Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer

Fetal safety of medications used in treating infertility

INTRODUCTION

The medications used in assisted reproduction are given before and during early pregnancy, and hence, they may potentially result in adverse fetal effects. In this review we present an updated account of their fetal safety and discuss methodological challenges in interpretation of existing data.

AREAS COVERED

The fetal safety/risks of clomiphene citrate, aromatase inhibitors, metformin, gonadotropins and progestins are discussed. We searched PubMed, EMBASE, Cochrane, Google, and Google Scholar from inception to 30 April 2020 for publications pertinent to our topic.

EXPERT OPINION

There are several major challenges in studying fetal safety of medications used in assisted reproduction. The fact is that the rates of congenital malformations among infertile women giving birth spontaneously is higher than the rates among healthy women conceiving spontaneously. In most clinical studies of assisted reproduction, the primary endpoint is the success in inducing pregnancy, neglecting to report pregnancy outcome and adverse neonatal event. As an example for this reality, it has been estimated that between 1977 and 2005 around 10 million pregnancies were treated with dydrogesterone (DYD), yet till 2019 only very few studies, with a total sample size of less than 600 were reported with regards to fetal safety.

Influencing factors of pregnancy loss and survival probability of clinical pregnancies conceived through assisted reproductive technology

BACKGROUND

Pregnancies following assisted reproductive technology (ART) may have elevated potential risk of pregnancy loss (PL) when compared to natural conception. However, rare studies comprehensively analyzed the IVF/ICSI cycle-dependent factors for loss of clinical pregnancy. Therefore, we aimed to determine the ART subgroup-specific risks of PL throughout pregnancy and explore different risk factors for early miscarriage and late miscarriage among pregnancies conceived through ART.

METHODS

A retrospective cohort study was launched in two infertility treatment centers in Nanjing and Changzhou including 5485 IVF/ICSI embryo transfer cycles with known outcomes after clinical pregnancy by the end of 2015. Cox proportional hazards regression analysis was performed to estimate the hazard ratios and their 95% confidence intervals. The associations between survival time during pregnancy and demographics and clinical characteristics of clinical pregnancies were estimated using the Kaplan-Meier method and the Log-rank test.

RESULTS

The overall PL rate in current ART population was 12.5%. Among the 685 pregnancy loss cycles, a total of 460 ended as early miscarriage, 191 as late miscarriage. We found couples in ART pregnancies demonstrated a significantly increased risk of PL as maternal age (HR = 1.31, Ptrend < 0.001) grows. Pregnancies received controlled ovarian hyperstimulation (COH) protocol like GnRH antagonist protocol (HR = 3.49, P < 0.001) and minimal stimulation protocol (HR = 1.83, P < 0.001) had higher risk of PL than GnRH-a long protocol. Notably, in contrast to fresh cycle, women who received frozen cycle embryo had a significant increased risk of early miscarriage (P < 0.001), while frozen cycle was linked with lower risk of late miscarriage (P = 0.045). In addition, four factors (maternal age, COH protocol, cycle type and serum hCG level 14 days after transfer) had independent impact on miscarriage mainly before 12 weeks of gestational age.

CONCLUSIONS

With these findings in this study, clinicians may make it better to evaluate a patient's risk of PL based on the maternal age at the time of treatment, COH protocol, cycle type and serum hCG level 14 days after transfer and the gestational week of the fetus, and we hope that it contributes to future study on its etiology and guide the clinical prevention and treatment.

Klinefelter twins presenting with discordant aneuploidies, acardia, forked umbilical cord and with different gonadal sex despite monozygosity

OBJECTIVE

A higher frequency of twin births in sibships of Klinefelter syndrome patients and also monozygotic or dizygotic twins, themselves being affected by Klinefelter syndrome have been noted repeatedly. To address this issue, we evaluated type and frequency of twinning among Klinefelter fetuses that we had received for autopsy within a 'Prenatal Diagnosis' program.

METHOD

We performed fetal autopsies, and genetic analyses on DNA extracted from stained histological slides.

RESULTS

Among 41 prenatal diagnoses of a 47, XXY karyotype we observed four twin pairs. One was dizygotic with discordant Klinefelter and Down syndrome. Three twin pairs were monozygotic as concluded from monochorial placentation. In two monozygotic pairs one twin partner was an acardiac monster and in one of these the acardiac twin showed a female gonadal sex and missing Y-chromosomal SRY-sequences as confirmed by polymerase chain reaction.

CONCLUSIONS

There is a high rate of twinning and twin reversed arterial perfusion sequence among our Klinefelter fetuses. Forked umbilical cords at the placental insertion site in one case allowed classification as conjoined twins in the sense of a 'funiculopagus'. Anaphase lagging or semidizygosity by second polar body twinning are proposed as explanations for the gonadal sex discordance and the excessive developmental disadvantage in the one acardiac. Problems may arise with regard to non-invasive prenatal diagnosis of aneuploidies in twin pregnancies.

Recurrent partial hydatidiform mole, with a first twin pregnancy, after treatment with clomiphene citrate

We present a patient, treated for 3 months with clomiphen citrate after 5 years of infertility. This treatment resulted in a twin pregnancy, one degenerated into a partial hydatidiform mole and the other into a very early embryo death. The karyotype was a mosaic one: 63% of metaphases showed triploidy - 69 XXX and 37% diploidy - 46 XX. Despite all medical advice, she returned 8 months later with a new pregnancy, which proved to be a new partial hydatidiform mole, this time a single one. Karyotype was, also, a triploidy - 69 XXX. The genetic map of both genitors was performed, showing no aberrations. Unfortunately, the patient came back, once again, 5 months later, with a new positive pregnancy test. Ultrasonography revealed a new very early embryo death, the histopathological analysis establishing to be a single 'pure' stop in evolution of the pregnancy. As all the three pregnancies obtained after treatment with clomiphene were abnormal, two being partial hydatidiform moles and one being a premature miscarriage, without any genetic aberrations of the genitors, it seems very possible that clomiphene, apart from improving fertility, also increases the risk of abnormal ovum appearance.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Increased prevalence of gestational diabetes mellitus in in vitro fertilization pregnancies inadvertently conceived during treatment with long-acting triptorelin acetate

Thirty-five pregnancies were inadvertently conceived during the midluteal application of the long-acting gonadotropin-releasing hormone agonist triptorelin acetate before ovarian stimulation for in vitro fertilization. Most of the conceptions occurred before the first or second IVF trial, and were associated with a significantly increased tendency to develop gestational diabetes. No increase in pregnancy wastage or appearance of congenital malformations occurred.

A benefit-risk assessment of medical treatment for uterine leiomyomas

The growth of a uterine leiomyoma growth stops and regresses after the menopause suggesting that leiomyoma growth is dependent on ovarian steroids. Therefore, estrogen has received much attention as the major factor responsible for the development of uterine leiomyomas, but progesterone also plays an important role in development of this disease. Cytogenetic analyses of resected samples has revealed that about 40 to 50% of leiomyomas show karyotypically detectable chromosomal abnormalities. Gonadotrophin releasing hormone (GnRH) agonists exert their action through the suppression of endogenous gonadotrophins and gonadal steroid secretion. Significant reductions of uterine/leiomyoma volume under GnRH agonist therapy has been reported in several studies. However, the leiomyoma generally returns to its pretreatment volume within a few months after discontinuation of the GnRH agonist. To minimise the adverse effects of hypoestrogenism during GnRH agonist treatment, add back therapy can be used (estrogen-progestin, progestin alone and recently tibolone). Antiprogestins have a potential clinical utility in uterine leiomyomas. Mifepristone is a synthetic steroid with both antiprogesterone and antiglucocorticoid activities, that may have an inhibitory effect on growth of leiomyoma. Danazol is an isoxazole of 17beta-ethinyl testosterone, a synthetic steroid, which has a suppressive effect on sex hormone binding globulin concentrations, resulting in efficacy in the short-term treatment of uterine leiomyomas. Gestrinone is a tri-enic steroid with antiestrogen and antiprogesterone properties and has been shown to reduce uterine volume and stop bleeding. Growth factors play a relevant role on the pathophysiology of uterine leiomyoma and probably the inhibition of the action of growth factors on the myometrium will be the basis for future therapy. A number of agents are under investigation for treating uterine leiomyoma. Agents developed from increasing genetic knowledge of this condition could represent, in the next few years, new trends in the medical treatment of uterine leiomyomas.

Ovulation induction for polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest cause of anovulatory infertility. Various factors influence ovarian function, and fertility is adversely affected by an individual being overweight or having high serum concentrations of LH. Strategies to induce ovulation include weight loss, oral anti-oestrogens (principally clomiphene citrate), parenteral gonadotrophin therapy and laparoscopic ovarian surgery. There have been no adequately powered randomized studies to determine which of these therapies provides the best overall chance of an ongoing pregnancy. Women with PCOS are at risk of ovarian hyperstimulation syndrome (OHSS) and so ovulation induction has to be monitored carefully with serial ultrasound scans. The recognition of an association between hyperinsulinaemia and PCOS has resulted in the use of insulin sensitizing agents, such as metformin, which appear to ameliorate the biochemical profile and improve reproductive function.

Clomiphene citrate in the twenty-first century

Clomiphene citrate is the drug most commonly prescribed for ovulation induction. It is the first choice medication in normogonadotrophic oligo/amenorrhoeic infertility (WHO group 2), essentially associated with polycystic ovaries. Anovulatory women who are responsive to clomiphene citrate should be treated for at least six cycles and the treatment should probably be limited to a maximum of 12 cycles. It is necessary to monitor at least the first cycle with ultrasonography because of the risk of multiple pregnancy and the variable response of patients to different doses of clomiphene. In addition, the risk of ovarian hyperstimulation syndrome should not be underestimated. More triplets and higher order pregnancies result from ovulation induction than from in vitro fertilization, and multiple pregnancy has many risks for both mother and babies. The role of empirical clomiphene in the treatment of unexplained infertility is debatable and the present data are inconclusive. Obesity, hyperandrogenaemia and insulin resistance are important factors in clomiphene-resistant patients. Failure to ovulate in response to clomiphene has been approached by either medical or surgical treatment. An effective alternative medical treatment is gonadotrophin injections. Treatment with metformin and the new generation of insulin-sensitizing drugs is under evaluation. The most widely used surgical treatment today is laparoscopic ovarian drilling, which appears to be as effective as gonadotrophin therapy.

The risk for cancer among children of women who underwent in vitro fertilization

BACKGROUND

The possible association between ovarian carcinoma and ovulation-inducing drugs has led to renewed interest in the potential carcinogenic risks of these drugs. In vitro fertilization (IVF) has been linked to multiple pregnancies and possibly congenital malformations. However, to the authors' knowledge the association between IVF and pediatric cancer has been described only in sporadic case reports. The aim of this study was to assess the incidence rate of pediatric cancer among a cohort of children born after IVF.

METHODS

A historic prospective study based on a cohort of 332 children from 1254 women who underwent IVF treatment between 1981-1994 was performed. Medical files were reviewed and names were linked to the National Population and Cancer Registries. Pediatric cancer incidence rates were compared with the expected age-adjusted rates of the general population during the respective time period.

RESULTS

No cancer cases were observed among the study cohort with respect to 1.7 cases that were expected.

CONCLUSIONS

Because the small cohort analysis in the current study lacked the necessary power to reach definite conclusions, larger prospective studies are needed to assess the potential carcinogenic effect on children born after ovulation induction and IVF.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic complication of assisted reproduction. In its most severe form, it is potentially fatal. The major clinical components are marked ovarian enlargement and increased capillary permeability leading to ascites, hydrothorax and pericardial effusion. Severe cases are associated with thromboembolic phenomena, respiratory distress and renal failure. The definitive pathophysiology is unknown. The available evidence would support a central role for inflammatory cytokines and angiogenic growth factors. Ultrasound examination and serum oestradiol values are currently used to predict patients at risk. The ideal treatment is prevention, but there has been only limited success. The main aims of treatment are to correct fluid imbalance, maintain renal perfusion and support the patient until the condition resolves. Drug therapy has a limited role, although anticytokine agents may prove useful.

What proportion of multiple births are due to ovulation induction? A register-based study in Italy

OBJECTIVES

This study evaluated the increase in risk of multiple births associated with ovulation induction and calculated the proportion of multiple births attributable to this treatment.

METHODS

Cases were 350 multiple births and controls were 737 single births enrolled from April 1993 to March 1994 in the Mercurio Project, an investigation of reproductive outcomes in Italy.

RESULTS

Ovulation induction was used in 45 case births (12.9%) and 24 control births (3.3%); the adjusted odds ratio was 4.1 (95% confidence interval [CI] = 2.4, 6.9). The odds ratio for triplet or higher order births was 72.2 (95% CI = 25.7, 202.8). When unlike-sexed multiple births were considered, the odds ratio increased for twin births, but not for triplet or higher births. The highest odds ratios were found when ovulation induction was used with assisted reproduction. The proportion of multiple births attributable to ovulation induction was 9.7% overall, 5.4% for twin births, and 69.8% for triplet or higher births.

CONCLUSIONS

Ovulation induction increases the risk of multiple births and has been responsible for the rise in the rate of triplet or higher order births in Italy in the last decade. Its indiscriminate and improper use should be avoided.

Minimal stimulation achieves pregnancy rates comparable to human menopausal gonadotropins in the treatment of infertility

OBJECTIVE

To examine the effectiveness of a novel clomiphene citrate (CC) and hMG combination protocol ("minimal stimulation") for controlled ovarian hyperstimulation. Minimal stimulation consists of administering 100 mg/d CC for 5 days followed by a single dose of 150 IU hMG. The results of this analysis are compared with those of an hMG-alone protocol. In vitro fertilization-embryo transfer and donor insemination patients are excluded from this analysis.

DESIGN

Retrospective review of minimal stimulation and hMG cycles from January 1, 1989 to December 31, 1992.

SETTING

Tertiary care center reproductive endocrinology and infertility clinic.

PATIENTS

Two hundred thirty-two women who underwent 549 treatment cycles.

MAIN OUTCOME MEASURES

Clinical and multiple pregnancy rates (PRs) and medication costs.

RESULTS

Sixty-one women received 106 cycles of minimal stimulation and 183 received 443 cycles of hMG. Although subject groups were not assigned randomly, multivariate analysis detected no significant differences between the treatment groups. The total ampules of hMG required differed significantly (2.0 for minimal stimulation versus 16.8 +/- 8.5 [mean +/- SD] for hMG). Pregnancy rates and multiple gestation rates were similar. Medication expense of minimal stimulation is 21% that of the hMG protocol.

CONCLUSIONS

Minimal stimulation is as effective as hMG in the population examined. The comparable PRs and decreased medication costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility.

Poland anomaly after in vitro fertilization

OBJECTIVES

To describe an extremely rare anomaly in an infant born after IVF-ET, and to assess its possible relationship to the artificial reproductive technology.

DESIGN

Case report.

SETTING

Infertility and IVF Unit, in a tertiary academic medical center.

PATIENT

A 31-year-old healthy patient with a 9-year history of secondary, unexplained infertility.

INTERVENTION

Standard IVF-ET treatment cycle, using GnRH-a (short protocol) and hMG for controlled ovarian hyperstimulation.

RESULTS

Poland anomaly (asymmetric thorax with absence of the right pectoralis major muscle, low set rudimentary right nipple, and very mild hypoplasia of the right upper limb) is described for the first time in an infant who is one of a trizygotic triplet after IVF treatment.

CONCLUSIONS

In view of the currently held hypothesis concerning the pathogenesis of Poland anomaly, the possibility of a teratogen or an event related to the reproductive procedure as the cause of this anomaly seems unlikely.

Perinatal outcome of triplet pregnancies following assisted reproduction

PURPOSE

This collaborative work was undertaken to assess perinatal outcome of in vivo conceived triplets to those following in vitro fertilization and assisted reproductive technologies (ART).

METHODS

151 triplets were examined; 56 delivered following ART, 55 following ovulation induction by gonadotropins (GN), 27 following clomiphene citrate (CC), and 13 conceived spontaneously.

RESULTS

Mean gestational length of triplets following ART (33.2 wks) was not different from those conceived following GN (33.4 wks) or CC (34.2 wks), but was significantly shorter compared to triplets following spontaneous conception (35.3 wks). Mean fetal birthweight following ART (1743 g) did not differ significantly from that following GN (1683 g) or CC (1863 g) but was significantly lower compared to those delivered after spontaneous conception (1963 g). Although no difference was found in the incidence of low birthweight infants between the groups studied, the incidence of very low birthweight newborns (<1500 g) following ART or GN was significantly higher than following spontaneous conceptions (30.6%, 30.3% vs 10.3%). Differences in perinatal mortality were not significantly different between the groups examined (77.9, 60.6, 111.0, 25.6/1000 for ART, GN, CC, and spontaneous conceptions respectively).

CONCLUSION

In conclusion, a similar perinatal outcome was shown for triplets conceived following ART and those following ovulation induction by GN, suggesting that the in vitro conditions as such were not the main contributing factor influencing the clinical outcome but rather the GN treatment. Triplets conceived spontaneously have a better outcome compared to those following ovulation induction or ART in terms of gestational length and birthweight.

Clomiphene citrate and pregnancy outcome

Data from Australia and elsewhere have shown consistently that adverse perinatal outcomes such as preterm birth and perinatal mortality are more common in pregnancies resulting from assisted conception with IVF and GIFT than normally conceived pregnancies. Factors that may contribute to the excess of poor outcomes include maternal factors, the assisted conception procedures themselves and possibly the influence of drugs used to induce superovulation. This review examines the medical literature describing pregnancies following ovulation induction with one of the drugs used to induce superovulation, clomiphene citrate, and compares their outcomes with Australian IVF and GIFT pregnancy outcomes. The review shows that whilst some studies have suggested higher rates of ectopic pregnancy, spontaneous abortion and congenital malformations in clomiphene citrate induced pregnancies, the findings are inconsistent and the data are flawed. There are only very poor data available on the incidence of preterm birth. Multiple pregnancy is a well-recognized adverse outcome of clomiphene citrate induced pregnancies. Attempts to improve perinatal outcomes of pregnancies following assisted conception will be helped by a better understanding of the relative contributions of maternal and treatment factors and further studies of pregnancy outcome after ovulation induction are needed.

Genetic survey of a group of children with clefting: implications for genetic counseling

A cleft lip, cleft palate, or both are associated with a high frequency of other anomalies. This study gives an inventory of associated anomalies in a consecutive group of children (n = 36) with clefts, referred to a local multidisciplinary cleft team in the Netherlands. In 47.2% of cleft patients associated anomalies were found, allowing diagnosis of provisionally unique syndromes or known entities. In 17 patients family history was positive for clefting; in five patients (13.9%) this influenced the occurrence risks for siblings. Both findings had an effect on genetic counseling of the parents of these children. Additional evidence is provided that all children with clefting should be carefully evaluated by a trained clinician for additional anomalies, including dysmorphic features.

Preovulatory administration of clomiphene citrate to mice causes fetal growth retardation and neural tube defects (exencephaly) by an indirect maternal effect

Clomiphene citrate was administered to female mice at different doses and different times prior to ovulation, in the preimplantation period after ovulation, and after implantation. Pregnancy outcome was determined on day 15 of gestation, when the number of implantations and resorptions were calculated relative to the number of ovulations, and fetuses were assessed for size and stage of development and morphological abnormalities. Preovulatory administration of clomiphene citrate caused decreased implantation rates and growth retardation of surviving fetuses, the degree of the effect being dependent on the dose and the time of drug injection relative to ovulation. The implantation rate was lowest, and the degree of fetal growth retardation highest, when clomiphene citrate was administered immediately before ovulation. An increased incidence of exencephaly was found in the fetuses of females injected with clomiphene citrate prior to ovulation. Transfer of blastocysts from treated mice to untreated fosters showed the effect of clomiphene citrate on implantation and fetal growth to be predominantly mediated through the female reproductive tract, rather than a direct effect on the embryo itself. Administration of clomiphene citrate in the preimplantational period resulted in complete inhibition of implantation, while the only effect when administration was after implantation was a slight reduction in fetal weight. These results indicate that preovulatory clomiphene citrate impairs uterine function, which has an indirect effect on the growth and development of the postimplantation embryo.

The difference in miscarriage rates between menotropin-induced and natural cycle pregnancies is not surveillance related

OBJECTIVE

To assess the reportedly higher miscarriage rate during menotropin-induced cycle pregnancies as compared with natural cycle.

DESIGN

Prospective cohort groups were selected, and pregnancies were identified 16 to 18 days after insemination and followed through to outcome.

PATIENTS

Three hundred twelve patients were studied: 251 women receiving human menopausal gonadotropin and 61 requiring donor insemination without medication.

RESULTS

A significant difference between the spontaneous abortion rate of gonadotropin-treated women (28.5%) and women conceiving during natural cycles (11.7%) was demonstrated.

CONCLUSION

The opinion that higher miscarriage rates in menotropin-treated women are related to a surveillance bias compared with natural cycle conceptions should be reconsidered.

Neural tube defects after infertility treatment: a review

OBJECTIVE

To investigate whether an association exists between ovulation induction and neural tube defects (NTDs).

MATERIALS AND METHODS

Risk estimations in the medical literature were identified through Medline, and validity and power were assessed. Large in vitro fertilization-embryo transfer (IVF-ET) registries represent another source of information. The total number of NTDs and the total number of fetuses were computed from five registries. These data were expressed as proportions and compared with data from the general population.

RESULTS

Only one study could be identified as both valid and powerful, through literature review. This case-control study concluded there was no association between ovulation induction and NTDs. The pool of IVF-ET registry data represents another powerful epidemiologic tool. Analysis of the registry data confirms the findings of the case-control study.

CONCLUSIONS

Ovulation induction does not seem to represent a risk factor for NTDs in the offspring.

Early pregnancy wastage: the role of repetitive human chorionic gonadotropin supplementation during the first 8 weeks of gestation

OBJECTIVE

To determine if repetitive administration of hCG causes decreased pregnancy wastage rates in patients who are at a high risk of luteal inadequacy.

DESIGN

Ovulation induction using human menopausal gonadotropin (hMG)/human chorionic gonadotropin (hCG) or clomiphene citrate (CC) is associated with luteal phase defects that may cause increased pregnancy wastage. An increased risk of abortion exists also in pregnancies in patients with previous repeated miscarriage, women older than 37 years, and various causes of infertility such as hyperprolactinemia. Because the presumed common denominator to the increased rate of pregnancy wastage in all these cases is luteal dysfunction, repetitive hCG administration, 2,500 U two times weekly, was carried out between the 4th and 8th week of gestation in 249 cases of ovulation induction and/or previous abortions, whereas 198 gestations served as controls (no hCG administration).

RESULTS

In the hCG treatment group, 43 ended in miscarriage (17.3%) versus 97 abortions in the control group (49%, P less than 0.01). In 160 cases of hMG/hCG generated gestations, 94 received hCG and 66 did not. The pregnancy wastage rates were 21.3% and 42.4%, respectively (P less than 0.05). In 144 cases of CC/hCG-induced pregnancies, 95 received hCG and 49 served as controls. The respective abortion rates were 15.8% and 44.8% (P less than 0.01). The remaining 143 spontaneous conceptions occurred in infertile patients with previous repeated abortions. In 60 of these conceptions, hCG was administered during the first 4 weeks of gestation and 83 cases served as control. The pregnancy wastage rates were 13.3% versus 56.6%, respectively (P less than 0.001).

CONCLUSION

Repetitive administration of hCG during the early gestation in cases that are at high risk of luteal inadequacy may significantly decrease the pregnancy wastage rate.