Pregnancy, birth, and infant outcomes by maternal fertility status: the Massachusetts Outcomes Study of Assisted Reproductive Technology

Assisted reproductive technologies (ART) and placental abnormalities

Objectives Assisted reproductive technologies (ART) may be associated with placental abnormalities including placenta previa, umbilical cord abnormalities, and placental abruption. Our study evaluates the relationship between ART and placental abnormalities compared with spontaneously conceived controls. Methods An IRB-approved cohort study was conducted including women who delivered between January 2013 and December 2018. We excluded delivery prior to 23 weeks and known fetal anomalies. Patients were matched with controls (2:1) for parity, age, and mode of delivery. Controls were women who had spontaneously conceived and delivered immediately preceding and following the index delivery. The primary outcome was placental abnormalities found on both antenatal ultrasound and pathology in ART gestations compared with spontaneously conceived gestations. Results There were 120 ART pregnancies and 240 matched control pregnancies identified. The groups were similar for parity, BMI, comorbidities, number of multiples, mode of delivery, and female newborns. The ART group had a higher maternal age (37.1±5 y vs. 30.0±5 y; p<0.001), greater preterm birth (29 vs. 6%; p<0.001), and lower BW (2,928±803 g vs. 3,273±586 g; p<0.001). The ART group had a higher incidence of placenta previa on ultrasound (4.0 vs. 0.4%, p=0.01), adherent placentas at delivery (3 vs. 0% p=0.014), placental abruption (2 vs. 0%; p=0.04), as well as an increased rate of velamentous cord insertion (12 vs. 3%, p<0.001) and marginal cord insertion (28 vs. 15%, p=0.002). ART demonstrated a two-fold likelihood of abnormal placental pathology. Conclusions ART is associated with increased rate of placental abnormalities, including abnormal umbilical cord insertion and increased rates of adherent placentation. This information may be beneficial in planning and surveillance in patients with ART pregnancies.

Increased risk of severe maternal morbidity among infertile women: analysis of US claims data

BACKGROUND

Severe maternal morbidity continues to be an issue of national and global concern and is increasing in incidence. The incidence of infertility is also on the rise, and infertile women experience a higher risk of incident chronic medical disease and cancer, suggesting that fertility may serve as a window to a woman's overall health.

OBJECTIVE

To investigate the risk of severe maternal morbidity by maternal fertility status.

MATERIALS AND METHODS

This was a retrospective cohort analysis using Optum's de-identifed Clinformatics Data Mart Database between 2003 and 2015. Infertile women stratified by infertility diagnosis, testing, or treatment were compared to fertile women seeking routine gynecologic care. In both groups, only women who underwent pregnancy and delivery of a singleton during the follow-up period were included. Main outcomes were severe maternal morbidity indicators, defined by the Centers for Disease Control and Prevention and identified by International Classification of Diseases 10^th Revision and Common Procedural Technology codes within 6 weeks of each delivery. Results were adjusted for maternal age, race, education, nulliparity, smoking, obesity, delivery mode, preterm birth, number of prenatal visits, and year of delivery.

RESULTS

A total of 19,658 women comprised the infertile group and 525,695 women comprised the fertile group. The overall incidence of any severe maternal morbidity indicator was 7.0% among women receiving fertility treatment, 6.4% among women receiving a fertility diagnosis, 5.5% among women receiving fertility testing, and 4.3% among fertile women. Overall, infertile women had a significantly higher risk of developing any severe maternal morbidity indicator (adjusted odds ratio, 1.22; confidence interval, 1.14-1.31, P < .01) as well as a significantly higher risk of disseminated intravascular coagulation (adjusted odds ratio, 1.48; confidence interval, 1.26-1.73, P < .01), eclampsia (adjusted odds ratio, 1.37; confidence interval, 1.05-1.79, P < .01), heart failure during procedure or surgery (adjusted odds ratio, 1.54; confidence interval, 1.21-1.97, P < .01), internal injuries of the thorax, abdomen, or pelvis (adjusted odds ratio, 1.59; confidence interval, 1.12-2.26, P < .01), intracranial injuries (adjusted odds ratio, 1.77; confidence interval, 1.20-2.61, P < .01), pulmonary edema (adjusted odds ratio, 2.18; confidence interval, 1.54-3.10, P < .01), thrombotic embolism (adjusted odds ratio, 1.58; confidence interval, 1.14-2.17, P < .01), and blood transfusion (adjusted odds ratio, 1.50; confidence interval, 1.30-1.72, P < .01) compared to fertile women. Fertile women did not face a significantly higher risk of any maternal morbidity indicator compared to infertile women. In subgroup analysis by maternal race/ethnicity, the likelihood of severe morbidity was significantly higher among fertile black women compared to fertile white women. There was no difference between infertile black women and infertile white women after multivariable adjustment.

CONCLUSION

Using an insurance claims database, we report that women diagnosed with infertility and women receiving fertility treatment experience a significantly higher risk of multiple indicators of severe maternal morbidity compared to fertile women. The increased risk of severe maternal morbidity noted among fertile black women compared to fertile white women is attenuated among infertile black women, who face risks similar to those of infertile white women.

Association between in vitro fertilization and ischemic placental disease by gestational age

OBJECTIVE

To evaluate the association between in vitro fertilization (IVF) and ischemic placental disease (IPD), stratified by gestational age.

DESIGN

We performed a secondary analysis of a retrospective cohort study of deliveries.

SETTING

Deliveries were performed over 15 years at a single tertiary hospital.

PATIENT(S)

We included all parturients who had a live born infant or an intrauterine fetal demise (IUFD).

INTERVENTION(S)

We compared pregnancies resulting from IVF cycles to non-IVF pregnancies.

MAIN OUTCOME MEASURE(S)

The primary outcomes were preterm and term IPD (preeclampsia, placental abruption, small-for-gestational age infant [SGA], or an intrauterine fetal demise [IUFD] due to placental insufficiency).

RESULT(S)

Of the 69,084 deliveries during the study period, 3,763 (5.4%) were conceived with IVF. The incidence of preterm delivery was 32.6% in IVF pregnancies and 10.8% in non-IVF pregnancies. Multiple gestations were more common in IVF pregnancies. Compared to non-IVF pregnancies, IVF pregnancies were more likely to develop both preterm and term IPD, even after adjustment for maternal age and parity. The risk of preterm IPD was 4 times higher (95% confidence interval, 3.7-4.4) in patients who underwent IVF compared with those who did not undergo IVF. Among parturients who delivered at ≥37 weeks of gestation, IVF pregnancies had 1.7 times the risk of term IPD (95% confidence interval, 1.6-1.9) compared with non-IVF pregnancies.

CONCLUSION(S)

IVF was strongly associated with preterm IPD. We found a similar, but attenuated, association between IVF and term IPD. The stronger association with preterm IPD suggests an association between IVF and placental insufficiency.

Contributions to prematurity of maternal health conditions, subfertility, and assisted reproductive technology

OBJECTIVE

To determine the maternal demographic, health, and fertility variables underlying prematurity.

DESIGN

Retrospective: Society for Assisted Reproductive Technology Clinic Outcome Reporting System data linked to Massachusetts birth certificates and hospital stays.

SETTING

Not applicable.

PATIENTS

We included 166,963 privately insured, singleton, first births to women ≥18 years of age between 2004 and 2013. Deliveries were as follows: assisted reproductive technology (ART) when linked to Society for Assisted Reproductive Technology Clinic Outcome Reporting System, medically assisted reproduction (MAR) when fertility treatment was indicated on the birth certificate, unassisted subfertile (USF) when there were indications of subfertility but no treatment, and fertile if none of the above.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Late preterm birth (LPTB; 34-36 weeks) and early preterm birth (EPTB; <34 weeks) were compared with term deliveries (≥37 weeks). Covariates that statistically significantly influenced prematurity in binary analysis were modeled by using multinomial logistic regression. Backward elimination and mediation analysis were used to determine the influence of single parameters on outcomes of others.

RESULTS

LPTB was increased in the USF (adjusted odds ratio [AOR] 1.32, 95% confidence interval [CI] 1.06-1.65) and ART (AOR 1.42, 95% CI 1.30-1.56) but not MAR (AOR 1.16, 95% CI 0.98-1.37). ETPB was increased in all (USF: AOR 1.67, 95% CI 1.21-2.31; MAR: AOR 1.67, 95% CI 1.31-2.12; ART: AOR 1.40, 95% CI 1.21-1.61). The strongest effectors of prematurity were placental problems (LPTB: AOR 4.02; EPTB: AOR 10.28), pregnancy hypertension (LPTB: AOR 2.14; EPTB: AOR 2.88), and chronic hypertension (LPTB: AOR 1.85; EPTB: AOR 2.79). Mediation analysis demonstrated a statistically significant indirect effect of placental problems for ART and subfertility.

CONCLUSION

The greatest effectors of prematurity were placental problems and hypertensive disorders. ART and, to a lesser extent, subfertility were both associated with preterm birth directly and indirectly mediated by placenta problems.

Examination of fetal growth trajectories following infertility treatment

PURPOSE

The objective of this retrospective cohort study was to compare fetal growth during the second and third trimesters for ovulation induction with intrauterine insemination (IUI), fresh embryo transfer (ET), frozen embryo transfer (FET), and spontaneous conception following infertility.

METHODS

Three hundred ninety-five women with viable pregnancies confirmed at a single academic fertility center participated. All women achieved pregnancy either by treatment or spontaneously after a diagnosis of infertility. Inclusion criteria included autologous singleton pregnancies. Exclusion criteria included pregnancies from donor oocytes, twins, unavailable ultrasound data, and treatment methods with small number of participants. Primary outcomes of interest were head circumference (HC), abdominal circumference (AC), HC/AC ratio, and estimated fetal weight (EFW). Conditional growth curve models were created, and growth curves were selected for each outcome of interest.

RESULTS

For ovulation induction with IUI, fresh ET, FET, and spontaneous conception, the slope analysis of growth curves for per-week growth rate of HC, AC, HC/AC ratio, and EFW demonstrated no difference. A subgroup analysis of fresh ET and FET groups, for same outcomes, also showed no difference.

CONCLUSION

These findings contribute to the very limited literature on fetal growth trajectories following infertility treatment and suggest no significant differences in fetal growth for ovulation induction with IUI, fresh ET, FET, and spontaneous conception following infertility. It is possible there were no differences in growth trajectories between these conception methods because the majority of children born following infertility are of normal birth weight. While results are reassuring, further research with larger populations is warranted.

Poor Embryo Quality Is Associated With A Higher Risk of Low Birthweight in Vitrified-Warmed Single Embryo Transfer Cycles

Background

Previous studies have reported the association between embryo quality and perinatal outcomes in fresh cycles, after cleavage-stage or blastocyst embryo transfer, and found no significant difference. However, in terms of vitrified-warmed embryo transfer cycles, the impact of embryo quality on neonatal and maternal outcomes has not been evaluated.

Objectives

To explore the association between the quality of a single vitrified-warmed embryo and perinatal outcomes.

Methods

This retrospective study included 2403 live-born singletons derived from single vitrified-warmed embryo transfer cycles during January 2006 and July 2018. Neonatal and maternal outcomes were compared between singletons resulting from the use of single good quality embryo (GQE) (n = 1854) and single poor quality embryo (PQE) (n = 549) and analyzed in the group of cleavage-stage embryo transfer and the group of blastocyst transfer, respectively.

Results

A significantly higher risk of low birthweight (LBW, birthweight <2500 g) was observed in the singletons derived from the transfer of single PQE compared with those derived from the transfer of single GQE both in cleavage and blastocyst stages (cleavage-stage, AOR 2.62, 95% CI 1.27-5.37; blastocyst stage, AOR 1.98, 95% CI 1.06-3.70). An increased risk of preterm birth (PTB, gestational age <37 weeks) was also observed in singletons born after transfer of a PQE of cleavage-stage compared with those after a GQE of cleavage-stage (AOR 2.40, 95% CI 1.28-4.49). The transfer of single poor quality blastocyst was associated with a higher risk of placenta previa compared with the transfer of single good quality blastocyst (AOR 2.65, 95% CI 1.26-5.57). Other maternal complications, neonatal malformations, and neonatal complications were similar between compared groups.

Conclusion

In vitrified-warmed cycles with single embryo transfer, poor embryo quality would result in a significantly higher risk of LBW, regardless of cleavage-stage or blastocyst embryo transfer. Meanwhile, the transfer of poor cleavage-stage embryo was also associated with an increased incidence of PTB.

Third grade academic achievement among children conceived with the use of in vitro fertilization: a population-based study in Texas

OBJECTIVE

To evaluate if there are differences in standardized testing results at the end of third grade between children conceived with the use of in vitro fertilization (IVF) and those conceived spontaneously.

DESIGN

Retrospective population-based cohort.

SETTING

Texas public school system.

PATIENT(S)

Singleton and twin children 8-9 years of age who took the third-grade public school standardized testing in Texas from 2012 to 2018.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Standardized testing in reading and mathematics.

RESULT(S)

After exclusions, there were 6,970 IVF and 12,690 non-IVF children with reading scores and 6,973 IVF and 12,729 non-IVF children with mathematics scores. IVF children scored significantly higher in reading (singletons: 1,543 ± 2 vs. 1,525 ± 1; twins: 1,534 ± 2 vs. 1,504 ± 5 [mean ± SE]), and mathematics (singletons: 1,566 ± 2 vs. 1,550 ± 1; twins: 1,557 ± 2 vs. 1,529 ± 5). Children of mothers ≥30 years of age scored consistently higher than children of mothers 18-29 years of age. The differences were of similar magnitude between IVF and control children for older ages, but not significant for IVF. Within the IVF group, there were no significant differences between children born from fresh versus froze-thawed embryos.

CONCLUSION(S)

Children of ages 8-9 years who were conceived with the use of IVF performed as well on third-grade reading and math assessments as their counterparts who were conceived spontaneously. We also found consistent racial and ethnic differences, gender differences, and beneficial effects of older maternal age. Because we were not able to adjust adequately for socioeconomic status and other confounding factors, which may explain some of the observed differences, we conclude that there is no negative effect of IVF conception on academic achievement in third grade.

Retrospective Analysis of Obstetric Intensive Care Unit Admissions Reveals Differences in Etiology for Admission Based on Mode of Conception

BACKGROUND

The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage.

METHODS

In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005-2016 at Mount Sinai Hospital, New York, NY, and 2005-2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non-in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non-in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage.

RESULTS

During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non-in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model.

CONCLUSIONS

Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.

In Vitro Fertilization Technology and Child Health

BACKGROUND

Just under 3% of children in Germany, and approximately 6% of children in some other countries, such as Denmark, are now being conceived with the aid of in vitro fertilization (IVF) technology. Alongside the increased risk of organ malformation, there is now evidence for functional abnormalities due to epigenetic modifications.

METHODS

This review is based on pertinent publications retrieved by a literature search on currently known associations of IVF therapy with malformations and functional abnormalities. The potential implications for the treatment of infertility are discussed.

RESULTS

The risk of congenital malformations is approximately one-third higher in children conceived with the aid of IVF technology than in other children; specifically, there is an odds ratio (OR) of 1.29 (95% confidence interval, [1.03; 1.60]) for cardiac malformations, and there is a relative risk (RR) of 1.35 ([1.12; 1.64]) for musculo- skeletal malformations and 1.58 ([1.28; 1.94]) for genitourinary malformations. The risks of preterm birth and low birth weight are, respectively, 1.7 and 1.5 times higher in IVF singleton pregnancies than in non-IVF pregnancies. Cardiovascular changes are the main type of functional disturbance. Some of the risks associated with IVF have decreased in recent years. An association has been revealed between cardiovascular abnormalities and epigenetic modifications; the causes are thought to include not only maternal and paternal factors, but also the IVF techniques that are used. A modification of IVF therapies might lower the risks, but might also lower the success rate.

CONCLUSION

For the well-being of the children to be conceived, IVF therapy should hat cannot be treated by any other means, as the precise causes of the risks of IVF to child health are unclear.

In vitro fertilization and risk for hypertensive disorders of pregnancy: associations with treatment parameters

BACKGROUND

Although in vitro fertilization has been associated with an increased risk for hypertensive disorders of pregnancy, the association of risk with in vitro fertilization treatment parameters is unclear.

OBJECTIVE

To evaluate risk for hypertensive disorders of pregnancy by maternal fertility status and in vitro fertilization treatment parameters.

MATERIALS AND METHODS

Women in 8 states who underwent in vitro fertilization resulting in a live birth during 2004-2013 were linked to their infant's birth certificates. A 10:1 sample of births from non-in vitro fertilization deliveries were selected for comparison. Those with an indication of infertility treatment on the birth certificate were categorized as subfertile and omitted from the study population; all others were categorized as fertile. The in vitro fertilization pregnancies were additionally categorized by oocyte source (autologous versus donor) and embryo state (fresh versus thawed). Both the fertile and in vitro fertilization births were limited to singletons only, and the in vitro fertilization pregnancies were limited to those using partner sperm. Hypertensive disorders of pregnancy (including gestational hypertension and preeclampsia) were identified from the birth certificate, modeled using logistic regression, and reported as adjusted odds ratios and 95% confidence intervals. For analyses of in vitro fertilization pregnancies from autologous oocytes-fresh embryos, the reference group was fertile women (subgroup analysis 1). For analyses within the in vitro fertilization group, the reference group was autologous oocytes-fresh embryos (subgroup analysis 2).

RESULTS

The study population included 1,465,893 pregnancies (1,382,311 births to fertile women and 83,582 births to in vitro fertilization-treated women). Compared to fertile women, in vitro fertilization-treated women with autologous-fresh cycles were not at increased risk for hypertensive disorders of pregnancy (adjusted odds ratio, 1.04; 95% confidence interval, 0.99, 1.08). Among in vitro fertilization births (subgroup analysis 2), the risk for hypertensive disorders of pregnancy was increased for the autologous-thawed (adjusted odds ratio, 1.30; 95% confidence interval, 1.20, 1.40); donor-fresh (adjusted oddds ratio, 1.92; 95% confidence interval, 1.71, 2.15); and donor-thawed (adjusted odds ratio, 1.70; 95% confidence interval, 1.47, 1.96) groups. Excluding women with pregestational diabetes or chronic hypertension as well as adjusting for body mass index and infertility diagnoses did not substantially change the results. When stratified by <34 weeks (early-onset hypertensive disorders of pregnancy) versus ≥34 weeks (late-onset hypertensive disorders of pregnancy), only the donor-fresh group had an increased risk of early-onset hypertensive disorders of pregnancy, but the risks for all other oocyte source-embryo state groups compared to autologous-fresh were increased for late-onset hypertensive disorders of pregnancy.

CONCLUSION

The risk for hypertensive disorders of pregnancy is increased for in vitro fertilization-treated women in pregnancies conceived via frozen embryo transfer (with both autologous or donor oocyte) and fresh donor oocyte embryo transfer. No increase in risk was seen with autologous oocyte-fresh embryo transfers in vitro fertilization cycles. Excluding women with pregestational diabetes or chronic hypertension as well as adjusting for body mass index and infertility diagnoses did not substantially change the results.

Maternal Vascular Health in Pregnancy and Postpartum After Assisted Reproduction

Although most pregnancies after assisted reproduction are associated with a favorable outcome for the mother and infant, reports of abnormal vascular adaptation in early pregnancy and emerging maternal and perinatal pathology warrant further investigations. Herein we extended our previous work and further examined whether perturbations of blood pressure and endothelial function during the first trimester in conceptions with nonphysiological corpus luteum (CL) numbers would persist through the third trimester of pregnancy and into the postpartum period. We investigated both maternal and perinatal outcomes. Participants were grouped according to CL number and method of conception: 0 CL (programmed autologous frozen-thawed embryo transfer, N=10-18); 1 CL (spontaneous conception [N=16] and natural cycle frozen-thawed embryo transfer [N=12]); or >3 CL associated with autologous fresh embryo transfer [N=8-12]. Augmentation index was higher during the third trimester in the absence of a CL compared to 1 CL (P=0.03) and in frozen-thawed embryo transfer in a programmed compared to a natural cycle (P=0.02). Moreover, baseline pulse-wave amplitude was higher in >3 CL conceptions at all time points (all P<0.05). The incidence of preeclampsia and preeclampsia with severe features was significantly higher in the absence of a CL compared to the presence of one or >3 CL (P=0.045 and P=0.03). Infants from conceptions with >3 CL had lower birth weights (P=0.02) and a higher rate of low birth weight offspring (P=0.008). Deficient vascular adaptation during early gestation in conceptions with nonphysiological CL numbers might predispose women to adverse pregnancy outcomes, for example, preeclampsia.

Neonatal and maternal outcome after frozen embryo transfer: Increased risks in programmed cycles

BACKGROUND

Frozen embryo transfer is associated with better perinatal outcome regarding preterm birth and low birthweight, yet higher risk of large for gestational age and macrosomia compared to fresh transfer. Further, higher rates of hypertensive disorders in pregnancy are noted after frozen embryo transfer. Whether these differences are due to the protocol used in frozen cycles remains unknown.

OBJECTIVE

To analyze the obstetric outcome after frozen embryo transfer depending on protocol used. Comparison was also made for frozen vs fresh transfer and for frozen transfer vs spontaneous conception.

STUDY DESIGN

A population-based retrospective registry study including all singletons born after frozen embryo transfer in Sweden from 2005 to 2015. The in vitro fertilization register was cross-linked with the Medical Birth Register, the Register of Birth Defects, the National Patient Register, the Swedish Neonatal Quality Register, and the Prescribed Drug Register. Singletons after frozen embryo transfer were compared depending on the presence of a corpus luteum in the actual cycle. All frozen transfer singletons were also compared with fresh transfer and spontaneous conception singletons. Primary outcomes were preterm birth (<37 w), low birthweight (<2500 g), hypertensive disorders in pregnancy, and postpartum hemorrhage (>1000 mL). Crude and adjusted odds ratio with 95% confidence interval were calculated and adjustment made for relevant confounders.

RESULTS

A total of 9726 singletons were born after frozen embryo transfer (natural cycles, n = 6297; stimulated cycles, n = 1983; programmed cycles, n = 1446), 24,365 after fresh transfer, and 1,127,566 after spontaneous conception. No significant differences were noticed for preterm birth and low birthweight between the different protocols used in frozen embryo transfer. Compared to natural and stimulated frozen cycles, programmed frozen cycles were associated with a higher risk of hypertensive disorders in pregnancy (adjusted odds ratio, 1.78; 95% confidence interval, 1.43-2.21 and adjusted odds ratio, 1.61; 95% confidence interval, 1.22-2,10, respectively) and postpartum hemorrhage (adjusted odds ratio, 2.63; 95% confidence interval, 2.20-3.13 and adjusted odds ratio, 2.87; 95% confidence interval, 2.29-2.60, respectively). Moreover, higher risks for postterm birth (adjusted odds ratio, 1.59; 95% confidence interval, 1.27-2.01 and adjusted odds ratio, 1.98; 95% confidence interval, 1.47-2.68) and macrosomia (adjusted odds ratio, 1.62; 95% confidence interval, 1.26-2.09 and adjusted odds ratio, 1.40; 95% confidence interval, 1.03-1.90) were detected. There were no significant differences in any outcomes between stimulated and natural cycles. Frozen cycles in general compared to fresh cycles and compared to spontaneous conceptions showed neonatal and maternal outcomes in agreement with earlier studies.

CONCLUSION

No significant difference could be seen regarding preterm birth and low birthweight between the different protocols. However, higher rates of hypertensive disorders in pregnancy, postpartum hemorrhage, postterm birth, and macrosomia were detected in programmed cycles. Stimulated cycles had outcomes similar to natural cycles. These findings are important in view of the increasing use of frozen cycles and the new policy of freeze-all cycles in in vitro fertilization. The results suggest a link between the absence of corpus luteum and adverse obstetric outcomes.

Perinatal outcomes in 521 gestations after fresh and frozen cycles: a secondary outcome of a randomized controlled trial comparing GnRH antagonist versus GnRH agonist protocols

RESEARCH QUESTION

Are perinatal outcomes different after treatment with the gonadotrophin-releasing hormone (GnRH) antagonist versus the long GnRH agonist protocol for IVF?

DESIGN

Perinatal outcomes were secondary outcomes in a large Phase IV, dual-centre, open-label, randomized controlled trial to compare GnRH antagonist and long GnRH agonist protocols in women <40 years undergoing their first assisted reproductive technology treatment. Women (n = 1050) were randomized in a ratio 1:1 from January 2009 to December 2013 and followed until December 2016. All fresh and frozen embryo transfer (FET) cycles from a single oocyte aspiration, resulting in a gestation (human chorionic gonadotrophin >10 IU/l) were included (n = 521). Data were analysed to compare preterm birth [PTB] (<37 weeks), very PTB (<32 weeks), low birthweight [LBW] (<2500 g) and very LBW (<1500 g) rates among singleton live births in GnRH antagonist versus agonist protocol.

RESULTS

Similar perinatal outcomes were found after both protocols. In singletons after fresh embryo transfer, mean gestational age at delivery was 39.1 ± 2.49 versus 39.3 ± 1.90 (P = 0.67) and very PTB rates 1.9% versus 0% (P = 0.17). Mean birthweight was 3264 ± 662 g in the antagonist and 3341 ± 562 g in the agonist group (P = 0.37). LBW was found in 12.4% versus 7% (P = 0.19) and very LBW in 2.9% versus 1% (P = 0.34). In FET cycles, the perinatal outcomes were similar. Small for gestational age and large for gestational age rates were similar in both protocols for singleton live births after fresh and FET.

CONCLUSIONS

Perinatal outcomes are similar after the GnRH antagonist versus GnRH agonist protocols for IVF. The choice of the GnRH analogue in ovarian stimulation should be based solely on optimizing the chance of pregnancy and not on risks in perinatal outcomes.

Epidemiology of obstetric critical illness

Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age- and sex-matched cohort.

Transitioning from Infertility-Based (ART 1.0) to Elective (ART 2.0) Use of Assisted Reproductive Technologies and the DOHaD Hypothesis: Do We Need to Change Consenting?

The use of assisted reproductive technologies (ARTs) has increased significantly in recent years. While this is partially due to improved access for infertile patients, another contribution to the growth of ART utilization is represented by individuals without infertility, who electively chose to freeze their gametes and embryos for future use, before ever attempting conception spontaneously. Overall, the safety of ART for parents and children is well described and the risks are modest. However, while long-term health consequences for offspring as postulated by the Developmental Origin of Health and Disease (DOHaD) hypothesis are unknown, numerous animal studies suggest a predisposition for chronic diseases like hypertension and glucose intolerance. In this article, we argue that a key difference exists between infertile patients, who need to use ART as the only means to achieve pregnancy, and (likely) fertile patients who elect to use ART techniques as a family planning option. We believe that these two sets of patients are different and their risks-benefit ratios are different. We propose that while all patients should be aware of the risks, patients planning to utilize ART techniques without a diagnosis of infertility should be encouraged to think critically about the additional risks, particularly the "potential" long-term risks that may be imposed from these elective procedures.

Factors associated with increased odds of cesarean delivery in ART pregnancies

OBJECTIVE

To quantify the effect of medical and obstetrical factors on the odds of cesarean delivery, comparing assisted reproductive technology (ART)-treated women and women with subfertility not treated with ART versus fertile women.

DESIGN

Retrospective cohort.

SETTING

Not applicable.

PATIENT(S)

Singleton deliveries to primiparous women; with the source of this data being the Massachusetts vital and hospital records linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System data (2004-2010).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mode of delivery.

RESULT(S)

The 173,130 deliveries included 5,768 ART-treated, 2,657 subfertile (1,627 non-ART medically assisted reproduction [MAR] and 1,030 unassisted infertile), and 164,705 fertile pregnancies and 117,743 vaginal and 55,387 cesarean deliveries. ART-treated women were older, more often white and non-Hispanic, and with more private insurance, previous uterine surgery, gestational diabetes, pregnancy hypertension, bleeding, and placental complications than fertile women. Overall rates of cesarean delivery were 45.7%, 43.3%, and 31.1% for ART-treated, subfertile, and fertile women and 41.7% and 45.9% for MAR and unassisted infertile deliveries. When adjusted for demographics, underlying medical factors, previous uterine surgery, and placental and delivery complications, adjusted odds ratios (ORs) compared with fertile women were 1.27 for ART-treated and 1.15 for subfertile women, with greater odds among unassisted infertile (OR 1.26) but not MAR (OR 1.09) women. The strongest confounders of odds of cesarean delivery were age and previous uterine surgery.

CONCLUSION(S)

ART and unassisted infertility were associated with greater odds of cesarean compared with fertile women. Underlying medical and obstetrical risks had strong confounding effects strongly attenuating the odds for cesarean delivery.

Delivery and feto-neonatal outcomes of diamniotic twin pregnancies in women with no chronic disease or gestational complications: impact of mode of conception

Introduction: Autologous and heterologous assisted reproductive technology (ART) conceptions have been on the rise for the last few decades and alongside with that have the rate of multiple pregnancies. Multiple gestations are associated with high odds of gestational complications and, in turn, adverse delivery and feto-neonatal outcomes. Whether ART-conception further increases such elevated risk is still debated. ART is more commonly accessed by older women with chronic diseases, which relate to heightened likelihood of complications. We decided to investigate the influence of autologous and heterologous ART conception compared to spontaneous conception on delivery and feto-neonatal outcomes of diamniotic twin pregnancies in a cohort of healthy women with no chronic conditions or gestational complications.Materials and methods: Retrospective cohort study among diamniotic twin pregnancies in mothers without pregestational or gestational disease. Delivery and feto-neonatal outcomes were compared among three groups according to mode of conception: (1) spontaneous conception (SC, referent group, n = 251 pregnancies), (2) autologous ART-conception (A-ART, n = 87), and (3) heterologous ART-conception (H-ART, n = 22).Results: At adjusted analyses, twin pregnancies conceived by A-ART showed a twofold heightened risk of delivery by urgent/emergent cesarean section, as well as four and sevenfold increase in odds of blood loss >1000 and >1500 mL, respectively. H-ART pregnancies were at fivefold higher risk of undergoing prelabor cesarean section compared to SC, whereas no differences were identified for odds of severe post-partum hemorrhage. Also, A-ART and H-ART gestations displayed fetal and neonatal outcomes similar to SC pregnancies when analysis was adjusted for relevant confounding factors.Conclusion: Our results suggest that both A-ART and H-ART conception associate with increased odds of operative delivery among diamniotic twin pregnancies in healthy mothers with no chronic diseases or gestational complications. Also, a higher risk of severe postpartum hemorrhage appears to relate to A-ART independent of mode of delivery and maternal age. Further studies with larger series of uncomplicated twin pregnancies are warranted to improve our understanding of the relationship of ART to adverse delivery outcomes.

Perinatal outcomes following assisted reproductive technology

As the use of routine assisted reproductive technology (ART) becomes widespread along with the extended applications such as ART with donor gametes, surrogacy, and preimplantation genetic testing (PGT), it becomes more pertinent to evaluate risks associated with them. Perinatal outcomes and long-term safety for the women and children are paramount. In this review, we aimed to detail the perinatal outcomes in relation to the ART procedures routinely applied as the extended applications of ART with a focus on singleton pregnancies. While there seems to be a higher risk of adverse perinatal outcomes with some of the ART procedures, the absolute risk increase is generally low. It is important for clinicians to have this knowledge to better counsel and care for their patients.

Risk of prematurity and infant morbidity and mortality by maternal fertility status and plurality

PURPOSE

To evaluate the risk of prematurity and infant mortality by maternal fertility status, and for in vitro fertilization (IVF) pregnancies, by oocyte source and embryo state combinations.

METHODS

Women in 14 States who had IVF-conceived live births during 2004-13 were linked to their infant's birth and death certificates; a 10:1 sample of non-IVF births was selected for comparison; those with an indication of infertility treatment on the birth certificate were categorized as subfertile, all others were categorized as fertile. Risks were modeled separately for the fertile/subfertile/IVF (autologous-fresh only) group and for the IVF group by oocyte source-embryo state combinations, using logistic regression, and reported as adjusted odds ratios (AORs) and 95% confidence intervals (CI).

RESULTS

The study population included 2,474,195 pregnancies. Placental complications (placenta previa, abruptio placenta, and other excessive bleeding) and prematurity were both increased with pregestational and gestational diabetes and hypertension, among subfertile and IVF groups, and in IVF pregnancies using donor oocytes. Both subfertile and IVF pregnancies were at risk for prematurity and NICU admission; IVF infants were also at risk for small-for-gestation birthweight, and subfertile infants had greater risks for neonatal and infant death. Within the IVF group, pregnancies with donor oocytes and/or thawed embryos were at greater risk of large-for-gestation birthweight, and pregnancies with thawed embryos were at greater risk of neonatal and infant death.

CONCLUSIONS

Prematurity was associated with placental complications, diabetes and hypertension, subfertility and IVF groups, and in IVF pregnancies, donor oocytes and/or thawed embryos.

Birth outcomes of singleton vaginal deliveries to ART-treated, subfertile, and fertile primiparous women

PURPOSE

To determine whether differences in birth outcomes among assisted reproductive technology (ART)-treated, subfertile, and fertile women exist in primiparous women with, singleton, vaginal deliveries.

METHODS

Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) data were linked to Massachusetts vital records and hospital discharges for deliveries between July 2004 and December 2010. Primiparous women with in-state vaginal deliveries, adequate prenatal care, and singleton birth at ≥ 20 weeks (n = 117,779) were classified as ART-treated (linked to ART data from SART CORS, n = 3138); subfertile (not ART-treated but with indicators of subfertility, n = 1507); or fertile (neither ART-treated nor subfertile, n = 113,134). Outcomes of prematurity (< 37 weeks), low birthweight (< 2500 g), perinatal death (death at ≥ 20 weeks to ≤ 7 days), and maternal prolonged length of hospital stay (LOS > 3 days) were compared using multivariable logistic regression.

RESULTS

Compared to fertile, higher odds were found for prematurity among ART-treated (adjusted odds ratio [AOR] 1.40, 95% confidence interval [CI] 1.25-1.50) and subfertile (AOR 1.25, 95% CI 1.03-1.50) women, low birthweight among ART-treated (AOR 1.41, 95% CI 1.23-1.62) and subfertile (AOR 1.40, 95% CI 1.15-1.71) women, perinatal death among subfertile (AOR 2.64, 95% CI 1.72-4.05), and prolonged LOS among ART-treated (AOR 1.33, 95% CI 1.19-1.48) women. Differences remained despite stratification by young age and absence of pregnancy/delivery complications.

CONCLUSIONS

Greater odds of prematurity and low birthweight in ART-treated and subfertile, and perinatal death in subfertile deliveries are evident among singleton vaginal deliveries. The data suggest that even low-risk pregnancies to ART-treated and subfertile women be managed for adverse outcomes.

Are singleton pregnancies after assisted reproduction technology (ART) associated with a higher risk of placental anomalies compared with non-ART singleton pregnancies? A systematic review and meta-analysis

BACKGROUND

Placental anomalies (placenta praevia, placental abruption, morbidly adherent placenta and cord insertion anomalies) are associated with maternal and fetal morbidity and mortality. It has been suggested these might be more prevalent in pregnancies after assisted reproduction technology (ART).

OBJECTIVES

To determine whether ART singleton pregnancies are associated with an increased risk of placental anomalies compared with non-ART singleton pregnancies.

SEARCH STRATEGY

MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus (January 2018).

SELECTION CRITERIA

Cohort studies reporting placental anomalies in ART and non-ART singleton pregnancies.

DATA COLLECTION AND ANALYSIS

We report pooled odds ratios (OR) for the comparisons: (1) ART versus SC (spontaneously conceived), (2) ART versus non-ART (unspecified), (3) FET-ART (frozen-embryo transfer) versus SC, (4) ART versus non-ART (subfertile patients). Study quality was assessed using a modified Newcastle -Ottawa scale.

MAIN RESULTS

33 low/moderate quality studies evaluated 124 215 ART and 6 054 729 non-ART singleton pregnancies. Risk of placenta praevia, placental abruption and morbidly adherent placenta was higher in ART than SC pregnancies: odds ratio (OR) (OR 3.76, 95% CI 3.09-4.59); (OR 1.87, 95% CI 1.70-2.06) and (OR 2.27, 95% CI 1.79-2.87) respectively. Risk of placenta praevia and placental abruption was higher in ART than in non-ART (subfertile patients): (OR 2.51, 95% CI 2.12-2.98) and (OR 1.61, 95% CI 1.33-1.95) respectively. Results were similar when comparing ART with unspecified non-ART pregnancies. Risk of placenta praevia was higher, but not significantly so, in FET-ART than in SC pregnancies (OR 2.42, 95% CI 0.63-9.30).

CONCLUSIONS

Singleton ART pregnancies are associated with an increased risk of placental anomalies compared with non-ART singleton pregnancies.

TWEETABLE ABSTRACT

A review of over 6 million singleton pregnancies finds increased risk of placental anomalies after ART.

Adverse pregnancy, birth, and infant outcomes in twins: effects of maternal fertility status and infant gender combinations; the Massachusetts Outcomes Study of Assisted Reproductive Technology

BACKGROUND

It is unknown whether the risk of adverse outcomes in twin pregnancies among subfertile women, conceived with and without in vitro fertilization, differs from those conceived spontaneously.

OBJECTIVE

We sought to evaluate the effects of fertility status on adverse perinatal outcomes in twin pregnancies on a population basis.

STUDY DESIGN

All twin live births of ≥22 weeks' gestation and ≥350 g birthweight to Massachusetts resident women in 2004 through 2010 were linked to hospital discharge records, vital records, and in vitro fertilization cycles. Women were categorized by their fertility status as in vitro fertilization, subfertile, or fertile, and by twin pair genders (all, like, unlike). Women whose births linked to in vitro fertilization cycles were classified as in vitro fertilization; those with indicators of subfertility but without in vitro fertilization treatment were classified as subfertile; all others were classified as fertile. Risks of 6 adverse pregnancy outcomes (gestational diabetes, pregnancy hypertension, uterine bleeding, placental complications [placenta abruptio, placenta previa, and vasa previa], prenatal hospitalizations, and primary cesarean) and 9 adverse infant outcomes (very low birthweight, low birthweight, small-for-gestation birthweight, large-for-gestation birthweight, very preterm [<32 weeks], preterm, birth defects, neonatal death, and infant death) were modeled by fertility status with the fertile group as reference, using multivariate log binomial regression and reported as adjusted relative risk ratios and 95% confidence intervals.

RESULTS

The study population included 10,352 women with twin pregnancies (6090 fertile, 724 subfertile, and 3538 in vitro fertilization). Among all twins, the risks for all 6 adverse pregnancy outcomes were significantly increased for the subfertile and in vitro fertilization groups, with highest risks for uterine bleeding (adjusted relative risk ratios, 1.92 and 2.58, respectively) and placental complications (adjusted relative risk ratios, 2.07 and 1.83, respectively). Among all twins, the risks for those born to subfertile women were significantly increased for very preterm birth and neonatal and infant death (adjusted relative risk ratios, 1.36, 1.89, and 1.87, respectively). Risks were significantly increased among in vitro fertilization twins for very preterm birth, preterm birth, and birth defects (adjusted relative risk ratios, 1.28, 1.07, and 1.26, respectively).

CONCLUSION

Risks of all maternal and most infant adverse outcomes were increased for subfertile and in vitro fertilization twins. Among all twins, the highest risks were for uterine bleeding and placental complications for the subfertile and in vitro fertilization groups, and neonatal and infant death in the subfertile group. These findings provide further evidence supporting single embryo transfer and more cautious use of ovulation induction.