Danish National In-Vitro Fertilization Registry 1994 and 1995: a controlled study of births, malformations and cytogenetic findings

When to avoid creating surplus human embryos

The advice that should be given to a couple considering assisted reproductive technologies for the treatment of their infertility, when they are completely opposed to the destruction of surplus embryos, is discussed. It is urged that they do not use treatments that generate surplus embryos. They should be given the options of declining IVF and considering adoption, or less efficient treatments, namely limited ovarian stimulation, limited insemination of available ova or natural cycle IVF where no surplus embryos are generated.

Neonatal outcome in a Danish national cohort of 8602 children born after in vitro fertilization or intracytoplasmic sperm injection: the role of twin pregnancy

BACKGROUND

In Denmark, 4% of all infants are born after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and 40% of these children are twins.

METHODS

We investigated neonatal outcome in a complete Danish IVF/ICSI birth cohort including 8602 infants born between 1995 and 2000: 3438 twins (40%) and 5164 singletons (60%). Births conceived after IVF or ICSI were identified by record linkage with the Danish IVF Registry and the National Medical Birth Registry. Data on neonatal outcome were collected from the National Patient Registry.

RESULTS

IVF/ICSI twins had a 10-fold increased age- and parity-adjusted risk of delivery before 37 completed weeks [odds ratio (OR) 9.9, 95% confidence interval (95% CI) 8.7-11.3] and a 7.4-fold increased risk of delivery before 32 completed weeks (OR 7.4, 95% CI 5.6-9.8) compared with singletons. Correspondingly, ORs of birthweight <2500 g and birthweight <1500 g in twins were 11.8 (95% CI 10.3-13.6) and 5.4 (95% CI 4.1-7.0), respectively. The stillbirth rate was doubled in twins (13.1/1000) compared with singletons (6.6/1000) (p = 0.002). The risk of cesarean section and of admittance to a neonatal intensive care unit (NICU) was 4.6- and 1.8-fold higher in IVF/ICSI twins than in singletons. The rate of major malformations was 40.4/1000 in twins and 36.8/1000 in singletons (p = 0.4), whereas the total malformation rate (major + minor) was higher in twins (73.7/1000) than in singletons (55.0/1000) (p = 0.001). After exclusion of patent ductus arteriosus (PDA), which is strongly associated with preterm birth, no significant differences in any malformation rates were observed between twins and singletons. Apart from the frequency of ICSI children with hypospadias, which reached a significance level of p = 0.05, malformation rates in ICSI children were similar to those in IVF children.

CONCLUSIONS

This study indicates that neonatal outcome in IVF/ICSI twins is considerably poorer than in singletons. Thus, the impact is to draw the attention of clinicians to the benefit of elective single embryo transfer (eSET).

Neurological sequelae in twins born after assisted conception: controlled national cohort study

OBJECTIVE

To compare neurological sequelae in twins born after assisted conception with singletons after assisted conception and naturally conceived twins and to assess neurological sequelae in children conceived after in vitro fertilisation (IVF) compared with intracytoplasmic sperm injection (ICSI).

DESIGN

Controlled, national register based, cohort study.

PARTICIPANTS

Twins (n = 3393) and singletons (n = 5130) conceived by using assisted reproductive technologies and naturally conceived twins (n = 10 239) born in Denmark between 1995 and 2000. The children's age at time of follow up was 2-7 years.

DATA SOURCES

Children were identified by cross linkage of the national medical birth registry and the national registry for in vitro fertilisation. Neurological and psychiatric diagnoses were retrieved from the national patients' registry and the Danish psychiatric central registry.

MAIN OUTCOME MEASURES

Neurological sequelae, defined as cerebral palsy, mental retardation, severe mental developmental disturbances, and retarded psychomotor development. Further we made separate analyses on the specific cerebral palsy diagnosis.

RESULTS

The crude prevalence rates per 1000 of neurological sequelae in twins and singletons after assisted conception and in naturally conceived twins were 8.8, 8.2, and 9.6, and of cerebral palsy 3.2, 2.5, and 4.0, respectively. In twins after assisted conception compared with control twins, the odds ratios of neurological sequelae and specifically of cerebral palsy, adjusted for child sex and year of birth, were 0.9 (95% confidence interval 0.6 to 1.4) and 0.8 (0.4 to 1.6), respectively. The corresponding odds ratios for twins after assisted conception compared with singletons after assisted conception were 1.1 (0.7 to 1.7) for neurological sequelae and 1.3 (0.6 to 2.9) for cerebral palsy. The odds ratio of neurological sequelae in children conceived by ICSI was 0.9 (0.5 to 1.7) nu children conceived by IVF.

CONCLUSIONS

Twins from assisted conception have a similar risk of neurological sequelae as their naturally conceived peers and singletons from assisted conception. Children born after ICSI have the same risk of neurological sequelae as children born after IVF.

Perinatal outcome among singleton infants conceived through assisted reproductive technology in the United States

OBJECTIVE

To examine perinatal outcome among singleton infants conceived with assisted reproductive technology (ART) in the United States.

METHODS

Subjects were 62,551 infants born after ART treatments performed in 1996-2000. Secular trends in low birth weight (LBW), very low birth weight (VLBW), preterm delivery, preterm LBW, and term LBW were examined. Detailed analyses were performed for 6,377 infants conceived in 2000. Observed numbers were compared with expected using a reference population from the 2000 U.S. natality file. Adjusted risk ratios were calculated.

RESULTS

The proportion of ART singletons born LBW, VLBW, and term LBW decreased from 1996 to 2000. The proportion delivered preterm and preterm LBW remained stable. After adjustment for maternal age, parity, and race/ethnicity, singleton infants born after ART in 2000 had elevated risks for all outcomes in comparison with the general population of U.S. singletons: LBW standardized risk ratio 1.62 (95% confidence interval 1.49, 1.75), VLBW 1.79 (1.45, 2.12), preterm delivery 1.41 (1.32, 1.51), preterm LBW 1.74 (1.57, 1.90), and term LBW 1.39 (1.19, 1.59). Risk ratios for each outcome remained elevated after restriction to pregnancies with only 1 fetal heart or any of 7 other categories: parental infertility diagnosis of male factor, infertility diagnosis of tubal factor, conception using in vitro fertilization without intracytoplasmic sperm injection or assisted hatching, conception with intracytoplasmic sperm injection, conception in a treatment with extra embryos available, embryo culture for 3 days, and embryo culture for 5 days.

CONCLUSION

Singletons born after ART remain at increased risk for adverse perinatal outcomes; however, risk for term LBW declined from 1996 to 2000, whereas preterm LBW was stable.

LEVEL OF EVIDENCE

III

Are children born after assisted reproductive technology at increased risk for adverse health outcomes?

As assisted reproductive technologies (ARTs) are increasingly used to overcome infertility, there is concern about the health of the children conceived. The empirical evidence for associations with outcomes related to child health is variable and should be evaluated with consideration of methodological shortcomings. Currently, there is convincing evidence that ART treatment may increase the risk of a few outcomes. Experimental laboratory studies document that various constituents in culture media affect various embryo characteristics both positively and negatively. Multiple-gestation pregnancy and birth are increased with ART, both because of multiple embryo transfer and embryo splitting. There is evidence of an increase in chromosomal abnormalities among pregnancies conceived using intracytoplasmic sperm injection and low birth weight and preterm delivery among singletons conceived with all types of ART; however, there remains uncertainty about whether these risks stem from the treatment or the parental infertility. For some outcomes, data of an increased risk with ART are suggestive at best largely because of lack of purposeful study of sufficient size and scope. These include specific perinatal morbidities, birth defects, developmental disabilities, and retinoblastoma. The evidence for an association between ART and spontaneous abortion is inconsistent and weak. There is inconclusive evidence that ART may be associated with genetic imprinting disorders. For childhood cancer, chronic conditions, learning and behavioral disorders, and reproductive effects there is insufficient empirical research to date, but given the data for more proximal outcomes, these outcomes merit further study. Future research needs to address the unique methodological challenges underlying study in this area.

The risk of birth defects in children born after assisted reproductive technologies

PURPOSE OF REVIEW

This review addresses the question of whether there is evidence of an increased risk of birth defects in children born following assisted reproductive technologies compared with spontaneously conceived children.

RECENT FINDINGS

Three recent studies added relatively little new information given their modest size (56-472 assisted reproductive technology children). We therefore considered all published papers that compared birth defects in children born following assisted reproductive technologies with those in children born following spontaneous conception. Overall, only six of the 26 relevant papers concluded there was an increased risk of birth defects following assisted reproductive technologies. The interpretation of many studies was based on statistical significance testing alone. When results showed a greater proportion of defects in the assisted reproductive technology group compared with the spontaneous group, but the results were not statistically significant, this was often interpreted as showing no increase in risk, rather than an increase in risk that may have been due to chance. The vast majority of individual studies were too small to have sufficient power to detect, as statistically significant, clinically relevant results. We found that although only eight (30%) of the studies had statistically significant results, 24 (89%) had an odds ratio estimate comparing assisted reproductive technology with spontaneously conceived children of over 1.0; 19 (70%) had an estimate of 1.20 or greater; and 14 (52%) had an estimate of 1.5 or greater.

SUMMARY

Current evidence suggests there is an elevated risk of birth defects in children born following assisted reproductive technologies. Whilst others may disagree with our interpretation, one certainly cannot exclude this possibility on the basis of the current evidence.

Present concept of unexplained infertility

Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.

Safety of GnRH agonists and antagonists

The widespread application of protocols using gonadotropin-releasing hormone (GnRH) agonists or antagonists in assisted reproduction treatment has led to an increasing number of pregnancies exposed to these drugs. This issue has raised scepticism as to the safety of these medications, concerning both pregnant women and their offspring. The main parameters that can be studied to ensure the safety of GnRH analogues include: a) systemic and local reactions to the medication; b) incidence of ovarian hyperstimulation syndrome (OHSS); c) direct effect on oocytes and embryos; and d) the health of those children exposed. So far, no systemic side effects and no major local reactions have been reported following the use of GnRH agonists or third-generation antagonists. On the other hand, the incidence of OHSS seems to be higher with GnRH agonist protocols compared to conventional or GnRH antagonist protocols. The recent cloning of the GnRH receptor has led to the demonstration of GnRH receptor gene expression in the human ovary, although the existence of GnRH receptors per se remains controversial. Similarly, the potential direct effect of GnRH analogues on the follicles and oocytes remains a matter of debate. The incidence of miscarriage and the health of children born as a result of in vitro fertilisation (IVF) treatment do not appear to be influenced by the GnRH agonist treatment. This also seems to be the case for the GnRH antagonists, although the available information on this issue is still limited. Therefore, most of the accumulated data concerning the safety of the GnRH analogues are encouraging, and no serious side effects have been reported. On the other hand, as no definite conclusions about the safety of these drugs can be drawn until now, continued assessment of the aforementioned parameters in long-term follow-up studies is recommended.

Comparison of the Validity of Preimplantation Genetic Diagnosis for Embryo Chromosomal Anomalies by Fluorescence In Situ Hybridization on One or Two Blastomeres

Is it necessary to analyze two blastomeres in preimplantation genetic diagnosis (PGD) by fluorescence in situ hybridization (FISH) or is one blastomere enough, as suggested by some teams? We analyzed the sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), false positives (FP), false negatives (FN), and the efficiency (Eff) of FISH performed on one (Group I) or two (Group II) blastomeres. Ninety embryos were analyzed (day 3), 19 blastocysts were replaced (day 5), 64 embryos were reanalyzed (day 5), (Group I = 23; Group II = 41). No differences were observed between the two groups for all of the parameters considered, but one false negative was observed in Group I. Furthermore, two embryos from Group II, which had a discordant diagnosis at PGD (one blastomere being normal and one abnormal), were read as abnormal after reanalysis. The accidental biopsy of the normal blastomere could have lead to the selection of these 2 embryos for transfer, causing a misdiagnosis rate of 4.8%. We conclude that embryo reanalysis is a useful tool to test the reliability of PGD in each laboratory: that PGD on two blastomeres is safer because the practice of PGD on one blastomere can result in a false-negative misdiagnosis.

Monitoring of IVF birth outcomes in Finland: a data quality study

BACKGROUND

The collection of information on infertility treatments is important for the surveillance of potential health consequences and to monitor service provision.

STUDY DESIGN

We compared the coverage and outcomes of IVF children reported in aggregated IVF statistics, the Medical Birth Register (subsequently: MBR) and research data based on reimbursements for IVF treatments in Finland in 1996-1998.

RESULTS

The number of newborns were nearly equal in the three data sources (N = 4331-4384), but the linkage between the MBR and the research data revealed that almost 40% of the reported IVF children were not the same individuals. The perinatal outcomes in the three data sources were similar, excluding the much lower incidence of major congenital anomalies in the IVF statistics (157/10 000 newborns) compared to other sources (409-422/10 000 newborns).

CONCLUSION

The differences in perinatal outcomes in the three data sets were in general minor, which suggests that the observed non-recording in the MBR is most likely unbiased.

Perinatal Outcomes in Singletons Following In Vitro Fertilization: A Meta-Analysis

OBJECTIVE

To estimate whether singleton pregnancies following in vitro fertilization (IVF) are at higher risk of perinatal mortality, preterm delivery, small for gestational age, and low or very low birth weight compared with spontaneous conceptions in studies that adjusted for age and parity.

DATA SOURCES

We searched MEDLINE, BIOSIS, Doctoral Dissertations On-Line, bibliographies, and conference proceedings for studies from 1978-2002 using the terms "in vitro fertilization," "female infertility therapy," and "reproductive techniques" combined with "fetal death," "mortality," "fetal growth restriction," "small for gestational age," "birth weight," "premature labor," "pre-term delivery," "infant," "obstetric," "perinatal," and "neonatal."

METHODS OF STUDY SELECTION

Inclusion criteria were singleton pregnancies following IVF compared with spontaneous conceptions, control for maternal age and parity; 1 of the above outcomes; and risk ratios or data to determine them. Study selection and data abstraction were performed in duplicate after removing identifying information.

TABULATION, INTEGRATION, AND RESULTS

Fifteen studies comprising 12,283 IVF and 1.9 million spontaneously conceived singletons were identified. Random-effects meta-analysis was performed. Compared with spontaneous conceptions, IVF singleton pregnancies were associated with significantly higher odds of each of the perinatal outcomes examined: perinatal mortality (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.6, 3.0), preterm delivery (OR 2.0; 95% CI 1.7, 2.2), low birth weight (OR 1.8; 95% CI 1.4, 2.2), very low birth weight (OR 2.7; 95% CI 2.3, 3.1), and small for gestational age (OR 1.6; 95% CI 1.3, 2.0). Statistical heterogeneity was noted only for preterm delivery and low birth weight. Sensitivity analyses revealed no significant changes in results. Early preterm delivery, spontaneous preterm delivery, placenta previa, gestational diabetes, preeclampsia, and neonatal intensive care admission were also significantly more prevalent in the IVF group.

CONCLUSION

In vitro fertilization patients should be advised of the increased risk for adverse perinatal outcomes. Obstetricians should not only manage these pregnancies as high risk but also avoid iatrogenic harm caused by elective preterm labor induction or cesarean.

The association of parity with mortality outcomes among triplets

OBJECTIVE

The purpose of this study was to evaluate the association of parity with stillbirth and neonatal and infant death among triplets.

STUDY DESIGN

This was a retrospective cohort study of 15,930 triplets who were delivered in the United States between 1995 and 1997. Infants of nulliparous mothers were compared with infants of multiparous mothers. Adjusted relative risks for death by parity were computed with the use of the generalized estimating equations framework.

RESULTS

The likelihood for stillbirth (odds ratio, 3.40; 95% CI, 2.20-5.26) was significantly greater among nulliparous mothers. Neonatal (odds ratio, 1.17; 95% CI, 0.95-1.43) and infant mortality rates (odds ratio, 1.10; 95% CI, 0.92-1.32) were comparable, however. With an increase in parity, there was a consistent declining trend in the risk for stillbirth (P<.0001).

CONCLUSION

Nulliparity more than triples the risk for intrauterine fetal death among triplets. This parity-related disparity underscores the need for care providers to be particularly concerned about triplet gestations among nulliparous mothers.

Early mortality among triplets in the United States: black-white disparity

OBJECTIVE

In this study, we sought to estimate the black-white gap in early mortality among triplets.

STUDY DESIGN

This was a retrospective cohort study on triplets delivered in the United States from 1995 to 1997. We computed relative risks for early mortality among triplets born to black mothers using the generalized estimating equation framework.

RESULTS

There were 1317 black and 14,364 white triplets analyzed. Black triplets were twice as likely to have neonatal and infant mortality compared with whites (Odds ratio [OR], 2.00, 95% CI, 1.38-2.77; and OR, 2.20, 95% CI, 1.59-3.00, respectively). The widest disparity was observed postneonatally, with black triplets sustaining a level of risk almost 4-fold that of whites (OR, 3.60, 95% CI, 2.10-6.10). Stillbirth and perinatal mortality were comparable for both races.

CONCLUSION

Black-white disparity for early mortality among triplets was widest postneonatally. This finding bears important clinical and public health implications.

A prospective longitudinal study of the physical, psychomotor, and intellectual development of singleton children up to 5 years who were conceived by intracytoplasmic sperm injection compared with children conceived spontaneously and by in vitro fertilization

OBJECTIVE

To assess the somatic, psychomotor, and intellectual development of children conceived through intracytoplasmic single sperm injection (ICSI) over the whole preschool period.

DESIGN

Prospective, controlled, cohort study.

SETTING

Fertility clinic in Brussels, Belgium.

PATIENT(S)

Sixty-six ICSI-conceived children prospectively compared with 52 IVF-conceived and 59 spontaneously conceived children. All children were full-term singletons.

INTERVENTION(S)

Home visits by a trained psychologist. Standardized interviews. Assessments using the revised Brunet-Lézine scale and the revised Wechsler preschool and primary scale of intelligence.

MAIN OUTCOME MEASURE(S)

Physical growth and general health. Formal developmental and intellectual assessments.

RESULT(S)

Children conceived by ICSI were healthy: no significant differences appeared in the incidence of combined congenital malformations (11.3%), health problems (44.1%), surgical interventions (18.6%), and hospitalizations (6.8%), nor for the developmental assessments (mean developmental quotient at 9 months: 93.9; at 18 months: 102.0). For the intellectual assessments, the between-group differences disappeared when adjusted for levels of parental education (mean intelligence quotient at 3 years: 97.0; at 5 years: 103.3).

CONCLUSION(S)

This pilot study shows that throughout the preschool period, ICSI-conceived children have psychomotor and intellectual development similar to that of IVF-conceived and spontaneously conceived children. These conclusions need to be confirmed by multicenter studies.

Cause and risk of stillbirth in twin pregnancies: a retrospective audit

BACKGROUND

The epidemiology of twin pregnancies complicated by stillbirth of one or both fetuses is a scarcely examined area. The risk of perinatal death in twin pregnancies is increased 2-5 times compared to singletons, and the identification of preventable risk factors becomes increasingly important as the number of multiple pregnancies is rising. We report the causes of death in twin pregnancies and their respective risk factors.

METHODS

Twin pregnancies (n = 54) complicated by antepartum or intrapartum stillbirth of one or both twins (n = 68) and twin pregnancies with normal outcome (n = 103) in the counties of Oslo and Akershus, Norway, from 1986 to 1995 were included. The cases were classified and compared to the controls in multiple logistic regression analyses with regard to risk factors.

RESULTS

The risk of stillbirth increased with monochorionicity, non-Western origin and assisted reproduction techniques (ART). The cases could be divided into eight different groups according to the primary diagnosis. The groups did not fit any of the existing cause-of-death classifications used on singleton stillbirths.

CONCLUSIONS

The identification of monochorionic gestation should be made early in pregnancy to designate the level of risk. Assisted reproduction techniques leading to a high incidence of twins should be avoided. Health care professionals in the immigrant population should address the detrimental effects of consanguinity on reproductive outcome. We emphasize the need of a new cause-of-death classification for twin stillbirths.

Maternal risks and perinatal outcome in a Danish national cohort of 1005 twin pregnancies: the role of in vitro fertilization

BACKGROUND

Twin pregnancies constitute 25% of all in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies. There is a lack of knowledge on maternal risks and perinatal outcome of IVF/ICSI twin pregnancies.

METHODS

National survey by questionnaire (n = 1769). The study population consisted of all IVF/ICSI twin mothers (n = 266) and the two control groups of all IVF/ICSI singleton mothers (n = 764) and non-IVF/ICSI twin mothers (n = 739) who delivered in Denmark in 1997. The response rate was 89% among IVF twin mothers and overall 81%.

RESULTS

In terms of maternal risks and perinatal outcome no significant differences were observed between IVF/ICSI twin and non-IVF/ICSI twin pregnancies after stratification for maternal age and parity. Nevertheless, IVF/ICSI twin mothers were more frequently on sick leave (OR 2.5, 95% CI 1.5-4.0) and hospitalized (OR 1.9, 95% CI 1.3-2.8) during pregnancy. Compared with IVF/ICSI singleton pregnancies, IVF/ICSI twin pregnancies were characterized by a higher incidence of preeclampsia (OR 2.4, 95% CI 1.5-4.2) and a higher frequency of sick leave (OR 6.8, 95% CI 4.4-10.5) and hospitalizations during pregnancy (OR 3.5, (95% CI 2.5-4.9); moreover, mean birthweight (p < 0.001) and gestational age (p < 0.001) were lower. No differences were observed in the incidence of pregnancy-induced hypertension and gestational diabetes between IVF/ICSI twin and singleton pregnancies.

CONCLUSION

Although this population study indicates that maternal risks in IVF/ICSI twin pregnancies are comparable with non-IVF/ICSI twin pregnancies, the IVF/ICSI twin mothers were more likely to be on sick leave or hospitalized during pregnancy. Furthermore, maternal risks were higher and obstetric outcome poorer in IVF/ICSI twin vs. IVF/ICSI singleton pregnancies.

Practitioner review: outcomes for parents and children following non-traditional conception: what do clinicians need to know?

BACKGROUND

The birth of the first 'test-tube' baby in 1978 has led to the creation of family types that would not otherwise have existed.

METHODS

This paper examines research on the psychological outcomes for parents and children in assisted reproduction families with particular attention to the issues and concerns that have been raised by creating families in this way.

RESULTS

Parents of children conceived by assisted reproduction appear to have good relationships with their children, even in families where one parent lacks a genetic link with the child. With respect to the children themselves, there is no evidence of cognitive impairment in singleton children born at full term as a result of assisted reproduction procedures, although the findings regarding the cognitive development of intracytoplasmic sperm injection (ICSI) children are currently unclear. In relation to socioemotional development, assisted reproduction children appear to be functioning well.

CONCLUSIONS

Few studies have included children at adolescence or beyond, and little is known about the consequences of conception by assisted reproduction from the perspective of the individuals concerned. In addition, there are some types of assisted reproduction family, such as families created through a surrogacy arrangement or through embryo donation, about whom little is known at all. Although existing knowledge about the impact of assisted reproduction for parenting and child development does not give undue cause for concern, there remain a number of unanswered questions in relation to children born in this way.

A benefit-risk assessment of medical treatment for uterine leiomyomas

The growth of a uterine leiomyoma growth stops and regresses after the menopause suggesting that leiomyoma growth is dependent on ovarian steroids. Therefore, estrogen has received much attention as the major factor responsible for the development of uterine leiomyomas, but progesterone also plays an important role in development of this disease. Cytogenetic analyses of resected samples has revealed that about 40 to 50% of leiomyomas show karyotypically detectable chromosomal abnormalities. Gonadotrophin releasing hormone (GnRH) agonists exert their action through the suppression of endogenous gonadotrophins and gonadal steroid secretion. Significant reductions of uterine/leiomyoma volume under GnRH agonist therapy has been reported in several studies. However, the leiomyoma generally returns to its pretreatment volume within a few months after discontinuation of the GnRH agonist. To minimise the adverse effects of hypoestrogenism during GnRH agonist treatment, add back therapy can be used (estrogen-progestin, progestin alone and recently tibolone). Antiprogestins have a potential clinical utility in uterine leiomyomas. Mifepristone is a synthetic steroid with both antiprogesterone and antiglucocorticoid activities, that may have an inhibitory effect on growth of leiomyoma. Danazol is an isoxazole of 17beta-ethinyl testosterone, a synthetic steroid, which has a suppressive effect on sex hormone binding globulin concentrations, resulting in efficacy in the short-term treatment of uterine leiomyomas. Gestrinone is a tri-enic steroid with antiestrogen and antiprogesterone properties and has been shown to reduce uterine volume and stop bleeding. Growth factors play a relevant role on the pathophysiology of uterine leiomyoma and probably the inhibition of the action of growth factors on the myometrium will be the basis for future therapy. A number of agents are under investigation for treating uterine leiomyoma. Agents developed from increasing genetic knowledge of this condition could represent, in the next few years, new trends in the medical treatment of uterine leiomyomas.

Obstetric outcome among women with unexplained infertility after IVF: a matched case-control study

BACKGROUND

Infertility itself and also assisted reproductive treatment increase the incidence of some obstetric complications. Women with unexplained infertility are reported to be at an increased risk of intrauterine growth restriction during pregnancy, but not for other perinatal complications.

METHODS

A matched case-control study was performed on care during pregnancy and delivery, obstetric complications and infant perinatal outcomes of 107 women with unexplained infertility, with 118 clinical pregnancies after IVF or ICSI treatment. These resulted in 90 deliveries; of these, 69 were singleton, 20 twin and one triplet. Two control groups were chosen from the Finnish Medical Birth Register, one group for spontaneous pregnancies (including 445 women and 545 children), matched according to maternal age, parity, year of birth, mother's residence and number of children at birth, and the other group for all pregnancies after IVF, ICSI or frozen embryo transfer treatment (FET) during the study period (including 2377 women and 2853 children).

RESULTS

Among singletons, no difference was found in the mean birthweight, and the incidence of low birthweight (<2500 g) was comparable with that of the control groups. No differences were found in gestational duration, major congenital malformations or perinatal mortality among the groups studied. Among singletons in the study group, there were more term breech presentations (10.1%) compared with both spontaneously conceiving women and all IVF women (P < 0.01). The rate of pregnancy-induced hypertension was significantly lower among singletons in the study group (P < 0.05) compared with other IVF singletons. The multiple pregnancy rate was 23.3% in the study group. The obstetric outcome of the IVF twins was similar to both control groups.

CONCLUSIONS

The overall obstetric outcome among couples with unexplained infertility treated with IVF was good, with similar outcome compared with spontaneous pregnancies and IVF pregnancies generally.

Low and very low birth weight in infants conceived with use of assisted reproductive technology

BACKGROUND

The increased risk of low birth weight associated with the use of assisted reproductive technology has been attributed largely to the higher rate of multiple gestations associated with such technology. It is uncertain, however, whether singleton infants conceived with the use of assisted reproductive technology may also have a higher risk of low birth weight than those who are conceived spontaneously.

METHODS

We used population-based data to compare the rates of low birth weight (less-than-or-equal 2500 g) and very low birth weight (<1500 g) among infants conceived with assisted reproductive technology with the rates in the general population.

RESULTS

We studied 42,463 infants who were born in 1996 and 1997 and conceived with assisted reproductive technology and used as a comparison group 3,389,098 infants born in the United States in 1997. Among singleton infants born at 37 weeks of gestation or later, those conceived with assisted reproductive technology had a risk of low birth weight that was 2.6 times that in the general population (95 percent confidence interval, 2.4 to 2.7). The use of assisted reproductive technology was associated with an increased rate of multiple gestations; however, its use was not associated with a further increase in the risk of low birth weight in multiple births. Among twins, the ratio of the rate of low birth weight after the use of assisted reproductive technology to the rate in the general population was 1.0 (95 percent confidence interval, 1.0 to 1.1). Infants conceived with assisted reproductive technology accounted for 0.6 percent of all infants born to mothers who were 20 years of age or older in 1997, but for 3.5 percent of low-birth-weight and 4.3 percent of very-low-birth-weight infants.

CONCLUSIONS

The use of assisted reproductive technology accounts for a disproportionate number of low-birth-weight and very-low-birth-weight infants in the United States, in part because of absolute increases in multiple gestations and in part because of higher rates of low birth weight among singleton infants conceived with this technology.

Neonatal data on a cohort of 2889 infants born after ICSI (1991-1999) and of 2995 infants born after IVF (1983-1999)

BACKGROUND

To evaluate the safety of ICSI, this study compared data of IVF and ICSI children by collecting data on neonatal outcome and congenital malformations during pregnancy and at birth.

METHODS

The follow-up study included agreement to genetic counselling and eventual prenatal diagnosis, followed by a physical examination of the children after 2 months, after 1 year and after 2 years. 2840 ICSI children (1991-1999) and 2955 IVF children (1983-1999) were liveborn after replacement of fresh embryos. ICSI was carried out using ejaculated, epididymal or testicular sperm.

RESULTS

In the two cohorts, similar rates of multiple pregnancies were observed. ICSI and IVF maternal characteristics were comparable for medication taken during pregnancy, pregnancy duration and maternal educational level, whereas maternal age was higher in ICSI and a higher percentage of first pregnancies and first children born was observed in the ICSI mothers. Birthweight, number of neonatal complications, low birthweight, stillbirth rate and perinatal death rate were compared between the ICSI and the IVF groups and were similar for ICSI and IVF. Prematurity was slightly higher in the ICSI children (31.8%) than in the IVF children (29.3%). Very low birthweight was higher in the IVF pregnancies (5.7%) compared with ICSI pregnancies (4.4%). Major malformations (defined as those causing functional impairment or requiring surgical correction), were observed at birth in 3.4% of the ICSI liveborn children and in 3.8% of the IVF children (P = 0.538). Malformation rate in ICSI was not related to sperm origin or sperm quality. The number of stillbirths (born > or =20 weeks of pregnancy) was 1.69% in the ICSI group and 1.31% in the IVF group. Total malformation rate taking into account major malformations in stillborns, in terminations and in liveborns was 4.2% in ICSI and 4.6% in IVF (P = 0.482).

CONCLUSIONS

The comparison of ICSI and IVF children taking part in an identical follow-up study did not show any increased risk of major malformations and neonatal complications in the ICSI group.

The European study of assisted reproduction families: the transition to adolescence

BACKGROUND

Findings are presented of the second phase of a European longitudinal study of families created by assisted reproduction. The present investigation reports on data obtained during the child's transition to adolescence.

METHODS

A total of 102 IVF families, 94 donor insemination (DI) families, 102 adoptive families, and 102 families with a naturally conceived child were compared on standardized interview and questionnaire measures of parenting and children's psychological well-being.

RESULTS

The assisted reproduction families were similar to the adoptive and natural conception families for many of the measures of the quality of parent-child relationships. To the extent that differences were found between the assisted reproduction families and the other family types, these reflected mainly more positive functioning among the assisted reproduction families, with the possible exception of the overinvolvement with their children of a small proportion of assisted reproduction mothers and fathers. The assisted reproduction children were functioning well and did not differ from the adoptive or naturally conceived children on any of the measures of psychological adjustment. However, only 8.6% had been told about their genetic origins.

CONCLUSIONS

IVF and DI families with an early adolescent child appear to be functioning well.

Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics

OBJECTIVE

To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change.

DESIGN

Narrative literature review, policy analysis.

SETTING

University Department of Obstetrics and Gynecology.

PATIENT(S)

Sub-fertile women and men.

INTERVENTION(S)

Fertility treatments, in particular IVF.

RESULT(S)

The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued.

CONCLUSION(S)

Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.

Congenital malformations in infants born after IVF: a population-based study

The presence of congenital malformations in infants born after IVF was studied from a register consisting of practically all infants born in Sweden after IVF, 1982--1997 (n = 9111). A further 64 infants were studied using only medical records. It is a nation-wide study and has a population-based control group (n = 1,690,577) and relevant potential confounders have been taken into account. There was an excess of congenital malformations registered in the Medical Birth Registry (n = 516, odds ratio = 1.47) but this excess disappeared when confounders were taken into consideration: year of birth, maternal age, parity, and period of unwanted childlessness (odds ratio = 0.89). For some specific conditions, an approximately 3-fold excess risk was seen: neural tube defects, alimentary atresia, omphalocele, and hypospadias (after intracytoplasmatic sperm injection). No excess risk for hypospadias was seen after standard IVF. Various explanations for these findings are discussed. It is postulated that the excess risk for alimentary atresia, like the excess risk for monozygotic twinning after IVF, is a direct consequence of the IVF procedure. The excess risk for hypospadias after ICSI may be related to paternal subfertility with a genetic background. The absolute risk for a congenital malformation in association with IVF is small.