Assisted Reproductive Technology Surveillance - United States, 2013

CDC Grand Rounds: Public Health Strategies to Prevent Preterm Birth

Preterm birth (delivery before 37 weeks and 0/7 days of gestation) is a leading cause of infant morbidity and mortality in the United States. In 2013, 11.4% of the nearly 4 million U.S. live births were preterm; however, 36% of the 8,470 infant deaths were attributed to preterm birth (1). Infants born at earlier gestational ages, especially <32 0/7 weeks, have the highest mortality (Figure) and morbidity rates. Morbidity associated with preterm birth includes respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage; longer-term consequences include developmental delay and decreased school performance. Risk factors for preterm delivery include social, behavioral, clinical, and biologic characteristics (Box). Despite advances in medical care, racial and ethnic disparities associated with preterm birth persist. Reducing preterm birth, a national public health priority (2), can be accomplished by implementing and monitoring strategies that target modifiable risk factors and populations at highest risk, and by providing improved quality and access to preconception, prenatal, and interconception care through implementation of strategies with potentially high impact.

Definition by FSH, AMH and embryo numbers of good-, intermediate- and poor-prognosis patients suggests previously unknown IVF outcome-determining factor associated with AMH

BACKGROUND

Though outcome models have been proposed previously, it is unknown whether cutoffs in clinical pregnancy and live birth rates at all ages are able to classify in vitro fertilization (IVF) patients into good-, intermediate- and poor prognosis.

METHODS

We here in 3 infertile patient cohorts, involving 1247, 1514 and 632 women, built logistic regression models based on 3 functional ovarian reserve (FOR) parameters, including (1) number of good quality embryos, (2) follicle stimulating hormone (FSH, mIU/mL) and (3) anti-Müllerian hormone (AMH, ng/mL), determining whether clinical pregnancy and live birth rates can discriminate between good, intermediate and poor prognosis patients.

RESULTS

All models, indeed, allowed at all ages for separation by prognosis, though cut offs changed with age. In the embryo model, increasing embryo production resulted in linear improvement of IVF outcomes despite transfer of similar embryo numbers; in the FSH model outcomes and FSH levels related inversely, while the association of AMH followed a bell-shaped polynomial pattern, demonstrating "best" outcomes at mid-ranges. All 3 models demonstrated increasingly poor outcomes with advancing ages, though "best" AMH even above age 43 was still associated with unexpectedly good pregnancy and delivery outcomes. Excessively high AMH, in contrast, was at all ages associated with spiking miscarriage rates.

CONCLUSIONS

At varying peripheral serum concentrations, AMH, thus, demonstrates hithero unknown and contradictory effects on IVF outcomes, deserving at different concentrations investigation as a potential therapeutic agent, with pregnancy-supporting and pregnancy-interrupting properties.

The Impact of ART on Live Birth Outcomes: Differing Experiences across Three States

BACKGROUND

Research has shown an association between assisted reproductive technology (ART) and adverse birth outcomes. We identified whether birth outcomes of ART-conceived pregnancies vary across states with different maternal characteristics, insurance coverage for ART services, and type of ART services provided.

METHODS

CDC's National ART Surveillance System data were linked to Massachusetts, Florida, and Michigan vital records from 2000 through 2006. Maternal characteristics in ART- and non-ART-conceived live births were compared between states using chi-square tests. We performed multivariable logistic regression analyses and calculated adjusted odds ratios (aOR) to assess associations between ART use and singleton preterm delivery (<32 weeks, <37 weeks), singleton small for gestational age (SGA) (<5th and <10th percentiles) and multiple birth.

RESULTS

ART use in Massachusetts was associated with significantly lower odds of twins as well as triplets and higher order births compared to Florida and Michigan (aOR 22.6 vs. 30.0 and 26.3, and aOR 37.6 vs. 92.8 and 99.2, respectively; Pinteraction < 0.001). ART use was associated with increased odds of SGA in Michigan only, and with preterm delivery (<32 and <37 weeks) in all states (aOR range: 1.60, 1.87).

CONCLUSIONS

ART use was associated with an increased risk of preterm delivery among singletons that showed little variability between states. The number of twins, triplets and higher order gestations per cycle was lower in Massachusetts, which may be due to the availability of insurance coverage for ART in Massachusetts.

Economic implications of the Society for Assisted Reproductive Technology embryo transfer guidelines: healthcare dollars saved by reducing iatrogenic triplets

OBJECTIVE

To estimate the national cost savings resulting from reductions in higher-order multiple (HOM) live births (defined as three or more fetuses), following the initial publication of the Society for Assisted Reproductive Technology (SART) guidelines on ET in 1998.

DESIGN

Descriptive use and cost analysis.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Estimates of the total number of HOM deliveries prevented (from 1998-2012) following the publication of SART guidelines; the associated healthcare savings (2014 US dollars).

RESULT(S)

A singleton live birth was estimated to cost $17,100-$24,200. A twin live birth was estimated at $66,000-$117,500. A triplet live birth was estimated at $190,800-$456,300. The percentage of HOM gestations among all ART pregnancies decreased from 11.4% in 1997 to 2.0% in 2012, with the sharpest year-over-year decline of 20.3% occurring in the year following the publication of the guidelines. The number of prevented HOM deliveries from 1998 through 2012 was estimated to be between 13,500 and 16,300, corresponding to cost savings of $6.02B (billion) (range, $2.35B-$7.03B, 2014 US dollars).

CONCLUSION(S)

Iatrogenic HOM gestations represent a substantial economic burden to our healthcare system. The introduction of guidelines for ET in 1998 coincided with a dramatic decrease in the HOM rate in subsequent years and an associated cumulative cost savings of more than $6B. Further reductions in HOM gestations could save up to an additional $2B annually.

Factors associated with the use of elective single-embryo transfer and pregnancy outcomes in the United States, 2004-2012

OBJECTIVE

To evaluate factors associated with elective single-embryo transfer (eSET) utilization and its effect on assisted reproductive technology outcomes in the United States.

DESIGN

Historical cohort.

SETTING

Not applicable.

PATIENT(S)

Fresh IVF cycles of women aged 18-37 years using autologous oocytes with either one (SET) or two (double-embryo transfer [DET]) embryos transferred and reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System between 2004 and 2012. Cycles were categorized into four groups with ([+]) or without ([-]) supernumerary embryos cryopreserved. The SET group with embryos cryopreserved was designated as eSET.

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

The likelihood of eSET utilization, live birth, and singleton non-low birth weight term live birth, modeled using logistic regression. Presented as adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULT(S)

The study included 263,375 cycles (21,917 SET[-]cryopreservation, 20,996 SET[+]cryopreservation, 103,371 DET[-]cryopreservation, and 117,091 DET[+]cryopreservation). The utilization of eSET (SET[+]cryopreservation) increased from 1.8% in 2004 to 14.9% in 2012 (aOR 7.66, 95% CI 6.87-8.53) and was more likely with assisted reproductive technology insurance coverage (aOR 1.60, 95% CI 1.54-1.66), Asian race (aOR 1.26, 95% CI 1.20-1.33), uterine factor diagnosis (aOR 1.48, 95% CI 1.37-1.59), retrieval of ≥16 oocytes (aOR 2.85, 95% CI 2.55-3.19), and the transfer of day 5-6 embryos (aOR 4.23, 95% CI 4.06-4.40); eSET was less likely in women aged 35-37 years (aOR 0.76, 95% CI 0.73-0.80). Compared with DET cycles, the likelihood of the ideal outcome, term non-low birth weight singleton live birth, was increased 45%-52% with eSET.

CONCLUSION(S)

Expanding insurance coverage for IVF would facilitate the broader use of eSET and may reduce the morbidity and healthcare costs associated with multiple pregnancies.

Expression of factors involved in the regulation of angiogenesis in the full-term human placenta: Effects of in vitro fertilization

The effects of assisted reproductive technologies (ARTs) on the safety of pregnancy and the resulting offspring remain controversial. Studies of placental functions, especially vasculogenesis and angiogenesis, in pregnancies established through ART are helpful for furthering our understanding of the safety of ART. This study compares the expression profiles of angiogenic factors in human term placentas obtained from natural (NAT) pregnancies vs. placentas obtained from pregnancies that resulted from ART. Term placentas were obtained from women who underwent an ART procedure (n=4), and these were compared with term placentas that were obtained from women who had experienced a spontaneous pregnancy (controls, n=4). An array analysis was performed using the Human Angiogenesis Antibody Array to detect 43 angiogenic factors and to identify which of these factors were differentially expressed between the two groups. The expression of six of these factors was greater in the ART group than in the NAT group. The levels of four of them, including vascular endothelial growth factor receptor-3 (VEGFR3), basic fibroblast growth factor (bFGF), interferon gamma (IFNG) and matrix metalloproteinase 1 (MMP1), were quantified using western blot analysis. These factors were examined using immunohistochemistry and microscopy in vascular endothelial cells or the cytoplasm and membranes of syncytiotrophoblast cells. Our finding that selected angiogenic factors exhibit altered expression profiles in ART placentas might be significant when evaluating ART safety.

Clinical vignettes and global health considerations of infertility care in under-resourced patients

The ability to receive standard of care for a diagnosis of infertility is a factor of one’s financial state and educational level, which are often correlated. Providing infertility care in an under-resourced tertiary care environment provides challenges but also opportunities for unique successes in creating a family. Among the under-represented populations are recent immigrants and refugees. Challenges arise when the infertility treatment is futile or when the standard of care is inaccessible due to cost and scheduling. Unique accomplishments are noted when families are built and hope is restored for couples fleeing from genocide and war-inflicted countries. This article will highlight two clinical vignettes from the Division of Reproductive Endocrinology and Infertility clinic at Boston University School of Medicine/Boston Medical Center. Thereafter, the article will summarize the barriers to care in the United States among those with low socioeconomic status, with non-dominant racial status (non-Caucasian), and with refugee status. All identifiers have been removed and names altered in the patient vignettes.

The double-edged sword of the mammalian oocyte--advantages, drawbacks and approaches for basic and clinical analysis at the single cell level

Oocytes are usually the largest cells in the body and as such offer unique opportunities for single-cell analysis. Unfortunately, these cells are also some of the rarest in the mammalian female, usually necessitating single-cell analysis. In cases of infertility in humans, determining the quality of the oocyte is often restricted to a morphological analysis or to the study of cellular behaviors in the developing embryo. Minimally invasive approaches could greatly assist the clinician to prioritize oocytes for fertilization or following fertilization, which embryo to transfer back into the woman. Transcriptomics of human and mouse oocytes may have great utility, and recently it was learned that the polar body faithfully reflects the transcript prevalence in the oocyte. The polar body may thus serve as a minimally invasive proxy for an oocyte in the clinic. In the mouse, the transcriptomes of oocytes from mice of the same strain are markedly similar; no significant differences are apparent in transcript prevalence or identity. In human oocytes however, the transcript pool is highly variable. This is likely the result of different histories of each oocyte, in the age of the donor woman, the different hormonal exposures and the prolonged time from specification of the primary oocyte to the fully grown and ovulated egg. This variability in human oocytes also emphasizes the need for cell-by-cell analysis of the oocytes in vitro; which oocytes have a better potential for fertilization and development? To this end, new imaging capabilities are being employed. For example, a single-cell analytical device for oocytes (the simple perfusion apparatus, or SPA) enables investigators to load multiple oocytes in individual wells, to visualize them on the microscope and to use controlled temperature and media flow by perfusion for optimal clinical applications. Recently, developed Raman microspectroscopy approaches suggest that this imaging modality may enable more in-depth analysis of the molecular characteristics of an oocyte that, in combination with the SPA and transcriptomic approaches, might assist the clinician to prioritize more effectively human oocytes and embryos for transfer into women. This review is intended to update the reader on the status of the examination of single oocytes from a variety of approaches and to emphasize areas that may be primed for advancement in the near future.

[DOHaD and pre- or peri-conceptional programming]

The pre- and peri-conceptional periods (before and just after fertilization, until the blastocyst stage) are critical in the context of the Developmental Origins of Health and Disease (DOHaD). Maternal in vivo environment, in particular nutrition, can disturb the apposition of epigenetic marks throughout gametogenesis, fertilization and the first steps of embryonic development, which are times during which major epigenetic changes take place. The in vitro environment, in the case of assisted reproduction techniques, also affects epigenetic marks. Whilst the embryo is a target of these changes, female and male gametes are both target and vector of these epigenetic changes, thus leading to multigenerational effects. Long term consequences on the phenotype of offspring vary according to the sex of the vector parent, the sex of the individual and the generation.

Assisted reproductive technology use, embryo transfer practices, and birth outcomes after infertility insurance mandates: New Jersey and Connecticut

OBJECTIVE

To explore whether recently enacted infertility mandates including coverage for assisted reproductive technology (ART) treatment in New Jersey (2001) and Connecticut (2005) increased ART use, improved embryo transfer practices, and decreased multiple birth rates.

DESIGN

Retrospective cohort study using data from the National ART Surveillance System. We explored trends in ART use, embryo transfer practices and birth outcomes, and compared changes in practices and outcomes during a 2-year period before and after passing the mandate between mandate and non-mandate states.

SETTING

Not applicable.

PATIENT(S)

Cycles of ART performed in the United States between 1996 and 2013.

INTERVENTION(S)

Infertility insurance mandates including coverage for ART treatment passed in New Jersey (2001) and Connecticut (2005).

MAIN OUTCOME MEASURES(S)

Number of ART cycles performed, number of embryos transferred, multiple live birth rates.

RESULT(S)

Both New Jersey and Connecticut experienced an increase in ART use greater than the non-mandate states. The mean number of embryos transferred decreased significantly in New Jersey and Connecticut; however, the magnitudes were not significantly different from non-mandate states. There was no significant change in ART birth outcomes in either mandate state except for an increase in live births in Connecticut; the magnitude was not different from non-mandate states.

CONCLUSION(S)

The infertility insurance mandates passed in New Jersey and Connecticut were associated with increased ART treatment use but not a decrease in the number of embryos transferred or the rate of multiples; however, applicability of the mandates was limited.

Defending male fertility

An estimated 10 to 15% of couples suffer from infertility, and many treatment decisions rely on trial and error. In this issue of Science Translational Medicine, Tollner and colleagues provide strong evidence from a human genetics study that a common variant in the beta defensin 126 gene, the "del" variant, can reduce male fertility substantially. In addition, they show a plausible mechanism for reduced fertility: Sperm from del/del homozygotes lack an important component of their glycoprotein coat and have difficulty penetrating a surrogate for cervical mucus. If replicated in future studies, these findings promise to guide choices about the timing and type of assisted reproduction interventions-and further hint at the possibility of treating sperm from del/del homozygotes to promote fertility.