In vitro fertilization is associated with an increase in major birth defects

Donor insemination and infertility: what general urologists need to know

Therapeutic donor insemination (TDI), also known as artificial insemination by donor, is one of the oldest forms of male infertility treatment. With the advent of assisted reproductive technologies and in vitro fertilization techniques over the past few decades, the use of TDI in male infertility treatment has decreased dramatically. Knowledge of its use, indications, efficacy, and related psychosocial issues has also declined among urologists treating male infertility. Despite the change in popularity of the procedure, though, TDI remains an appropriate therapeutic option for certain cases of male infertility, particularly in patients who have failed multiple cycles of in vitro fertilization/intracytoplasmic sperm injection or in men with no available sperm even after attempted microdissection testicular sperm extraction. Further consideration and research should be focused on the potential uses and indications for TDI.

The risk of malformation following assisted reproduction

INTRODUCTION

Intracytoplasmatic sperm injection (ICSI) is currently the most frequently used human reproductive technology in Germany. ICSI was introduced as routine, insurance-funded medical care in 2002 by the Federal Joint Committee. A re-evaluation of published literature on malformation rates in children born of ICSI pregnancies within a period of three years formed part of the committee's decision. The analysis investigated whether ICSI increases the risk of malformation in the offspring, compared to in vitro fertilization (IVF) and natural conception.

METHODS

Systematic literature review.

RESULTS

929 studies were identified. Three meta-analyses, 15 studies investigating malformations, and 12 studies analyzing imprinting disorders were included. The risk of malformation was not significantly different in nine studies comparing ICSI versus IVF. Two meta-analyses and three of eight cohort studies and retrospective analysis showed significantly more severe malformations after assisted reproduction than after natural conception. The remaining five studies displayed no significant results. Current evidence does not show a higher risk of major malformations in the offspring resulting from the use of ICSI compared to IVF. However, there is evidence that both techniques increase the risk for major malformations considerably, compared to natural conception, and further research is needed. The validity of the results is low since the studies were heterogeneous and the cohorts used in the studies had limited comparability.

Perinatal outcome, health, growth, and medical care utilization of 5- to 8-year-old intracytoplasmic sperm injection singletons

OBJECTIVE

To evaluate short- and long-term health in intracytoplasmic sperm injection (ICSI) singletons.

DESIGN

Follow-up study.

SETTING

University medical center, assessments between March 2004 and May 2005.

PATIENT(S)

Singletons born between June 1996 and December 1999 after ICSI in the Leiden University Medical Center laboratory were compared with matched singletons born after IVF and natural conception.

INTERVENTION(S)

Mode of conception.

MAIN OUTCOME MEASURE(S)

An examiner blinded to the conception mode of the child assessed congenital malformations and growth. Information on pregnancy, perinatal period, birth defects, general health, and medical consumption was obtained through questionnaires.

RESULT(S)

Outcomes of children conceived by ICSI and IVF (n = 81/81, preterm infants excluded) were comparable or even more positive for ICSI. Perinatal outcomes were poorer after ICSI than natural conception: prematurity: P=.014; low birth weight: odds ratio = 7.4, 95% confidence interval (CI) [0.9; 62.5]; mean birth weight: Delta = 186 g, 95% CI [21; 351]. The ICSI mothers had more pregnancy complications (n = 33 vs. 18) and in-hospital deliveries (prevalence ratio 1.36, 95% CI 1.17; 1.48). No further differences were found between ICSI and natural conception children on congenital malformations, health, growth, and medical consumption (n = 87/85, preterm infants included).

CONCLUSION(S)

No adverse health outcomes were identified in ICSI singletons up to age 5-8 years compared to IVF and natural conception singletons, besides poorer perinatal outcomes after ICSI versus natural conception.

Growth and development of children born after in vitro fertilization

OBJECTIVE

To evaluate growth and development of children born after IVF treatment.

DESIGN

Literature review.

CONCLUSION(S)

At present there is substantial evidence that children born after IVF are at increased risk for adverse perinatal outcome, congenital malformations, and rare epigenetic defects. It is still unclear whether observed health problems originate from the IVF procedure itself or the underlying subfertility problems of the parents. Current follow-up studies regarding postnatal growth and morbidity rates are scarce with conflicting results and other areas of long-term research in children born after IVF are still in its infancy. The importance of the worldwide continuing monitoring of children born after IVF to investigate potential long-term consequences including the development of cardiovascular diseases is therefore highlighted.

Manipulations of mouse embryos prior to implantation result in aberrant expression of imprinted genes on day 9.5 of development

In vitro culture of mouse embryos results in loss of imprinting. The aim of the present study was to examine how two of the techniques commonly used during assisted reproduction, namely embryo culture and embryo transfer, affect genomic imprinting after implantation in the mouse. F1 hybrid mouse embryos were subjected to three experimental conditions: control (unmanipulated), embryo transfer and in-vitro-culture followed by embryo transfer. Concepti were collected on d9.5 of development and allelic expression determination of ten imprinted genes (H19, Snrpn, Igf2, Kcnq1ot1, Cdkn1c, Kcnq1, Mknr3, Ascl2, Zim1, Peg3) was performed. Although control concepti had monoallelic imprinted gene expression in all tissues, both manipulated groups had aberrant expression of one or more imprinted genes in the yolk sac and placenta. Culture further exacerbated the effects of transfer by increasing the number of genes with aberrant allelic expression in extraembryonic, as well as embryonic tissues. Additionally, placentae of both groups of manipulated concepti exhibited reduced levels of Igf2 mRNA and increased levels of Ascl2 mRNA when compared with their unmanipulated counterparts. Furthermore, we show that biallelic expression of Kcnq1ot1 coincided with loss of methylation on the maternal allele of the KvDMR1 locus, a phenotype often associated with the human syndrome Beckwith-Wiedemann. In conclusion, our results show that even the most basic manipulation used during human-assisted reproduction, namely, embryo transfer, can lead to misexpression of several imprinted genes during post-implantation development. Additionally, our results serve as a cautionary tale for gene expression studies in which embryo transfer is used.

In vitro fertilization and the cloacal/bladder exstrophy-epispadias complex: a continuing association

OBJECTIVE

To expand on a previously published analysis of children fertilized in vitro (IVF) who demonstrate the cloacal/bladder exstrophy-epispadias complex (CBEEC).

PATIENTS AND METHODS

Data were collected on CBEEC patients who were fertilized in vitro and seen at The Brady Urological Institute of The Johns Hopkins Hospital (Brady/JHH) from 1997 to 2004. The numbers of live births and IVF births were acquired/estimated from the US Centers for Disease Control. Incidence rates for CBEEC were estimated using International Clearinghouse for Birth Defects Monitoring Systems data. A Pearson-type chi-squared analysis evaluated the association between IVF and CBEEC.

RESULTS

An estimated 322,937 IVF births occurred in the US in 1997-2004. The rate of CBEEC was estimated at 6.2:100,000. A total of 150 CBEEC patients born in 1997-2004 were evaluated at Brady/JHH of whom eight were IVF. Under the hypothesis of no association between IVF and CBEEC, the expected incidence of IVF in CBEEC children ranged between 0.60% and 1.59%. The observed incidence of IVF in CBEEC children evaluated at Brady/JHH ranged between 4.2% and 6.7%. Comparison of the expected and observed incidence using a Pearson-type chi-squared test resulted in a bootstrapped P value of 0.0182.

CONCLUSION

The incidence of IVF in CBEEC children appears to be higher than what would be expected if there was no association between IVF and CBEEC.

Progestogen for treating threatened miscarriage

BACKGROUND

Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

OBJECTIVES

To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (January 1966 to April 2006), EMBASE (1980 to April 2006) and CINAHL (1982 to April 2006). We scanned bibliographies of all located articles for any unidentified articles.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage.

DATA COLLECTION AND ANALYSIS

At least two authors assessed the trials for inclusion in the review and extracted the data.

MAIN RESULTS

Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30).

AUTHORS' CONCLUSIONS

Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed.

Use of multivitamins, intake of B vitamins, and risk of ovulatory infertility

OBJECTIVE

To examine whether use of multivitamins and intake of specific nutrients in multivitamins is associated with ovulatory infertility.

DESIGN

A prospective cohort study.

SETTING

The Nurses' Health Study II.

PATIENT(S)

Eighteen thousand five hundred fifty-five married, premenopausal women without a history of infertility who attempted a pregnancy or became pregnant between 1991 and 1999.

INTERVENTION(S)

None, observational study.

MAIN OUTCOME MEASURE(S)

Incident reports of infertility caused by anovulation.

RESULT(S)

During 8 years of follow-up, 438 women reported infertility caused by ovulatory disorder. There was an inverse association between frequency of multivitamin use and ovulatory infertility. The multivariate-adjusted relative risk (95% confidence interval) of ovulatory infertility was 0.88 (0.60, 1.28) for women consuming two tablets per week or less, 0.69 (0.51, 0.95) for women consuming three to five tablets per week, and 0.59 (0.46, 0.75) for women consuming six or more tablets per week, when compared with women who did not use these supplements (P, trend <.001). Folic acid appeared to explain part of the association between multivitamin supplement use and risk of ovulatory infertility.

CONCLUSION(S)

Regular use of multivitamin supplements may decrease the risk of ovulatory infertility.

Antisperm antibodies and conception

Sperm have been known to be antigenic for more than a century. There is a strong body of evidence that in humans and in other species at least some antibodies that bind to sperm antigens can cause infertility. Therefore, these antibodies are of interest today for two practical reasons. Firstly, the association of the antibodies with infertility means that they must be detected and then the couples treated appropriately. Secondly, because these antibodies can induce infertility they have the potential to be developed for contraceptive purposes in humans and also for the control of feral animal populations.

Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop

The National Institute of Child Health and Human Development held a workshop on September 12-13, 2005, to summarize the risks for adverse pregnancy outcomes after assisted reproductive technology (ART), develop an approach to counseling couples regarding these risks, and establish a research agenda. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30% of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. Assisted reproductive technology singleton pregnancies also demonstrate increased rates of perinatal complications-small for gestational age infants, preterm delivery, and perinatal mortality-as well as maternal complications, such as preeclampsia, gestational diabetes, placenta previa, placental abruption, and cesarean delivery. Although it is not possible to separate ART-related risks from those secondary to the underlying reproductive pathology, the overall increased frequency of obstetric complications, including preterm birth and small for gestational age neonates, should be discussed with the couple. Significant gaps in knowledge were identified, and the basic science and clinical and epidemiologic research required to address these gaps is outlined.

Prenatal ascertainment of OEIS complex/cloacal exstrophy—15 new cases and literature review

Omphalocele-exstrophy of the bladder-imperforate anus-spinal defects (OEIS) complex or cloacal exstrophy (EC), describes a rare grouping of more commonly occurring component malformations [Carey et al., 1978]. The etiology is unknown, but likely heterogeneous. While postnatal identification of its associated gastrointestinal, spinal, and genitourinary systems delineates the extent and natural history of OEIS complex, prenatal findings may provide additional information regarding early detection, possible causative factors, and outcome. The purposes of this study were to: (1) present the prenatal ascertainment of OEIS complex in this series of 15 cases identified through several different sources compared to the literature, and (2) discuss the relationship of these prenatal findings to possible abnormal developmental mechanisms causing OEIS complex. These 15 cases indicate that OEIS complex may be difficult to diagnose prenatally, and that the full extent of abnormalities may not be clear until postnatal exam. Confusion with limb-body wall complex (two of our cases) and pentalogy of Cantrell (one of our cases) can occur. Anal/gastrointestinal malformations and genital ambiguity are under-ascertained. Conversely, prenatal defects may resolve postnatally, yet may provide clues for pathogenetic mechanisms. For instance, the finding of nuchal thickening in our three cases (one reported) suggests vascular/hemodynamic compromise early in embryologic development, or intrathoracic compression leading to jugular lymphatic obstruction may play a role. The association of twinning and OEIS complex suggests they may occur as early as blastogenesis. Our three sets of discordant twins also suggest a non-genetic etiology for OEIS complex of uteroplacental insufficiency. This study also indicates that OEIS complex may be more common than previously thought.

Non-invasive genetic diagnosis of male infertility using spermatozoal RNA: KLHL10 mutations in oligozoospermic patients impair homodimerization

Infertility affects an estimated 7% of men worldwide, nearly a quarter of whom are diagnosed as idiopathic. The genetic etiologies of idiopathic male infertility are unknown, partly due to lack of simple diagnostic techniques. Moreover, the transmission risk of such genetic defects to offspring born from assisted reproductive techniques is increasingly becoming a concern for physicians and infertile couples. We explored the feasibility of obtaining full-length mRNAs from transcriptionally inert human spermatozoa in semen as a non-invasive diagnostic tool for identifying germline mutations in candidate infertility-associated genes. The efficacy of reverse-transcription PCR on spermatozoal RNA from infertile patients with wide-ranging sperm concentrations varied between 91 and 99% for multiple haploid germ cell-expressed genes. Using this methodology, we identified seven oligozoospermic patients with missense and splicing mutations in the germ cell-specific gene, KLHL10. Three of 270 (1.1%) severely oligozoospermic patients (<10(6) sperm/ml) harbor KLHL10 alterations that were absent in 394 controls and exhibited significant association (P=0.02). Two KLHL10 missense mutations (A313T and Q216P) resulted in impaired homodimerization with the wild-type protein in yeast interaction assays, suggesting a functional deficiency. This study demonstrates the utility of this approach for analysis of haploid germ cell-expressed genes regulating post-meiotic events including sperm maturation, motility and fertilization. The development of non-invasive techniques to analyze genetic defects of human spermatogenesis, previously possible only with invasive testis biopsies, provides important diagnostic and therapeutic implications for reproductive medicine.

Meta-analysis of sperm DNA fragmentation using the sperm chromatin structure assay

Meta-analyses were conducted to investigate the relationship of sperm DNA fragmentation on pregnancy outcome using in-vivo fertilization, IUI, routine IVF and ICSI. Couples with no known infertility problems were 7.0 times (CI 3.17, 17.7) more likely to achieve a pregnancy/delivery if the DNA fragmentation index (DFI) was <30% (n = 362, P = 0.0001) using in-vivo fertilization. Infertile couples using IUI were 7.3 times (CI 2.88, 18.3) more likely to achieve a pregnancy/delivery if their DFI was <30% (n = 518, P = 0.0001). With routine IVF, infertile couples were approximately 2.0 times (CI 1.02, 2.84) more likely to become pregnant if their DFI was <30% (n = 381, P = 0.03). For ICSI and/or routine IVF, the results showed a non-significant trend where infertile couples were 1.6 times (CI 0.92, 2.94) more likely to achieve a pregnancy/delivery if the DFI was <30% (n = 323,P = 0.06). The in-vivo and IUI meta-analyses were similar, indicating that IUI infertility patients with <30% DFI have as good a statistical probability of obtaining a pregnancy/delivery as in-vivo presumably fertile couples with the same DFI. These meta-analyses show that the Sperm Chromatin Structure Assay infertility test was significantly predictive for reduced pregnancy success using in-vivo, IUI and routine IVF, and to a lesser extent ICSI fertilization.

Multiple gestations and late preterm (near-term) deliveries

Multiple gestations present unique challenges to the modern obstetrician. Many twin and high-order multiple pregnancies are delivered between 34 and 37 weeks' gestation either secondary to preterm labor or obstetrical complications necessitating intervention. Recognizing the increasing prevalence of multiple gestations and the impact of late preterm deliveries in modern practice, this review analyzes the impact of multiple pregnancies on perinatal outcomes, reviews the strategies to prevent preterm labor, and summarizes potential indications for late preterm delivery. In this paper, "late preterm" has been used instead of "near-term," as the former was considered more appropriate to reflect this subgroup of preterm infants in a workshop on this topic held in July 2005, organized by the National Institute of Child Health and Human Development.

Outcomes From Assisted Reproductive Technology

The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, including extended embryo culture, may allow the transfer of fewer embryos to maintain pregnancy rates while reducing the risk of multiple gestations. Although much of the morbidity in children born after ART is the result of multiples, recent analysis suggests that even singletons are at higher risk for perinatal morbidity, including preterm delivery and small for gestational age infants. In vitro fertilization may be associated with a slight increased risk for birth defects. The major short-term complication of ART in women is the development of ovarian hyperstimulation syndrome. This syndrome is difficult to predict, but new treatments are being developed that may limit its frequency. Because of its high pregnancy rate, couples are moving to ART more quickly in the management of their infertility. All outcomes of ART, including pregnancy rates and adverse complications, need to be compared with standard non-ART therapy when deciding the appropriate course of treatment for a given couple.