Twin pregnancy, contrary to consensus, is a desirable outcome in infertility

Pregnancy outcomes of monochorionic diamniotic and dichorionic diamniotic twin pregnancies conceived by assisted reproductive technology and conceived naturally: a study based on chorionic comparison

OBJECTIVE

To evaluate monochorionic diamniotic (MCDA) and dichorionic diamniotic (DCDA) twin pregnancies conceived by assisted reproductive technology (ART) and conceived naturally.

METHODS

We retrospectively analyzed the data on twin pregnancies conceived by ART from January 2015 to January 2022,and compared pregnancy outcomes of MCDA and DCDA twins conceived by ART with those of MCDA and DCDA twins conceived naturally, pregnancy outcomes between MCDA and DCDA twins conceived by ART, and pregnancy outcomes of DCT and TCT pregnancies reduced to DCDA pregnancies with those of DCDA pregnancies conceived naturally.

RESULT

MCDA pregnancies conceived by ART accounted for 4.21% of the total pregnancies conceived by ART and 43.81% of the total MCDA pregnancies. DCDA pregnancies conceived by ART accounted for 95.79% of the total pregnancies conceived by ART and 93.26% of the total DCDA pregnancies. Women with MCDA pregnancies conceived by ART had a higher premature delivery rate, lower neonatal weights, a higher placenta previa rate, and a lower twin survival rate than those with MCDA pregnancies conceived naturally (all p < 0.05). Women with DCDA pregnancies conceived naturally had lower rates of preterm birth, higher neonatal weights, and higher twin survival rates than women with DCDA pregnancies conceived by ART and those with DCT and TCT pregnancies reduced to DCDA pregnancies (all p < 0.05).

CONCLUSION

Our study confirms that the pregnancy outcomes of MCDA pregnancies conceived by ART are worse than those of MCDA pregnancies conceived naturally. Similarly, the pregnancy outcomes of naturally-conceived DCDA pregnancies are better than those of DCDA pregnancies conceived by ART and DCT and TCT pregnancies reduced to DCDA pregnancies.

Recurrence risk and risk factors for monozygotic twin and triplet birth in over 65,000 single-embryo transfers

PURPOSE

To determine the recurrence risk and risk factors for monozygotic splitting after elective single-embryo transfers (eSET).

METHODS

A retrospective cohort study was performed investigating 65,664 eSET cycles that resulted in a clinical pregnancy as reported in the Society for Assisted Reproductive Technology (SART) Clinical Outcomes Reporting System (CORS) between 2004 and 2017. Monozygosity was defined as more than one fetal heart tone by the first-trimester ultrasound and concordant sex at live birth. The primary outcome was recurrence risk, with recurrence defined as one patient having two or more cycles of eSET resulting in monozygotic multiples. The secondary objective was to identify factors associated with smonozygotic splitting, using a multivariable logistic regression model and a stepwise purposeful model selection.

RESULTS

There were 1355 (2.05%) pregnancies that resulted in two or more fetal heart tones after SET, including 840 monozygotic twins and triplets at birth. Recurrence occurred in two cases-0.0001% of patients with multiple eSET cycles. One case resulted from embryos created from a single cohort with intracytoplasmic sperm injection (ICSI), assisted hatching (AH), and blastocyst transfers. The second case resulted from donor egg embryos with ICSI and blastocyst transfers. Risk factors associated with monozygotic live birth were blastocyst transfer (OR 1.23, 95% CI 1.04-1.47, P = 0.0176) and AH (OR 1.23, 95% CI 1.05-1.44, P = 0.0081).

CONCLUSION

Recurrence of monozygotic live births in eSET was very rare. Blastocyst transfer and AH were confirmed to be risk factors for monozygotic live births, while ICSI, PGT, and FET do not appear to be associated.

Temporal Trends in Multiple Births in Greece: The Evolution of an Epidemic

Introduction Multiple births constitute the dominant adverse effect of fertility treatments and are associated with increased perinatal risks. The aim of this study was to comprehensively examine and present time trends in multiple births in Greece. Methods Data on live births by multiplicity were derived from the Hellenic Statistical Authority, covering a 65-year period from 1957 to 2021. Temporal trends in multiple birth rates (MBR), twin birth rates (TwBR), as well as in triplet and higher-order birth rates (Tr+BR) were assessed using joinpoint regression analysis, and the annual percentage changes (APC) were calculated with a 95% confidence interval (95% CI) and level of statistical significance (p < 0.05). Results The MBR in Greece showed a downward trend from 1957 to 1979 (APC = -1.7, 95% CI: -2.0 to -1.4, p < 0.001). However, the rate started to climb in the 1980s, accelerated during the 1990s, and continued to rise in the two most recent decades, reaching a historic high and a world record of 57.2 per 1,000 births in 2021, i.e., a 3.4-fold increase since 1985. The TwBR increased from an all-time low of 16.5 per 1,000 births in 1978 with APC = 1.4 (95% CI: 0.2 to 2.5, p = 0.021) during 1979-1989, APC = 6.3 (95% CI: 5.5 to 7.2, p < 0.001) during 1989-2001, and APC = 1.2 (95% CI: 0.8 to 1.5, p < 0.001) during the last two decades (2001-2021). The Tr+BR, after an all-time low of 17.5 per 100,000 births in 1966, increased dramatically from 1982 to 2000 (APC = 12.4, 95% CI: 9.6 to 15.2, p < 0.001), leveled off during 2000-2011, and after reaching a historic maximum of 351.1 per 100,000 births in 2010, there was a sharp decreasing trend during the last decade (2011-2021: APC = -12.1, 95% CI: -16.8 to -7.2, p < 0.001). Conclusion The dramatic increases in maternal age as well as in medically assisted conceptions have resulted in an epidemic increase in MBR in Greece reaching world record levels. During the last decade, there was an encouraging decline in the Tr+BR; however, the TwBR has continued to trend upwards.

Developmental Potential of embryos does not Impact Pregnancy Outcomes, but it Affects Live Birth Rates in Frozen Blastocyst Transfer Cycles

OBJECTIVE

This study aimed to determine whether or not developmental potential impacts clinical outcomes, when good grade blastocysts from Days 5 and 6 were transferred in frozen embryo transfer (FET) cycles.

METHODS

654 women, including 460 (70.33%) on Day 5 and 194 (29.66%) on Day 6 were analyzed, in which 905 Day-5 and 274 Day-6 blastocysts were transferred. Only grade AA, AB, BA, BB quality and expansion grade between 3-6 (Gardner grading system) blastocysts survived and were included.

RESULTS

The implantation rate was higher, 41.9% (379/905) in normal Day-5 compared to delayed Day-6 blastocyst transfers - 36.5% (100/274), but not significant (p=0.1). The clinical pregnancy rate was similar and not significant (p=0.4) in normal Day-5 (32.4%), compared to delayed Day-6 (35%). Miscarriage rates were higher in normal Day-5 (13.3%) compared to delayed Day-6 (6.3%) blastocyst transfers but were not significant (p=0.06). On the other hand, the biochemical pregnancy rate was significantly higher (p=0.001) in the delayed Day-6 blastocysts (16.7%) transfer group compared to patients with normal Day-5 (2.4%) blastocyst transfers. Two patients had ectopic pregnancies from the delayed Day-6 blastocyst transfer group. Live-Birth rates were significantly higher in Day-5 blastocysts compared to Day-6 (p=0.03).

CONCLUSIONS

The developmental potential of embryos should not be considered a negative influence on pregnancy outcomes, especially good grade blastocysts vitrified on Days 5 and 6. Fully expanded blastocysts on Day-5 are considered similar in terms of outcomes to delayed Day-6 blastocysts; however, live-birth rates are significantly higher in Day-5 blastocysts.

Transferring more than 1 embryo simultaneously is justifiable in most patients

Elective single embryo transfer (eSET), first introduced to in vitro fertilization (IVF) in 1999, is one of the most consequential changes introduced. It can be viewed as the first (among many since) "add-ons" to IVF that has significantly and adversely affected how IVF is practiced, resulting in astonishing declines in live birth rates following fresh non-donor IVF cycles around the world. We offer that, like most "add-ons" to IVF over recent years, the almost universal use of eSET worldwide not only lacks proper validation of its underlying hypothesis, but is based on statistically incorrect assumptions and incorrect data interpretation. As eSET, like most other recent "add-ons" to IVF, lacks evidentiary support, its remarkable success in the marketplace must be based on expert opinions, the lowest level of evidence in medicine and widely recognized as frequently biased. Like other "add-ons" to IVF, eSET-practice, therefore, must be reassessed since it, not only does not offer the benefits it has been widely claimed to provide, but prolongs time to conception and adversely affects live birth chances for many women. Moreover, by ignoring that infertile women value quick conception over most other considerations, provider-insistence on eSET frequently deprives them of the right to self-determination.

Protein C global assay evaluation in naturally conceived vs. assisted reproduction-achieved twin pregnancies: a prospective longitudinal study

PURPOSE

Protein C global assay tests the global function of the protein C pathway, the most clinically significant anticoagulant pathway in humans. The objective of this study is to assess the difference in protein C global assay levels, throughout twin gestation, in naturally conceiving and ART-treated women.

METHODS

This is a prospective cohort longitudinal study of pregnant women with twin gestation. Protein C Global evaluation was performed on frozen blood samples. Ninety-eight women with twin pregnancy, thirty-eight naturally conceived and sixty following ART, were evaluated on four occasions: during the first, second, and third trimesters, and 6 weeks or later after delivery (baseline).

RESULTS

Protein C global assay levels were lower throughout pregnancy as compared to basal levels in both the naturally conceived and ART-conceived groups. However, protein C global assay levels were similar between the ART-conceived and naturally conceived twin pregnancies in all three trimesters. Perinatal complications were associated with decreased protein C global assay levels during the third trimester, although no difference was encountered between naturally conceived and ART-complicated twin pregnancies.

CONCLUSION

While protein C global assay levels drop during twin pregnancy, there is no difference between ART-conceived and naturally conceived gestations. Decreased levels of protein C global assay during the third trimester were similarly associated with perinatal complications in both groups. Our results imply that twin pregnancy of itself is a more dominant factor for perinatal complications as compared to other factors, such as subfertility or the exposure to ART per se.

Strategies to reduce multiple pregnancies during medically assisted reproduction

Multiple birth rates after fertility treatment are still high in many countries. Multiple births are associated with increased rates of preterm birth and low birth weight babies, in turn increasing the risk of severe morbidity for the children. The multiple birth rates vary in different countries between 2% and 3% and up to 30% in some settings. Elective single-embryo transfer, particularly in combination with frozen-embryo transfer and milder stimulation in ovulation induction/intrauterine insemination, to avoid multifollicular development is an effective strategy to decrease the multiple birth rates while still achieving acceptable live-birth rates. Although this procedure is used successfully in many countries, it ought to be implemented broadly to improve the health of the children. One at a time should be the normal routine.

[Delivery of twin pregnancy and materno-fetal prognosis in a level 3 Tunisian University Center: a retrospective study about 399 cases]

En dépit des progrès obstétricaux et pédiatriques, les grossesses gémellaires représentent une situation à haut risque aussi bien pour le déroulement de la grossesse que pour l´accouchement et reste encore une situation angoissante pour l´équipe obstétricale. Le but de cette étude était de décrire la pratique des accouchements des grossesses gémellaires au service de gynécologie obstétrique de Sousse, de décrire le pronostic maternel et fœtal et d´analyser les facteurs pouvant l´influencer. Nous avons réalisé une étude descriptive, rétrospective portant sur les accouchements des grossesses gémellaires sur une période de deux ans. Ont été incluses dans l´étude les grossesses gémellaires ayant atteint au moins 28 semaines d´aménorrhée (SA) et les femmes ayants une grossesse gémellaire compliquée d'une mort fœtale in utéro. Ont été exclues les femmes ayant une grossesse gémellaire et ayant accouchés avant 28 SA. Les grossesses bi-choriales bi-amniotiques représentaient 67% des cas, contre seulement 11,5% de grossesses mono-choriales bi-amniotiques et 3% de grossesses mono-choriale mono-amniotique. Nous avons recensé 52 césariennes programmées. Le travail a été spontané dans 304 cas. Il a été déclenché dans 43 cas. Au total 178 parturientes ont accouché par voie basse (44,6%), contre 215 par voie haute (53,9%). Le taux de césarienne pour le deuxième jumeau était de 1,5%. Quand l'accouchement était par voie basse, 19 cas de complications ont été observés (10,7%). Nous avons analysé le score d'Apgar du premier jumeau et du deuxième jumeau en fonction du mode d'accouchement. Il n'y a pas eu de différence statistiquement significative du score d'Apgar entre les deux voies d'accouchement. La morbi-mortalité périnatale est plus importante pour le deuxième jumeau que pour le premier jumeau. La morbidité maternelle en cas d´accouchement par voie basse était supérieur à la morbidité en cas d´accouchement par césarienne. Il n´y a pas de différences significatives dans le score d´Apgar selon que les enfants sont nés par voie basse ou par césarienne.

The role of maternal age in twin pregnancy outcomes

BACKGROUND

There are limited data on how maternal age is related to twin pregnancy outcomes.

OBJECTIVE

The purpose of this study was to assess the relationship between maternal age and risk for preterm birth, fetal death, and neonatal death in the setting of twin pregnancy.

STUDY DESIGN

This population-based study of US birth, fetal death, and period-linked birth-infant death files from 2007-2013 evaluated neonatal outcomes for twin pregnancies. Maternal age was categorized as 15-17, 18-24, 25-29, 30-34, 35-39, and ≥40 years of age. Twin live births and fetal death delivered at 20-42 weeks were included. Primary outcomes included preterm birth (<34 weeks and <37 weeks), fetal death, and neonatal death at <28 days of life. Analyses of preterm birth at <34 and <37 weeks were adjusted for demographic and medical factors, with maternal age modeled with the use of restricted spline transformations.

RESULTS

A total of 955,882 twin live births from 2007-2013 were included in the analysis. Preterm birth rates at <34 and <37 weeks gestation were highest for women 15-17 years of age, decreased across subsequent maternal age categories, nadired for women 35-39 years old, and then increased slightly for women ≥40 years old. Risk for fetal death generally decreased across maternal age categories. Risk for fetal death was 39.9 per 1000 live births for women 15-17 years old, 24.2 for women 18-24 years old, 17.8 for women 25-29 years old, 16.4 for women 30-34 years old, 17.2 for women 35-39 years old, and 15.8 for women ≥40 years old. Risk for neonatal death at <28 days was highest for neonates born to women 15-17 years old (10.0 per 1,000 live births), decreased to 7.3 for women 18-24 years old and 5.5 for women 25-29 years old and ranged from 4.3-4.6 for all subsequent maternal age categories. In adjusted models, risk for preterm birth at <34-<37 weeks gestation was not elevated for women in their mid-to-late 30s; however, risk was elevated for women <20 years old and increased progressively with age for women in their 40s.

CONCLUSION

Although twin pregnancy is associated with increased risk for most adverse perinatal outcomes, this analysis did not find advanced maternal age to be an additional risk factor for fetal death and infant death. Preterm birth risk was relatively low for women in their late 30s. Risks for adverse outcomes were higher among younger women; further research is indicated to improve outcomes for this demographic group. It may be reasonable to counsel women in their 30s that their age is not a major additional risk factor for adverse obstetric outcomes in the setting of twin pregnancy.

A 50% reduction in multiple live birth rate is associated with a 13% cost saving: a real-life retrospective cost analysis

Belgian legislation limiting the number of embryos for transfer has been shown to result in a 50% reduction of the multiple live birth rate (MLBR) per cycle without having a negative impact on the cumulative delivery rate per patient within six cycles or 36 months. The objective of the current study was to evaluate the cost saving associated with a 50% reduction in MLBR. A retrospective cost analysis was performed of 213 couples, who became pregnant and had a live birth after one or more assisted reproductive technology treatment cycles, and their 254 children. The mean cost of a singleton (n = 172) and multiple (n = 41) birth was calculated based on individual hospital invoices. The cost analysis showed a significantly higher total cost (assisted reproductive technology treatment, pregnancy follow-up, delivery, child cost until the age of 2 years) for multiple births (both children: mean €43,397) than for singleton births (mean: €17,866) (Wilcoxon-Mann-Whitney P < 0.0001). A 50% reduction in MLBR resulted in a significant cost reduction related to hospital care of 13%.

Is a Blanket Elective Single Embryo Transfer Policy Defensible?

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.

Systematic review of worldwide trends in assisted reproductive technology 2004-2013

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 ).

Deciding how many embryos to transfer: ongoing challenges and dilemmas

Despite the risks associated with twin and higher-order multiple births, and calls in many countries for single-embryo transfer as the standard of care for good-prognosis patients, providers frequently transfer additional embryos, raising critical questions as to why this is the case and what can be done about it. In-depth interviews of approximately 1 h each were conducted with 27 IVF providers (17 physicians and 10 other healthcare providers) and 10 patients. Professional guidelines often contain flexibility and ambiguities or are unenforced. Thus, both providers and patients frequently wrestle with several dilemmas. Decisions about the number of embryos to transfer emerge as dyadic, dynamic and affected by several factors (e.g. providers' type of institution, and personal and professional experiences and perceptions of the data), leading to differences in whether, how and with what effectiveness clinicians address these issues with patients. Many clinicians feel that the evidence concerning the apparent increased risk associated with a twin birth is not 'compelling', and patients frequently minimize the hazards. These data, the first to explore several critical aspects of how providers and patients view and make decisions about the number of embryos to transfer, thus highlight tensions, uncertainties and challenges that providers and patients confront, and have key implications for future practice, research, policy and education.

Risks of spontaneously and IVF-conceived singleton and twin pregnancies differ, requiring reassessment of statistical premises favoring elective single embryo transfer (eSET)

A published review of the literature by Dutch investigators in 2004 suggested significant outcome differences between spontaneously - and in vitro fertilization (IVF) - conceived singleton and twin pregnancies. Here we review whether later studies between 2004-2015 confirmed these findings. Though methodologies of here reviewed studies varied, and all were retrospective, they overall confirmed results of the 2004 review, and supported significant outcome variances between spontaneously- and IVF-conceived pregnancies: IVF singletons demonstrate significantly poorer and IVF twins significantly better perinatal outcomes than spontaneously conceived singletons and twins, with differences stable over time, and with overall obstetrical outcomes significantly improved. Exaggerations of severe IVF twin risks are likely in the 50 % range, while exaggerations of milder perinatal risks are approximately in 25 % range. Though elective single embryo transfers (eSET) have been confirmed to reduce pregnancy chances, they are, nevertheless, increasingly utilized. eSET, equally unquestionably, however, reduces twin pregnancies. Because twin pregnancies have been alleged to increase outcome risks in comparison to singleton pregnancies, here reported findings should affect the ongoing discussion whether increased twin risks are factual. With no risk excess, eSET significantly reduces IVF pregnancy chances without compensatory benefits and, therefore, is not advisable in IVF, unless patients do not wish to conceive twins or have medical contraindications to conceiving twins.

Two consecutive singleton pregnancies versus one twins pregnancy as preferred outcome of in vitro fertilization for mothers and infants: a retrospective case-control study

OBJECTIVE

Many infertile couples request a multiple embryo transfer because they desire more than one child. Based on this consideration, the current study aimed to compare the reproductive and perinatal outcomes of two consecutive singleton pregnancies versus one twin pregnancy in a large cohort of in vitro fertilization (IVF) patients.

RESEARCH DESIGN AND METHODS

Retrospective analysis of data from patients with clinical twin pregnancy after IVF fresh cycles and from patients with two consecutive IVF fresh cycles and clinical singleton pregnancy.

MAIN OUTCOME MEASURES

Miscarriage rate, delivery rate, gestational age at birth, neonatal birth weight, and perinatal complications. A sub-analysis of data according to vanishing twin syndrome (VTS) was also performed.

RESULTS

A total of 18,703 autologous fresh cycles were analyzed. One hundred seven patients had two consecutive singleton clinical pregnancies, whereas one clinical twin pregnancy occurred in 641 women. In patients who had two consecutive singleton clinical pregnancies the rates of overall pregnancies lost (odds ratio [OR] 4.9, 95% confidence interval [CI] 3.4, 6.9) and live births (OR 0.2, 95% CI 0.1, 0.3) were, respectively, higher and lower when compared to patients who had one clinical twin pregnancy. That data did not change after sub-analysis for VTS. The overall risk of perinatal complications was significantly higher in patients who had one twin delivery rather than patients who had two consecutive singleton deliveries (OR 31.8, 95% CI 14.1, 71.5). No difference between groups was detected in terms of intrauterine/neonatal deaths, perinatal mortality and neonatal intensive care unit admission. Data did not change after adjusting for confounders.

CONCLUSIONS

When compared with two consecutive singleton pregnancies, twin pregnancies are characterized by higher success rates but worse perinatal outcomes irrespectively of VTS. Well designed prospective controlled studies are needed to confirm or rebut current retrospective findings.

Debating Elective Single Embryo Transfer after in vitro Fertilization: A Plea for a Context-Sensitive Approach

The number of embryos transferred after in vitro fertilization (IVF) have been a topic of debate for over a decade now. Due to the risk associated with multiple pregnancy, there has been a global effort at reducing the multiple pregnancy rates to a minimum while maintaining an acceptable level of successful IVF pregnancy rate. Elective single embryo transfer (eSET) is advocated in most European countries. In Belgium and Sweden, eSET is mandatory for couples with a good prognosis. However, despite clinical recommendations and policy statements, patients in clinical practice frequently do request for the transfer of multiple embryos in order to have twins. Such requests conflict with policy guidelines and create an ethical dilemma for physicians: Should the physician do as the couple requests, and there with respect the autonomy of patients, or adhere to medical policy that takes the health of the mother and children at heart? This article provides an exploration of the arguments found in the literature that plays a role in the discussion on this topic and eventually argues that what a physician should do depends on the specificities of the context in which patients and physicians are implicated. These contextual issues can be taken into account in a shared decision-making procedure, which allows reflections and the responsibilities of both patients and physicians to be attended in decision about assisted reproduction.

Clinical predictive criteria associated with live birth following elective single embryo transfer

OBJECTIVE

We aimed to define clinical criteria from the patients related to the occurrence of live birth in case of elective single embryo transfer (eSET).

STUDY DESIGN

We analyzed retrospectively 409 eSET at day 2/3 between March 2005 and July 2012, proposed in case of (i) woman's age <37 years, (ii) first/second IVF0 cycle, (iii) ≥2 good quality embryos obtained (3-5/6-10 blastomeres at day 2/3 and <20% fragmentation), including one top embryo (4/8 cells). In all, 124/409 live births (30.3%) were obtained, separating patients into groups of women who had birth or not. Different clinical parameters of interest were compared between each group, using appropriate statistical tests at p<0.05 significance level.

RESULTS

By comparing Body Mass Index (BMI), we report a statistically higher BMI among women who did not deliver (24.6 vs. 23.4kg/m(2); p=0.014). Using an analysis by BMI categories, we also precise a threshold of BMI≥30kg/m(2), negatively associated with the occurrence of live birth.

CONCLUSION

BMI appears to be the only clinical parameter statistically associated with delivery following eSET strategy in a good prognosis infertile population.

The risk of neurodisability and other long-term outcomes for infants born following ART

Children born after assisted reproductive technologies (ART) have an increased morbidity. The risk of developing cerebral palsy is nearly doubled and the risk of developing epilepsy is also higher. Behavioural problems including attention deficit/hyperactivity disorder may be more common in children born following ART than among naturally conceived children but the finding is uncertain. Data on autism are difficult to interpret. There may exist a small increase in the incidence of childhood cancer and there is greater evidence of an elevated risk of asthma. To some extent, these risks are mediated by neonatal complications including prematurity and low birth weight but some effects such as cerebral palsy are likely to be linked to the increased rate of multiple births after ART. Many of the neonatal complications after ART are most likely linked to parental subfertility and are less an effect of the ART technology. The possibility exists that imprinting errors, associated with subfertility and/or ART, may result in long-term morbidity.

Obstetric and perinatal outcomes of twin pregnancies conceived following IVF/ICSI treatment compared with spontaneously conceived twin pregnancies

OBJECTIVE

Twin pregnancy is associated with increased obstetric and perinatal risk. There are conflicting reports on whether assisted conception (ART) further increases these risks. The aim of this study is to assess the obstetric and perinatal outcomes of twin pregnancies according to mode of conception.

STUDY DESIGN

A retrospective study of all viable dichorionic-diamniotic (DCDA) twin pregnancies (n=539) delivered at Cork University Maternity Hospital, Ireland between 2009 and 2012, divided according to spontaneous conception (SC) and ART conception, specifically IVF or ICSI.

RESULTS

The ART conceived group were on average 4 years older (36.8±4.23 vs 32.3±4.93 years) and more frequently nulliparous (73.7%; n=126 vs 36.1%; n=133) than their SC counterparts (p<0.001). There was no significant difference in maternal antenatal complications. ART twins were twice as likely to be delivered by caesarean section (CS) (OR 2.35; 95% CI 1.76-3.14). There was no significant difference in the rates of preterm birth or NICU admission according to mode of conception. ART conceived twins were almost twice as likely to be delivered moderately preterm (32-33(+6)) (OR 1.98, 95% CI 1.21-3.23) and were more likely to have RDS and neonatal hypoglycaemia

CONCLUSIONS

Twin pregnancy, irrespective of mode of conception, carries an increased risk of morbidity and mortality for both mother and babies and therefore couples should be counselled regarding the increased risk of iatrogenic twinning associated with double embryo transfer. However, for those that do conceive twins, they can be advised that assisted conception conveys no significant disadvantage over naturally conceived twin pregnancies.

The Desire for Multiple Pregnancy among Patients with Infertility and Their Partners

Objective. To study the predictors for desire for multiple pregnancies and the influence of providing information regarding the maternal and fetal complications associated with multiple pregnancies on their preference for multiple pregnancies. Methods. Couples attending an infertility clinic were offered to fill up a questionnaire separately. Following this, they were handed a pamphlet with information regarding the risks associated with multiple pregnancies. The patients will then be required to answer the question on the number of pregnancies desired again. Results. Two hundred fifty three out of 300 respondents completed the questionnaires adequately. A higher proportion of respondents, 60.3% of females and 57.9% of males, prefer singleton pregnancy. Patients who are younger than 35 years, with preexisting knowledge of risks associated with multiple pregnancies and previous treatment for infertility, have decreased desire for multiple pregnancies. However, for patients who are older than 35, with longer duration of infertility, and those patients who have preexisting knowledge of the increased risk, providing further information regarding the risks did not change their initial preferences. Conclusion. Providing and reinforcing knowledge on the risks to mother and fetus associated with multiple pregnancies did not decrease the preference for multiple pregnancies in patients.

Maternal and perinatal outcomes in spontaneous versus assisted conception twin pregnancies

OBJECTIVE

To compare maternal and perinatal outcomes in twin pregnancies conceived via assisted reproductive techniques (ART) compared with spontaneous twin pregnancies.

STUDY DESIGN

This retrospective study examined 345 dichorionic, di-amniotic twin pregnancies (207 conceived spontaneously and 138 conceived via ART), delivered between January 2007 and June 2011 at the San Pietro Fatebenefratelli Hospital, Rome, a tertiary medical centre. Maternal and perinatal outcomes were compared. A multiple logistic regression analysis was performed to calculate risk estimates as odds ratios (OR) adjusted for maternal age, parity and systemic diseases. Patient data were obtained from a computerized database and analyzed using Statistical Package for the Social Sciences Version 17.

RESULTS

Gestational age and birth weight were lower in the ART group, and preterm delivery, gestational diabetes and placental abruption were higher in the ART group compared with the spontaneous conception group. The incidence rates of respiratory complications, patent ductus arteriosus and admission to the neonatal intensive care unit were higher among ART newborns. Length of hospital stay for mothers and newborns was longer in the ART group. No differences in mode of delivery, Apgar score at 5min, congenital anomalies, perinatal mortality, and other considered pregnancy and neonatal complications were found between the two groups. Multivariate analysis adjusted for maternal age, parity and systemic diseases revealed that only the rates of placental abruption [OR 7.45, 95% confidence interval (CI) 2.05-26.98] and patent ductus arteriosus (OR 3.39, 95% CI 1.01-11.46) were significantly higher for the ART group.

CONCLUSIONS

Twin pregnancies conceived via ART are at greater risk of poorer outcomes than spontaneous twin pregnancies. This may be related to the type of conception and specific negative features of subfertile patients undergoing infertility treatment.

Refuting a misguided campaign against the goal of single-embryo transfer and singleton birth in assisted reproduction

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.

What are the risks of the assisted reproductive technologies (ART) and how can they be minimized?

Although assisted reproductive technologies (ART) have become established procedures performed around the world, there are still many unanswered questions regarding safety. Possible risks associated with infertility and ART include (1) those inherent to pregnancy, delivery, and childhood; (2) those associated with the infertility itself and its causes; and (3) risks iatrogenic to ART. Although there are many potential risks associated with ART, it has become clear that the major risk is multiple pregnancy and its consequences. Major efforts are warranted to reduce the risk of multiple gestations with IVF, but it is also clear that single-embryo transfer is not the solution in all cases. Moreover, several studies have now documented that perinatal outcomes are somewhat poorer in IVF singleton infants than in spontaneously conceived singletons, but it is not clear if this increased risk is due to the ART or the infertility. Concerns about the impact of abnormalities in genomic imprinting persist at this time, as do risks associated with the culture conditions and even our environment. Only time will tell if children born following ART are at any increased risk of developing certain chronic diseases as they age. In any case, the risks to IVF children and mothers are likely to remain higher than those for children and mothers conceived spontaneously without medical assistance. However, since there have been over 5 million births after ART worldwide, and the vast majority of pregnancies and children have been essentially "normal", it is obvious that any excess risk must be relatively small. The normality of most pregnancies mandates that extreme care be exercised in making any changes to current practice.

Mistaken advocacy against twin pregnancies following IVF

PURPOSE

A recent publication by Swedish Colleagues in Fertility & Sterility for the first time, statistically correctly, attempted to assess risks of twin IVF pregnancies in comparison to two consecutive singleton IVF pregnancies. Historic comparisons have been statistically incorrect, comparing risks of one twin to one singleton pregnancy. We here analyze data and conclusions presented in this Swedish study.

METHODS

We reviewed the manuscript by Sazonova et al. (Fertil Steril, 2013) (doi: 10.1016/j.fertnstert.2012.11.023 ).

RESULTS

Based on incorrect statistical methodology, twins after in vitro fertilization (IVF) have come under attack as "adverse" outcomes. Above noted study recently, for the first time, correctly compared one twin to two consecutive singleton pregnancies. Investigators, however, in our opinion interpreted their own data incorrectly by claiming "dramatically" higher maternal and neonatal risks in twin pregnancies. Our interpretation of reported data, indeed, in contrast suggests surprisingly minor differences in observed twin-risks. Moreover, such minor risk increases do not offer adequate compensatory benefits for significantly lower pregnancy chances in first IVF cycles with eSET in comparison to two-embryo transfers (2-ET).

CONCLUSIONS

As significantly higher maternal and neonatal risks of twin IVF pregnancies represent the principal rationale for eSET, the Swedish study actually suggests that eSET offers neither patient-friendly nor cost-effective treatment options for IVF, except where patients object to twins or have medical contraindications. The need for a second pregnancy to achieve equal outcome (2 children), resulting treatment delays, increased efforts and costs, in absence of any guarantees that a second successful singleton pregnancy/delivery will ever be accomplished, invalidates eSET as a routine procedure.

Twin pregnancies: evaluation of major depression, stress, and social support

BACKGROUND

Twin pregnancies are at increased physiological and psychosocial risks.

OBJECTIVE

To investigate the prevalence of major depression in twin pregnancies and correlate with stress and social support.

METHOD

The study included 51 pregnant women under specialized prenatal care who were evaluated by a Portuguese version of the semi-structured questionnaire Primary Care Evaluation of Mental Disorders (PRIME-MD) for Major Depression, and the Prenatal Psychosocial Profile (PPP) for evaluation of stress and social support.

RESULTS

Major depression was found in 33.3% of pregnant women, and prevailing symptoms were fatigue or loss of energy (100%), insomnia or hypersomnia (82.4%), changes in appetite (82.4%), decreased interest in daily activities (82.4%), and psychomotor agitation or retardation (82.4%). Among pregnant women who were diagnosed depressive, 76.5% also had a high level of stress and 47.1% complained about lack of social support. Statistical significance was found when correlating depression with perception of negative aspects of having twins and belief in significant body changes during pregnancy (p = .005 and .03, respectively). Marital status, occupation, and pregnancy planning were not significantly associated with the diagnosis of depression.

CONCLUSION

Major depression occurs in one-third of pregnant women expecting twins and is associated with higher levels of stress and lack of social support. A multidisciplinary approach in these cases is fundamental to minimize further risks and complications.

Elective single-embryo transfer in women aged 40-44 years

STUDY QUESTION

Is an elective single-embryo transfer (eSET) policy feasible for women aged 40 or older?

SUMMARY ANSWER

For older women (aged 40-44 years) with a good prognosis, an eSET policy can be applied with acceptable cumulative clinical pregnancy rates and live birth rates.

WHAT IS KNOWN ALREADY

Various studies have shown the effectiveness of eSET in women aged <35 years with high cumulative pregnancy rates and low rates of multiple births.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 628 women treated between 2000 and 2009.

PARTICIPANTS, SETTING, METHODS

Women aged 40-44 years underwent a fresh cycle of IVF or ICSI treatment with eSET (n = 264) or double-embryo transfer (DET) (n = 364). In the subsequent frozen-thawed embryo transfer cycles, SET/DET was performed in both groups according to the number of embryos available and the opinion of the couple. The study was performed at the Family Federation of Finland Helsinki Fertility Clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

In the fresh cycles, the clinical pregnancy rates were 23.5 and 19.5% in the eSET and DET groups, respectively, and live birth rates were 13.6 and 11.0%, respectively. In the fresh cycles with eSET, there were no twin pregnancies, but in the DET group, there were three sets of twins (7.5%). The cumulative clinical pregnancy rates per oocyte retrieval were 37.1 and 24.2% in the eSET and DET groups, respectively (P < 0.001), and the cumulative live birth rates were 22.7 and 13.2%, respectively (P = 0.002). Cumulative twin rates were 6.7% (n = 4) in the eSET group and 8.3% (n = 4) in the DET group (P = 0.726). All of the twin pregnancies in the eSET group resulted from frozen and thawed DET embryo transfer cycles.

LIMITATIONS

The characteristics of the two patients groups are not comparable because the suitability of eSET was individually assessed by a clinician based on both clinical prognostic factors and the outcome of IVF or ICSI, i.e. the number and quality of embryos.

WIDER IMPLICATIONS OF THE FINDINGS

This study may be generalized to IVF units having experience in eSET and cryopreservation.

The irrational attraction of elective single-embryo transfer (eSET)

In this issue of the journal, Niinimäki et al., colleagues from a pioneering Finnish center in the development of elective single-embryo transfer (eSET), propose the expansion of eSET to suitable women at ages of 40-44 years. This paper offers not only a critique of their proposal but also of eSET in general.

Lessons from elective in vitro fertilization (IVF) in, principally, non-infertile women

BACKGROUND

We here report the first investigation of exclusively elective in vitro fertilization (IVF) cycles in women with no apparent history of infertility. Since IVF outcome in women with infertility are always influenced by underlying causes of infertility, a study on non-infertile women may offer new insights.

METHODS

We investigated 88 females without history of infertility in 109 consecutive elective IVF cycles, almost exclusively performed for purposes of preimplantation genetic screening (PGS; i.e., elective gender selection). The following questions were addressed: (i) impact of PGS on IVF pregnancy chances; (ii) impact of transfer of 1 vs. ≥2 embryos on IVF pregnancy chances; (iii) correlation of anti-Müllerian hormone (AMH) levels to embryo ploidy (iv) effect of gonadotropin dosage used in stimulation on available embryos for transfer; and (v) in form of a 1:1 case control study, compared 33 elective PGS cycles with matched control cycles without PGS, performed in couples with either prior tubal ligations and/or severe male factor infertility as indication of IVF.

RESULTS

The overall clinical pregnancy rate for the group was 36.7%; pregnancy was associated with number of euploid (P = 0.009) and number of embryos transferred (P = 0.001). Odds of pregnancy were 3.4-times higher if ≥4 euploid embryos were produced in comparison to <4 (95% CI 1.2 to 9.2; P = 0.019), and odds of pregnancy were 6.6-times higher if greater than or equal to 2 rather than <1 euploid embryos were transferred (95% CI 2.0 to 21.7; P = 0.002). Increasing AMH (P = 0.001) and gonadotropin dosage used in ovarian stimulation (P = 0.024), was, independently, associated with number of available euploid embryos. Increasing AMH, but not follicle stimulating hormone (FSH), was associated with number of embryos available for biopsy and PGS (P = 0.0001). Implantation rates were 26.4% with PGS and 9.5% without (P = 0.008). Women undergoing PGS, demonstrated 4.58-times higher odds of pregnancy than matched controls (95% CI 1.102 to 19.060, Exp 4.584, P = 0.036).

CONCLUSIONS

This study suggests that outcomes of elective IVF cycles may significantly deviate from infertility-associated cycles. Affirming proof of concept for PGS, utilizing day-3 embryo biopsy and fluorescence in-situ hybridization (FISH), both widely held responsible for earlier failures to establish such proof, suggests that the principal cause of prior failures were likely not insufficient laboratory techniques but poor patient selection for PGS. Such a conclusion questions the current reintroduction of PGS with improved techniques and technologies in absence of prior determination of suited patient populations.

Predicting personalized multiple birth risks after in vitro fertilization-double embryo transfer

OBJECTIVE

To report and evaluate the performance and utility of an approach to predicting IVF-double embryo transfer (DET) multiple birth risks that is evidence-based, clinic-specific, and considers each patient's clinical profile.

DESIGN

Retrospective prediction modeling.

SETTING

An outpatient university-affiliated IVF clinic.

PATIENT(S)

We used boosted tree methods to analyze 2,413 independent IVF-DET treatment cycles that resulted in live births. The IVF cycles were retrieved from a database that comprised more than 33,000 IVF cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The performance of this prediction model, MBP-BIVF, was validated by an independent data set, to evaluate predictive power, discrimination, dynamic range, and reclassification.

RESULT(S)

Multiple birth probabilities ranging from 11.8% to 54.8% were predicted by the model and were significantly different from control predictions in more than half of the patients. The prediction model showed an improvement of 146% in predictive power and 16.0% in discrimination over control. The population standard error was 1.8%.

CONCLUSION(S)

We showed that IVF patients have inherently different risks of multiple birth, even when DET is specified, and this risk can be predicted before ET. The use of clinic-specific prediction models provides an evidence-based and personalized method to counsel patients.

Hype or hope? Ethical and practical considerations with clinical research in women with diminished ovarian reserve

This communication suggests that investigations of treatments for women with diminished functional ovarian reserve (DOR) call for specific practical and ethical considerations, as women with DOR, because of limited remaining reproductive life spans, appropriately feel under time constraints. Another medical journal recently published an opinion piece on the use of dehydroepiandrosterone in women with DOR, raising important questions about what approaches should be taken to develop best available evidence in such patients. Their manuscript offers an excellent opportunity to consider ethical and clinical aspects of study design in clinical circumstances where patients have little to lose but face the promise of considerable gains in clinical pregnancy chances if effective treatments can be developed. This commentary concludes that, in such circumstances, common sense as well as ethical considerations support the introduction of new treatments into the clinical mainstream even in absence of prospectively randomized studies if lower levels of evidence are supportive of positive treatment effects.

Effect of age on decisions about the numbers of embryos to transfer in assisted conception: a prospective study

BACKGROUND

Elective single-embryo transfer has been proposed as a strategy to reduce the risk of multiple birth and adverse pregnancy outcomes after in-vitro fertilisation (IVF). Whether this approach should be restricted to young women is unclear.

METHODS

In a prospective study of UK Human Fertilisation and Embryology Authority data, we investigated whether perinatal livebirth outcomes varied by the number of embryos transferred in relation to maternal age. We compared rates of livebirth, multiple births, low birthweight (<2·5 kg), preterm birth (<37 weeks), and severe preterm birth (<33 weeks) in women younger than 40 years and those aged 40 years or older. We used logistic and binomial regression methods to assess, respectively, relative risk and absolute differences in risk.

FINDINGS

We assessed 124,148 IVF cycles overall, which yielded 33,514 livebirths. The odds ratios of livebirth were higher in women aged 40 years or older than in those younger than 40 years when two embryos were transferred compared with one embryo (3·12, 95% CI 2·58-3·77 [corrected] vs 2·33, 2·20-2·46; p=0·0006 for interaction), but the absolute difference in risk of livebirth was smaller (0·090, 0·080-0·099 for women ≥40 years vs 0·156, 0·148-0·163 for those <40 years; p<0·0001). The odds ratios and absolute risk differences for multiple birth, preterm birth, and low birthweight were all smaller in older than in younger women (analyses were done in 32,732 cycles in which a livebirth had resulted and data on gestational age and birthweight were complete). Livebirth rates did not increase with transfer of three embryos, but the risk of adverse perinatal outcomes did increase.

INTERPRETATION

Transfer of three or more embryos at any age should be avoided. The decision to transfer one or two embryos should be based on prognostic indicators, such as age.

FUNDING

None.

The use of single embryo transfer to reduce the incidence of twins: Implications and questions for practice from the 'towardSET?' project

In vitro fertilisation treatments where multiple embryos are transferred are associated with high multiple birth rates leading to a corresponding high infant morbidity. Here we review the results from a multidisciplinary project which aimed to combine state of the art statistical modelling of routine clinical data with consideration of patient perspectives to explore options for reducing multiple birth incidence by increased use of single embryo transfer (SET). Modelling was based on a large multicentre cohort, supplemented by analysis of HFEA register data. Patient perspectives were explored in qualitative interviews and focus groups. The data confirm the reduction of around one-third in the chance of a live birth for any couple in moving from double embryo transfer (DET) to SET in a fresh cycle. This can be somewhat offset by appropriate patient and cycle selection for SET, with many suggested schemes performing similarly, although many patients perceive such selection as unfair. If we take a complete cycle perspective, and consider the transfer of all good-quality embryos with cryopreservation then it is possible for SET to match or even outperform DET. However, the additional treatment cycles are seen by patients as physically and emotionally burdensome. Such treatments will require optimisation of embryo freezing policies and a number of options are explored.

Eliminating multiple pregnancies: an appropriate target for government intervention?

The manuscript in this issue of the journal by Bissonette et al. reports on a new government-sponsored intervention into the practice of IVF within the province of Quebec, Canada, which in the authors' opinion highly successfully reduced twinning rates, while maintaining overall acceptable pregnancy rates. Given the opportunity to comment, their manuscript, in my opinion, only reemphasizes why, despite wide professional support, the concept of single embryo transfer (SET) is: (i) damaging to most infertility patients by reducing pregnancy chances; (ii) does so without compensatory benefits; (iii) impinges on patients' rights to self-determination; (iv) has significant negative impact on IVF-generated birth rates; and (v) thus, demonstrating, once more, that governments should not interfere with the patient-physician relationships.

During IVF treatment patient preference shifts from singletons towards twins but only a few patients show an actual reversal of preference

BACKGROUND

Knowledge of patients' preferences for elective single embryo transfer (eSET) or double embryo transfer (DET) and for singletons or twins is of great importance in counselling for embryo transfer (ET) strategies. In this study, the stability of IVF patients' preferences over time for either a healthy single child or healthy twins was measured and we investigated which factors could explain preference shifts.

METHODS

Infertile women (n = 177) who participated in an RCT comparing one cycle eSET with one cycle DET were included. A satisfaction questionnaire was developed to measure patient preferences and attitudes at two moments in time, i.e. at 2 weeks before ET and at 2 weeks following ET, after the results of the pregnancy test. Regression analysis examined the effect of several variables on preference shifts.

RESULTS

Before ET, most patients expressed a preference for a singleton, whereas most patients were indifferent 2 weeks after ET, resulting in an overall preference shift towards twins (P = 0.002; n = 145). Overall, 62% of patients showed a preference shift. Preference shifts were explained by patients' global satisfaction of the information given by the fertility clinic staff received by the fertility clinic staff, and an interaction between the occurrence of pregnancy and transfer policy (eSET or DET).

CONCLUSIONS

In general, patients' preferences for a singleton or twins are not stable during IVF treatment. Possible explanations of a shift in preference are that pregnant patients attuned their preferences to what they expect their pregnancy to result in, whereas non-pregnant patients shifted towards a preference for twins in order to be able to fulfil their ultimate child wish.

Prevention of prematurity by single embryo transfer

The development of assisted reproduction techniques (ART) represents an important advance in the treatment of human infertility. However, their great effectiveness has brought with it an excessive increase in multiple pregnancy rates with the serious medical, financial and social consequences that they entail. Now, the scientific societies, the health professionals, and the infertile couples themselves are aware of these risks and have worked together to implement various strategies to deal with this situation. The result that is being obtained from the strategy of selectively reducing the number of embryos transferred is obvious. The pandemic of multiple pregnancies is being brought under control and so we have effective prevention of the obstetric and neonatal complications arising from it. It is to be hoped that it will also contribute to significantly reducing the rates of prematurity and thus of severe neonatal complications.

Maternal and child outcome after in vitro fertilization--a review of 25 years of population-based data from Sweden

OBJECTIVE

To summarize data on deliveries after in vitro fertilization (IVF) performed in Sweden up to 2006.

DESIGN

Cohort study of women and children, conceived after IVF, with comparisons of deliveries after IVF before and after 1 April 2001.

SETTING

Study based on Swedish health registers.

POPULATION

Births registered in the Swedish Medical Birth Register with information on IVF from all IVF clinics in Sweden.

METHODS

Results from the second study period are summarized, and outcomes between the two periods are compared. Long-term follow-up is based on data from both periods.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes, long-term sequels.

RESULTS

Some maternal pregnancy complications decreased in rate, notably pre-eclampsia and premature rupture of membranes. The rate of multiple births and preterm births decreased dramatically, with a better neonatal outcome, including reduced neonatal mortality. No difference in outcome existed between IVF and intracytoplasmic sperm injection or between the use of fresh and cryopreserved embryos, but children born after blastocyst transfer had a slightly higher risk for preterm birth and congenital malformations than children born after cleavage stage transfer. An increased risk for cerebral palsy, possibly for attention deficit and hyperactivity disorder, for impaired visual acuity and for childhood cancer was noted, but these outcomes were rare also after IVF. An increased risk for asthma was demonstrated. No effect on maternal cancer risk was seen.

CONCLUSION

A marked decrease in multiple births was the main reason for better pregnancy and neonatal outcome and may also have a beneficial effect on long-term results, notably cerebral palsy.

Epidemiology of multiple pregnancy and the effect of assisted conception

Multiple pregnancy is one of the greatest perinatal challenges facing clinicians today. In a society of rising expectations among fertility and maternity service users, the potential for adverse outcomes associated with multiple pregnancy is a source of concern. This article examines the impact of assisted conception on the incidence of multiple pregnancies and associated complications. It explores some of the reasons for the strong association between assisted reproductive technology and multiple pregnancies and suggests possible ways of addressing this continuing problem.

Fertility treatment in women with polycystic ovary syndrome: a decision analysis of different oral ovulation induction agents

OBJECTIVE

To compare different oral ovulation induction agents in treating infertile women with polycystic ovary syndrome (PCOS).

DESIGN

Decision-analytic model comparing three treatment strategies using probability estimates derived from literature review and sensitivity analyses performed on the baseline assumptions.

SETTING

Outpatient reproductive medicine and gynecology practices.

PATIENT(S)

Infertile women with PCOS.

INTERVENTION(S)

Metformin, clomiphene citrate, or metformin with clomiphene citrate.

MAIN OUTCOME MEASURE(S)

Live birth.

RESULT(S)

Within the baseline assumptions, combination therapy with metformin and clomiphene citrate was the preferred therapy for achieving live birth in women with PCOS. Sensitivity analysis revealed the model to be robust over a wide range of probabilities.

CONCLUSION(S)

Combination therapy with metformin and clomiphene citrate should be considered as first-line treatment for infertile women with PCOS.