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Abstract
For the purpose of reducing maternal and neonatal morbidity, elective single transfer (eSET) in in vitro fertilization (IVF) was first proposed in 1999. The purpose of this review is to summarize recent oral debate between a proponent and an opponent of expanded eSET utilization in an attempt to determine whether a blanket eSET policy, as is increasingly considered, is defensible. While eSET is preferable when possible, and agreed upon by provider and patient, selective double embryo transfer (DET) must be seriously entertained if deemed more appropriate or is desired by the patient. Patient autonomy, let alone prolonged infertility and advancing age, demand nothing less. Importantly, IVF-generated twins represent only 15.7% of the national twin birth rate in the United States. Non-IVF fertility treatments have been identified as the main cause of all multiple births for quite some time. However, educational and regulatory efforts over the last decade, paradoxically, have exclusively only been directed at the practice of IVF, although IVF patient populations are rapidly aging. It is difficult to understand why non-IVF fertility treatments, usually applied to younger women, have so far escaped attention. This debate on eSET utilization in association with IVF may contribute to a redirection of priorities.
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Affiliation(s)
- Eli Y Adashi
- Professor of Medical Science, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Norbert Gleicher
- Medical Director and Chief Scientist, The Center for Human Reproduction, New York, NY, USA
- President, The Foundation for Reproductive Medicine, New York, NY, USA
- Professor (Adj.), Stem Cell Biology and Molecular Embryology Laboratory, Rockefeller University, New York, NY, USA
- Professor (Adj.), Department of Obstetrics and Gynecology, Vienna University School of Medicine, Vienna, Austria
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Kushnir VA, Barad DH, Albertini DF, Darmon SK, Gleicher N. Systematic review of worldwide trends in assisted reproductive technology 2004-2013. Reprod Biol Endocrinol 2017; 15:6. [PMID: 28069012 PMCID: PMC5223447 DOI: 10.1186/s12958-016-0225-2] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/21/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Assisted Reproductive Technology (ART) has undergone considerable changes over the last decade, with consequences on ART outcomes in different regions of the world being unknown. METHODS We conducted a systematic review of published national and regional ART registry data to assess how changes in clinical practice between 2004 and 2013 have impacted outcomes in Australia and New Zealand, Canada, Continental Europe, the United Kingdom (U.K.), Japan, Latin America, and the United States (U.S.). The data reflect 7,079,145 total ART cycles utilizing both fresh and previously cryopreserved embryos from autologous oocytes that resulted in 1,454,724 live births. This review focused on the following measures: ART cycle volume, use of cryopreserved embryos, single embryo transfer (SET), live birth rates in fresh and frozen-thawed cycles, and perinatal outcomes in recent years. RESULTS SETs and utilization of frozen-thawed embryos increased worldwide over the study period. In 2012 SET utilization in all ART cycles was highest in Japan and Australia/New Zealand (82.6% and 76.3% respectively) and lowest in Latin America (16.0%). While gradual improvements in live birth rates were observed in most regions, some demonstrated declines. By 2012-2013, fresh cycle live birth rates were highest in the U.S. (29%) and lowest in Japan (5%). In Japan, the observed decline in fresh cycle live birth rate coincided with transition to minimal stimulation protocols, transfer of frozen-thawed rather than fresh embryos, and implementation of an SET policy. Similarly, implementation of an SET policy in parts of Canada was followed by a decline in fresh cycle live birth rate. Increasing live birth rates in frozen-thawed embryo cycles, seen all over the world, partially compensated for declines in fresh ART cycles. During 2012-2013 Australia/New Zealand and Japan reported the lowest multiple delivery rates of 5.6 and 4% respectively while the US had the highest of 27%. In recent years, preterm delivery rates in all regions ranged between 9.0 to 16.6% for singletons, 53.9 to 67.3% for twins, and 91.4 to 100% for triplets and higher order multiples. Inconsistencies in the way perinatal outcome data are presented by various registries, made comparison between regions difficult. CONCLUSIONS ART practices are characterized by outcome differences between regions. International consensus on the definition of ART success, which accounts for perinatal outcomes, may help to standardize worldwide ART practice and improve outcomes. TRIAL REGISTRATION PROSPERO ( CRD42016033011 ).
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Affiliation(s)
- Vitaly A. Kushnir
- The Center for Human Reproduction, 21 East 69th Street, New York, NY 10021 USA
- Wake Forest School of Medicine, Winston-Salem, NC USA
| | - David H. Barad
- The Center for Human Reproduction, 21 East 69th Street, New York, NY 10021 USA
- Foundation for Reproductive Medicine, New York, NY USA
| | - David F. Albertini
- The Center for Human Reproduction, 21 East 69th Street, New York, NY 10021 USA
- University of Kansas Medical Center, Kansas City, KS USA
- The Rockefeller University, New York, NY USA
| | - Sarah K. Darmon
- The Center for Human Reproduction, 21 East 69th Street, New York, NY 10021 USA
| | - Norbert Gleicher
- The Center for Human Reproduction, 21 East 69th Street, New York, NY 10021 USA
- Foundation for Reproductive Medicine, New York, NY USA
- University of Vienna School of Medicine, Vienna, Austria
- The Rockefeller University, New York, NY USA
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Perinatal Outcome in Assisted Reproductive Pregnancies: Comparative Analysis of Reduced versus Unreduced Gestation. Int J Reprod Med 2016; 2016:7504609. [PMID: 27999824 PMCID: PMC5141530 DOI: 10.1155/2016/7504609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/13/2016] [Accepted: 08/21/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives. This study aims to evaluate perinatal outcomes such as gestational age at delivery and live birth rate in singleton and twin gestation with or without fetal reduction. Method. A retrospective analysis was done on patients which were divided into reduced and unreduced groups on the basis of order of reduction of one or more fetuses between 6 and 13 weeks of gestation. Patients records were studied to note gestational age at delivery/abortion, birth weight, and neonatal outcome. Result. The cohort included a total of 292 patients: 102 singletons and 190 twins. 52 pregnancies were reduced in singleton cohort and 68 were reduced in twin cohort. No statistical difference was observed in live birth rate, gestational age at delivery, and birth weight and significant higher incidence of IUGR was observed in reduced and unreduced twin gestation. In singleton pregnancies however preterm delivery rate increased with fetal reduction. Conclusion. Although reduction does not reduce the live birth rate, it does reduce gestation age of delivery and birth weight of newborn. This effect is more apparent when multiple gestation is reduced to singleton.
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Messini CI, Daponte A, Anifandis G, Mahmood T, Messinis IE. Standards of Care in infertility in Europe. Eur J Obstet Gynecol Reprod Biol 2016; 207:S0301-2115(16)30951-4. [PMID: 28029396 DOI: 10.1016/j.ejogrb.2016.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/14/2016] [Indexed: 11/25/2022]
Abstract
Evidence-based medicine is the principal approach to medical practice. There are several debatable issues in infertility, which require clarification. Over the past 20 years, reliable methodology has been developed for the management of infertile couples. This includes high quality diagnostic and therapeutic procedures, which are applied in highly specialised infertility centres. The European Board and College of Obstetrics and Gynaecology (EBCOG) has published Standards of Care for Women's Health in Europe, which should be the cornerstone for the clinicians and service providers in the European Union to establish common protocols within their centres. Each infertility treatment should result in the highest possible success rate and all appropriate measures for the patient's safety should be in place. The treatment protocols should minimise risk of complications, such as ovarian hyperstimulation syndrome (OHSS). The current use of GnRH agonists to trigger final follicle maturation has provided the means for avoiding this syndrome. Additionally, multiple pregnancy rates are still high in assisted reproductive technology (ART). These rates should be reduced by the adoption of single embryo transfer during IVF treatment and by the proper monitoring of ovulation induction protocols. EBCOG Standards of Care for infertility and assisted conception treatment derived from the best available evidence should underpin the provision of high quality infertility services in European countries.
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Affiliation(s)
- Christina I Messini
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Daponte
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Anifandis
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tahir Mahmood
- Department of Obstetrics & Gynaecology, Victoria Hospital, Kirkcaldy, Scotland, UK; European Board and College of Obstetrics & Gynaecology (EBCOG), UK
| | - Ioannis E Messinis
- Department of Obstetrics & Gynaecology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; European Board and College of Obstetrics & Gynaecology (EBCOG), UK.
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Vega MG, Gleicher N, Darmon SK, Weghofer A, Wu YG, Wang Q, Zhang L, Albertini DF, Barad DH, Kushnir VA. IVF outcomes in average- and poor-prognosis infertile women according to the number of embryos transferred. Reprod Biomed Online 2016; 33:370-5. [PMID: 27390063 DOI: 10.1016/j.rbmo.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/19/2022]
Abstract
Outcome measures of IVF success, which account for effectiveness of IVF and perinatal outcome risks, have recently been described. The association between number of embryos transferred in average and poor-prognosis IVF patients, and the chances of having good or poor IVF and perinatal outcomes, was investigated. Good IVF and perinatal outcome was defined as the birth of a live, term, normal-weight infant (≥2500 g). Poor IVF and perinatal outcome was defined as no live birth or birth of a very low weight neonate (<1500 g) or severe prematurity (birth at <32 weeks gestation). Each neonate was analysed as a separate outcome. A total of 713 IVF cycles in 504 average and poor-prognosis patients from January 2010 to December 2013 were identified. The odds of having good IVF and perinatal outcomes increased by 28% for each additional embryo transferred. The odds of poor IVF and perinatal outcome decreased by 32% with an additional embryo transferred. The likelihood of live birth with good perinatal outcome in average- and poor-prognosis patients after IVF increases with additional embryos being transferred. These data add to recently reported evidence in favour of multiple embryo transfer in older women and those with average or poor IVF prognosis.
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Affiliation(s)
- Mario G Vega
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Norbert Gleicher
- The Center for Human Reproduction, New York, NY 10021, USA; The Foundation for Reproductive Medicine, New York, NY 10021, USA; Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY 10065-6399, USA
| | - Sarah K Darmon
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Andrea Weghofer
- The Center for Human Reproduction, New York, NY 10021, USA; Vienna University School of Medicine, Vienna 1090, Austria
| | - Yan-Guang Wu
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Qi Wang
- The Center for Human Reproduction, New York, NY 10021, USA
| | - Lin Zhang
- The Center for Human Reproduction, New York, NY 10021, USA
| | - David F Albertini
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Molecular and Integrative Physiology, The University of Kansas School of Medicine, Kansas City, KS 66160, USA
| | - David H Barad
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY 10065-6399, USA
| | - Vitaly A Kushnir
- The Center for Human Reproduction, New York, NY 10021, USA; Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC 27106, USA.
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Andrijasevic S, Dotlic J, Aksam S, Micic J, Terzic M. Impact of Conception Method on Twin Pregnancy Course and Outcome. Geburtshilfe Frauenheilkd 2014; 74:933-939. [PMID: 25364033 DOI: 10.1055/s-0034-1383148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/01/2014] [Accepted: 09/12/2014] [Indexed: 10/24/2022] Open
Abstract
Objective: The aim of the study was to investigate the course and outcomes of twin pregnancies conceived by different methods of assisted reproduction (ART) compared to those conceived spontaneously. Methods: The study involved patients with twin pregnancies who delivered at the Ob/Gyn Clinic of the Clinical Center of Serbia over a period of three years. Patients were differentiated according to method of conception and type of ART. Age, parity, etiology of infertility, pregnancy complications, time of membrane rupture and type of delivery was recorded for each patient. Gestational week at delivery, presentation, birth weight, Apgar score, chorionicity and accompanying disorders were separately recorded for each twin. The data were analyzed statistically. Results: A total of 431 patients were included in the study. Although more twins were conceived by ART, the difference was not statistically significant (p = 0.092). The most common ART procedure was IVF/ICSI (p = 0.001). ART procedures, particularly IVF/ICSI, were significantly correlated with more advanced maternal age, fewer previous pregnancies and delivery by cesarean sections, usually planned (p = 0.001). Preterm membrane rupture was more common after ICSI, but preterm delivery and pregnancy complications were infrequent, irrespective of the method of conception (p = 0.001). ART twins were mostly dichorionic (p = 0.036). Monochorionic twins were conceived either spontaneously or with ICSI. Conception by ART was not correlated with twins' outcome (weight, Apgar score, disorders). Conclusions: ART procedures do not have a negative impact on twin pregnancy course and outcome. Twin pregnancies conceived spontaneously or by ART have similar outcomes.
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Affiliation(s)
- S Andrijasevic
- Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade, Serbia
| | - J Dotlic
- Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - S Aksam
- Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade, Serbia
| | - J Micic
- Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - M Terzic
- Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
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Gleicher N, Kushnir VA, Barad DH. The danger of ignoring pregnancy and delivery rates in ART. Hum Reprod 2014; 29:1828-9. [PMID: 24491299 DOI: 10.1093/humrep/deu009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N Gleicher
- The Center for Human Reproduction - New York, 21 East 69th Street, New York, NY 10021, USA
| | - V A Kushnir
- The Center for Human Reproduction - New York, 21 East 69th Street, New York, NY 10021, USA
| | - D H Barad
- The Center for Human Reproduction - New York, 21 East 69th Street, New York, NY 10021, USA
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Gleicher N, Kushnir VA, Barad DH. What 'misguided campaign' against single embryo transfer? Hum Reprod 2013; 29:380-1. [DOI: 10.1093/humrep/det444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Stillman RJ, Richter KS, Jones HW. Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction. Hum Reprod 2013; 28:2599-607. [PMID: 23904468 DOI: 10.1093/humrep/det317] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Much recent progress has been made by assisted reproductive technology (ART) professionals toward minimizing the incidence of multiple pregnancy following ART treatment. While a healthy singleton birth is widely considered to be the ideal outcome of such treatment, a vocal minority continues a campaign to advocate the benefits of multiple embryo transfer as treatment and twin pregnancy as outcome for most ART patients. Proponents of twinning argue four points: that patients prefer twins, that multiple embryo transfer maximizes success rates, that the costs per infant are lower with twins and that one twin pregnancy and birth is associated with no higher risk than two consecutive singleton pregnancies and births. We find fault with the reasoning and data behind each of these tenets. First, we respect the principle of patient autonomy to choose the number of embryos for transfer but counter that it has been shown that better patient education reduces their desire for twins. In addition, reasonable and evidentially supported limits may be placed on autonomy in exchange for public or private insurance coverage for ART treatment, and counterbalancing ethical principles to autonomy exist, especially beneficence (doing good) and non-maleficence (doing no harm). Second, comparisons between success rates following single-embryo transfer (SET) and double-embryo transfers favor double-embryo transfers only when embryo utilization is not comparable; cumulative pregnancy and birth rates that take into account utilization of cryopreserved embryos (and the additional cryopreserved embryo available with single fresh embryo transfer) consistently demonstrate no advantage to double-embryo transfer. Third, while comparisons of costs are system dependent and not easy to assess, several independent studies all suggest that short-term costs per child (through the neonatal period alone) are lower with transfers of one rather than two embryos. And, finally, abundant evidence conclusively demonstrates that the risks to both mother and especially to children are substantially greater with one twin birth compared with two singleton births. Thus, the arguments used by some to promote multiple embryo transfer and twinning are not supported by the facts. They should not detract from efforts to further promote SET and thus reduce ART-associated multiple pregnancy and its inherent risks.
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Affiliation(s)
- Robert J Stillman
- Shady Grove Fertility Reproductive Science Center, 15001 Shady Grove Road, Rockville, MD 20850, USA
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