Discriminant analysis forecasting model of first trimester pregnancy outcomes developed by following 9,963 infertile patients after in vitro fertilization

Diagnosis and management of heterotopic intramural pregnancy after in vitro fertilization: an eight-case series

PURPOSE

To analyze the ultrasound characteristics, clinical management, and pregnancy outcomes of heterotopic intramural pregnancies (HIMPs) after embryo transfer.

METHODS

This was a retrospective observational study of women who were diagnosed with HIMPs. The ultrasound characteristics, clinical treatment, and pregnancy outcomes of patients with HIMPs were evaluated.

RESULTS

Eight women with HIMPs were included. Among them, 6 patients were diagnosed by transvaginal sonography, and 2 patients were misdiagnosed with heterotopic interstitial pregnancy. The diagnostic accuracy was 75% (6/8). Five patients with HIMPs were diagnosed at the time of the initial scan (5+6-6+3 weeks). An intramural gestational sac was observed in all 6 patients, and an embryo with cardiac activity was detected in one patient on the follow-up scans. Intrauterine pregnancies (IUPs) were revealed in all 6 patients, and embryo(s) with cardiac activity were observed in 5 patients at the time of the initial diagnosis or later. The patients receiving expectant treatment all presented with bagel signs, while patients with embryos with cardiac activity all underwent surgery. Among the 6 diagnosed women, 1 patient was initially treated medically, 4 were treated expectantly, and 1 was treated surgically. Among the 6 diagnosed patients, the IUPs of 5 patients resulted in live infants.

CONCLUSION

Single ET should be recommended to decrease the possibility of HIMP. An accurate diagnosis of HIMP was reached in most cases by detailed ultrasound early in the first trimester. Most IUPs of HIMPs seem to have good outcomes with timely and proper management. Expectant management might be a possible choice for nonviable intramural pregnancies.

A simple scoring system for the prediction of early pregnancy loss developed by following 13,977 infertile patients after in vitro fertilization

A retrospective study was conducted to investigate a convenient simple scoring system for the prediction of early pregnancy loss (EPL) based on simple demographics. A total of 13,977 women undergoing transvaginal ultrasound scans on Days 27-29 after in vitro fertilization-embryo transfer (IVF-ET) from June 2016 and December 2017 were included. The first trimester pregnancy outcome was recorded at 12 weeks of gestation. The areas under the curve of this scoring system were 0.884 (95% confidence interval (CI) 0.870-0.899) and 0.890 (95% CI 0.878-0.903) in the training set and test set, respectively. The score totals ranged from -8 to 14 points. A score of 5 points, which offered the highest predictive accuracy (94.01%) and corresponded to a 30% miscarriage risk, was chosen as the cutoff value, with a sensitivity of 62.84%, specificity of 98.79%, positive predictive value (PPV) of 88.87% and negative predictive value (NPV) of 94.54% for the prediction of EPL in the training set. In the test set, a score of 5 points had a sensitivity of 64.69%, specificity of 98.78%, PPV of 89.87% and NPV of 93.62%, and 93.91% of the cases were correctly predicted. Therefore, the simple scoring system using conventionally collected data can be conveniently used to predict EPL after ET. However, considering the limitations, its predictive value needs to be further verified in future clinical practice.

Biomarkers at 6 weeks' gestation in the prediction of early miscarriage in pregnancy following assisted reproductive technology

INTRODUCTION

Miscarriage is a major concern in early pregnancy among women having conceived with assisted reproductive treatments. This study aimed to examine potential miscarriage-related biophysical and biochemical markers at 6 weeks' gestation among women with confirmed clinical pregnancy following in vitro fertilization (IVF)/embryo transfer (ET) and evaluate the performance of a model combining maternal factors, biophysical and biochemical markers at 6 weeks' gestation in the prediction of first trimester miscarriage among singleton pregnancies following IVF/ET.

MATERIAL AND METHODS

A prospective cohort study was conducted in a teaching hospital between December 2017 and January 2020 including women who conceived through IVF/ET. Maternal mean arterial pressure, ultrasound markers including mean gestational sac diameter, fetal heart activity, crown rump length and mean uterine artery pulsatility index (mUTPI) and biochemical biomarkers including maternal serum soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), kisspeptin and glycodelin-A were measured at 6 weeks' gestation. Logistic regression analysis was carried out to determine significant predictors of miscarriage prior to 13 weeks' gestation and performance of screening was estimated by receiver-operating characteristics curve analysis.

RESULTS

Among 169 included pregnancies, 145 (85.8%) pregnancies progressed to beyond 13 weeks' gestation and had live births whereas 24 (14.2%) pregnancies resulted in a miscarriage during the first trimester. In the miscarriage group, compared to the live birth group, maternal age, body mass index, and mean arterial pressure were significantly increased; mean gestational sac diameter, crown rump length, mUTPI, serum sFlt-1, glycodelin-A, and the rate of positive fetal heart activity were significantly decreased, while no significant differences were detected in PlGF and kisspeptin. Significant prediction for miscarriage before 13 weeks' gestation was provided by maternal age, fetal heart activity, mUTPI, and serum glycodelin-A. The combination of maternal age, ultrasound (fetal heart activity and mUTPI), and biochemical (glycodelin-A) markers achieved the highest area under the curve (AUC: 0.918, 95% CI 0.866-0.955), with estimated detection rates of 54.2% and 70.8% for miscarriage before 13 weeks' gestation, at fixed false positive rates of 5% and 10%, respectively.

CONCLUSIONS

A combination of maternal age, fetal heart activity, mUTPI, and serum glycodelin-A at 6 weeks' gestation could effectively identify IVF/ET pregnancies at risk of first trimester miscarriage.

Machine learning algorithms to predict early pregnancy loss after in vitro fertilization-embryo transfer with fetal heart rate as a strong predictor

BACKGROUND AND OBJECTIVE

According to previous studies, after in vitro fertilization-embryo transfer (IVF-ET) there exist a high early pregnancy loss (EPL) rate. The objectives of this study were to construct a prediction model of embryonic development by using machine learning algorithms based on historical case data, in this way doctors can make more accurate suggestions on the number of patient follow-ups, and provide decision support for doctors who are relatively inexperienced in clinical practice.

METHODS

We analyzed the significance of the same type of features between ongoing pregnancy samples and EPL samples. At the same time, by analyzing the correlation between days after embryo transfer (ETD) and fetal heart rate (FHR) of those normal embryo samples, a regression model between the two was established to obtain FHR model of normal development, and the residual analysis was used to further clarify the importance of FHR in predicting pregnancy outcome. Finally we applied six representative machine learning algorithms including Logistic Regression (LR), Support Vector Machine (SVM), Decision Tree (DT), Back Propagation Neural Network (BNN), XGBoost and Random Forest (RF) to build prediction models. Sensitivity was selected to evaluate prediction results, and accuracy of what each algorithm above predicted under both the conditions with and without FHR was compared as well.

RESULTS

There were statically significant differences in the same type of features between ongoing pregnancy samples and EPL samples, which could serve as predictors. FHR, of which the normal development showed a strong correlation with ETD, had great predictive value for embryonic development. Among the six predictive models the one predicted with the highest accuracy was Random Forest, of which recall ratio and F1 could reach 97%, and AUC could reach 0.97, FHR taken into account as a feature. In addition, Random Forest had a higher prediction accuracy rate for samples with longer ETD-its accuracy rate could reach 99% when predicting those at 10 weeks after embryo transfer.

CONCLUSION

In this study, we established and compared six classification models to accurately predict EPL after the appearance of embryonic cardiac activity undergoing IVF-ET. Finally, Random Forest model outperformed the others. The implementation of Random Forest model in clinical environment can assist doctors to make clinical decisions.

Reference intervals of gestational sac, yolk sac, embryonic length, embryonic heart rate at 6-10 weeks after in vitro fertilization-embryo transfer

Background

Accurately determining the normal range of early pregnancy markers can help to predict adverse pregnancy outcomes. The variance in ovulation days leads to uncertain accuracy of reference intervals for natural pregnancies. While the gestational age (GA) is accurate estimation during in vitro fertilization-embryo transfer (IVF-ET). Thus, the objective of this research is to construct reference intervals for gestational sac diameter (GSD), yolk sac diameter (YSD), embryonic length (or crown–rump length, CRL) and embryonic heart rate (HR) at 6–10 gestational weeks (GW) after IVF-ET.

Methods

From January 2010 to December 2016, 30,416 eligible singleton pregnancies were retrospectively recruited. All included participants had full records of early ultrasound measurements and phenotypically normal live neonates after 37 GW, with birth weights > the 5th percentile for gestational age. The curve-fitting method was used to screen the optimal models to predict GSD, CRL, YSD and HR based on gestational days (GD) and GW. Additionally, the percentile method was used to calculate the 5th, 50th, and 95th percentiles.

Results

There were significant associations among GSD, CRL, YSD, HR and GD and GW, the models were GSD = − 29.180 + 1.070 GD (coefficient of determination [R²] = 0.796), CRL = − 11.960 - 0.147 GD + 0.011 GD² (R² = 0.976), YSD = − 2.304 + 0.184 GD - 0.011 GD² (R² = 0.500), HR = − 350.410 + 15.398 GD - 0.112 GD² (R² = 0.911); and GSD = − 29.180 + 7.492 GW (R² = 0.796), CRL = − 11.960 - 1.028 GW + 0.535 GW² (R² = 0.976), YSD = − 2.304 + 1.288 GW - 0.054 GW² (R² = 0.500), HR = − 350.410 + 107.788 GW - 5.488 GW² (R² = 0.911), (p < 0.001).

Conclusions

Reference intervals for GSD, YSD, HR and CRL at 6–10 gestational weeks after IVF-ET were established.

Risk of miscarriage in women conceiving after medically assisted reproduction with an ultrasound-verified viable pregnancy at 6-8 weeks' gestation

RESEARCH QUESTION

What is the risk of miscarriage after a viable fetus verified on ultrasound at 6-8 weeks' gestation among women who conceive with medically assisted reproduction (MAR), stratified by type of fertility treatment?

DESIGN

A nationwide register-based cohort study of women identified in the Danish ART-Registry with a viable singleton pregnancy at 6-8 weeks' gestation between 2007 and 2010 (n = 10,011). Women were identified from The Danish Fetal Medicine Database (DFMD), which holds information on early (between 6-8 and 11-14 weeks) and late (between 11-14 and 22 weeks) miscarriages. The late miscarriage rate was compared with a control group of naturally conceived pregnancies with a viable fetus at 11-14 weeks' gestation from 2008 to 2010, identified in the DFMD (n = 146,932).

RESULTS

In the MAR1 cohort, the overall miscarriage rate was 11.8% (1091/9261) after an ultrasound verified viable pregnancy at 6-8 weeks' gestation. Most miscarriages occurred before the 11-14-week scan (1035/1091 [94.9%]). The early miscarriage rate was slightly higher in women who conceived with frozen embryo transfer compared with intrauterine insemination (IUI), corresponding to an adjusted OR of 1.31 (1.02 to 1.68). We found no significant risk associated with IVF and intracytoplasmic sperm injection compared with IUI pregnancies. The late miscarriage rate was 0.8% in women conceiving with MAR and 0.6% among controls (P = 0.013).

CONCLUSIONS

After adjustment for maternal characteristics, none of the fertility treatment types were associated with an increased risk of miscarriage compared with naturally conceiving women.

Pregnancy and perinatal outcomes of first-trimester crown-rump length discordant IVF dichorionic twin pregnancies - a retrospective cohort study

RESEARCH QUESTION

This study aimed to evaluate the association between discordance in crown-rump length (CRL) and adverse pregnancy and perinatal outcomes in dichorionic twin pregnancies.

DESIGN

This was a retrospective cohort study of dichorionic twin pregnancies after IVF that showed two live fetuses at the first ultrasound scan between 6 ⁺⁵ and 8 weeks gestational age from 1 January 2015 to 31 December 2016. Study groups were defined by the presence or absence of 20% or more discordance in CRL. The primary outcomes were early fetal loss of one or both fetuses before 12 weeks and birthweight discordance. Secondary outcomes included fetal anomalies, fetal loss between 12 and 28 weeks, stillbirth, small for gestational age (SGA) at birth, low birthweight (LBW), very low birthweight (VLBW), admission to the neonatal intensive care unit (NICU) and preterm delivery (PTD).

RESULTS

CRL-discordant twin pregnancies were more likely to end in the loss of one fetus before 12 weeks' gestation (odds ratio [OR] 15.877, 95% confidence interval [CI] 10.495-24.019). Discordant twin pregnancies with twin deliveries had a significantly higher risk of birthweight discordance (OR 1.943, 95% CI 1.032-3.989). There was no significant difference in perinatal outcomes including fetal anomalies, PTD, LBW, VLBW, SGA, neonatal death and admission to NICU between singleton or twin deliveries.

CONCLUSIONS

Discordant twin pregnancies were at increased risk of one fetal loss prior to 12 weeks' gestation. Except for birthweight discordance, there was no significant difference between CRL discordance and other adverse perinatal outcomes.

Difference between mean gestational sac diameter and crown-rump length as a marker of first-trimester pregnancy loss after in vitro fertilization

OBJECTIVE

To investigate whether the difference between mean gestational sac diameter and crown-rump length (mGSD - CRL) is associated with first-trimester pregnancy loss or adverse pregnancy outcomes after in vitro fertilization (IVF) and to determine if mGSD - CRL is a better predictor of pregnancy loss than either measurement alone.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

A total of 1,243 IVF cycles with fresh or cryopreserved autologous embryo transfers resulting in singleton gestations performed at the University of Iowa Hospitals and Clinics from January 2005 through December 2014. Cycles included ultrasound measurements of mGSD and CRL at 45-56 days' gestation.

INTERVENTION(S)

Mean gestational sac diameter to crown-rump length difference.

MAIN OUTCOME MEASURE(S)

Primary outcomes were first-trimester pregnancy loss and gestational age at delivery. Secondary outcomes were infant birth weight and pregnancy complications.

RESULT(S)

First-trimester pregnancy loss rates were significantly higher in pregnancies with mGSD - CRL <5 mm (43.7%) compared with 5-9.99 mm (15.8%), 10-14.99 mm (9.9%), and ≥15 mm (7.1%). No correlations were found with infant birth weight, gestational age at delivery, or other pregnancy complications. mGSD - CRL was not a better predictor of pregnancy loss than mGSD or CRL alone.

CONCLUSION(S)

There is a strong inverse relationship between mGSD - CRL and first-trimester pregnancy loss in IVF patients, although the incidence of pregnancy loss with a mGSD - CRL <5 mm was significantly lower than previously reported. Small mGSD - CRL was not associated with an increased risk of complications in pregnancies that continued beyond 20 weeks. The association between mGSD, CRL, and miscarriage is complex.

Correlation between chromosomal distribution and embryonic findings on ultrasound in early pregnancy loss after IVF-embryo transfer

STUDY QUESTION

Do early pregnancy losses (EPLs) with and without embryos differ in chromosomal distributions?

SUMMARY ANSWER

The chromosomal abnormality rate is significantly higher in miscarriages with embryos than without after in vitro fertilization (IVF)-embryo transfer.

WHAT IS KNOWN ALREADY

Chromosomal abnormalities are the main causes of EPLs, the rate of which is up to 24-30% in the IVF population. Little research has been conducted on the correlations between the chromosomal distributions of EPL and the existence of an embryo or with the postmortem embryonic pole length, and the existing results have been inconsistent.

STUDY DESIGN, SIZE, DURATION

The data of 2172 women who underwent dilation and curettage (D&C) from January 2008 to December 2013 for missed abortion were analyzed retrospectively. The existence of an embryonic pole and the length of the postmortem embryonic pole of the EPL were evaluated by transvaginal sonography (TVS). Ultrasound findings were compared with karyotype results.

PARTICIPANTS/MATERIALS, SETTING, METHOD

This analysis included 2172 infertility patients who had singleton pregnancies and experienced EPLs after IVF-embryo transfer. The EPLs were divided into embryonic and anembryonic groups based on TVS diagnosis. The crown-rump length of the fetal pole (observed once) was measured twice for each fetus after confirmation of fetal death, subject to the final measurement before D&C. The karyotype analysis was performed using comparative genomic hybridization (CGH) plus fluorescence in situ hybridization technology.

MAIN RESULTS AND THE ROLE OF CHANCE

The chromosomal abnormality rate was significantly higher in male miscarriages with an embryo than in those without an embryo (54.14% versus 37.50%, P ≤ 0.001). In the anembryonic group, the abnormal karyotype rate was significantly higher in the yolk sac only than that in the empty sac group (46.11% versus 29.77%, P = 0.001); in the embryonic group, the abnormal karyotype rate in miscarriages with postmortem embryonic pole length >20 mm was significantly lower than that in miscarriages with pole length <10 mm (P = 0.006) and 10-20 mm (P = 0.036). There were significant differences in abnormal karyotype rates among miscarriages of different developmental stages (P ≤ 0.001). The cases with embryonic stages had the highest risk (54.89%) of an abnormal karyotype and those with fetal stages had the lowest risk (18.18%). There were significant differences in the length of postmortem embryonic poles among groups with different karyotypes (P ≤ 0.001). In addition, trisomy 21, monosomy X and triploidy had the longest lengths of postmortem embryonic poles (16, 15.3 and 11.6 mm, respectively).

LIMITATIONS, REASONS FOR CAUTION

Although the efficacy of a non-parametric test is less than that of a parametric test, non-parametric testing was used to compare the embryonic pole lengths in this study, owing to the non-normal distribution and non-homogeneous variances caused by limited cases of some rare chromosomal abnormalities. Another limitation was that CGH was unable to detect mosaicism. Furthermore, the results were not compared with a non-IVF population. Finally, maternal cell contamination is a major problem in studying miscarriage tissue, even using molecular techniques.

WIDER IMPLICATIONS OF THE FINDINGS

Although TVS findings clearly cannot replace karyotype information, our results are important because they call attention to the fact that EPLs that occur after implantation but prior to embryo formation frequently have normal karyotypes. This finding might direct future research towards studies of DNA sequences, or of epigenetic correlations with pregnancy failure.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the Scientific Research Foundation of Reproductive and Genetic Hospital of Citic-Xiangya. The authors have declared that no conflicts of interest exist.

TRIAL REGISTRATION NUMBER

N/A.