The Canadian Assisted Reproductive Technologies Register (CARTR) Plus database: a validation study

STUDY QUESTION

Are data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database?

SUMMARY ANSWER

Measures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer.

WHAT IS KNOWN ALREADY

Health databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada's national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated.

STUDY DESIGN SIZE DURATION

This study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection.

PARTICIPANTS/MATERIALS SETTING METHODS

Twenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables.

MAIN RESULTS AND THE ROLE OF CHANCE

Six clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90.

LARGE-SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

CARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Complications of the third stage of labor are more prevalent in IVF pregnancies

Background: Pregnancies conceived by in vitro fertilization (IVF) are associated with a higher prevalence of perinatal complications than pregnancies conceived spontaneously, even after correction of confounding factors. Little is known about the prevalence of complications of the third stage of labor in IVF pregnancies.Objective: To compare the prevalence and types of complications of the third stage of labor following vaginal delivery of singleton infants born to matched groups of women who conceived through IVF or spontaneously.Study design: A retrospective case-control study design was used. The electronic delivery files of a tertiary medical center were reviewed for all women with a singleton IVF pregnancy who gave birth by vaginal delivery from August 2011 to March 2014. The women were matched 1:2 for age, gravidity, parity, and week of delivery to women with a singleton spontaneously conceived pregnancy who gave birth by vaginal delivery during the same period at the same hospital. The impact of mode of conception on the length and complications of the third stage of labor was evaluated.Results: The study group consisted of 242 women with IVF pregnancies (cases), and 484 matched controls with spontaneously conceived pregnancies (controls). The length of the third stage was similar in the cases and controls (14.23 ± 8.89 and 13.69 ± 9.19 min, respectively). IVF pregnancy was associated with a significantly higher rate of postpartum hemorrhage (PPH) (5.79 versus 1.45%, p = .001), manual removal of retained placenta (11.98 versus 7.02%, p = .025), and blood transfusion (2.07 versus 0.41%, p = .032). On multivariate analysis, pregnancy conceived by IVF was an independent risk factor for an adverse outcome of the third stage of labor (OR 2.86, 95% CI 1.53-5.33).Conclusion: After correction for confounders, IVF conception proved to be a significant independent risk factor for PPH, manual removal of the placenta, and blood transfusion in the third stage of labor. Therefore, the management of women who give birth vaginally following IVF pregnancy should be designed to anticipate complications in the third stage even in the absence of other risk factors.

Maternal and child-health outcomes in pregnancies following Assisted Reproductive Technology (ART): a prospective cohort study

BACKGROUND

Studies comparing the outcome of spontaneous versus assisted reproductive technologies (ART) pregnancies report heterogeneous results. Despite the success of ART to overcome infertility, concern is growing regarding both its safety and its effect on maternal and child health. The objective of this study was to compare maternal and child-health outcomes after ART relative to natural conception.

METHODS

A population-based birth cohort study was carried out among pregnant women expected to deliver in 2015 in Pelotas, southern Brazil. Maternal outcomes included pregnancy complications and gestational weight gain. Gestational age, weight, intrauterine growth restriction, length and head circumference, and 1-min and 5-min Apgar, as well as health problems at birth and breastfeeding were defined as offspring outcomes. Statistical analyses were performed using linear and logistic regression. G-formula was used to perform mediation analysis.

RESULTS

The study included 4252 babies born by spontaneously pregnancies and 23 babies born after ART. Adjusted analyses showed that children conceived from ART presented lower means of gestational age (p = 0.001), birth weight (p = 0.002), length (p < 0.001), and head circumference at birth (p = 0.02). However, more than 90% of the effect of ART over these outcomes was mediated by multiple pregnancy.

CONCLUSION

Our findings suggest that the possible negative effect on the child-health outcomes is due mainly to the higher incidence of multiple pregnancies and not because of ART. The reasons for the increase in adverse pregnancy outcomes associated with ART singleton pregnancies are still uncertain and warrants further research. Further large-population studies are needed to confirm these results.

Assisted reproductive technology and the risk of gestational diabetes mellitus: a systematic review and meta-analysis

Background

The use of assisted reproductive technology (ART) is increasing worldwide, and observational studies have indicated that women who conceived by ART have an increased risk of pregnancy complications including gestational diabetes mellitus (GDM). We aimed to determine the risk of GDM among women who conceived with ART by systematic review and meta-analysis.

Main text

A systematic literature search was conducted in ISI Web of Knowledge, MEDLINE, Scopus, and Embase through May 2017 for English-language articles using a list of keywords. All studies comparing GDM in women conceived by ART and those who conceived spontaneously were included. Data extraction was performed by two authors independently and discrepancies were resolved by discussion. In total, 48 studies with 91,487 pregnancies conceived through ART and 2,525,234 spontaneously conceived met the inclusion criteria. There was evidence of substantial heterogeneity among these studies (P < 0.001, I2 = 98.6%). Random effects meta-analysis showed a significant increase in GDM among those who conceived by ART compared with those who conceived spontaneously (pooled relative risk = 1.51, 95% confidence interval = 1.18–1.93). Visual inspection of the funnel plot did not reveal any publication bias, which was supported by Egger’s test and Begg’s test.

Conclusion

The findings of this systematic review indicate that the use of ART treatment is associated with a 1.51-fold increase in GDM. Women need to be counselled carefully before undergoing ART treatment about the possibility and risk of GDM.

Frozen-thawed embryo transfer: the potential importance of the corpus luteum in preventing obstetrical complications

The use of frozen-thawed embryo transfer (FET) has increased over the past decade with improvements in technology and increasing live birth rates. FET facilitates elective single-embryo transfer, reduces ovarian hyperstimulation syndrome, optimizes endometrial receptivity, allows time for preimplantation genetics testing, and facilitates fertility preservation. FET cycles have been associated, however, with an increased risk of hypertensive disorders of pregnancy for reasons that are not clear. Recent evidence suggests that absence of the corpus luteum (CL) could be at least partly responsible for this increased risk. In a recent prospective cohort study, programmed FET cycles (no CL) were associated with higher rates of preeclampsia and preeclampsia with severe features compared with modified natural FET cycles. FET cycles are commonly performed in the context of a programmed cycle in which the endometrium is prepared with the use of exogenous E2 and P. In these cycles, ovulation is suppressed and therefore the CL is absent. The CL produces not only E2 and P, but also vasoactive products, such as relaxin and vascular endothelial growth factor, which are not replaced in a programmed FET cycle and which are hypothesized to be important for initial placentation. Emerging evidence has also revealed other adverse obstetrical and perinatal outcomes, including postpartum hemorrhage, macrosomia, and post-term birth specifically in programmed FET cycles compared with natural FET cycles. Despite the widespread use of FET, the optimal protocol with respect to live birth rate, maternal health, and perinatal outcomes has yet to be determined. Future practice regarding FET should be based on high-quality evidence, including rigorous controlled trials.

Increased blood pressure and impaired endothelial function after accelerated growth in IVF/ICSI children

STUDY QUESTION

What is the effect of growth velocity (height and weight) in early infancy on metabolic end-points and endothelial function in children born after ART?

SUMMARY ANSWER

Neonatal, infant and childhood growth is positively related to blood pressure in 9-year-old IVF/ICSI offspring, while growth in childhood was negatively associated with endothelial function.

WHAT IS KNOWN ALREADY

Offspring of pregnancies conceived after ART are at risk for later cardiometabolic risk factors. It is well established that early growth is related to numerous later cardiometabolic risk factors such as high blood pressure. This concept is known as the Developmental Origin of Health and Disease theory.

STUDY DESIGN SIZE DURATION

The relation between early growth and later cardiometabolic risk profile was studied in the MEDIUM-KIDS study, a prospective observational cohort study in children born after an IVF/ICSI treatment. In 131 children (48.1% males) at the average age of 9.4 years, cardiometabolic outcomes were assessed and growth data from birth until age 9 years were collected from child welfare centers.

PARTICIPANTS/MATERIALS SETTINGS METHODS

The following cardiometabolic outcomes were assessed: blood pressure, skinfolds, lipid spectrum, hair cortisone and glucose and insulin levels. Data on maximum skin perfusion after transdermal delivery of acetylcholine as a measure of endothelial function were collected.Growth charts were obtained electronically from child welfare centers, which offer free consultations and vaccinations to all Dutch children. At these centers, height and weight are recorded at predefined ages. Growth was defined as z-score difference in weight between two time points. Multivariable linear regression analysis was used to model the relation between growth and cardiometabolic outcomes. The following growth windows were -studied simultaneously in each model: 0-1 month, 1-3 months, 3-6 months, 6-11 months, 11-24 months and 2-6 years. The model was adjusted for height growth in all intervals except for 0-1 month.

MAIN RESULTS AND THE ROLE OF CHANCE

In multivariable linear regression analyses, multiple growth windows were positively associated with blood pressure, for example growth from 2-6 years was significantly related to systolic blood pressure: B = 4.13, P = 0.005. Maximum skin perfusion after acetylcholine was negatively associated with height-adjusted weight gain from 2 to 6 years: B = -0.09 (log scale), P = 0.03. Several growth windows (weight 1-3 months, 3-6 months, 6-11 months, 11-24 months, 2-6 years) were positively linked with total adiposity. Lipids, glucose tolerance indices and cortisone were not related to growth.

LIMITATIONS REASONS FOR CAUTION

This study is of modest size and of observational nature, and we did not include a control group. Therefore, we cannot assess whether the observed associations are causal. It is also not possible to analyze if our observations are specific for, or exacerbated in, the ART population. Ideally, a control group of naturally conceived siblings of IVF/ICSI children should simultaneously be studied to address this limitation and to assess the impact of the ART procedure without the influence of parental (subfertility) characteristics.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study contribute to our understanding of the reported increased risk for hypertension in ART offspring. We speculate that early, accelerated growth may be involved in the reported increased risk for hypertension in ART offspring, with endothelial dysfunction as a possible underlying mechanism. However, additional research into the mechanisms involved is required.

STUDY FUNDING/COMPETING INTERESTS

The study was financially supported by the March of Dimes, grant number #6-FY13-153. The sponsor of the study had no role in study design, data collection, data analysis, data interpretation or writing of the paper. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

NTR4220.

Epigenetic changes and assisted reproductive technologies

Children conceived by Assisted Reproductive Technologies (ART) are at moderately increased risk for a number of undesirable outcomes, including low birth weight. Whether the additional risk is associated with specific procedures used in ART or biological factors that are intrinsic to infertility has been the subject of much debate, as has the mechanism by which ART or infertility might influence this risk. The potential effect of ART clinical and laboratory procedures on the gamete and embryo epigenomes heads the list of mechanistic candidates that might explain the association between ART and undesirable clinical outcomes. The reason for this focus is that the developmental time points at which ART clinical and laboratory procedures are implemented are precisely the time points at which large-scale reorganization of the epigenome takes place during normal development. In this manuscript, we review the many human studies comparing the epigenomes of ART children with children conceived in vivo, as well as assess the potential of individual ART clinical and laboratory procedures to alter the epigenome.

Maternal age and risk of low birth weight and premature birth in children conceived through medically assisted reproduction. Evidence from Finnish population registers

STUDY QUESTION

Does the risk of low birth weight and premature birth increase with age among mothers who conceive through medically assisted reproduction (MAR)?

SUMMARY ANSWER

Among MAR mothers, the risk of poorer birth outcomes does not increase with maternal age at birth except at very advanced maternal ages (40+).

WHAT IS KNOWN ALREADY

The use of MAR treatments has been increasing over the last few decades and is especially diffused among women who conceive at older ages. Although advanced maternal age is a well-known risk factor for adverse birth outcomes in natural pregnancies, only a few studies have directly analysed the maternal age gradient in birth outcomes for MAR mothers.

STUDY DESIGN, SIZE, DURATION

The base dataset was a 20% random sample of households with at least one child aged 0-14 at the end of 2000, drawn from the Finnish population register and other administrative registers. This study included children who were born in 1995-2000, because the information on whether a child was conceived through MAR or naturally was available only from 1995 onwards.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The outcome measures were whether the child had low birth weight (LBW, <2500 g at birth) and whether the child was delivered preterm (<37 weeks of gestation). Conceptions through MAR were identified by examining data on purchases of prescription medication from the National Prescription Register. Linear probability models were used to analyse and compare the maternal age gradients in birth outcomes of mothers who conceived through MAR or naturally before and after adjustment for maternal characteristics (i.e. whether the mother suffered from acute/chronic conditions before the pregnancy, household income and whether the mother smoked during pregnancy).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 56 026 children, 2624 of whom were conceived through MAR treatments, were included in the study. Among the mothers who used MAR to conceive, maternal age was not associated with an increased risk of LBW (the overall prevalence was 12.6%) at ages 25-39. For example, compared to the risk of LBW at ages 30-34, the risk was 0.22 percentage points lower (95% CI: -3.2, 2.8) at ages 25-29 and was 1.34 percentage points lower (95% CI: -4.5, 1.0) at ages 35-39. The risk of LBW was increased only at maternal ages ≥40 (six percentage points, 95% CI: 0.2, 12). Adjustment for maternal characteristics only marginally attenuated these associations. In contrast, among the mothers who conceived naturally, the results showed a clear age gradient. For example, compared to the risk of LBW (the overall prevalence was 3.3%) at maternal ages 30-34, the risk was 1.1 percentage points higher (95% CI: 0.6, 1.6) at ages 35-39 and was 1.5 percentage points higher (95% CI: 0.5, 2.6) at ages ≥40. The results were similar for preterm births.

LIMITATIONS, REASON FOR CAUTION

A limited number of confounders were included in the study because of the administrative nature of the data used. Our ability to reliably distinguish mothers based on MAR treatment type was also limited.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to analyse the maternal age gradient in the risk of adverse birth outcomes among children conceived through MAR using data from a nationally representative sample and controlling for important maternal health and socio-economic characteristics. This topic is of considerable importance in light of the widespread and increasing use of MAR treatments.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this project was provided by the European Research Council (grant no. 803959 MARTE to Alice Goisis and grant no. 336475 COSTPOST to Mikko Myrskylä). E.S. reports personal fees from Theramex, personal fees from Merck Serono, personal fees from Health Reimbursement Arrangement, non-financial support from Merck Serono and grants from Ferring, grants from Theramex, outside the submitted work. The remaining authors have no competing interests.

TRIAL REGISTRTION NUMBER

N/A.

Is Embryo Cryopreservation Causing Macrosomia-and What Else?

The number of embryos transferred during an IVF cycle is directly related to the high incidence of multiple births, which is the culprit of perinatal morbidity. Therefore, single fresh embryo transfer (ET) strategy, or freeze-all, followed by a single frozen-thawed embryo transfer (FET) cycle, may dramatically reduce the rate of multiple births, without compromising the cumulative live birth rates (LBRs). A literature review was conducted for all available evidences assessing obstetrics and perinatal outcomes associated with FET compared to fresh ET and natural conception. While studies comparing fresh and FET cycles in normal responders have yielded conflicting results for pregnancy rate, FET was associated with lower risk of prematurity and low birth weight and increased risk of large for gestational age (LGA) and/or macrosomic in singletons, when compared with fresh ET. Macrosomic/LGA births have a higher risk of fetal hypoxia, stillbirth, shoulder dystocia, perineal lacerations, cesarean section, postpartum hemorrhage and neonatal metabolic disturbances at birth. Nonetheless, it seems that other than higher risk of fetal macrosomia, there are additional obstetric complications associated with FET. The relative risk of hypertensive disorders in pregnancy, as well as perinatal mortality were also demonstrated to be increased in FET compared with singletons from fresh ET and natural conception. Therefore, when considering elective freeze-all policy, in addition to LBR and the risk of ovarian hyperstimulation syndrome, physicians should consider the aforementioned increased FET cycles' pregnancy complications, including LGA/ macrosomia, hypertensive disorders of pregnancy, as well as perinatal mortality.

Maternal and Neonatal Complications in Twin Deliveries as Compared to Singleton Deliveries following In vitro Fertilization

BACKGROUND

Twin pregnancy is an iatrogenic complication following in vitro fertilization (IVF) that can be decreased using elective single-embryo transfer. However, the risks associated with twin pregnancy following IVF as compared to singleton IVF pregnancy need to be further evaluated.

AIM

This study aims to compare the maternal, perinatal, and neonatal complications in singleton and twin pregnancies following IVF-intracytoplasmic sperm injection (ICSI). Settings and Design: Retrospective observational cohort study using previously collected routine patient data.

MATERIALS AND METHODS

Singleton and twin deliveries following IVF/ICSI from January 2014 to August 2015 were included. Data were collected from patient records and the obstetricians of the patients.

STATISTICAL ANALYSIS USED

SPSS was used for analysis. Student's t-test and Fisher's exact test were used for continuous and categorical data, respectively. Significance was kept at 0.05.

RESULTS

There were 897 singleton and 382 twin deliveries (total of 1661 babies). The mean gestational age at delivery was lower in twin deliveries (34.9 ± 3.1 weeks) as compared to singleton deliveries (36.8 ± 3.2 weeks, P < 0.001). The overall incidence of maternal complications was higher in twin pregnancies (29.3% vs. 21.3%, odds ratio = 1.53, 95% confidence interval = 1.17-2.01; P = 0.003). The mean birth weight of babies was significantly lower (2.02 ± 0.58 kg vs. 2.71 ± 0.68 kg; P < 0.001) and the incidence of stillbirth plus neonatal death was higher (7.5% vs. 4.6%, P = 0.01) in the twin group as compared to the singleton group.

CONCLUSION

Twin deliveries, following IVF/ICSI deliver at lower gestational age, have lower birth weight and have higher odds of stillbirth plus neonatal death as compared to singleton deliveries following IVF/ICSI.

Prenatal attachment in pregnancy following assisted reproductive technology: a literature review

Objective: To summarise the literature on prenatal attachment in pregnancies following Assisted Reproductive Technology (ART).Background: Prenatal attachment can predict the quality of the postpartum parent-infant relationship and is linked to perinatal mental health of the parents and their adjustment to the parental role. It might be expected prenatal attachment will be influenced by fertility treatment such as ART, but there are contradictory results.Methods: In this review, studies with a cross-sectional and longitudinal design, published in 1990-2019 were included. A search was conducted in MEDLINE/PubMed, EMbase, Web of Science and Scopus, and using the Google Scholar search engine. A total of 17 articles were found which met the inclusion criteria and after these articles were reviewed using the STROBE-checklist, 15 articles were included in the study.Results: In most couples who conceived following ART, the level of prenatal attachment was either similar to or higher than in couples who conceive without ART.Conclusions: The findings challenge the idea that infertility problems affect attachment in pregnancies following ART. However, ART- couples may be more susceptible to anxiety due to pregnancy loss and support may be better focused on the pregnancy-related anxiety in these couples rather than any attachment intervention.

Clinical utility of freeze-all approach in ART treatment: A mini-review

A significant proportion of couples at reproductive age rely on assisted reproductive technology to overcome infertility. In vitro fertilisation (IVF) involves typically the use of exogenous gonadotropins to stimulate the ovary to produce oocytes, which are collected surgically. After fertilization by conventional IVF or intracytoplasmic sperm injection (ICSI), embryos are cultured in the embryology laboratory for a few days before being replaced into the uterus (fresh embryo transfer). Spare embryos can be vitrified and stored in liquid nitrogen to be transferred in a subsequent cycle. Over the years, concerns have arisen about possible adverse outcomes of transferring embryos back to the uterus immediately after controlled ovarian stimulation (COS) as regards to obstetrical and perinatal outcomes. It has been suggested that high hormonal levels during COS could create a relatively hostile environment for embryo implantation whilst increasing the risk of ovarian hyperstimulation syndrome (OHSS). With the remarkable improvement of vitrification as an alternative to the slow-freezing technique for human embryos, a new strategy the so-called "freeze-all" (FA) or "elective frozen embryo transfer" (eFET) was introduced. This approach involves COS, followed by the elective cryopreservation of the entire cohort of viable embryos to be transferred to the uterus in subsequent cycles in a possibly more physiological environment, thus avoiding the supra-physiologic hormonal levels observed during COS. The initial reports suggested that this policy could lead to improved pregnancy rates and reduced perinatal complications, which resulted in a steady increase and widespread use of FA globally. However, as data accumulated, it became clear that the use of FA to unselected couples undergoing ART offered no additional benefits over the conventional approach. Nonetheless, current evidence based on randomized controlled trials and observational studies indicates that FA might be justified in selected clinical scenarios, such as those involving the risk of OHSS. By contrast, there is a lack of evidence to support the FA policy for other indications, such as implantation failure or high progesterone levels on the trigger day. This review summarizes the clinical effectiveness of FA with the main focus on the health of offspring.

Increased Preeclampsia Risk and Reduced Aortic Compliance With In Vitro Fertilization Cycles in the Absence of a Corpus Luteum

In vitro fertilization involving frozen embryo transfer and donor oocytes increases preeclampsia risk. These in vitro fertilization protocols typically yield pregnancies without a corpus luteum (CL), which secretes vasoactive hormones. We investigated whether in vitro fertilization pregnancies without a CL disrupt maternal circulatory adaptations and increase preeclampsia risk. Women with 0 (n=26), 1 (n=23), or >1 (n=22) CL were serially evaluated before, during, and after pregnancy. Because increasing arterial compliance is a major physiological adaptation in pregnancy, we assessed carotid-femoral pulse wave velocity and transit time. In a parallel prospective cohort study, obstetric outcomes for singleton livebirths achieved with autologous oocytes were compared between groups by CL number (n=683). The expected decline in carotid-femoral pulse wave velocity and rise in carotid-femoral transit time during the first trimester were attenuated in the 0-CL compared with combined single/multiple-CL cohorts, which were similar (group-time interaction: P=0.06 and 0.03, respectively). The blunted changes of carotid-femoral pulse wave velocity and carotid-femoral transit time from prepregnancy in the 0-CL cohort were most striking at 10 to 12 weeks of gestation ( P=0.01 and 0.006, respectively, versus 1 and >1 CL). Zero CL was predictive of preeclampsia (adjusted odds ratio, 2.73; 95% CI, 1.14-6.49) and preeclampsia with severe features (6.45; 95% CI, 1.94-25.09) compared with 1 CL. Programmed frozen embryo transfer cycles (0 CL) were associated with higher rates of preeclampsia (12.8% versus 3.9%; P=0.02) and preeclampsia with severe features (9.6% versus 0.8%; P=0.002) compared with modified natural frozen embryo transfer cycles (1 CL). In common in vitro fertilization protocols, absence of the CL perturbed the maternal circulation in early pregnancy and increased the incidence of preeclampsia.

Rethinking mechanisms, diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Risk of gestational diabetes mellitus following assisted reproductive technology: systematic review and meta-analysis of 59 cohort studies

OBJECTIVE

The use of assisted reproductive technology (ART) has been associated with an increased risk of gestational diabetes mellitus (GDM) in previous studies, but its risk has not been consistent. Therefore, we aimed to estimate the risk of GDM in women who conceived with ART via a systematic review and meta-analysis of cohort studies.

METHODS

ISI Web of Knowledge, Medline/PubMed, Scopus, and Embase databases were searched to identify studies that evaluated the risk of GDM through May 2017 using the relevant keywords. Two reviewers independently performed the screening, data extraction, and quality assessment. Meta-analysis was performed with a random effects model.

RESULTS

The search yielded 957 records relating to GDM and use of ART, from which 59 eligible cohorts were selected for meta-analysis (n = 96,785). There was evidence of substantial heterogeneity among these studies (χ₍₅₈₎² = 3072.34, p < .001; I²=98.1%). The pooled estimate of GDM risk using the random effects model was 9.00% (95% CI: 7.90-10.20). Visual inspection of the funnel plot indicated the presence of low publication bias, but Egger's test did not reveal publication bias.

CONCLUSIONS

The findings revealed that the risk of GDM was very high among women who conceived with ART treatment. GDM screening, management, and improved care are vital in ART pregnancy.

Birthweight of IVF children is still a current issue and still related to maternal factors

RESEARCH QUESTION

Does fresh embryo transfer after IVF with or without intracytoplasmic sperm injection (ICSI) increase the small for gestational age (SGA) rate, and frozen embryo transfer (FET) after IVF with or without ICSI increase the large for gestational age (LGA) rate versus natural conception?

DESIGN

Retrospective comparison of an exposed historical group/cohort involving singletons conceived after fresh embryo transfer and after FET with an unexposed group/cohort involving singletons conceived after a natural conception.

RESULTS

A total of 1961 fresh embryo transfer babies and 366 FET babies were compared with 6981 natural conception babies. The SGA rate in fresh embryo transfer babies was not significantly different to natural conception babies (6.9% versus 6.8%, P = 0.856). This outcome was not influenced by the fresh embryo transfer (adjusted odds ratio [aOR] 1.0; 95% confidence interval [CI] 0.8-1.3), but rather by a low rate of multiparity (aOR 0.5; 95% CI 0.3-0.7), advanced maternal age (aOR 1.1; 95% CI 1.0-1.2), maternal underweight (aOR 1.5; 95% CI 1.1-2.1), maternal smoking or cessation during pregnancy (aOR 1.8; 95% CI 1.4-2.3), pre-existing hypertension (aOR 2.3; 95% CI 1.3-4.1) and pregnancy-induced hypertension (aOR 2.5; 95% CI 1.7-3.7). The LGA rate in FET babies was significantly different from natural conception babies (6.6% versus 3.2%, P = 0.012). This outcome was influenced by the transfer of frozen embryos (aOR 2.2; 95% CI 1.3-3.8) and by a high maternal weight (aOR 1.9; 95% CI 1.1-3.6).

CONCLUSIONS

Maternal background and obstetric parameters are more likely to influence the SGA rate than fresh embryo transfer conception. FET conception could be associated with an increase in LGA rate.

Maternal and Fetal Risk Associated With Assisted Reproductive Technology

Infertility is a disease that affects up to 15.5% of reproductive-aged couples. Until the birth of the first neonate born from in vitro fertilization (IVF) in 1978, many infertile couples did not have an opportunity to conceive a biological child. Over the past 40 years, access to and effectiveness of IVF have increased; currently 1.7% of births in the United States result from IVF. As with any medical intervention, potential risk exists. In the case of IVF, both maternal risks (ovarian stimulation, oocyte retrieval, and subsequent pregnancy) and fetal risks that vary based on maternal age and fetal number must be considered. Importantly, risk quantification varies by comparison group, which is typically either spontaneous conception in a fertile couple or assisted non-IVF conception in an infertile couple. It must also be considered compared with the alternative of not undergoing IVF, which may mean not having a biological child. Although increased compared with spontaneous conception, absolute maternal-fetal-assisted reproductive technology risks are low and can be minimized by optimizing ovarian stimulation and transferring a single embryo. In this article, we aim to summarize maternal and fetal risk associated with use of assisted reproductive technology. The review focuses on ovarian stimulation and procedural risks as well as adverse perinatal outcomes among resultant singleton and twin pregnancies in young women and women of advanced maternal age.

Preterm Birth, Low Gestational Age, Low Birth Weight, Parity, and Other Determinants of Breech Presentation: Results from a Large Retrospective Population-Based Study

Aim of this study is to analyze determinants of breech presentation using information from two regional databases of Lombardy (Italy) including data on consecutive singleton breech and vertex deliveries occurred in the Region, between January 2010 and December 2015. Breech presentation occurred in 3.8% of all single deliveries. Main determinants of breech presentation at birth were: gestational age and birth weight (the lower, the higher the incidence of breech presentation), maternal age (the older the mother, the higher the risk of breech presentation), parity (the frequency of breech decreased with increasing parity) and previous cesarean section. Breech presentation resulted more frequent after assisted reproduction procedures.

The PLART study: incidence of preterm labor and adverse pregnancy outcomes after assisted reproductive techniques-a retrospective cohort study

KEY MESSAGE

Even though assisted reproductive techniques represent one of the greatest achievements in modern medicine, the risk of preterm birth related to these pregnancies is about twice as high. This must be highlighted and further investigated to optimize the management of both mothers and newborns.

PURPOSE

The purpose of this study was to compare adverse pregnancy outcomes after assisted reproductive techniques (ART) and spontaneous conceptions, focusing on the incidence of preterm births (PTB) and distinguishing between iatrogenic and spontaneous events.

METHODS

This retrospective cohort study analyzed single births of one Italian hospital. The incidence of PTBs in ART pregnancies, divided into iatrogenic procedures, spontaneous preterm labors and preterm premature ruptures of the membranes (pPROMs), was compared with the non-ART control group. The incidence of other adverse pregnancy outcomes and the types of delivery were also reported and compared.

RESULTS

Of the 11,769 single births included, 2.39% were conceived by ART. The incidence of PTBs was 4.74% for spontaneous pregnancies and 12.8% for ART pregnancies (aOR 1.93; 95% CI 1.29-2.88). The percentage of iatrogenic procedures was 27.78% in the ART-PTBs' group and 30.88% in the non-ART-PTBs' controls. ART pregnancies showed an increased incidence of pPROMs (6.40% versus 2.41%), preterm labors (2.85% versus 0.93%), hypertensive disorders of the pregnancy (8.19% versus 2.32%), placenta previa (3.20% versus 0.59%), cesarean sections (28.47% versus 16.27%) and vacuum extractions (10.32% versus 5.19%).

CONCLUSIONS

Singleton ART pregnancies have a higher risk of PTB which is mostly linked to a higher incidence of pPROMs and spontaneous preterm labor. The concurrency of a demonstrated higher risk of hypertensive gestational disorders and placenta previa suggests that placental development plays an important role in the pathogenesis of PTB.

Intracytoplasmic sperm injection for male infertility and consequences for offspring

Intracytoplasmic sperm injection (ICSI) has become the most commonly used method of fertilization in assisted reproductive technology. The primary reasons for its popularity stem from its effectiveness, the standardization of the procedure, which means that it can easily be incorporated into the routine practice of fertility centres worldwide, and the fact that it can be used to treat virtually all forms of infertility. ICSI is the clear method of choice for overcoming untreatable severe male factor infertility, but its (over)use in other male and non-male factor infertility scenarios is not evidence-based. Despite all efforts to increase ICSI efficacy and safety through the application of advanced sperm retrieval and cryopreservation techniques, as well as methods for selecting sperm with better chromatin integrity, the overall pregnancy rates from infertile men remain suboptimal. Treating the underlying male infertility factor before ICSI seems to be a promising way to improve ICSI outcomes, but data remain limited. Information regarding the health of ICSI offspring has accumulated over the past 25 years, and there are reasons for concern as risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility, cancer, delayed psychological and neurological development, and impaired cardiometabolic profile have been observed to be greater in infants born as a result of ICSI than in naturally conceived children. However, as subfertility probably influences the risk estimates, it remains to be determined to what extent the observed adverse outcomes are related to parental factors or associated with ICSI.

Assisted reproductive technologies are associated with limited epigenetic variation at birth that largely resolves by adulthood

More than 7 million individuals have been conceived by Assisted Reproductive Technologies (ART) and there is clear evidence that ART is associated with a range of adverse early life outcomes, including rare imprinting disorders. The periconception period and early embryogenesis are associated with widespread epigenetic remodeling, which can be influenced by ART, with effects on the developmental trajectory in utero, and potentially on health throughout life. Here we profile genome-wide DNA methylation in blood collected in the newborn period and in adulthood (age 22–35 years) from a unique longitudinal cohort of ART-conceived individuals, previously shown to have no differences in health outcomes in early adulthood compared with non-ART-conceived individuals. We show evidence for specific ART-associated variation in methylation around birth, most of which occurred independently of embryo culturing. Importantly, ART-associated epigenetic variation at birth largely resolves by adulthood with no direct evidence that it impacts on development and health.

Use of Assisted Reproductive Technologies (ART) is increasing globally but their impact on long term health remains unclear. Here the authors show that ART-conceived individuals show variation in epigenetic profile at birth that largely resolves by adulthood, with no evidence of an impact on long term outcomes.

The greater incidence of small-for-gestational-age newborns after gonadotropin-stimulated in vitro fertilization with a supraphysiological estradiol level on ovulation trigger day

Introduction

Reproductive scientists have postulated various risk factors for lower birthweight following conventional gonadotropin‐stimulated in vitro fertilization compared with spontaneously conceived children: parental factors (age, health, duration of subfertility and smoking habits); ovarian stimulation; laboratory procedures; the number of oocytes retrieved and the number of embryos transferred. Our aim was to investigate the impact of gonadotropin stimulation and serum estradiol level on the risk of a newborn being small‐for‐gestational‐age.

Material and methods

We conducted a cohort study (2010‐2016) of singletons (n = 155) born either after conventional gonadotropin‐stimulated in vitro fertilization (using ≥150 IU/d human gonadotropin for stimulation) or after natural cycle in vitro fertilization without any stimulation. We analyzed perinatal outcomes using birthweight percentiles, adjusted for gestational age and sex.

Results

The proportion of small‐for‐gestational‐age was 11.8% following conventional gonadotropin‐stimulated in vitro fertilization and 2.9% after natural cycle in vitro fertilization (P = 0.058). The odds of small‐for‐gestational‐age were significantly higher with supraphysiological estradiol levels in maternal serum on ovulation trigger day (unadjusted odds ratio 4.58; 95% confidence interval 1.35‐15.55; P = 0.015). It remained significant after adjusting for maternal height, age and body mass index (adjusted odds ratio 3.83; 95% confidence interval 1.06‐13.82; P = 0.041).

Conclusions

We found an associated risk of children being born small‐for‐gestational‐age after conventional gonadotropin‐stimulated in vitro fertilization compared with natural cycle in vitro fertilization. This higher risk is significantly associated with supraphysiological estradiol levels. We propose a reduction in the dosage of gonadotropin to minimize the risk of small‐for‐gestational‐age and future health consequences.

Risk of preterm delivery in singletons conceived by in vitro fertilization

To evaluate the preterm delivery and other obstetrics complications similar in singleton pregnancies achieved through IVF compared to spontaneous pregnancies. Retrospective case-control study included 1663 women with singleton pregnancies following IVF-ICSI (study group) and 3326 women with singleton spontaneous pregnancies (control group) who delivered between January 2015 and January 2018 at the Peking University Third Hospital. The control group matched 1:2 by age, BMI, parity, and gravidity. Maternal outcomes included preterm delivery and complications. There was significantly higher incidence of gestational diabetes, hypertensive disorders, and placenta previa in IVF-ICSI pregnancies versus controls (p < .05). IVF-ICSI resulted in significantly higher rate of preterm birth than in spontaneous pregnancies (p < .05) and the difference remained significant for deliveries that occurred before 28, 32, and 34 weeks gestation (p < .05). Multivariate logistic regression analysis revealed that female-factor infertility, hypertensive disorder, placenta previa, and PROM were significant prognostic factors associated with increased risk of prematurity. IVF-ICSI is associated with increased risk of obstetric complications including preterm delivery in singleton pregnancies. Female-factor infertility is an independent prognostic factor for preterm birth. This information is important for patient counseling and helps to refine the recommendation to optimize maternal health before embarking on fertility treatments.

Gestational age at delivery of twins and perinatal outcomes: a cohort study in Aberdeen, Scotland

Background: Twin pregnancy is associated with a threefold increase in perinatal death compared to singletons.  The objective of this study was to determine the risk of perinatal death in twins by week of gestation and to quantify the effect of known risk factors. Methods: A cohort analysis was performed using data from the Aberdeen Maternity and Neonatal Databank (AMND).  The exposure was gestational age at delivery and the primary outcome was perinatal death.  Adjusted hazard ratios (aHRs) for perinatal death according to gestational age at delivery were determined by multivariate Cox proportional hazards regression modelling with robust standard errors to account for clustering in the twin infants.  Confounders and risk factors quantified and adjusted for in the model included maternal age, smoking, parity, marital status and year of birth.  Kaplan-Meier time to event analysis was used to determine the differences in survival according to chorionicity and assisted reproduction technologies (ART) conception status. Results: The population comprised of 7,420 twin babies born between 1950 and 2013 in the Grampian area of Northern Scotland.  There were 272 stillbirths in the cohort (3.67%) and 273 neonatal deaths (3.68%). Compared to delivery at 37-38 weeks, delivery before 37 weeks was associated with a 2-fold increase in perinatal death. Monochorionic twins had a 2-fold increase in perinatal death compared to dichorionic twins (aHR 2.15, 95% CI 1.60-2.90). Twins conceived by ART did not have a greater risk of perinatal death compared to those naturally conceived (aHR 1.21, 95% CI 0.87-1.68) Conclusion:  This study suggests that delivery of twins at 37-38 weeks is associated with the lowest risk of perinatal death.

Neonatal outcomes of singleton live births with vanishing twin syndrome following double embryos transfer in assisted reproductive technology: a retrospective cohort study

Background

Women with vanishing twin syndrome are associated with increased risks of adverse neonatal outcomes, such as preterm birth (PTB) and low birthweight (LBW), compared with those in singleton live births following single embryo transfer (SET) in assisted reproductive technology (ART).

Methods

Anonymized data on all cycles performed in China were obtained from the Reproductive Medicine Department at the Third Affiliated Hospital of Zhengzhou University, which had involved 127597 cycles following double embryos transfer (DET), including 54585 fresh embryos transfer (ET) cycles and 73012 frozen embryos transfer (FET) cycles. In addition, the obstetric outcomes, such as gestation age, PTB, small for gestation age (SGA), birthweight (BW), LBW, congenital malformation, pediatric admission and Neonatal Intensive Care Unit (NICU) admission in the fresh ET and FET cycles, were analyzed. Moreover, logistic regression analysis was performed to adjust the confounders, including age of women, body weight index (BMI), value of AMH, infertile years, current cycle, antral follicles, cause of infertility, number of oocytes retrieved, endometrial thickness at the date of transplantation, number of high-quality embryos, and embryo stage.

Results

In the fresh ET cycles, the BW and gestational age in study group were lower than those in control group, which were (2962.4 ± 563.1vs. 3104.9 ± 498. 5, p = 0.000) and (262.8 ± 8.4 vs. 268.9 ± 13.9, p = 0.000), respectively. Relative to control group, the study group was linked with increased risks of PTB (adjusted odds ratio (aOR) 2.45, 95% CI:1.98–3.03, adjusted p = 0.000), LBW (aOR2.11, 95% CI:1.67–2.65, adjusted p = 0.000), pediatric admission (aOR 2.55, 95% CI2.07–3.13, adjusted p = 0.000), and NICU admission (aOR 1.98, 95% CI1.32–2.96, adjusted p = 0.001), but there were no statistically significant differences in the risks of SGA (aOR 1.09, 95% CI0.82–1.45, adjusted p = 0.960) and congenital malformation (aOR 0.94, 95% CI0.53–1.68, adjusted p = 0.640) between the two groups. In the FET cycles, the gestational age and BW in study group were lower than those in control group, which were (263.0 ± 15.7vs. 273.0 ± 10.5, p = 0.000) and (3099 ± 662.1vs. 3352 ± 671.5), respectively. The study group was associated with increased risks of PTB (aOR2. 45, 95% CI: 2.23–3.43, adjusted p = 0.000), LBW (aOR 2.67, 95% CI: 2.13–3.34, adjusted p = 0.000), pediatric admission (aOR2.62, 95% CI2.14–3.21, adjusted p = 0.000), and NICU admission (aOR 2.22, 95% CI1.43, 3.46, adjusted p = 0.001) compared with those in control group, but differences in the risks of SGA (aOR 0.98, 95% CI0.71–1.36, adjusted p = 0.730) and congenital malformation (aOR 0.99, 95% CI 0.60,1.63, adjusted p = 0.940) between the two groups were not statistically significant.

Conclusions

Our study finds that singleton live births with VTS have higher risks of LBW, PTB, pediatric admission and NICU admission than those without VTS in both the fresh and frozen cycles, even after adjusting for confounders. However, no increased risks of SGA or congenital malformation are observed in singleton live births in both the fresh and frozen ART cycles following DET.

The 'Pleasure&Pregnancy' web-based interactive educational programme versus expectant management in the treatment of unexplained subfertility: protocol for a randomised controlled trial

INTRODUCTION

Many subfertile couples are diagnosed with (relatively) unexplained subfertility and a good prognosis. National professional guidelines (eg, the Netherlands and UK) advise 'expectant management (EM)' for 6-12 months, in which no interaction with healthcare staff is offered. Underpowered studies indicate that face-to-face sex-counselling increases the ongoing pregnancy rates of these couples. In patients with other conditions, web-based interactive educational programmes have the same effect on sexual functioning as face-to-face sex counselling. The 'Pleasure&Pregnancy randomised controlled trial (RCT)' will examine in couples with unexplained subfertility and a good prognosis whether a new web-based interactive educational programme results in a higher chance of naturally conceiving an ongoing pregnancy within 6 months as compared with EM.

METHODS AND ANALYSIS

A multicentre RCT with cost-effectiveness analysis will include heterosexual couples diagnosed with (relatively) unexplained subfertility and a good prognosis in Dutch and Belgian secondary or tertiary fertility clinics. Couples will be randomised between 6 months of EM and 6 months of the Pleasure&Pregnancy-programme. This new web-based interactive educational programme includes eight progressive modules of information (on the biology of conception and pleasurable sex) and sensate focus, couple communication and mindfulness exercises. Couples are offered interaction with their coaches via email and can take part in three moderated chat sessions with peers. The primary outcome of this RCT is the probability of naturally conceiving an ongoing pregnancy within 6 months after randomisation. Secondary outcomes include time-to-pregnancy, live birth rate, costs, sexual functioning and personal and relational well-being. Analysis will be according to intention to treat.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethical Committees of the Academic Medical Centre (the Netherlands) and the Leuven University Hospital (Belgium). The findings of this RCT will be disseminated through presentations at international scientific meetings and peer-reviewed publications.

TRAIL REGISTRATION NUMBER

NTR5709; Pre-results.

The mediation effect of multiple gestations on the association between in vitro fertilisation and severe maternal morbidities: a retrospective cohort study

OBJECTIVE

To investigate whether the association between in vitro fertilisation (IVF) and severe maternal morbidity (SMM) was mediated by multiple gestations.

DESIGN

A retrospective cohort study.

SETTING

The study was conducted at six hospitals in China.

PARTICIPANTS

Pregnant women at 20 gestational weeks or longer.

OUTCOME MEASURE

The outcome was SMM, which was a composite of potential life-threatening conditions, the use of critical medical interventions, or the status of maternal near-miss that occurred during pregnancy, childbirth or within 42 days of pregnancy termination, as defined by WHO.

RESULTS

In total, 22 368 eligible pregnant women were included, among whom 497 (2.2%) received IVF, and 776 developed SMM (incidence 34.7/1000 live births, 95% CI 32.3/1000 to 37.1/1000). Four multivariable logistic regression models were constructed. Model 1, without including the variable of multiple gestations, showed that IVF was associated with higher risk of SMM (adjusted OR (aOR) 1.54, 95% CI 1.03 to 2.29). Model 2, assessing the association between IVF and multiple gestations, showed that IVF was strongly associated with multiple gestations (aOR 14.75, 95% CI 11.38 to 19.10). Model 3, by adding the variable of multiple gestations to model 1, showed that IVF was not statistically associated with SMM (aOR 0.89, 95% CI 0.58 to 1.36), but multiple gestations were associated with higher risk of SMM (aOR 5.92, 95% CI 4.88 to 7.83). Model 4, investigating the association between IVF and SMM among singleton pregnancies, showed no statistically significant association (aOR 0.70, 95% CI 0.37 to 1.32). An additional analysis by adding the interaction term of IVF by multiple gestations to model 3 showed no statistical significance of the interaction term (aOR 1.15, 95% CI 0.36 to 3.68), confirming the absence of exposure-mediator interaction.

CONCLUSIONS

Using the established rule for judging mediation effect, the results suggested that multiple gestations might mediate the association between the use of IVF and higher risk of SMM. Further prospective studies are warranted to test our finding.

Study protocol: E-freeze - freezing of embryos in assisted conception: a randomised controlled trial evaluating the clinical and cost effectiveness of a policy of freezing embryos followed by thawed frozen embryo transfer compared with a policy of fresh embryo transfer, in women undergoing in vitro fertilisation

Background

Infertility affects one in seven couples; many of these need in vitro fertilisation (IVF). IVF involves external hormones to stimulate a woman’s ovaries to produce eggs which are harvested surgically. Embryos, created in the laboratory by mixing eggs with sperm, are grown in culture for a few days before being replaced within the uterus (fresh embryo transfer). Spare embryos are usually frozen with a view to transfer at a later point in time – especially if the initial fresh transfer does not result in a pregnancy. Despite improvements in technology, IVF success rates remain low with an overall live birth rate of 25–30% per treatment. Additionally, there are concerns about health outcomes for mothers and babies conceived through IVF, particularly after fresh embryo transfer, including maternal ovarian hyperstimulation syndrome (OHSS) and preterm delivery. It is believed that high levels of hormones during ovarian stimulation could create a relatively hostile environment for embryo implantation whilst increasing the risk of OHSS. It has been suggested that freezing all embryos with the intention of thawing and replacing them within the uterus at a later stage (thawed frozen embryo transfer) instead of fresh embryo transfer, may lead to improved pregnancy rates and fewer complications. We aim to compare the clinical and cost effectiveness of fresh and thawed frozen embryo transfer, with the primary aim of identifying any difference in the chance of having a healthy baby.

Methods

E-Freeze is a pragmatic, multicentre two-arm parallel group randomised controlled trial where women aged ≥18 and < 42 years, with at least three good quality embryos are randomly allocated to receive either a fresh or thawed frozen embryo transfer. The primary outcome is a healthy baby, defined as a term, singleton, live birth with appropriate weight for gestation. Cost effectiveness will be calculated from a healthcare and societal perspective.

Discussion

E-Freeze will determine the relative benefits of fresh and thawed frozen embryo transfer in terms of improving the chance of having a healthy baby. The results of this pragmatic study have the potential to be directly transferred to clinical practice.

Trial registration

ISRCTN registry: ISRCTN61225414. Date assigned 29/12/2015.

Perinatal outcomes of singleton live births with and without vanishing twin following transfer of multiple embryos: analysis of 113 784 singleton live births

STUDY QUESTION

Does transfer of multiple embryos affect perinatal outcomes of resulting singleton live births following ART?

SUMMARY ANSWER

There is a higher risk of preterm birth (PTB) and low birthweight (LBW) in singleton live births associated with spontaneous reduction of an initial multiple to singleton gestation following transfer of multiple embryos.

WHAT IS KNOWN ALREADY

Singleton pregnancies following ART are at a higher risk of adverse perinatal outcomes compared to spontaneous conceptions. Earlier studies have found an increased risk of PTB and LBW in singletons following transfer of multiple embryos versus single embryo transfer (SET). However, these studies did not address the specific role of vanishing twin, i.e. spontaneous reduction of an initial multiple to singleton gestation.

STUDY DESIGN, SIZE, DURATION

Anonymised data on all ART cycles performed in the UK were obtained from the Human Fertilization and Embryology Authority. Data from 1991 to 2011 involving 508 410 fresh and 131 157 frozen autologous ART cycles resulting in 95 779 and 18 005 singleton live births, respectively, were analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fresh and frozen ART cycles were analyzed separately to compare perinatal outcomes of PTB and LBW of singleton live births resulting from transfer of multiple (≥2) embryos versus SET. Logistic regression analysis was performed adjusting for confounders. Subgroup analyses were carried out for perinatal outcomes of singleton live births with initial multiple or initial single gestational sacs following transfer of multiple embryos versus singleton live births following SET.

MAIN RESULTS AND THE ROLE OF CHANCE

In fresh cycles, there was a significantly higher risk of PTB (adjusted odds ratio (aOR) 2.70, CI 2.37-3.05) and LBW (aOR 2.76, CI 2.44-3.13) in singleton live births with initial multiple gestational sacs but there was no significant difference in the risk of PTB (aOR 1.08, CI 1.00-1.16) or LBW (aOR 1.08, CI 1.00-1.16) in singleton live births with an initial single gestational sac following transfer of ≥2 embryos compared to those following SET. In frozen cycles, there was a significantly higher risk of PTB (aOR 2.13, CI: 1.55-2.93) and LBW (aOR 2.61, CI: 1.87-3.64) in singleton live births with initial multiple gestational sacs but there was no significant difference in the risk of PTB (aOR 1.02, CI: 0.88-1.18) or LBW (aOR 0.91, CI: 0.77-1.07) in the singleton live births with an initial single gestational sac following transfer of ≥2 embryos compared to those following SET.

LIMITATIONS, REASONS FOR CAUTION

While the analysis was adjusted for a number of known confounders, the dataset had no information for confounders such as smoking, BMI, previous obstetric history and comorbid medical conditions during pregnancy. The lack of information about the timing of occurrence of the vanishing phenomenon is another limitation because poorer perinatal outcomes of a surviving twin have been reported following second trimester fetal demise compared to the first trimester.

WIDER IMPLICATIONS OF THE FINDINGS

The study results suggest that the vanishing twin phenomenon is associated with increased risk of PTB and LBW in the resulting singleton live births and there was no increased risk when there was a single gestational sac from the outset following transfer of multiple embryos.

STUDY FUNDING/COMPETING INTERESTS

Nil.

Risk of juvenile idiopathic arthritis among children conceived after fertility treatment: a nationwide registry-based cohort study

STUDY QUESTION

Is the risk of juvenile idiopathic arthritis (JIA) increased in children conceived after fertility treatment, and is an observed association caused by specific types of fertility treatment or by factors associated with the underlying infertility?

SUMMARY ANSWER

The risk of JIA in children conceived after fertility treatment (any and specific types of fertility treatment) was not convincingly affected when compared with children born to fertile women.

WHAT IS KNOWN ALREADY

It has been suggested that fertility treatment may affect the development of the immune system and thereby increase the risk of developing autoimmune diseases, including JIA.

STUDY DESIGN, SIZE, DURATION

This retrospective population-based cohort study included all live-born children in Denmark between 1 January 1996 and 31 December 2012 (n = 1 084 184). The study population was followed from date of birth until first diagnosis of JIA as registered in the Danish National Patient Registry, date of 16th birthday, date of emigration, date of death or end of follow-up (31 December 2014), whichever occurred first.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study cohort was linked to the Danish Infertility Cohort in order to identify children born to women with fertility problems (n = 174 702) and fertility treatment (n = 89 931). Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

During a median follow-up period of 10.3 years, 2237 children were diagnosed with JIA. Children born to women with fertility problems had an increased risk of JIA (HR 1.18, 95% CI 1.05-1.32) compared with children born to fertile women. However, the risk was not increased in children conceived after any fertility treatment (HR 1.11; 95% CI 0.95-1.29), or after specific types of fertility treatment being ART (HR 1.05; 95% CI 0.83-1.33), IVF (HR 1.01; 95% CI 0.73-1.38), ICSI (HR 0.98; 95% CI 0.64-1.50) or any fertility drugs (HR 1.10; 95% CI 0.94-1.28) compared with children born to fertile women. The associations between fertility treatment and JIA were also assessed by using children born to women with fertility problems without fertility treatment in the index pregnancy as a reference group, however, the findings did not change substantially.

LIMITATIONS REASONS FOR CAUTION

Despite a large study population, the statistical precision in some subgroup analyses may be affected due to the low number of JIA cases. There may be some misclassification of fertility problems, as some women have undiagnosed fertility problems and are therefore not included in the Danish Infertility Cohort; potentially leading to slight attenuation of the association between fertility problems and JIA.

WIDER IMPLICATIONS OF THE FINDINGS

The results are based on national data and our findings can therefore be applied to other similar populations. Our results indicate that fertility treatment per se do not increase the risk of JIA but merely that the increased risk of JIA observed among children born to women with fertility problems may be due to underlying factors related to both infertility and JIA. However, as this is the first large study in this field, further studies are needed to confirm our findings.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by grants from the Jascha Foundation, the Aase and Ejner Danielsens Foundation and The Danish Rheumatism Association. All authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Genetics and Epigenetics of Infertility and Treatments on Outcomes

CONTEXT

Infertility affects 10% of the reproductive-age population. Even the most successful treatments such as assisted reproductive technologies still result in failed implantation. In addition, adverse pregnancy outcomes associated with infertility have been attributed to these fertility treatments owing to the presumed epigenetic modifications of in vitro fertilization and in vitro embryo development. However, the diagnosis of infertility has been associated with adverse outcomes, and the etiologies leading to infertility have been associated with adverse pregnancy and long-term outcomes.

EVIDENCE ACQUISITION

We have comprehensively summarized the data available through observational, experimental, cohort, and randomized studies to better define the effect of the underlying infertility diagnosis vs the epigenetics of infertility treatments on treatment success and overall outcomes.

EVIDENCE SYNTHESIS

Most female infertility results from polycystic ovary syndrome, endometriosis, and unexplained infertility, with some cases resulting from a polycystic ovary syndrome phenotype or underlying endometriosis. In addition to failed implantation, defective implantation can lead to problems with placentation that leads to adverse pregnancy outcomes, affecting both mother and fetus.

CONCLUSION

Current research, although limited, has suggested that genetics and epigenetics of infertility diagnosis affects disease and overall outcomes. In addition, other fertility treatments, which also lead to adverse outcomes, are aiding in the identification of factors, including the supraphysiologic hormonal environment, that might affect the overall success and healthy outcomes for mother and child. Further studies, including genome-wide association studies, epigenomics studies, and experimental studies, are needed to better identify the factors leading to these outcomes.

Association between fertility treatments and early placentation markers

INTRODUCTION

Pregnancies resulting from fertility treatments are at higher risk of placenta-mediated complications. Hence, we aimed to estimate the association between fertility treatment and levels of first-trimester markers of placentation.

METHODS

We conducted a cohort study in an academic center from 03/2011 to 12/2014. Adult nulliparous women with singleton pregnancies were recruited between 11 ^+ 0 and 13 ^+ 6 weeks of gestation. Data on maternal characteristics, medical history, and pregnancies conceived through fertility treatments (whether ovulation agents, insemination or assisted reproductive technologies) were collected. Maternal serum concentrations of PlGF, sFlt-1, PAPP-A, AFP, and free β-hCG were obtained, and notches and UtA-PI were measured using Doppler ultrasound. Mean Multiple of the Medians (MoM) and frequencies were computed to estimate the mean differences (MD) or risk ratios (RR) comparing fertility treatment to spontaneous pregnancies.

RESULTS

427 (9%) pregnancies out of 4815 were conceived through fertility treatments, using ovulation agents (n = 233, 5%), insemination (n = 174, 4%) and/or assisted reproductive technologies (n = 85, 2%). The latter were associated with significantly lower log₁₀PAPP-A MoM (adjusted MD: -0.02, 95%CI: -0.04 to -0.01), lower log₁₀PlGF MoM (adjusted MD: -0.04, 95%CI: -0.06 to -0.01) and higher log₁₀free β-hCG MoM (adjusted MD: 0.05, 95%CI: 0.01 to 0.09) compared to spontaneous pregnancies. Ovulation agents and insemination were associated with the presence of notches (adjusted RR: 1.24, 95%CI: 1.14 to 1.35; and 1.27, 95%CI: 1.15 to 1.42, respectively) and higher log₁₀UtA-PI MoM (adjusted MD: 0.16, 95%CI: 0.08 to 0.24; and 0.17, 95%CI: 0.07 to 0.27, respectively) than spontaneous pregnancies.

CONCLUSION

Fertility treatments are associated with significant variations in markers of placentation.

Pregnancy complications following fertility treatment-disentangling the role of multiple gestation

Background

To assess the extent to which multiple gestations mediate risk of pregnancy complications from fertility treatment and to address possible confounding by the underlying infertility.

Methods

From the nearly 1.8 million pregnancies recorded in the Swedish Medical Birth Register between 1996 and 2013, we selected the 9.9% (N = 174 067) that occurred to couples with known trouble conceiving (clinical infertility). Fertility treatment was identified from self-reports, medical records and procedural information from fertility clinics. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (CIs), and decomposed the total effect into direct and mediated effects to estimate the proportion mediated by multiple gestations.

Results

Compared with pregnancies achieved without any assistance, those having received some treatment had higher odds of all studied complications except gestational diabetes. Associations with placenta previa (OR 2.17, 95% CI 1.95-2.40) and placental abruption (OR 1.77, 95% CI 1.54-2.03) were almost entirely independent of multiple gestations. In contrast, the majority of the associations with preterm birth (OR 1.69, 95% CI 1.62-1.77), caesarean delivery (RR 1.15, 95% CI 1.13-1.17) and pre-eclampsia (OR 1.17, 95% CI 1.11-1.22) were mediated by multiple gestations (87%, 62% and 91% of the effect mediated, respectively). Both direct and mediated pathways contributed to the remaining positive associations with chorioamnionitis, labour induction and postpartum haemorrhage. Results were similar when considering primi- and multi-parous women separately, and after restriction to assisted reproductive technologies only.

Conclusion

Multiple gestations are responsible for a large proportion of pregnancy complications associated with fertility treatment, suggesting that interventions to restrict the occurrence of multiples could reduce excess risk of pre-eclampsia, preterm birth and caesarean delivery after fertility treatment. However, the elevated risk of serious placental complications after fertility treatment appears to be largely independent of multiple gestations.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention

Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.

Perinatal outcome of in vitro fertilization singletons - 10 years' experience of one center

INTRODUCTION

In vitro fertilization (IVF) singletons have a worse perinatal outcome than spontaneously conceived singletons, especially in terms of preterm birth and its complications.

MATERIAL AND METHODS

An observational retrospective case control study was carried out. The study population consisted of 644 women in singleton pregnancies (336 IVF/intracytoplasmic sperm injection (ICSI); 308 controls) who delivered > 22 weeks of gestation at the 1^st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland, between 2004 and 2014. Controls were initially matched by age and parity and drawn from the group of deliveries following each IVF delivery. Collected data included maternal characteristics, incidence of pregnancy complications, time and mode of delivery, and neonatal outcome at delivery.

RESULTS

The two study groups were initially matched for age and parity and were also similar with regard to BMI and gestational weight gain. The IVF treatment increased the odds of having vaginal bleeding in the first trimester (OR = 1.68; 95% CI: 1.0-2.86), placenta previa (OR = 5.15; 95% CI: 1.1-33.9), preterm delivery (OR = 2.06; 95% CI: 1.16-3.68), newborn's low birth weight (OR = 2.27; 95% CI: 1.19-4.36) and elective cesarean section (OR = 2.39; 95% CI: 1.7-3.4).

CONCLUSIONS

The IVF singleton pregnancies have an increased risk of adverse perinatal outcome, among which prematurity remains the greatest problem. Therefore, they should be managed as high risk not only due to psychological reasons.

Assisted reproductive technology is associated with premature rupture of membranes

Objective: To evaluate the elements more likely to be associated with premature rupture of membrane (PROM) in patients that use assisted reproductive technology (ART).Materials and methods: A retrospective case-control study was performed from January 2014 to August 2017. We included 301 patients, 257 patients were without PROM in the non-PROM group and 44 patients with PROM in the PROM group.Results: In the PROM group, the rate of intracytoplasmic sperm injection (ICSI) and BMI were significantly higher than the non-PROM group. Moreover, the rate of preterm birth was significantly higher in the PROM group. When using logistic regression analysis to decrease the impact of confounding factors, it showed that overweight and ICSI were confirmed to be associated with PROM. After matching 1:2 by BMI, the process of controlled ovarian hyperstimulation was all similar in the two groups. What is more, the rate of twin pregnancies was significantly higher in the preterm PROM (PPROM) group compared with the term PROM group and twin pregnancies were associated with preterm birth.Conclusions: ART parameters ICSI may increase the risk of PROM. Single embryo transfer during ART should be supported to decrease the incidence of PPROM and losing weight is essential for patients before embarking on ART.

Ovarian response to stimulation and suboptimal endometrial development are associated with adverse perinatal outcomes in intracytoplasmic sperm injection cycles

Objective:

To study which factors affect perinatal outcomes in intracytoplasmic sperm injection (ICSI) cycles.

Methods:

Data was obtained from 402 live births born to 307 patients undergoing ICSI cycles in a private university-affiliated IVF center between Jan/2014 and Dec/2015. The influences of the cycles' characteristics on the number of gestational weeks to livebirth (GW), baby birth weight (BW), and baby birth length (BL) were evaluated by linear regression models, adjusted for maternal age and body mass index, number of transferred embryos, number of gestational sacs, and number of born infants. In a subsequent analysis, GW, BW and baby sex were utilized for cycle classification into the groups Appropriate for gestational age (AGA n=256) and Small for gestational age (SGA n=146), which were compared by general linear models adjusted for the same confounder variables.

Results:

The number of follicles (β=-0.069 p=0.018) and retrieved oocytes (β=-0.087 p=0.049) were negatively correlated with BL. The endometrial thickness was positively correlated with GW (β=0.198 p=0.003) and BW (β=28.351 p=0.044). When each baby was classified into AGA and SGA groups, it was observed that SGA babies were derived from cycles with higher estradiol levels at hCG day (SGA: 3897.01±550.35 vs. AGA: 2324.78±101.86 p=0.006) and higher number of retrieved oocytes (SGA: 16.70±1.78 vs. AGA: 12.92±0.42 p=0.042). The endometrial thickness was significantly lower in the SGA group (SGA: 10.2±0.23 vs. AGA: 11.68±0.17 vs. p=0.029).

Conclusion:

Higher ovarian response to stimulation and suboptimal endometrial development are associated with adverse perinatal outcomes in ICSI cycles.

Assisted Reproductive Technology Surveillance - United States, 2016

PROBLEM/CONDITION

Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016.

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico).

RESULTS

In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants.

INTERPRETATION

Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment.

PUBLIC HEALTH ACTION

Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.

Risk factors for gestational diabetes: An umbrella review of meta-analyses of observational studies

BACKGROUND/OBJECTIVE

Gestational diabetes mellitus (GDM) is a common pregnancy complication, with complex disease mechanisms, and several risk factors may contribute to its onset. We performed an umbrella review to summarize the evidence from meta-analyses of observational studies on risk factors associated with GDM, evaluate whether there are indications of biases in this literature and identify which of the previously reported associations are supported by convincing evidence.

METHODS

We searched PubMed and ISI Web of Science from inception to December 2018 to identify meta-analyses examining associations between putative risk factors for GDM. For each meta-analysis we estimated the summary effect size, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, evidence of small-study effects, and evidence of excess-significance bias.

RESULTS

Thirty eligible meta-analyses were identified, providing data on 61 associations. Fifty (82%) associations had nominally statistically significant findings (P<0.05), while only 15 (25%) were significant at P<10-6 under the random-effects model. Only four risk factors presented convincing evidence:, low vs. normal BMI (cohort studies), BMI ~30-35 kg/m2 vs. normal BMI, BMI >35 kg/m2 vs. normal BMI, and hypothyroidism.

CONCLUSIONS

The compilation of results from synthesis of observational studies suggests that increased BMI and hypothyroidism show the strongest consistent evidence for an association with GDM. Diet and lifestyle modifications in pregnancy should be tested in large randomized trials. Our findings suggest that women with known thyroid disease may be offered screening for GDM earlier in pregnancy.

Interpregnancy interval and singleton pregnancy outcomes after frozen embryo transfer

OBJECTIVE

To describe the relationship between interpregnancy interval (IPI) and perinatal outcomes in singleton live births after frozen embryo transfer (FET).

DESIGN

Retrospective analysis of the Society for Assisted Reproductive Technology Clinical Outcome Reporting System cohort including patients with a history of live birth from ART who returned for an FET cycle between 2004 and 2013.

SETTING

Not applicable.

PATIENT(S)

A total of 19,270 singleton live births from FET subsequent to a live birth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Odds for preterm delivery (<37, <34, <28 weeks) and low birth weight (<2,500, <1,500 g) adjusted for age, body mass index, and history of prior preterm delivery.

RESULT(S)

Of 74,456 autologous FET cycles following an index live birth, 24,091 resulted in a repeat live birth, with 19,270 singleton live births. An IPI of <12 months occurred in 19% of cycles. Adjusted odds (aORs) for preterm delivery at <37 weeks were significantly increased for an IPI of <6 months (aOR 2.05, 95% confidence interval [CI] 1.48-2.84), 6 to <12 months (aOR 1.26, 95% CI 1.06-1.49), and 18 to <24 months (aOR 1.23, 95% CI 1.06-1.43) when compared with the reference interval of 12 to <18 months. Additionally, an IPI of <6 months was associated with increased odds for low birth weight (aOR 3.06, 95% CI 2.07-4.52) and very low birth weight (aOR 5.65, 95% CI 2.96-10.84) compared with an IPI of 12 to <18 months.

CONCLUSION(S)

In this nationally representative population, an interval from delivery to start of an FET cycle of <12 months is associated with increased odds for preterm delivery among singleton live births. Consistent with data for patients undergoing fresh IVF, the data support delaying FET 12 months from a live birth.

Gestational age at delivery of twins and perinatal outcomes: a cohort study in Aberdeen, Scotland

Background: Twin pregnancy is associated with a threefold increase in perinatal death compared to singletons.  The objective of this study was to determine the risk of perinatal death in twins by week of gestation and to quantify the effect of known risk factors. Methods: A cohort analysis was performed using data from the Aberdeen Maternity and Neonatal Databank (AMND).  The exposure was gestational age at delivery and the primary outcome was perinatal death.  Adjusted hazard ratios (aHRs) for perinatal death according to gestational age at delivery were determined by multivariate Cox proportional hazards regression modelling with robust standard errors to account for clustering in the twin infants.  Confounders and risk factors quantified and adjusted for in the model included maternal age, smoking, parity, marital status and year of birth.  Kaplan-Meier time to event analysis was used to determine the differences in survival according to chorionicity and assisted reproduction technologies (ART) conception status. Results: The population comprised of 7,420 twin babies born between 1950 and 2013 in the Grampian area of Northern Scotland.  There were 272 stillbirths in the cohort (3.67%) and 273 neonatal deaths (3.68%). Compared to delivery at 37-38 weeks, delivery at or beyond 39 weeks was associated with a significant increase in perinatal death (aHR 2.00 [95% CI 1.45-2.78]).  Monochorionic twins had a 2-fold increase in perinatal death compared to dichorionic twins (aHR 2.15, 95% CI 1.60-2.90). Twins conceived by ART did not have a greater risk of perinatal death compared to those naturally conceived (aHR 1.21, 95% CI 0.87-1.68) Conclusion:  This study suggests that delivery of twins at 37-38 weeks is associated with the lowest risk of perinatal death.

A meta-analysis of pregnancy-related outcomes and complications in women with polycystic ovary syndrome undergoing IVF

This meta-analysis aimed to study whether pregnancy-related outcomes and complications differed between patients with polycystic ovary syndrome (PCOS) and those with other causes of infertility who had undergone IVF. A systematic search of PubMed, Embase, the Cochrane Library and Chinese databases was carried out to identify relevant studies published before July 2018. Outcomes were expressed as odds ratios (OR) and 95% confidence intervals (CI). Subgroup analyses and sensitivity analyses were also conducted. Twenty-nine studies were identified for inclusion. Women with PCOS had higher risks of miscarriage (OR 1.41, 95% CI 1.04-1.91), ovarian hyperstimulation syndrome (OR 4.96, 95% CI 3.73-6.60), gestational diabetes mellitus (OR 2.67, 95% CI 1.43-4.98), pregnancy-induced hypertension (OR 2.06, 95% CI 1.45-2.91), preterm birth (OR 1.60, 95% CI 1.25-2.04) and large-for-gestational-age babies (OR 2.10, 95% CI 1.01-4.37). Women with PCOS showed similar rates of clinical pregnancy, multiple pregnancy, ectopic pregnancy, small for gestational age and congenital malformations, and a higher live birth rate, compared with women without PCOS. This study provides an update on and comprehensive evidence to support the observation that despite the fact that PCOS patients achieve a better live birth rate, physicians should continue to consider them to be at high risk of adverse pregnancy-related outcomes.

Medically assisted reproduction and birth outcomes: a within-family analysis using Finnish population registers

BACKGROUND

Children born after medically assisted reproduction are at higher risk of adverse birth outcomes than are children conceived naturally. We aimed to establish the extent to which this excess risk should be attributed to harmful effects of treatment or to pre-existing parental characteristics that confound the association.

METHODS

We used data from Finnish administrative registers covering a 20% random sample of households with at least one child aged 0-14 years at the end of 2000 (n=65 723). We analysed birthweight, gestational age, risk of low birthweight, and risk of preterm birth among children conceived both by medically assisted reproduction and naturally. First, we estimated differences in birth outcomes by mode of conception in the general population, using standard multivariate methods that controlled for observed factors (eg, multiple birth, birth order, and parental sociodemographic characteristics). Second, we used a sibling-comparison approach that has not been used before in medically assisted reproduction research. We compared children conceived by medically assisted reproduction with siblings conceived naturally and, thus, controlled for all observed and unobserved factors shared by siblings.

FINDINGS

Between 1995 and 2000, 2776 (4%) children in our sample were conceived by medically assisted reproduction; 1245 children were included in the sibling comparison. Children conceived by medically assisted reproduction had worse outcomes than did those conceived naturally, for all outcomes, even after adjustments for observed child and parental characteristics-eg, difference in birthweight of -60 g (95% CI -86 to -34) and 2·15 percentage point (95% CI 1·07 to 3·24) increased risk of preterm delivery. In the sibling comparison, the gap in birth outcomes was attenuated, such that the relation between medically assisted reproduction and adverse birth outcomes was statistically and substantively weak for all outcomes-eg, difference in birthweight of -31 g (95% CI -85 to 22) and 1·56 percentage point (95% CI -1·26 to 4·38) increased risk of preterm delivery.

INTERPRETATION

Children conceived by medically assisted reproduction face an elevated risk of adverse birth outcomes. However, our results indicate that this increased risk is largely attributable to factors other than the medically assisted reproduction treatment itself.

FUNDING

European Research Council, the Academy of Finland, and the Signe and Ane Gyllenberg Foundation.

Endocrine and reproductive profile of boys and young adults conceived after ICSI

PURPOSE OF REVIEW

The impact of intracytoplasmic sperm injection (ICSI), on the reproductive health of the offspring is largely unknown. Here we provide a comprehensive overview of the endocrine and reproductive profile in boys and young male adults born after ICSI using ejaculated spermatozoa alleviating male factor infertility in their parents.

RECENT FINDINGS

Levels of testosterone, anti-Müllerian hormone and inhibin B were found comparable in prepubertal and pubertal boys conceived by ICSI when compared with levels in boys conceived spontaneously. Also, at young adulthood, mean levels of reproductive hormones did not differ from control peers. However, semen analysis showed significantly lower sperm concentration, total sperm count and total motile sperm count when compared with controls. Furthermore, the risk of having sperm concentration and sperm count below the reference values was increased in ICSI offspring while sperm parameters did not correlate in paired father-son semen analysis.

SUMMARY

Although endocrine gonadal function was normal at puberty, exocrine function at young adulthood was not. We observed decreased semen quality and quantity in young adults conceived by ICSI performed to circumvent male factor infertility. The possibility of transgenerational transmission of impaired spermatogenesis after ICSI needs further investigation.

Complications and adverse outcomes in pregnancy and childbirth among women who conceived by assisted reproductive technologies: a nationwide birth cohort study of Japan environment and children's study

BACKGROUND

Although pregnancies conceived by assisted reproductive technology (ART) have a higher risk of maternal/perinatal complications, the overall risk of adverse outcomes necessitating advanced obstetric care has not been closely examined. The present study aimed to assess and compare the risk of maternal/perinatal complications and adverse outcomes in pregnancy and childbirth conceived by ART with those conceived naturally.

METHODS

This study was conducted as a part of the Japan environment and children's study (JECS), an ongoing nationwide birth cohort study in Japan. The risk of maternal/perinatal complications and adverse outcomes was assessed by mode of conception (natural conception, ovulation induction [OI] without ART, conventional in vitro fertilization and embryo transfer [IVF-ET], or intracytoplasmic sperm injection [ICSI]) using logistic regression and generalized estimating equations controlling for potential confounders.

RESULTS

The final dataset included women who conceived naturally (N = 90,506), by OI without ART (N = 3939), by conventional IVF-ET (N = 1476), and by ICSI (N = 1671). Compared with women who conceived naturally, those who conceived by conventional IVF-ET were at higher risk of placenta previa (adjusted OR 2.90 [95% CI 1.94, 4.34]), morbidly adherent placenta (6.85 [3.88, 12.13]), and pregnancy-induced hypertension (1.40 [1.10, 1.78]) whereas those who conceived by ICSI had a higher risk of placental abruption (2.16 [1.20, 3.88]) as well as placenta previa (2.01 [1.29, 3.13]) and morbidly adherent placenta (7.81 [4.56, 13.38]). Women who conceived by ART had a higher risk of blood transfusion (conventional IVF-ET: 3.85 [2.52, 5.88]; ICSI: 3.76 [2.49, 5.66]) and ICU admission (conventional IVF-ET: 2.58 [1.11, 6.01]; ICSI: 3.45 [1.68, 7.06]) even after controlling for potential confounders. Neonates conceived by ART had a higher risk of preterm birth (conventional IVF-ET: 1.42 [1.13, 1.78]; ICSI: 1.31 [1.05, 1.64]).

CONCLUSIONS

Women who conceived by ART had a higher risk of maternal/perinatal complications necessitating advanced obstetric care. Obstetricians should be aware of the increased risk of adverse outcomes among this population.