Multiple births from assisted reproductive technologies: a challenge that must be met

Global fertility care with assisted reproductive technology

Assisted reproductive technology has progressed greatly since the birth of Louise Brown in 1978. The pregnancy rates have increased, care is safer with significantly reduced multiple pregnancy and complication rates, infants have good health, and millions of people have been able to have the families they desired. The major challenges facing assisted reproductive technology are to continue to increase the quality of care, increase utilization through more societal funding, and expand care to nontraditional and marginalized populations in all countries, especially lower- and middle-income countries where access is currently limited. Significant collaboration among professionals, organizations, the World Health Organization, and policymakers is occurring and will be necessary to achieve these goals.

The impact of assisted reproductive technology treatment coverage on marriage, pregnancy, and childbirth in women of childbearing age: an interrupted time-series analysis

BACKGROUND

Korea is encountering major challenges related to its declining birth rate and aging population. Various policies have been introduced to prevent further population decrease and boost the birth rate, but their effectiveness has not been verified. Therefore, this study examined the effects of assisted reproductive technology (ART) insurance coverage on marriage, pregnancy, and childbirth in women of childbearing age.

METHODS

All information on marriage, pregnancy, childbirth of women of childbearing age was obtained from Statistics Korea and Korean National Health Insurance Service database. During a total follow-up period of 54 months (July 2015 to December 2019), an average of 12,524,214 women of childbearing age per month, and 29,701 live births per month were included in the analysis. An interrupted time series with segmented regression was performed to analyze the time trend and changes in outcomes.

RESULTS

The implementation of ART coverage policies had no significant impact on marriage or pregnancy rates. However, it did affect multiple pregnancy and multiple birth rates, which increased by 1.0% (Exp(β3) = 1.010, P-value = 0.0001) and 1.4% (Exp(β3) = 1.014, P-value = < 0.0001), respectively, compared to the pre-intervention period. Although the effect of covering ART treatment on total birth rates were not confirmed, a slightly slower decline was observed after the intervention (Exp(β1) = 0.993, P-value = < 0.0001, Exp(β1 + β3) = 0.996 P-value = 0.012).

CONCLUSION

This study identified the effects of ART health insurance coverage policy on the rates of multiple pregnancies and births. After the policy implementation, the downward trend in the total birth rate reduced slightly. Our findings suggest that interventions to support infertile couples should be expanded to solve the problem of low fertility rates. To address the intricate problems related to low birth rates, the Korean government introduced a policy that provides financial support and health insurance coverage for assisted reproductive technology (ART) treatment for infertile couples. As a result of evaluating the effectiveness of the ART coverage policy, it led to higher rates of pregnancies and births. In addition, although the total birth rate has been continuously decreasing over time, the decline may have been slowed down slightly by this policy.

Iranian school-aged twin registry: preliminary reports and project progress

BACKGROUND

National Persian school-aged twin registry was established to provide a platform for twin studies. In this report, we describe defining registry characteristics, database design, and preliminary results regarding gathered data in the first phase of the registry program.

METHOD

Through focus group discussions, the required data elements to design the database and data collection process were defined. First, a list of twins in school-aged groups was retrieved from the electronic database of the Ministry of Education. Tehran schools were selected for the first phase of our registry. Standard "Pea-in-Pods" questionnaire and twins' similarity questionnaires were filled out by the parents themselves in addition to demographic information. Data were analyzed using SPSS v.22.

RESULTS

The first national school-aged twin registry was established in 2018. Firstly, the required data sets and data collection process were defined using focus group discussions. At the country level, the initial information on 189,738 students was retrieved from the national database of the Ministry of Education. They were born between 2003 and 2017, of which 94,997 are boys (50.1%) and 94,741 are girls (49.9%). Of them, a total of 5,642 pairs of school-aged twins participated in the first phase of our program. Our sample size comprised 9772 twins, 906 triples, and 92 quadruplets. The analysis of the zygosity questionnaire showed that 14% of twin pairs were identified as monozygotic twins.

CONCLUSION

Recruiting school-aged twins through school health assistants leads to high enrollment and decreasing costs for the twin registry. The study showed a high rate of dizygotic twins that need to be verified by twin bio-sample in the next phase of studies.

Noninvasive amino acid turnover predicts human embryo aneuploidy

Assisted reproduction technology has two significant problems: low success rates and multiple pregnancies. Because of these problems, the priority in IVF clinics is to develop a potential diagnostic test that can be used to select the embryos with the ultimate developmental competence. Aneuploidy screening as embryo selection criteria will ensure that the transferred embryos are euploid and high implantation rate. We hypothesize that aneuploidy in human preimplantation embryos could be discriminated by their amino acid metabolism profile in the spent culture media. Preimplantation genetic testing for aneuploidy results and spent embryo culture medium amino acid content were analyzed for 58 couples. The next-generation sequencing technique was used and coupled with TE biopsy. Forty euploid and 71 aneuploid blastocysts were evaluated. Embryos were cultured individually until day 5 or 6 of embryo development. Spent culture medium was collected after finishing the culture. There was no statistical difference between D3 and D5 embryo morphology between euploid and aneuploid embryos (p > .05). Eight amino acids, including SER, GLY, HIS, ARG, THR, ALA, PRO, and TYR, were detected in the culture medium from the blank control group, euploid group, and aneuploid group. Only TYR amino acid concentration was found significantly higher in the aneuploid group compared to the euploid group (p < .003). Tyrosine amino acid levels equal to and above 76.38 µmol/L could be considered aneuploid. Aneuploid embryos demonstrate altered amino acid turnover in vitro relative to euploid counterparts. A noninvasive method of amino acid profiling will be of value as a tool for routine preimplantation embryo selection among all patient groups.

Quadruple term gestation of quadri-chorionic quadri-amniotic pregnancy after artificial insemination: a case report

Background

To solve infertility, modern science has promoted assisted reproduction techniques such as in vitro fertilization, ovulation induction, and artificial insemination. Quadruple-type multiple pregnancies occur in 1 of every 500,000 pregnancies, and it is estimated that 90% occur due to assisted reproductive techniques, which often lead to numerous complications.

Case presentation

Here we present a case of a 33-year-old woman, who desired pregnancy, but had a history of primary infertility diagnosed by hysterosalpingography, and endometriosis, which was treated by fulguration and medical management. Concomitantly, the patient was anovulatory. To fulfill her wish, she underwent homologous artificial insemination, after treatment, she successfully conceived quadri-chorionic quadri-amniotic infants, who were born at 37.2 weeks, without perinatal or maternal complications.

Conclusion

This paper presented the parameters of prenatal care, appropriate management approach, and successful resolution without maternal–fetal complications despite the inherent risks of this type of pregnancy.

Infertility is a common reproductive system problem; modern science has promoted assisted reproduction techniques as an alternative for these cases. High-order pregnancies it is estimated to occur in 90% of the cases due to assisted reproductive techniques, which often lead to numerous complications. A 33-year-old woman, who desired pregnancy, but had a history of infertility underwent artificial insemination, conceiving successfully quadruplets without any perinatal or maternal complications. Knowledge of maternal history and proper management of assisted reproductive techniques in addition to adequate prenatal follow-up are necessary for a successful pregnancy.

Vanquishing multiple pregnancy in in vitro fertilization in the United States-a 25-year endeavor

The practice of in vitro fertilization has changed tremendously since the birth of the first in vitro fertilization infant in 1978. With the success of early in vitro fertilization programs in the United States, there was a substantial rise in twin births nationwide. In the mid-1990s, more than 30% of in vitro fertilization cycles resulted in twin or higher-order multifetal pregnancies. Since that time, we not only have witnessed improvements in laboratory and treatment efficacy but also have seen a dramatic impact on pregnancy outcomes, specifically regarding twin pregnancies. Because the field evolved and the risks of multifetal pregnancies became more salient, in 2019, the rate of twin pregnancies had dropped to <7% of cycles. This improvement was largely because of technical advancements and revised professional guidance: culturing embryos longer before transfer, improved freezing technology, embryo preimplantation genetic testing, and revised professional guidance regarding the number of embryos to transfer. These developments have led to single-embryo transfer becoming the standard of care in most scenarios. We used national in vitro fertilization surveillance data of all autologous in vitro fertilization cycles from 1996 to 2019 to illustrate trends in the following improved outcomes: autologous embryo transfer cycles involving blastocyst-stage embryos, vitrified embryos, preimplantation genetic testing cycles, total number of embryos being transferred per cycle, and single-embryo transfer usage over time. Among deliveries from autologous embryo transfers, we highlighted trends in singleton births over time and proportion of deliveries involving twins, triplets, quadruplets, or greater. The notable progress in reducing the rate of multifetal pregnancies with in vitro fertilization was largely attributed to a series of technical and clinical actions, culminating in an 80% reduction in the incidence of multiple births without a loss in overall treatment effectiveness.

Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins

AIM

The aim of this study was to determine the safety of vaginal delivery with a non-vertex second twin when the first twin is in the vertex presentation.

MATERIALS AND METHODS

A retrospective analysis was undertaken, utilizing a cohort of twin gestations in which the presenting twin was vertex and the second twin was either vertex (group A) or non-vertex (group B). We assessed maternal and neonatal outcomes including emergency cesarean delivery, 5-minute Apgar scores, cord arterial pH, NICU admissions, and adverse maternal postpartum outcomes including ICU admissions and the requirement of blood products.

RESULTS

Six hundred and eighty-five women with a vertex presenting twin were admitted to labor and delivery. Three hundred and ninety-five women were included in group A (vertex/vertex) and 290 were included in group B (vertex/non-vertex). No statistically significant differences were found in the 5-minute Apgar scores, cord arterial pH, or in the rates of emergency cesarean deliveries, NICU admission, maternal blood transfusion or ICU admissions.

CONCLUSION

In conclusion, vaginal delivery of a breech second twin when the presenting twin is vertex was found as safe as vaginal delivery of twins in the vertex/vertex presentation.

Association of assisted reproductive technology with autism spectrum disorder in the offspring: an updated systematic review and meta-analysis

This study aims to provide an up-to-date meta-analysis of data from studies investigating the risk of bearing a child with autism spectrum disorder (ASD) after being conceived by assisted reproductive technology (ART). The study was conducted according to the PRISMA Statement. PubMed and Scopus databases were searched up to August 2, 2020. Observational studies using a type of conception of assisted reproductive technology and examined as outcome offspring with ASD were included. A random effect model was applied due to the heterogeneity of the studies. Statistical analysis was performed with Stata 13 software. The Newcastle-Ottawa scale was used to assess the methodological quality of the included studies. The search strategy identified 587 potentially relevant studies. A total of 15 studies provided adequate data for statistical comparisons and, therefore, were included in the meta-analysis. Analysis of the subset of studies that examined all offspring and controlled for confounder factors revealed that the use of ART is associated with a higher risk of ASD (RR = 1.11, 95% CI = 1.03-1.19, p < 0.009), while in the case of studies that focused on singletons, a statistically significant association between ART and ASD was not observed (RR = 0.96, 95% CI = 0.82-1.13, p = 0.654).Conclusion: The present meta-analysis confirmed the existing positive correlation between ART and ASD in offspring, suggesting that ART is correlated with a higher risk for bearing a child with ASD. In contrast, this relationship is not confirmed in singletons. High quality prospective studies with a larger number of participants are still required. What is Known: • Studies that investigated the association between ART and ASD in offspring have shown conflicting results. • A previous meta-analysis showed that offspring conceived by ART are 1.35 times more likely to develop ASD than offspring spontaneously conceived. What is New: • This investigation separately considered studies with and without adjustment for confounders. • The findings from the two analyses were similar.

The impact of prolonged second stage in twins on perinatal outcomes

OBJECTIVE

To assess the duration of the second stage of labor in twin pregnancies in relation to maternal and neonatal outcomes.

METHODS

A retrospective study between 2014 and 2020. Eligible cases were twin pregnancies that reached the second stage. The pre-defined groups were based on the total time spent in the second stage of labor; Group 1 (<1 h), group 2 (1-2 h), and group 3 (>2 h), which was considered the prolonged second stage group.

RESULTS

Among the 439 planned vaginal births, successful vaginal delivery of both twins was achieved in 63.8%. Prolonged second stage was observed in 25.8% (89/345). Nulliparity (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.5-13.4) and use of epidural analgesia (OR 5.45, 95% CI 1.2-24.7), were the only independent variables significantly associated with prolonged second stage. Prolonged second stage was associated with a greater risk of intrapartum cesarean delivery (32.6%, P < 0.001), combined delivery (10.1%, P < 0.001), chorioamnionitis (8.3%, P = 0.006) and a admission to neonatal intensive care unit of at least one of the twins (30.3%, P = 0.02).

CONCLUSION

Prolonged second stage of labor affects maternal and fetal outcome in twin pregnancies.

Why are multiple pregnancy rates and single embryo transfer rates so different globally, and what do we do about it?

In the early years of in vitro fertilization, overall pregnancy rates were low, and it was considered necessary to transfer more than one embryo to increase the chances of pregnancy. It was not until advances in assisted reproductive technologies resulting in increased pregnancy rates that the concept of transferring just one embryo was considered possible. A consequence of improvements in implantation rates was also an increase in multiple pregnancies when more than one embryo was transferred. Although some countries have reduced the number of embryos transferred, international data show that in many parts of the world high twin and higher order multiple pregnancy rates still exist. Even in developed countries these problems persist depending on clinical practice, funding of health services, and patient demands. Perinatal and other outcomes are significantly worse with twins compared with singleton pregnancies and there is an urgent need to reduce multiple pregnancy rates to at least 10%. This has been achieved in several countries and clinics by introducing single embryo transfer but there are many barriers to the introduction of this technique in most clinics worldwide. We discuss the background to the high multiple rate in assisted reproduction and the factors that contribute to its persistence even in excellent clinics and in high-quality health services. Practices that may promote single embryo transfer are discussed.

Being a mother of preterm multiples in the context of socioeconomic disadvantage: perceived stress and psychological symptoms

OBJECTIVE

This study aimed to examine the differences between mothers of preterm multiples and mothers of preterm singletons regarding perceived stress and maternal psychological symptoms, and to explore the putative adverse amplified effect of socioeconomic disadvantage.

METHOD

Ninety-five mothers of 1-year-olds born preterm participated in this cross-sectional study. Data collection was carried out in two public hospitals from Northern Portugal. To assess maternal perceived daily stress and psychological symptoms, mothers completed two questionnaires. Mothers reported on socioeconomic factors, including family poverty, parent unemployment, and low education, and two groups of family socioeconomic disadvantage were created. A child medical risk index was calculated.

RESULTS

Results indicated that mothers of preterm multiples reported higher levels of stress than mothers of preterm singletons. Moreover, and specifically regarding psychological functioning, mothers of preterm multiples reported more symptoms than mothers of preterm singletons, but only when living in a context of socioeconomic adversity.

CONCLUSIONS

The results of the present study have important implications for practice. Mothers of preterm multiples are at higher risk to present mental health difficulties, in comparison to mothers of singletons, especially when exposed to socioeconomic adversities. The development of psychosocial intervention programs and public policies are of decisive importance in helping mothers of multiples adjust to parenthood.

Omics in Reproductive Medicine: Application of Novel Technologies to Improve the IVF Success Rate

Treatment for many infertile couples often consists of in vitro fertilization (IVF) but an estimated 70% of IVF cycles fail to produce a live birth. In an attempt to improve the live birth rate, the vast majority of IVF cycles performed in the United States involve the transfer of multiple embryos, a practice that increases the risk of multiple gestation pregnancy. This is a concern because multiple gestation pregnancies are associated with an increased incidence of maternal and fetal complications and significant cost associated with the care of preterm infants. As the ideal outcome of each IVF cycle is the birth of a single healthy baby, significant effort has focused on identifying embryos with the greatest developmental potential. To date, selection of euploid embryos using comprehensive chromosome screening (CCS) is the most promising approach while metabolomic and proteomic assessment of spent culture medium have the potential to noninvasively assess embryo viability. Endometrial gene expression profiling may help determine the optimal time to perform embryo transfer. While CCS has been implemented in some clinics, further development and optimization will be required before analysis of spent culture medium and endometrial gene expression profiling make the transition to clinical use. This review will describe efforts to identify embryos with the greatest potential to result in a healthy, live birth, with a particular emphasis on detection of embryo aneuploidy and metabolic profiling of spent embryo culture medium. Assessment of endometrial receptivity to identify the optimal time to perform embryo transfer will also be discussed.

The Quality of Life in Pregnant Women Conceiving Through in Vitro Fertilization

Objective

The aim was to determine whether pregnant women conceiving through in vitro fertilization (IVF) differ from those conceiving spontaneously in terms of psychological well-being and the quality of life.

Methods

In a prospective study we included 75 women conceived after IVF and 78 who conceived spontaneously in the same time period (control group). All the women were sent a self-report questionnaire about demographic and reproductive history, health, pregnancy concerns, containing Subjective Quality of Life Scale (QLS), Positive and Negative Affect Schedule (PANAS), the Psychological Well-Being Scale (PWB), Beck Depression Inventory (BDI), and Zung Self-Assessment Anxiety Scale (SAS); obstetric and newborn’s data were obtained from medical records. Response rate was 66.6% in the IVF and 83.3% in control group.

Results

The mean women’s age was 33.8 years in the IVF, and 32.5 years in the control group (NS). There were no significant differences between groups on the most of the outcome measures assessing psychological status. IVF mothers were just less satisfied in “friend/acquaintances” (P=0.03), a higher percentage had sexual problems prior to conception (P=0.03); the length of hospitalization during pregnancy was longer (P=0.02), and the preterm delivery rate was higher (P=0.01). Withingroup changes over gestation time indicated that IVF women, not controls, showed an increase in positive affect (P=0.04) and purpose in life (P=0.05).

Conclusions

IVF women are inclined to social isolation. Despite more medical problems during pregnancy, they reported improved positive emotions and purpose in life as the pregnancy progressed.

Twins conceived using assisted reproduction: parent mental health, family relationships and child adjustment at middle childhood

STUDY QUESTION

Compared with singletons, what is the parent mental health, parent-child and couple relationship satisfaction, and child adjustment of 6- to 12-year-old assisted reproduction technology (ART) twins and their families?

SUMMARY ANSWER

There are no differences between 6- and 12-year-old ART twin and singleton families in parent mental health or family relationships; however, twins had significantly fewer behavior and attention problems than singletons in middle childhood.

WHAT IS KNOWN ALREADY

When ART twins are younger than 5 years old, parents have more mental health difficulties and poorer parent-child relationship quality, and no differences have been found in ART twin and singletons' psychosocial adjustment. However, studies have only examined the implications of ART twin status in families with infant and toddler aged children.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of 300 6-12-year-old ART children (n = 124 twins and n = 176 singletons) from 206 families at a reproductive endocrinology clinic in the USA.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients from one clinic with a child born between 1998 and 2004 were invited to participate in an online survey (82% recruitment rate). Participants provided information on each 6- to 12-year-old ART child in the family, and responded to questions on parent mental health, family relationships and child adjustment.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in parent mental health or family relationships in families with 6- to 12-year-old ART twins versus singletons. However, twins (M = 2.40, SE = 0.35) had significantly fewer behavior problems than singletons (M = 3.47, SE = 0.36; F(1, 201) = 4.54, b = 1.08, P < 0.05). Twins (M = 1.86, SD = 0.23) also had fewer attention problems than singletons (M = 2.64, SD = 0.23; F(1, 156) = 5.75, b = 0.78, P < 0.05). Results also suggest that full-term twins had significantly fewer attention problems (M = 1.37, SE = 0.33; F(1, 222) = 2.65, P = 0.05) than premature twins (M = 2.32, SE = 0.32, b = 0.95, P < 0.05), full-term singletons (M = 2.25, SE = 0.21, b = 0.88, P < 0.05) and premature singletons (M = 2.84, SE = 0.49, b = 1.47, P = 0.01). There were no significant differences between the other groups.

LIMITATIONS, REASONS FOR CAUTION

Although the response rate is high (82%) and family demographics are representative of US ART patients, patients are from one US clinic. Responses also are from one family member and may be subject to social desirability biases. Additionally, our data did not include identification of monozygotic and dizygotic twins.

WIDER IMPLICATIONS OF THE FINDINGS

Studies on infant and toddler ART twins suggest these families have parents with more mental health difficulties and lower parent-child relationship quality than singleton families. This study indicates the negative effects of twin status may have ameliorated by middle childhood, and twins may even have more optimum psychosocial adjustment than singletons in this developmental period.

STUDY FUNDING/COMPETING INTERESTS

This research is based on a collaborative research effort supported by University of Minnesota Agriculture Experiment Station Project Number MN-52-107, a University of Minnesota Grant-in-Aid of Research, Artistry and Scholarship grant, a University of Minnesota College of Education and Human Development Research Development Investment Grant and the M. Janice Hogan Fellowship. The authors of this article have no commercial or corporate interests to declare.

Outcomes for women and infants following assisted conception: implications for perinatal education, care, and support

Assisted conception is becoming an increasingly more common treatment option for women and couples who experience fertility problems. Links have been made in the literature between assisted conception and a greater incidence of pregnancy or birth complications, low birth weight or premature babies, and babies with congenital abnormalities. In addition, evidence suggests that the experience of assisted conception may influence the development of early mothering relationships and impact parenting adjustment. Although this commentary article does not strategically review all available literature, it provides an overview of the health issues that women and families undergoing assisted conception have experienced or may experience. Through raising awareness and promoting discussion of these issues, practitioners will be better equipped to provide informed education and support.

Preimplantation genetic screening: does it help or hinder IVF treatment and what is the role of the embryo?

Despite an ongoing debate over its efficacy, preimplantation genetic screening (PGS) is increasingly being used to detect numerical chromosomal abnormalities in embryos to improve implantation rates after IVF. The main indications for the use of PGS in IVF treatments include advanced maternal age, repeated implantation failure, and recurrent pregnancy loss. The success of PGS is highly dependent on technical competence, embryo culture quality, and the presence of mosaicism in preimplantation embryos. Today, cleavage stage biopsy is the most commonly used method for screening preimplantation embryos for aneuploidy. However, blastocyst biopsy is rapidly becoming the more preferred method due to a decreased likelihood of mosaicism and an increase in the amount of DNA available for testing. Instead of using 9 to 12 chromosome FISH, a 24 chromosome detection by aCGH or SNP microarray will be used. Thus, it is advised that before attempting to perform PGS and expecting any benefit, extended embryo culture towards day 5/6 should be established and proven and the clinical staff should demonstrate competence with routine competency assessments. A properly designed randomized control trial is needed to test the potential benefits of these new developments.

Association between amino acid turnover and chromosome aneuploidy during human preimplantation embryo development in vitro

This study investigated the relationship between human preimplantation embryo metabolism and aneuploidy rates during development in vitro. One hundred and eighty-eight fresh and cryopreserved embryos from 59 patients (33.9 +/- 0.6 years) were cultured for 2-5 days. The turnover of 18 amino acids was measured in spent media by high-performance liquid chromatography. Embryos were either fixed for interphase fluorescent in situ hybridization analysis of chromosomes 13, 18, 19, 21, X or Y, or were assayed for mitochondrial activity. Amino acid turnover was different (P < 0.05) between stage-matched fresh and cryopreserved embryos due to blastomere loss following warming. The proportion of embryos with aneuploid cells increased as cell division progressed from pronucleate- (23%) to late cleavage stages (50-70%). Asparagine, glycine and valine turnover was significantly different between uniformly genetically normal and uniformly abnormal embryos on Days 2-3 of culture. By Days 3-4, the profiles of serine, leucine and lysine differed between uniformly euploid versus aneuploid embryos. Gender significantly (P < 0.05) affected the metabolism of tryptophan, leucine and asparagine by cleavage-stage embryos. Pronucleate zygotes had a significantly higher proportion of active:inactive mitochondria compared with cleavage-stage embryos. Furthermore, mitochondrial activity was correlated (P < 0.05) with altered aspartate and glutamine turnover. These results demonstrate the association between the metabolism, cytogenetic composition and health of human embryos in vitro.

Assessing the reproductive competence of individual embryos: a proposal for the validation of new "-omics" technologies

Rapid technological advances now provide the tools needed to evaluate the molecular genetics, proteomics, and microenvironment of an individual embryo in an effort to predict its reproductive competence. Rigorous criteria for accepting any test as a validated marker of embryonic reproductive competence should be established, and practitioners should be cautious about applying these tests clinically before the availability of comprehensive and convincing evidence.

Amino acid metabolism of bovine blastocysts: a biomarker of sex and viability

The ratio of male/female embryos may be modified by environmental factors such as maternal diet in vivo and the composition of embryo culture media in vitro. We have used amino acid profiling, a noninvasive marker of developmental potential to compare the effect of sex on the metabolism of bovine blastocysts conceived in vivo and in vitro. Blastocysts were incubated individually for 24 hr in a close-to-physiological mixture of amino acids and the depletion or appearance of 18 amino acids measured using HPLC. Blastocysts were then sexed by PCR. Amino acid depletion by in vitro-produced blastocysts and expanded blastocysts was higher than in embryos conceived in vivo (P = 0.02). When cultured in vitro, female embryos exhibited increased depletion of arginine, glutamate, and methionine and appearance of glycine, while male embryos displayed increased depletion of phenylalanine, tyrosine, and valine. Overall, in vitro-produced blastocysts exhibited sex-specific differences in metabolic profiles of 7 out of 18 amino acids; in vivo-produced, in 2 out of 18. These differences had disappeared by the expanded blastocyst stages. We have also shown that amino acid metabolism can predict the ability of bovine zygotes to develop to the blastocyst stage, providing "proof of principle" for the use of this technology in clinical IVF to select single embryos for transfer and thereby avoid the problem of multiple births.

[Elective single embryo transfer - the Scandinavian experiment]

Limiting the number of embryos transferred from three to two does not reduce the high risk of twin pregnancy (between 21 and 40%). Scandinavian centers have proposed in the 2000s the elective single embryo transfer (eSET) as the only means to reduce maternal, neonatal and psychological consequences related to multiple births. Pooled results from prospective randomized controlled trials and prospective cohort studies comparing eSET and transfer of two embryos (DET) in a selected population have confirmed the almost complete disappearance of twins when eSET was effective but the compromising effect of eSET upon live birth rates was discussed. Optimizing the eSET overall pregnancy rate need to associate a freezing policy and to define risk factors for increased chance of multiple birth (patient age, diagnosis, number of top-embryos or unsuccessful attempts). The extension of eSET practice to an unselected population irrespective of embryo quality is still controversial. The choice between offering one cycle of SET or DET in an unselected patient population depends on the society's willingness to optimize the in vitro fertilization results according to a defined health care policy: the first one is the twins disappearance with reduced overall pregnancy rate and the second one is a reduced twin birth rate with maintain of the total pregnancy percentage. The real question is to define what percentage of twin pregnancy could be considered as acceptable.

Distributive justice and infertility treatment in Canada

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

Factors and perceptions that influence women's decisions to have a single embryo transferred

The aim of this study was to identify factors that inhibit or promote the adoption of single embryo transfer (SET). A cohort of 163 women patients receiving IVF/intracytoplasmic sperm injection treatment, comprising 87 women choosing SET and 63 women choosing double embryo transfer (DET), were interviewed using a structured questionnaire. The data were compared using logistic regression analysis. Confidence in the chance of pregnancy with SET, younger age and first treatment were predictive of a decision for SET. Preference for a healthy and singleton pregnancy was predictive but perceptions of the incidence or risk of multiple gestation were not. Factors such as a sense of time urgency and past experience of treatment were significant and predictive of diminished choice of SET. The clinic doctor was an important influencing factor. The results of this study confirm that improved pregnancy rates in SET coupled with an official clinic policy to promote SET in younger, first cycle patients influenced many women to choose SET. However, repeated treatment, advancing age and urgency to become pregnant are factors that moderate a woman's choice for SET.

Laparoscopic tubal reanastomosis using robotics: experience from a teaching institution

PURPOSE

Tubal reanastomosis typically requires a laparotomy and in the past few years has been performed much less frequently due to the development and success of in vitro fertilization. Laparoscopic tubal anastomosis eliminates the need for laparotomy and can be performed in an out-patient setting.

MATERIALS AND METHODS

From October 2003 to September 2004, five patients who had previous tubal sterilization and requested tubal reanastomosis underwent laparoscopic tubal reanastomosis with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA).

RESULTS

Ten fallopian tubes were successfully reconstructed, as confirmed by chromopertubation at the end of the procedure. Patency was confirmed by hysterosalpingogram in seven out of eight tubes. The mean (+/- standard deviation) time of the procedure was 172 +/- 53 min. The mean time for docking the robotic arms to the patient was 62 +/- 16.8 min and the mean robotic time was 97 +/- 36 min. There were two live births, one ectopic pregnancy, and one biochemical pregnancy. The mean time to conception was 5.5 +/- 2 months.

CONCLUSION

Laparoscopic microsurgical tubal reanastomosis after tubal sterilization can be performed using a remote-controlled robotic system. Systematization of the operative steps allowed for operative times that compare favorably with the time needed for open microsurgical techniques. Larger series are needed to standardize the procedure and confirm postoperative fecundity rates.

A 47-year-old woman with fertility problems who desires a multiple pregnancy

Mrs Z is a 47-year-old woman with long-standing infertility who is about to undergo in vitro fertilization (IVF) using donor oocytes from an anonymous donor. She has already undergone an IVF cycle with her own oocytes and an IVF cycle using donor oocytes from a known donor without a successful pregnancy. Mrs Z has been advised by her infertility physician to consider the transfer of a single embryo, but she does not wish to decrease her likelihood of conception, and, after her long and expensive infertility saga, wishes to conceive twins. The science of IVF has evolved significantly in the last several years, increasing the likelihood of successful pregnancy and reducing the need to transfer more than 1 embryo with its inherent risks of multiple pregnancy. The state of the science and why patients may continue to want multiple embryos transferred, including costs and lack of insurance coverage for infertility treatments, are discussed.

The problem of multiple pregnancies

A meeting of experts on the subject of multiple pregnancies was held on 25 November 2005 at the invitation of the Bertarelli Foundation, Switzerland. Swiss law on reproductive medicine prohibits the selection of embryos, a situation that not only reduces the success rate of IVF, but also makes it virtually impossible to achieve a further reduction in multiple pregnancy rates resulting from IVF. The medical profession, the couples affected and the general public need to be better informed about this restrictive law. Furthermore, it is a little known fact that a considerable number of multiple pregnancies are due to simple ovulation induction.

Guidelines for the number of embryos to transfer following in vitro fertilization

OBJECTIVE

To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies.

OPTIONS

Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared.

OUTCOMES

Clinical pregnancy, multiple pregnancy, and live birth rates.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles.

VALUES

Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.

Preconception care and treatment with assisted reproductive technologies

Couples with fertility problems seeking treatment with assisted reproductive technologies (ART) such as in vitro fertilization should receive preconception counseling on all factors that are provided when counseling patients without fertility problems. Additional counseling should address success rates and possible risks from ART therapies. Success rates from ART are improving, with the highest live birth rates averaging about 40% per cycle among women less than 35 years old. A woman's age lowers the chance of achieving a live birth, as do smoking, obesity, and infertility diagnoses such as hydrosalpinx, uterine leiomyoma, or male factor infertility. Singletons conceived with ART may have lower birth weights. Animal studies suggest that genetic imprinting disorders may be induced by certain embryo culture conditions. The major risk from ovarian stimulation is multiple gestation. About one-third of live-birth deliveries from ART have more than one infant, and twins represent 85% of these multiple-birth children. There are more complications in multiple gestation pregnancies, infants are more likely to be born preterm and with other health problems, and families caring for multiples experience more stress. Transferring fewer embryos per cycle reduces the multiple birth rate from ART, but the patient may have to pay for additional cycles of ART because of a lower likelihood of pregnancy.

Trends in embryo transfer practices and multiple gestation for IVF procedures in the USA, 1996-2002

BACKGROUND

Increasing use of IVF in the USA has been a major contributor to the rising national multiple birth rate. Many have advocated that reducing the number of embryos transferred is essential for addressing the IVF-associated multiple birth problem.

METHODS

A population-based sample of 506 072 IVF transfers performed in the USA in 1996-2002 was used to investigate trends in embryo transfer practices and to determine whether any changes in practice patterns have impacted the multiple gestation risk associated with IVF.

RESULTS

The proportion of procedures in which >or=3 embryos were transferred declined significantly for most patient groups between 1996 and 2002. However, declines for some groups were not sizeable (from 79 to 73% and from 76 to 71% for fresh, non-donor procedures among women aged 38-40 and 41-42 years respectively) and transferring >or=3 embryos remained the norm for all groups. As of 2002, single embryo transfer had not increased for most groups and remained uncommon. Some declines in overall multiple gestation rates were observed, although multiple gestation risk associated with 2 embryos transferred increased significantly for all groups.

CONCLUSIONS

Despite changes in embryo transfer practices, multiple gestation risk remains high, in part due to increased multiple gestation rates associated with the transfer of two embryos.

Assisted conception is a risk factor for postnatal mood disturbance and early parenting difficulties

OBJECTIVE

To investigate whether assisted conception is associated with an increased risk of admission to a residential early parenting program for treatment of maternal mood disorder or infant feeding or sleeping disorders in the postpartum year.

DESIGN

Systematic audit of consecutive medical records.

SETTING

Masada Private Hospital Mother Baby Unit (MPHMBU), Melbourne, Australia.

PATIENT(S)

Medical records of all mother-infant dyads admitted to MPHMBU between July 2000 and August 2002.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Modes of conception and delivery of index infant, maternal and infant age on admission, multiplicity of birth, infant birth weight, and Edinburgh Postnatal Depression Scale scores.

RESULT(S)

A total of 745 records were audited, and mode of conception was recorded in 526 (70.6%) of records. Overall 6% (45/745) of the admitted infants had been conceived through assisted reproductive technologies compared with 1.52% in the general population (relative risk 4.0; 95% confidence interval, 3.0-5.4). Mothers who had conceived with assisted reproductive technologies were older and more likely to have had cesarean and multiple births than those who conceived spontaneously.

CONCLUSIONS

Assisted conception appears to be associated with a significantly increased rate of early parenting difficulties. Women who experience assisted conception may require additional support before and after their babies are born.

Belgian legislation and the effect of elective single embryo transfer on IVF outcome

In order to reduce the number of multiple pregnancies following IVF, the Belgian government agreed to reimburse laboratory expenses for six IVF cycles up to the age of 42 years, in exchange for restriction of the number of embryos replaced. Data on assisted reproduction outcome before and after the introduction of this new legislation were analysed retrospectively in terms of implantation, pregnancy and multiple pregnancy rates. After the introduction of the new law, the percentage of single embryo transfer increased from 14 to 49%. Implantation rates were 25.9 and 23% respectively. There was no difference in the overall pregnancy rate before and after the introduction (36 versus 37%). Twin pregnancies, however, decreased from 19 to 3%. These findings indicate that elective single embryo transfer significantly decreases the twin pregnancy rate without a reduction in the overall pregnancy rate.

Psychosocial risks associated with multiple births resulting from assisted reproduction

OBJECTIVE

To determine if increased psychosocial risks are associated with each increase in birth multiplicity (i.e., singleton, twin, triplet) resulting from assisted reproduction.

DESIGN

Stratified random sample (n = 249).

SETTING

An academic teaching hospital and private practice infertility center.

PATIENT(S)

Mothers raising 1- to 4-year-old children (n = 128 singletons, n = 111 twins, and n = 10 triplets) conceived through assisted reproduction.

INTERVENTION(S)

Self-administered, mailed survey.

MAIN OUTCOME MEASURE(S)

Scales measuring material needs, quality of life, social stigma, depression, stress, and marital satisfaction.

RESULT(S)

Using multivariate logistic regression models, for each additional multiple birth child, the odds of having difficulty meeting basic material needs more than tripled and the odds of lower quality of life and increased social stigma more than doubled. Each increase in multiplicity was also associated with increased risks of maternal depression.

CONCLUSION(S)

To increase patients' informed decision-making, assisted reproduction providers might consider incorporating a discussion of these risks with all patients before they begin fertility treatment, and holding the discussion again if the treatment results in a multiple gestation. These data may also help providers to identify appropriate counseling, depression screening, and supports for patients with multiple births.

Comparison of outcome of pregnancy after intra-uterine insemination (IUI) and IVF

INTRODUCTION

Pregnancy outcome after IVF has been shown to be worse than after spontaneous conception. There is discussion as to whether this results from the technique itself or the patient characteristics. This study compares pregnancy outcome after IVF and intra-uterine inemination (IUI) in a matched patient group.

METHODS

Data were obtained from our IVF and IUI databases (1997-2001). Matching was performed for maternal age, parity and plurality, and 126 IUI pregnancies were compared with 126 IVF pregnancies. Outcome variables were pregnancy duration, birth weight, Caesarean section rates, preterm contraction rates, neonatal intensive care unit admission, Apgar score, blood loss rates and maternal hypertension.

RESULTS

None of the analysed parameters was statistically different between the groups.

CONCLUSION

This matched case-control study does not show different pregnancy outcomes after IVF and IUI. Since there is no reason to believe that the IUI technique in itself leads to an increased obstetric or neonatal risk, this study suggests that the worse pregnancy outcome after IVF as compared with spontaneous conceptions is due to the specific patient characteristics, rather than to the use of IVF itself.

Effect of in vitro fertilization practices on multiple pregnancy rates in Finland

The high occurrence of multiple pregnancies associated with IVF and embryo transfer is the main complication of assisted reproduction. The Finnish experience shows that the practice of reducing the number of transferred embryos can be implemented while maintaining good pregnancy rates.

Single embryo transfer and IVF/ICSI outcome: a balanced appraisal

This review considers the value of single embryo transfer (SET) to prevent multiple pregnancies (MP) after IVF/ICSI. The incidence of MP (twins and higher order pregnancies) after IVF/ICSI is much higher (approximately 30%) than after natural conception (approximately 1%). Approximately half of all the neonates are multiples. The obstetric, neonatal and long-term consequences for the health of these children are enormous and costs incurred extremely high. Judicious SET is the only method to decrease this epidemic of iatrogenic multiple gestations. Clinical trials have shown that programmes with >50% of SET maintain high overall ongoing pregnancy rates ( approximately 30% per started cycle) while reducing the MP rate to <10%. Experience with SET remains largely European although the need to reduce MP is accepted worldwide. An important issue is how to select patients suitable for SET and embryos with a high putative implantation potential. The typical patient suitable for SET is young (aged <36 years) and in her first or second IVF/ICSI trial. Embryo selection is performed using one or a combination of embryo characteristics. Available evidence suggests that, for the overall population, day 3 and day 5 selection yield similar results but better than zygote selection results. Prospective studies correlating embryo characteristics with documented implantation potential, utilizing databases of individual embryos, are needed. The application of SET should be supported by other measures: reimbursement of IVF/ICSI (earned back by reducing costs), optimized cryopreservation to augment cumulative pregnancy rates per oocyte harvest and a standardized format for reporting results. To make SET the standard of care in the appropriate target group, there is a need for more clinical studies, for intensive counselling of patients, and for an increased sense of responsibility in patients, health care providers and health insurers.