage, major uterine anomalies seemed to increase the risk of first-trimester miscarriage.

The impact of stress and psychosocial interventions on assisted reproductive technology outcome

In natural cycles of attempted conception, stress has been shown to predict lower conception rates. The objective of this article is to determine whether stress affects the outcome of assisted reproductive technology (ART) as well. In addition, this article analyzes the effect that psychosocial interventions targeting the reduction of stress have on ART outcomes. This review examined available PubMed articles published in the past 15 years, and 28 articles were included. Looking specifically at numbers of women studied, stress appears to negatively affect ART outcome; interventions targeting stress reduction appear beneficial. Because stress appears to negatively affect ART outcome, and psychosocial interventions do not have detrimental effects, screening for stress should occur and some type of intervention considered during the ART process.

The risk of cytogenetic abnormalities in the late first trimester of pregnancies conceived through assisted reproduction

OBJECTIVE

To determine if pregnancies conceived through infertility treatment are at increased risk of cytogenetic abnormalities in the late first trimester compared with spontaneously conceived pregnancies, or if there is increased risk when comparing less invasive infertility treatment (in vivo group) to in vitro fertilization (in vitro group).

DESIGN

Retrospective case-controlled study.

SETTING

University hospital.

PATIENT(S)

A total of 1,606 women who spontaneously conceived and 559 women who conceived through infertility treatment undergoing chorionic villus sampling (CVS).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cytogenetic abnormalities diagnosed by CVS.

RESULT(S)

No difference in cytogenetic abnormalities was found when comparing spontaneously conceived pregnancies to those conceived through infertility treatment (7.0% versus 5.4%). We also found no difference in the prevalence of cytogenetic abnormalities when comparing in vivo and in vitro fertilization subgroups (4.7% versus 5.8%). Finally, no difference was found when comparing the prevalence of different types of cytogenetic abnormalities between groups.

CONCLUSION(S)

Infertility treatment does not increase the risk of carrying a cytogenetically abnormal fetus in the late first trimester, nor does it increase the preponderance for any specific type of abnormality.

Reproduction beyond menopause: how old is too old for assisted reproductive technology?

BACKGROUND

Due to the recent media attention on postmenopausal women giving birth, there has been an increased scrutiny on the utility and safety of assisted reproductive technology in postmenopausal women.

OBJECTIVE

The purpose of this commentary is to discuss the following: 1) the limitations and complications of ART in women of advanced reproductive age; 2) the balance between the welfare of the mother and that of the child; 3) the double standards of advanced reproductive age; and 4) the importance of financial and social support systems and preconception counseling with advanced reproductive age.

CONCLUSION

When providing in-vitro fertilization services to women of advanced reproductive age, special considerations must be given to ensure the welfare of mother and the child and that the principles of beneficence and nonmaleficence are guaranteed.

Analysis of pronuclear zygote configurations in 459 clinical pregnancies obtained with assisted reproductive technique procedures

BACKGROUND

Embryos selection is crucial to maintain high performance in terms of pregnancy rate, reducing the risk of multiple pregnancy during IVF. Pronuclear and nucleolar characteristics have been proposed as an indicator of embryo development and chromosomal complement in humans, providing information about embryo viability.

METHODS

To correlate the zygote-score with the maternal age and the outcome of pregnancy, we analyzed the pronuclear and nucleolar morphology, the polar body alignment and the zygote configuration in 459 clinical pregnancies obtained by IVF and ICSI in our public clinic in Reggio Emilia, Italy. We derived odds ratios (OR) and Corenfield's 95% confidence intervals (CI). Continuous variables were compared with Student's t-test; P lower than .05 was considered statistically significant.

RESULTS

We observed a significant increase of "A" pronuclear morphology configuration in 38-41 years old patients in comparison to that lower than or equal to 32 years old and a significant decrease of "B" configuration in 38-41 years old patients in comparison to that lower than or equal to 32 and in comparison to that of 33-37 years old. Related to maternal age we found no significant differences in P1 and in P2 configuration. We found no correlation between zygote-score, embryo cleavage and embryo quality.

CONCLUSIONS

Our results confirm the limited clinical significance of zygote-score suggesting that it can not be associated with maternal age, embryo cleavage and embryo quality. The evaluation of embryo quality based on morphological parameters is probably more predictive than zygote-score.

The evolution of oocyte donation in China

OBJECTIVE

To review the experience with and clinical outcomes for recipients of embryos from oocytes donated under different regulatory standards in China. Initially, the oocytes were provided by one of the patient's consanguineous sisters. Then, the oocytes were obtained from another patient treated with assisted reproduction techniques (ART). Presently, oocytes thus produced are cryopreserved for at least 6months before transfer.

METHODS

The records from all women treated with ART at First Affiliated Hospital of Zhengzhou University since 2001 were reviewed and the pregnancy rates and clinical outcomes were determined for each of the 3 periods.

RESULTS

In the second period, the mean implantation and clinical pregnancy rates were significantly higher for the 22 oocyte recipients than for their donors. In the third period, the rates for the 56 recipients were compared with the 78 other regular ART patients fertilized with their own oocytes. There were 40 live births for 32 of the recipients over 28 cycles, and the rates of implantation and clinical pregnancy were much higher for the recipients than for the other ART patients (P<0.001).

CONCLUSION

Using freshly donated eggs yields a higher pregnancy rate but there is a risk of infectious disease. Using frozen oocytes can significantly decrease this risk but implantation rates are lower.

Assisted reproductive technologies in public and private clinics

The aim of this study was to analyse the influence of the type of service provided by assisted reproduction clinics. The activities, treatment patterns and results achieved by assisted reproduction centres in Spain were examined, comparing public and private clinics. A retrospective study was carried out using the Assisted Reproductive Technology Register of the Spanish Fertility Society for 2002-2004. The results showed that 74%, 96% and 99% of IVF/intracytoplasmic sperm injection, oocyte donation and preimplantation genetic diagnosis cycles, respectively, were carried out in the private sector. Public clinics performed proportionally more transfers of three embryos than the private clinics (48.1% versus 41.7%). More elective transfers were performed in private clinics. Pregnancy rates per cycle started, per puncture and per transfer were significantly higher among private than public clinics (29.1%, 32.7% and 35.9% versus 25.2%, 28.5% and 32.6%, respectively) (P < 0.05). Implantation rate has risen year on year in both types of clinic and was significantly higher (P < 0.05), every year, among the private clinics. The multiple-pregnancy rate was significantly higher among the private clinics (30.8% versus 26.4%) (P < 0.05). In conclusion, differences exist between public and private clinics as regards to their volume of activity, the range of services offered, clinical practice and results achieved.

[Retrospective study--pregnancy after assisted medical reproduction from 2001 to 2009 at the Central Hospital of Luxembourg (first section)]

Retrospective study on a nine year ART practice focusing on pregnancy outcomes and multiple pregnancies, their complications, the gestational duration, delivery options, the new born weights and health statements til the age of two. Post ART pregnancies seem to have an increased complication rate; multiple births are more frequent than with spontaneous conception. The first chapter deals with the entire group. The second chapter analyses several sub-groups according to the ART method employed. The results are compared to publications in PubMed and Medline.

[Retrospective studies of pregnancies after assisted medical reproduction from 2001-2009 and Central Hospital in Luxembourg (part 2)]

The first chapter analyses the ART methods of the Centre Hospitalier of Luxembourg, in the department of reproductive medicine between 2001 and 2009. The second chapter examines the techniques individually, their influence on pregnancy outcomes, the complications on offsprings and their health. The results coincide with literature in that risks are acceptable as long as good medical and biological conditions are maintained. Multiple pregnancies remain the most frequent complication, particularly once out of IVF. These are analysed separately as well as the pregnancies after egg and semen donation.

Estimation of the contribution of non-assisted reproductive technology ovulation stimulation fertility treatments to US singleton and multiple births

Infertility treatments that include ovulation stimulation, both assisted reproductive technologies (ARTs) and non-ART ovulation stimulation, are associated with increased risks of multiple birth and concomitant sequelae and adverse outcomes, even among singletons. While a US surveillance system for ART-induced births is ongoing, no population-based tracking system exists for births resulting from non-ART treatments. The authors developed a multistage model to estimate the uncertain proportion of US infants born in 2005 who were conceived by using non-ART ovulation treatments. Using published surveillance data, they estimated proportions of US multiple births conceived naturally and by ART and assumed that the remainder were conceived with non-ART treatments. They used Bayesian meta-analyses to summarize published clinical studies on the multiple-gestation risk associated with non-ART ovulation treatments, applied a fetal survival factor, and used this multiple-birth risk estimate and their own estimate of the proportion of US multiple births attributable to non-ART ovulation stimulation to estimate the total (and, through subtraction, singleton) proportion of infants conceived with such treatments. On the basis of the model, the authors estimate that 4.6% of US infants born in 2005 (95% uncertainty range: 2.8%-7.1%) resulted from non-ART ovulation treatments. Notably, this figure is 4 times greater than the ART contribution.

The hidden infertile: infertile women without pregnancy intent in the United States

A national probability sample reveals two relatively distinct groups of infertile women: those with intent, who have experienced a period of 12 or more months during which they tried to conceive but did not, and those without intent, who had a period of at least 12 months during which they could have conceived and did not but who do not describe themselves as having tried to become pregnant at that time. Those with intent are more likely to identify as having a fertility problem, to be distressed, and to pursue infertility treatment than those without intent, suggesting that many women do not realize that they meet the medical criteria for infertility and may wait longer to get help, therefore lowering their chances of conception.

Assisted reproductive technology surveillance--United States, 2006

PROBLEM/CONDITION

Assisted Reproductive Technology (ART) includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization and related procedures).Patients who undergo ART procedures are more likely to deliver multiple-birth infants than women who conceive naturally. Multiple births are associated with increased risk for mothers and infants (e.g., pregnancy complications, premature delivery, low-birthweight infants, and long-term disability among infants). This report presents the most recent national data and state-specific results.

REPORTING PERIOD COVERED

2006.

DESCRIPTION OF SYSTEM

In 1996, CDC initiated data collection regarding 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]). Beginning with 2004, CDC has contracted with Westat, Inc., a statistical survey research organization, to obtain data from ART medical centers in the United States. Westat, Inc., maintains the National ART Surveillance System (NASS), CDC's web-based data collection system.

RESULTS

In 2006, a total of 138,198 ART procedures were reported to CDC. These procedures resulted in 41,343 live-birth deliveries, and 54,656 infants. ART procedures are categorized into four major procedure types: procedures that used embryos from freshly fertilized eggs (fresh embryos) from the patient's eggs (72%); procedures that used thawed embryos from the patient's eggs (16%); procedures that used fresh embryos from donor eggs (8%); and procedures that used thawed embryos from donor eggs (4%). Overall, 44% of ART transfer procedures resulted in a pregnancy, and 36% in a live-birth delivery (delivery of one or more live-born infants). Live-birth rates were generally higher among ART procedures that used fresh embryos from donor eggs (54%) than among other types. The highest numbers of ART procedures were performed among residents of California (18,886); New York (13,259); Illinois (9,594); New Jersey (9,237); and Massachusetts (8,305). All five states reported the highest number of live-birth deliveries as a result of ART. Of 54,656 infants born through ART, 48% were multiple-birth deliveries. The risk for a multiple-birth delivery was highest for women who underwent ART transfer procedures that used fresh embryos from either donor eggs (39%) or their own eggs (31%). Approximately 1% of U.S. infants born in 2006 were conceived through ART. Those infants accounted for 18% of multiple births nationwide. Approximately 9% of ART singletons, 57% of ART twins, and 96% of ART triplets or higher-order multiples were low birthweight. Similarly, 14% of ART singletons, 65% of ART twins, and 97% of ART triplets or higher-order multiples were born preterm.

INTERPRETATION

Whether an ART procedure resulted in a pregnancy and live-birth delivery varied, according to different patient and treatment factors. ART poses a major risk for multiple births associated with adverse maternal and infant outcomes (e.g., placenta previa, preterm delivery, cesarean delivery, low birthweight, and infant mortality). This risk varied according to the patient's age, the type of ART procedure performed, the number of embryos available for transfer to the uterus, the number transferred, and the day of transfer (day 3 or 5).

PUBLIC HEALTH ACTIONS

ART-related multiple births represent a sizable proportion of all multiple births nationwide and in selected states. To minimize the adverse maternal and child health effects associated with multiple pregnancies, ongoing efforts to limit the number of embryos transferred in each ART procedure should be continued and strengthened. Adverse maternal and infant outcomes (e.g., low birthweight and preterm delivery) associated with ART treatment choices should be explained thoroughly when counseling patients considering ART.

Oocyte diameter as a predictor of fertilization and embryo quality in assisted reproduction cycles

OBJECTIVE

To assess the impact of the mean oocyte diameter (MOD) on occurrence of fertilization and embryo quality in assisted reproduction cycles.

DESIGN

Prospective observational study.

SETTING

Sector of Human Reproduction of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo (HCFMRP-USP).

PATIENT(S)

Thirty-five women undergoing intracytoplasmic sperm injection (ICSI) at the University Hospital of Ribeirão Preto from May to October 2007.

INTERVENTION(S)

MOD assessment.

MAIN OUTCOME MEASURE(S)

Occurrence of fertilization and qualitative embryo classification on 2nd and 3rd day after ICSI.

RESULT(S)

We divided 160 metaphase II oocytes according to MOD into groups A (MOD below the 25th percentile), B (MOD between 25th and 75th percentile), and C (MOD above the 75th percentile). There was no statistically significant association between MOD and the occurrence of fertilization or the qualitative embryo classification on days 2 and 3. There was no statistically significant difference between groups regarding number of cells or the qualitative embryo classification on days 2 and 3.

CONCLUSION(S)

The MOD of mature oocytes does not seem to be related to the occurrence of fertilization or to the developmental quality of human embryos on days 2 and 3 after ICSI.

Giving hope

As one of two nurses recently appointed to the Human Fertilisation and Embryology Authority, Debbie Barber plans to ensure patients' concerns are addressed.