Embryonic Loss in Iatrogenic Multiples

A Chinese practice guideline of the assisted reproductive technology strategies for women with advanced age

More women postpone childbearing nowadays while female fertility begins to decline with advancing age. Furthermore, with the rolling out of the two-child policy, there is a huge demand for a second child for Chinese aged women. There are various assisted reproductive technology (ART) strategies applied for age-related infertility without solid evidence. On behalf of the Society of Reproductive Medicine, Chinese Medical Association, we would like to develop a Chinese guideline of ART strategies for age-related infertility. This guideline was produced following the recommendations for standard guidelines described in the 2012 WHO Handbook for guideline development. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was also followed. A protocol was formulated and a Guideline Development Group was formed with specialists of reproductive medicine, methodologists from Chinese GRADE working group, and patient representative. Questions regarding the ART strategies for aged infertility were formulated and 8 most important ones were chosen to be structured in PICO format (Population, Intervention, Comparison, Outcomes). Comprehensive search and review of the literature were performed and the quality of the evidence was assessed and rated based on certain criteria and be categorized as high, moderate, low, or very low. Twenty-five recommendations were formulated among members of the Guidelines Development Group (Delphi method) basing on the overall quality of the evidence, in addition to the balance between benefits and harms, values and preferences, and resource implications. The final recommendations were agreed on by consensus during face-to-face meetings. This is the first Chinese practice guideline in reproductive medicine developed following the standard and scientific method.

A unique case of unilateral synophthalmia

Developmental anomalies resulting in a single eye (cyclopia) or fusion of the eyes (synophthalmia) are rare. Examples of unilateral synophthalmia-in which there are 1 normal and 2 fused eyes from 3 anlagen in 2 orbits, 1 lateral proboscis, and 3 optic nerves-are even more rare. Herein, I report a unique fetus with unilateral synophthalmia that was not associated with a lateral proboscis but instead had an extra cerebral hemisphere. I postulate that the unilateral synophthalmia, accessory cerebral hemisphere, and minor structural abnormalities in the skull base were the result of failure in separating a monozygous twin, a situation similar to that postulated as the cause of fetus in fetu.

Spontaneous reduction before 12 weeks' gestation and selective reduction similarly extend time to delivery in in vitro fertilization of trichorionic-triamniotic triplets

OBJECTIVE

To determine the prevalence and the relative benefits conferred by selective and spontaneous reduction of one or more fetuses in trichorionic triamniotic triplet pregnancies on time to delivery.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

IVF patients with trichorionic triamniotic triplets between January 1998 and December 2007.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Gestational length at time of delivery.

RESULT(S)

Selective reduction to twins was used in 87 of the 153 (56.9%) triplet pregnancies that did not spontaneously reduce prior to <12 weeks, and was associated with longer gestation (13.9 days) with a fourfold greater likelihood of delivery at ≥ 34 weeks' gestation (odds ratio [OR], 4.3; 95% confidence interval [CI] = 2.2-8.6), compared with pregnancies not undergoing selective reduction. Compared with ongoing triplets, spontaneous reduction at <12 weeks' gestation (28 cases) was associated with longer gestation (13.7 days) and significantly greater likelihood delivering at or after 34 weeks' gestation (OR, 3.7; 95% CI, 1.4-9.9).

CONCLUSION(S)

Selective reduction of one fetus was used in 56.9% of patients in this population. Early spontaneous reduction (<12 weeks) and selective reduction to twins each conferred similar benefits by extending time to delivery and increasing the likelihood of delivery at or after 34 weeks' gestation.

Factors influencing adverse perinatal outcomes in pregnancies achieved through use of in vitro fertilization

OBJECTIVE

To determine the associations of specific components of IVF treatment with abnormal perinatal outcomes.

DESIGN

Case-control study.

SETTING

University-based and community-based infertility centers.

PATIENT(S)

All viable pregnancies achieved through IVF procedures performed between January 1999 and March 2004.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Infertility etiology, gonadotropin exposure, embryo manipulation, and quality.

RESULT(S)

Of 455 viable pregnancies identified during the study period, 435 met inclusion criteria. While adjusting for maternal age, race, parity, body mass index, infertility center, and year of IVF procedure, multiple gestations were associated with a 12-fold increased risk of poor perinatal outcome compared to singletons. Ovarian hyperstimulation syndrome significantly increased the risk more than 3-fold (odds ratio = 3.14; 95% confidence interval, 1.08-9.14), while endometrial thickness was found to have a significant protective effect (odds ratio = 0.89; 95% confidence interval, 0.80-0.99). We found no effect of etiology of infertility, dose or type of medication used for stimulation, use of embryo-manipulation techniques, or quality on perinatal outcome.

CONCLUSION(S)

These data confirm and quantify the risk of perinatal morbidity associated with multiple births. After adjusting for multiple births, ovarian hyperstimulation syndrome and suboptimal endometrial development are associated with adverse outcomes in pregnancies achieved through IVF. Our findings suggest that it may be the endometrium rather than the embryo that influences fetal growth and perinatal outcomes after IVF.

Perinatal outcome of 12,021 singleton and 3108 twin births after non-IVF-assisted reproduction: a cohort study

Perinatal outcome of pregnancies caused by assisted reproduction technique (ART) is substantially worse when compared with pregnancies following natural conception. We investigated the possible risks of non-IVF ART on perinatal health. We conducted a retrospective cohort study with two exposure groups: a study group of pregnancies after controlled ovarian stimulation (COS), with or without artificial insemination (AI), and a naturally conceived comparison group. We used the data from the regional registry of all hospital deliveries in the Dutch-speaking part of Belgium during the period from January 1993 until December 2003 to investigate differences in perinatal outcome of singleton and twin pregnancies. 12 021 singleton and 3108 twin births could be selected. Naturally conceived subjects were matched for maternal age, parity, fetal sex and year of birth. The main outcome measures were duration of pregnancy, birth weight, perinatal morbidity and perinatal mortality. Our overall results showed a significantly higher incidence of prematurity (<32 and <37 weeks), low and very low birth weight, transfer to the neonatal intensive care unit and most neonatal morbidity parameters for COS/AI singletons. Twin pregnancies resulting from COS/AI showed an increased rate of neonatal mortality, assisted ventilation and respiratory distress syndrome. After excluding same-sex twin sets, COS/AI twin pregnancies were at increased risk for extreme prematurity and very low birth weight. In conclusion, COS/AI singleton and twin pregnancies are significantly disadvantaged compared to naturally conceived children.