Medical follow-up study of 5-year-old ICSI children

Reproductive genetics and health

For those affected, infertility is linked to impaired overall health and reduced life expectancy. In particular, infertile individuals bear an increased risk for cardiovascular disease (CVD) and different types of cancer, partially due to lifestyle differences and to genetic alterations that cause both infertility and an increased cancer risk. Genetic variants causing an increased CVD risk are more commonly found in infertile individuals, but their link to infertility remains unclear. Offspring of infertile couples, conceived via medically assisted reproduction, are as likely as their parents to exhibit or develop adiposity, hormonal alterations such as insulin resistance, and infertility. The effects on health of subsequent generations are completely unclear.

The use of ICSI in ART: evidence for practice

This article reviews the evidence regarding the safety and efficacy of intra-cytoplasmic sperm injection (ICSI). It provides evidence-based clinical and laboratory guidelines and recommendations for use of ICSI within an assisted reproductive technology (ART) service. The guidelines address the evidence for the use of ICSI rather than conventional IVF (cIVF); the use of ART techniques supplementary to ICSI; and risks associated with ICSI. This article is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs and medical history of the patient, available resources, and institutional or clinical practice limitations.

Psychosocial health and quality of life in ICSI and naturally conceived adolescents: a cross-sectional comparison

PURPOSE

Psychosocial health (PH) and quality of life (QoL) are important health outcomes. We compared PH and QoL of adolescents conceived with intrazytoplasmatic sperm injection (ICSI) and of naturally conceived controls. The impact of disclosure of ICSI-conception on QoL and PH was quantified.

METHODS

The cross-sectional sample consisted of 545 ICSI-conceived adolescents and 427 unmatched singleton controls aged 14-18 years. Adolescents reported PH with the 'Strengths and Difficulties Questionnaire' (low values indicating high PH), and QoL with the KINDL questionnaire (high values indicating high QoL). Because of clustering of multiples within families, adjusted linear regressions with generalized estimating equations were used to compare ICSI- and naturally conceived adolescents. Missing values were treated by multiple imputation. Minimal importance was defined as half a standard deviation.

RESULTS

Both ICSI and control adolescents had high PH (low mean 'total difficulties' score: 9 of 40) and high QoL (mean 'total KINDL' score: 75 of 100). Differences were generally in favour of the ICSI group. Significant differences occurred for 'impact of behavioural problems' (p = 0.033), the 'total KINDL' score (p = 0.021) and the dimensions 'physical wellbeing' (p = 0.031) and 'school' (p = 0.005), but all differences were far below minimal importance. About 80% of ICSI adolescents were informed about their mode of conception. PH and QoL were slightly higher in informed adolescents; behavioural difficulties ('total behavioural problems' and 'conduct problems') were significantly lower (p = 0.013 and p = 0.003), behavioural strengths ('prosocial behaviour') and 'physical QoL' significantly higher (p = 0.004 and p = 0.018), but differences remained clearly below minimal importance.

CONCLUSIONS

Our results are reassuring for parents using ICSI and their children. Speaking openly about an ICSI conception in the family may be beneficial.

De novo mutations in children born after medical assisted reproduction

STUDY QUESTION

Are there more de novo mutations (DNMs) present in the genomes of children born through medical assisted reproduction (MAR) compared to spontaneously conceived children?

SUMMARY ANSWER

In this pilot study, no statistically significant difference was observed in the number of DNMs observed in the genomes of MAR children versus spontaneously conceived children.

WHAT IS KNOWN ALREADY

DNMs are known to play a major role in sporadic disorders with reduced fitness such as severe developmental disorders, including intellectual disability and epilepsy. Advanced paternal age is known to place offspring at increased disease risk, amongst others by increasing the number of DNMs in their genome. There are very few studies reporting on the effect of MAR on the number of DNMs in the offspring, especially when male infertility is known to be affecting the potential fathers. With delayed parenthood an ongoing epidemiological trend in the 21st century, there are more children born from fathers of advanced age and more children born through MAR every day.

STUDY DESIGN, SIZE, DURATION

This observational pilot study was conducted from January 2015 to March 2019 in the tertiary care centre at Radboud University Medical Center. We included a total of 53 children and their respective parents, forming 49 trios (mother, father and child) and two quartets (mother, father and two siblings). One group of children was born after spontaneous conception (n = 18); a second group of children born after IVF (n = 17) and a third group of children born after ICSI combined with testicular sperm extraction (ICSI-TESE) (n = 18). In this pilot study, we also subdivided each group by paternal age, resulting in a subgroup of children born to younger fathers (<35 years of age at conception) and older fathers (>45 years of age at conception).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Whole-genome sequencing (WGS) was performed on all parent-offspring trios to identify DNMs. For 34 of 53 trios/quartets, WGS was performed twice to independently detect and validate the presence of DNMs. Quality of WGS-based DNM calling was independently assessed by targeted Sanger sequencing.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant differences were observed in the number of DNMs per child for the different methods of conception, independent of parental age at conception (multi-factorial ANOVA, f(2) = 0.17, P-value = 0.85). As expected, a clear paternal age effect was observed after adjusting for method of conception and maternal age at conception (multiple regression model, t = 5.636, P-value = 8.97 × 10-7), with on average 71 DNMs in the genomes of children born to young fathers (<35 years of age) and an average of 94 DNMs in the genomes of children born to older fathers (>45 years of age).

LIMITATIONS, REASONS FOR CAUTION

This is a pilot study and other small-scale studies have recently reported contrasting results. Larger unbiased studies are required to confirm or falsify these results.

WIDER IMPLICATIONS OF THE FINDINGS

This pilot study did not show an effect for the method of conception on the number of DNMs per genome in offspring. Given the role that DNMs play in disease risk, this negative result is good news for IVF and ICSI-TESE born children, if replicated in a larger cohort.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Netherlands Organisation for Scientific Research (918-15-667) and by an Investigator Award in Science from the Wellcome Trust (209451). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Long-term growth in offspring of infertile parents: A 20-year follow-up study

INTRODUCTION

Long-term growth has been poorly investigated in boys and girls born to parents receiving fertility treatment. This study aimed to investigate the growth of children born following fertility treatment up to adulthood hypothesizing comparable growth in children born to parents receiving fertility treatment or to subfertile parents conceiving spontaneously to that in children spontaneously conceived by fertile parents.

MATERIAL AND METHODS

In this historical long-term follow-up study the study population consisted of 4151 singletons born at term in the Aarhus Birth Cohort between 1990 and 1992. Parental lifestyle and sociodemographic characteristics together with multiple measurements of weight and height were collected up to 20 years of age (6.1% of children contributed with at least one measurement for height or weight at age 20 years). The main outcome was difference in z-score for height (m) and weight (kg) between children conceived spontaneously (reference) and children conceived following fertility treatment, children conceived spontaneously by subfertile parents, or unplanned. Results were adjusted for pre-pregnancy maternal and paternal body mass index, maternal educational level, smoking during pregnancy, maternal age, and parity.

RESULTS

Singletons conceived following fertility treatment (n = 164; 4.0%) or by subfertile parents (n = 271; 6.5%) had comparable magnitude of weight estimates to children conceived spontaneously (difference in z-score per year 0.0148 [95% CI 0.0026-0.0270] and 0.0069 [95% CI -0.0028 to 0.0165], respectively). Height estimates were also comparable between groups of children conceived following fertility treatment or by subfertile parents (difference in z-score per year 0.0022 [95% CI -0.0075 to 0.0119]) compared with children conceived spontaneously (difference in z-score per year -0.0026 (95% CI -0.0103 to 0.0052). From the beginning of adolescence, we found lower weight for children born to subfertile parents and to parents receiving fertility treatment compared with spontaneously conceived children.

CONCLUSIONS

The main finding was equal long-term growth for children born at term by parents who received fertility treatment or parents waiting more than 12 months to conceive compared with spontaneously conceived children.

Growth in children conceived by ART

STUDY QUESTION

Is the growth pattern of children conceived by ART different compared to naturally conceived children.

SUMMARY ANSWER

Both ART and underlying parental subfertility may contribute to differences in early childhood growth between children conceived with and without the use of ART.

WHAT IS KNOWN ALREADY

Children conceived by ART weigh less and are shorter at the time of delivery. The extent to which differences in growth according to mode of conception persist during childhood, and the role of underlying parental subfertility, remains unclear.

STUDY DESIGN, SIZE, DURATION

We conducted a prospective study population-based study. We studied 81 461 children participating in the Norwegian Mother, Father and Child Cohort Study (MoBa) and 544 113 adolescents screened for military conscription.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Conception by ART as registered in the Medical Birth Registry. We compared maternally reported length/height and weight among children in MoBa from mid-pregnancy to age 7 according to mode of conception using mixed-effects linear regression. Differences in self-reported height and weight at 17 years of age at screening for military conscription were assessed with linear regression.

MAIN RESULTS AND THE ROLE OF CHANCE

At birth, children conceived by ART were shorter (boys −0.3 cm; 95% CI, −0.5 to −0.1), girls −0.4 cm; 95% CI, −0.5 to −0.3) and lighter (boys −113 grams; 95% CI, −201 to −25, girls −107 grams; 95% CI, −197 to −17). After birth, children conceived by ART grew more rapidly, achieving both greater height and weight at age 3. Children conceived by ART had a greater height up to age 7, but did not have a greater height or weight by age 17. Naturally conceived children of parents taking longer time to conceive had growth patterns similar to ART children. Children born after frozen embryo transfer had larger ultrasound measures and were longer and heavier the first 2 years than those born after fresh embryo transfer.

LIMITATIONS, REASONS FOR CAUTIONS

Selection bias could have been introduced due to the modest participation rate in the MoBa cohort. Our reliance on self-reported measures of length/height and weight could have introduced measurement error.

WIDER IMPLICATIONS OF THE FINDINGS

: Our findings provide reassurance that offspring conceived by ART are not different in height, weight or BMI from naturally conceived once they reach adolescence.

STUDY FUNDING/COMPETING INTEREST(S)

Research Council of Norway; Medical Research Council; National Institute of Environmental Health Sciences. The authors have no competing interest.

TRIAL REGISTRATION NUMBER

N/A.

Assisted reproductive technologies and the risk of congenital urogenital tract malformations: A systematic review and meta-analysis

A systematic review was conducted to evaluate the relationship between ART and the risk of urogenital tract malformations, especially hypospadias and cryptorchidism. Thirty-three papers were selected. Meta-analysis showed that ART was correlated with an increased risk of urogenital tract malformation in offspring (odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.41-1.85), hypospadias (OR = 1.87, 95% CI: 1.47-2.40) and cryptorchidism (OR = 1.83, 95% CI: 1.54-2.18). Among offspring conceived by ART, multiple pregnancies appeared to result in a higher risk of urogenital tract malformation than singleton pregnancies (OR = 1.42, 95% CI: 0.99-2.04; P = 0.058). No significant difference in the risk of urogenital tract malformation was found between in vitro fertilization and intracytoplasmic sperm injection technologies. A sensitivity analysis showed that the above conclusions were relatively consistent. Conclusion: ART is correlated with an increased risk of urogenital tract malformations in offspring, especially hypospadias and cryptorchidism. Among ART offspring, multiple pregnancies may lead to a higher risk of urogenital tract malformations than singleton pregnancies, but more studies are needed for confirmation.

Is Intracytoplasmic Sperm Injection the Solution for all in Unexplained Infertility?

Intracytoplasmic sperm injection (ICSI) was first introduced as a supplemental method to conventional in vitro fertilization (c-IVF) for couples with severe male factor infertility to overcome the poor fertilization rate, while its indications expanded in current clinical practice and gained worldwide popularity. However, ICSI is invasive and crosses all natural barriers, raising several unresolved concerns regarding procedure-dependent and procedure-independent risks, as well as the characteristic of being labor-intensive and more expensive than c-IVF. This review is aimed to draw readers' attention, to the widespread use of ICSI worldwide, with its effectiveness in different indications of infertility, especially in those with unexplained infertility, as well as the cost-effectiveness of the ICSI-for-all strategy. Also, we covered current evidence on the short- and long-term safety of children born thanks to ICSI-aided conception. Further well-designed, adequately powered, and randomized controlled clinical trials are absolutely needed to arrive at a consensus on the use of ICSI over c-IVF in different populations.

Health and fertility of ICSI-conceived young men: study protocol

STUDY QUESTIONS

What are the long-term health and reproductive outcomes for young men conceived using ICSI whose fathers had spermatogenic failure (STF)? Are there epigenetic consequences of ICSI conception?

WHAT IS KNOWN ALREADY

Currently, little is known about the health of ICSI-conceived adults, and in particular the health and reproductive potential of ICSI-conceived men whose fathers had STF. Only one group to date has assessed semen parameters and reproductive hormones in ICSI-conceived men and suggested higher rates of impaired semen quality compared to spontaneously conceived (SC) peers. Metabolic parameters in this same cohort of men were mostly comparable. No study has yet evaluated other aspects of adult health.

STUDY DESIGN SIZE DURATION

This cohort study aims to evaluate the general health and development (aim 1), fertility and metabolic parameters (aim 2) and epigenetic signatures (aim 3) of ICSI-conceived sons whose fathers had STF (ICSI study group). There are three age-matched control groups: ICSI-conceived sons whose fathers had obstructive azoospermia (OAZ) and who will be recruited in this study, as well as IVF sons and SC sons, recruited from other studies. Of 1112 ICSI parents including fathers with STF and OAZ, 78% (n = 867) of mothers and 74% (n = 823) of fathers were traced and contacted. Recruitment of ICSI sons started in March 2017 and will finish in July 2020. Based on preliminary participation rates, we estimate the following sample size will be achieved for the ICSI study group: mothers n = 275, fathers n = 225, sons n = 115. Per aim, the sample sizes of OAZ-ICSI (estimated), IVF and SC controls are: Aim 1-OAZ-ICSI: 28 (maternal surveys)/12 (son surveys), IVF: 352 (maternal surveys)/244 (son surveys), SC: 428 (maternal surveys)/255 (son surveys); Aim 2-OAZ-ICSI: 12, IVF: 72 (metabolic data), SC: 391 (metabolic data)/365 (reproductive data); Aim 3-OAZ-ICSI: 12, IVF: 71, SC: 292.

PARTICIPANTS/MATERIALS SETTING METHODS

Eligible parents are those who underwent ICSI at one of two major infertility treatment centres in Victoria, Australia and gave birth to one or more males between January 1994 and January 2000. Eligible sons are those aged 18 years or older, whose fathers had STF or OAZ, and whose parents allow researchers to approach sons. IVF and SC controls are age-matched men derived from previous studies, some from the same source population. Participating ICSI parents and sons complete a questionnaire, the latter also undergoing a clinical assessment. Outcome measures include validated survey questions, physical examination (testicular volumes, BMI and resting blood pressure), reproductive hormones (testosterone, sex hormone-binding globulin, FSH, LH), serum metabolic parameters (fasting glucose, insulin, lipid profile, highly sensitive C-reactive protein) and semen analysis. For epigenetic and future genetic analyses, ICSI sons provide specimens of blood, saliva, sperm and seminal fluid while their parents provide a saliva sample. The primary outcomes of interest are the number of mother-reported hospitalisations of the son; son-reported quality of life; prevalence of moderate-severe oligozoospermia (sperm concentration <5 million/ml) and DNA methylation profile. For each outcome, differences between the ICSI study group and each control group will be investigated using multivariable linear and logistic regression for continuous and binary outcomes, respectively. Results will be presented as adjusted odds ratios and 95% CIs.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by an Australian National Health and Medical Research Council Partnership Grant (NHMRC APP1140706) and was partially funded by the Monash IVF Research and Education Foundation. L.R. is a minority shareholder and the Group Medical Director for Monash IVF Group, and reports personal fees from Monash IVF group and Ferring Australia, honoraria from Ferring Australia, and travel fees from Merck Serono, MSD and Guerbet; R.J.H. is the Medical Director of Fertility Specialists of Western Australia and has equity in Western IVF; R.I.M. is a consultant for and a shareholder of Monash IVF Group and S.R.C. reports personal fees from Besins Healthcare and non-financial support from Merck outside of the submitted work. The remaining authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

TRIAL REGISTRATION DATE

Not applicable.

DATE OF FIRST PATIENT’S ENROLMENT

Not applicable.

Hearing Screening Test Results of Newborns Conceived by Intracytoplasmic Sperm Injection: A Retrospective Study of Tertiary Referral Center

Objective: Assisted reproductive technologies (ART), especially intracytoplasmic sperm injection (ICSI), is associated with birth defects. However, there are few reports on hearing screening tests of these babies. We aimed to determine the association between ART and hearing loss in newborns.Materials and methods: This retrospective study examined 246 ICSI newborns between 2013 and 2015. All the patients conceived by ICSI. We examined the hearing screening results of the babies.Results: A total of 25 newborns did not pass the first screening test, including 17 by transient evoked otoacoustic emission (TEOAE) and 8 by auditory brainstem response (ABR). Ten babies did not pass the advanced examination. Total hearing loss affected 4% of ART babies.Conclusion: Hearing screening tests exposed deficient results in 4% of ICSI babies, which is ten times more frequent than spontaneously conceived newborns.

Between innovation and precaution: how did offspring safety considerations play a role in strategies of introducing new reproductive techniques?

The field of reproductive medicine has been criticized for introducing ARTs without systematic research on possible safety risks and for failing to meet the standards of evidence-based innovation held elsewhere in medicine. In this paper, firstly, we ask whether ‘responsible innovation’ has been a concern for the field, and if so, how it has understood the practical implications of this idea for the development and introduction of potentially risky new ARTs. Secondly, we consider whether the field has indeed fallen short of its responsibilities in this respect, and if so, how things can be improved. To answer these questions, we present three case studies involving the introduction of a new reproductive technology: ICSI, preimplantation genetic testing and mitochondrial replacement therapy. As a framework for analyzing these cases, we used Per Sandin’s account of the four dimensions of dealing with risks (threat, uncertainty, action, command) that are central to debates about the possible role of the so-called precautionary principle. We conclude that, although offspring safety concerns have been on the agenda of the debate about bringing the relevant technologies to the clinic, systematic safety and effectiveness studies were not always conducted. As professionals in assisted reproduction have a responsibility to take account of the welfare of the children they are creating, we suggest a policy of proceeding with systematic caution. Legal measures may be needed to ensure that professional guidance is followed in practice. Finally, an open question concerns the threshold for acceptable risk in the context of introducing new ARTs. Multiple stakeholders, including professional societies and patient organizations, should have a role in the urgent debate about this.

Childhood growth of singletons conceived following in vitro fertilisation or intracytoplasmic sperm injection: a systematic review and meta-analysis

BACKGROUND

Assisted reproductive techniques are associated with an increased risk of adverse pregnancy outcomes, including low birthweight and intrauterine growth restriction. Yet, the long-term follow-up on the growth of these children is limited.

OBJECTIVE

To systematically review the literature on post-neonatal height and weight among children conceived following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment, compared with that of children born after spontaneous conception.

SEARCH STRATEGY

A systematic computerised literature search using the online databases PubMed, Embase, and Scopus.

SELECTION CRITERIA

Cohort or case-control studies with an exposed group of singletons conceived following IVF or ICSI along with a control group of spontaneously conceived singletons.

DATA COLLECTION AND ANALYSIS

Studies were reviewed by at least two authors. Meta-analyses were conducted using Cochrane Review Manager. The quality of the studies was assessed with the Newcastle-Ottawa Scale.

MAIN RESULTS

Twenty studies were included, with 13 of these eligible for meta-analyses. The meta-analyses compared 3972 children born after IVF/ICSI with 11 012 spontaneously conceived children and revealed no statistically significant difference in child weight [mean difference (MD) in weight of -160 g; 95% confidence interval (95% CI) -360, 3]. When stratifying by age of child at follow-up, we found a significant lower weight in children aged 0-4 years conceived following IVF/ICSI treatment (MD -180 g; 95% CI -320, -4), but this was no longer significant in children from 5 years of age (MD -160 g; 95% CI -580, 260). The pooled analysis revealed no statistically significant difference in childhood height.

CONCLUSIONS

In vitro fertilisation/ICSI was not associated with long-term weight and height.

TWEETABLE ABSTRACT

Children born following IVF/ICSI do not have impaired long-term weight or height compared with spontaneously conceived children.

Do the children born after assisted reproductive technology have an increased risk of birth defects? A systematic review and meta-analysis

Background: Assisted reproductive technologies (ARTs) have made great progress. However, whether tube baby born after ART were at an increased risk of birth defects is not clear.Objective: To assess whether the ART increases the risk of birth defects in children born after ART.Search strategy: Medline, Google Scholar, and the Cochrane Library were searched.Selection criteria: Clinical trials that evaluate the risk of birth defect in children born after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and natural conceptions (NC) were included. The primary outcome was the prevalence of birth defects.Data collection and analysis: The relative risk was used as the summary measure with random effects model. We assessed heterogeneity between studies using the I² index.Main results: Totally 46 studies were included. The pooled relative risk (RR) estimated suggested there was an increased risk of birth defects in ART compared with the NC group (RR: 1.40; 95% CI 1.31-1.49). Twenty and fifteen studies were included to compare the risk of birth defects between NC and IVF/ICSI, respectively. The results indicated that both IVF and ICSI increase the risk of birth defects (IVF: RR 1.25; 95% CI 1.12-1.40; ICSI: RR 1.29; 95% CI 1.14-1.45). When subgroup according to plurality, 22 studies assessed the risk of birth defects after ART or NC in singletons and 15 studies evaluated the risk of birth defects in twins. The pooled RRs were 1.41 (95% CI 1.30-1.52) and 1.18 (95% CI 0.98-1.42), respectively.Conclusions: Children born after ART were at an increased risk of birth defects compared with NC. There was no difference in birth defects risk between ART twins and NC twins.

The safety of intracytoplasmic sperm injection and long-term outcomes

The pioneering of intracytoplasmic sperm injection (ICSI) approximately 25 years ago revolutionized the treatment of infertile couples. Today, ICSI remains an indispensable part of assisted reproductive treatments (ART) and has resulted in the birth of millions of babies. The 25th anniversary of ICSI marks a chronologic landmark in its evolving history. This landmark also serves as an opportunity to thoroughly appraise the safety of ICSI and analyze the long-term outcomes of ICSI-conceived children. In this review, we collate and analyze salient data accrued over the past 25 years pertaining to the long-term safety of ICSI and ICSI conceptions. We also evaluate the effects of ICSI on the perinatal outcomes, congenital malformation rates, cognitive development and reproductive health of ICSI-conceived neonates, children, adolescents and adults, respectively. In doing so, we also highlight the existence of potential confounders and biases that frequently obscure the interpretation of clinical follow-up studies.

Are children born from singleton pregnancies conceived by ICSI at increased risk for congenital malformations when compared to children conceived naturally? A systematic review and meta-analysis

Since 1992, the development of intra-cytoplasmic sperm injection (ICSI) has allowed infertile couples and couples affected by severe male factor infertility in particular, many of which with a history of failed traditional IVF, to become parents. This has generated considerable controversy over the safety of the procedure for the offspring. This systematic review seeks to determine whether evidence indicates that the use of ICSI increases the risk of congenital malformation in children born from singleton pregnancies versus naturally conceived children. Twenty-one of the 104 publications listed in the literature search were included in the analysis. Observational studies reported mostly an increased risk for congenital malformation; the risk of congenital malformations is 7.1% in ICSI and 4.0% in the general population (OR 1.99 (95% CI [1.87 - 2.11]). However, attributing higher risk solely to ICSI might seem far-fetched, as in vitro and simulation procedures, patient diseases, and ICSI indication may also be associated with higher risk of malformation.

Cardiovascular and metabolic profiles of offspring conceived by assisted reproductive technologies: a systematic review and meta-analysis

OBJECTIVE

To evaluate cardiovascular and metabolic features of offspring conceived by in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI).

DESIGN

Literature review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Offspring from IVF-ICSI versus natural conception.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Systolic and diastolic blood pressure (SBP and DBP), cardiovascular function, body mass index (BMI), and lipid and glucose profiles.

RESULT(S)

We included 19 studies that had recruited 2,112 IVF-ICSI and 4,096 naturally conceived offspring, ranging from childhood to early adulthood. The blood pressure levels of IVF-ICSI offspring were statistically significantly higher than those of naturally conceived offspring (weighted mean differences and confidence intervals: 1.88 mm Hg [95% CI, 0.27, 3.49] for SBP and 1.51 mm Hg [95% CI, 0.33, 2.70] for DBP). In addition, cardiac diastolic function was suboptimal and vessel thickness was higher among IVF-ICSI offspring. Compared with the metabolism of naturally conceived offspring, IVF-ICSI offspring displayed comparable BMI, lower low-density lipoprotein cholesterol levels, and higher fasting insulin levels.

CONCLUSION(S)

Children conceived by IVF-ICSI manifested a minor yet statistically significant increase in blood pressure without the clustering of increased BMI or impaired lipid metabolism by early adulthood. Our findings indicate a risk of cardiovascular disease among IVF-ICSI offspring, which calls for longer-term follow-ups and further investigation.

Safety of intracytoplasmic sperm injection

Early follow-up studies of IVF children showed that the frequency of birth anomalies resembled those arising with natural conception. More detailed analyses confirmed these findings, reinforcing the concept of the preimplantation period as teratologically "safe." The use of intracytoplasmic sperm injection (ICSI) to achieve fertilization introduced another variable.ICSI's safety has often been criticized because the fertilizing spermatozoon neither binds to the zona pellucida nor fuses with oolemma. Bypassing these physiologic steps together with the arbitrary selection of the spermatozoon has been reason for concern. Thus far, ICSI offspring undergoing adolescence and beyond has provided sufficient information to reassure these qualms. In fact, the health of the offspring generated through ICSI, once taken into consideration the gestational order, the age and the genetic makeup of the couples are generally reassuring.

Treatment of male infertility

Major difficulties exist in the accurate and meaningful diagnosis of male reproductive dysfunction, and our understanding of the epidemiology and etiology of male infertility has proven quite complex.The numerous spermatozoa produced in mammals and other species provides some degree of protection against adverse environmental conditions represented by physical and chemical factors that can reduce reproductive function and increase gonadal damage even resulting in testicular cancer or congenital malformations. The wide fluctuations of sperm production in men, both geographical and temporal, may reflect disparate environmental exposures, occurring on differing genetic backgrounds, in varying psychosocial conditions, and leading to the diversified observed outcomes.Sperm analysis is still the cornerstone in diagnosis of male factor infertility, indeed, individually compromised semen paramaters while adequately address therapeutic practices is progressively flanked by additional tests. Administration of drugs, IUI, correction of varicocele, and, to a certain extent, IVF although they may not be capable of restoring fertility itself often result in childbearing.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

Long-term follow-up of children conceived through assisted reproductive technology

Children conceived via assisted reproductive technologies (ART) are nowadays a substantial proportion of the population. It is important to follow up these children and evaluate whether they have elevated health risks compared to naturally conceived (NC) children. In recent years there has been a lot of work in this field. This review will summarize what is known about the health of ART-conceived children, encompassing neonatal outcomes, birth defects, growth and gonadal developments, physical health, neurological and neurodevelopmental outcomes, psychosocial developments, risk for cancer, and epigenetic abnormalities. Most of the children conceived after ART are normal. However, there is increasing evidence that ART-conceived children are at higher risk of poor perinatal outcome, birth defects, and epigenetic disorders, and the mechanism(s) leading to these changes have not been elucidated. Continuous follow-up of children after ART is of great importance as they progress through adolescence into adulthood, and new ART techniques are constantly being introduced.

ART and health: clinical outcomes and insights on molecular mechanisms from rodent studies

Since the birth of the first IVF-conceived child in 1978, the use of assisted reproductive technologies (ART) has grown dramatically, contributing to the successful birth of 5 million individuals worldwide. However, there are several reported associations of ART with pregnancy complications, such as low birthweight (LBW), preterm birth, birth defects, epigenetic disorders, cancer and poor metabolic health. Whether this is attributed to ART procedures or to the subset of the population seeking ART remains a controversy, but the most relevant question today concerns the potential long-term implications of assisted conception. Recent evidence has emerged suggesting that ART-conceived children have distinct metabolic profiles that may predispose to cardiovascular pathologies in adulthood. Because the eldest IVF individuals are still too young to exhibit components of chronic middle-aged syndromes, the use of animal models has become particularly useful in describing the effects of unusual or stressful preimplantation experiences on adult fitness. Elucidating the molecular mechanisms by which embryos integrate environmental signals into development and metabolic gene expression programs will be essential for optimizing ART procedures such as in vitro culture conditions, embryo selection and transfer. In the future, additional animal studies to identify mechanisms underlying unfavorable ART outcomes, as well as more epidemiological reviews to monitor the long-term health of ART children are required, given that ART procedures have become routine medical practice.

Comparison of Growth Parameters of 5-year-old Singleton Children Born in Assisted Versus Natural Conception

Introduction: At present, about 1% of newborns are delivered through assisted reproductive technologies (ART) worldwide. This study aimed to evaluate and compare the growth parameters of children born in assisted and natural conception at 5 years of age. Materials and Methods: In a cross-sectional case control study, weight, height and head circumference of 5-year old children were assessed. The case group consisted of term, singleton babies who were products of ART in the Center for Infertility of Shahid Sadoughi University, Yazd, Iran in 2005. The control group consisted of term, first child, singleton and spontaneously conceived 5-year-old children who were referred for vaccination to primary health care center of Shahid Akbari in 2010. Results: Fifty-eight girls (47.5%) and 64 boys (52.5%) “with equal numbers in each of the 2 groups” were evaluated. Sex distribution, mean ages of fathers and mothers were not statistically significant different in both groups. Children born after ART tend to have lower birth weight, smaller birth head circumference and lower weight at 5 years of age. Having low birth weight (<2500 g), being underweight and having short stature at the age of 5 were more common in babies born through ART. Conclusion: Growth retardation is more prevalent in babies born through ART. Thus, growth assessment, parents’ knowledge about child physical development, and timely and accurate follow-up of these children are necessary for early detection of any growth disorders. Key words: ART, Growth, Height, Natural Conception, Weight

Birth defects in children conceived by in vitro fertilization and intracytoplasmic sperm injection: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of studies assessing the effect of IVF and intracytoplasmic sperm injection (ICSI) on birth defects.

DESIGN

Meta-analysis.

SETTING

Centers for reproductive care.

PATIENT(S)

Patients treated by IVF and/or ICSI.

INTERVENTION(S)

We identified all studies published by September 2011 with data related to birth defects in children conceived by IVF and/or ICSI compared with spontaneously conceived children, or birth defects in the children conceived by IVF compared with those by ICSI. Risk ratios from individual studies were pooled with the fixed and random effect models.

MAIN OUTCOME MEASURE(S)

Risk of birth defects in children conceived by IVF and/or ICSI.

RESULT(S)

Of 925 studies reviewed for eligibility, 802 were excluded after screening titles and abstracts, 67 were excluded for duplicated data, data unavailable, or inappropriate control group, 56 were included in the final analysis. Among the 56 studies, 46 studies had data on birth defects in children conceived by IVF and/or ICSI (124,468) compared with spontaneously conceived children. These studies provided a pooled risk estimation of 1.37 (95% confidence interval [CI]: 1.26-1.48), which is also evident in subgroup analysis. In addition, 24 studies had data on birth defects in children conceived by IVF (46,890) compared with those by ICSI (27,754), which provided an overall no risk difference.

CONCLUSION(S)

Children conceived by IVF and/or ICSI are at significantly increased risk for birth defects, and there is no risk difference between children conceived by IVF and/or ICSI.

Development and current applications of assisted fertilization

Since the very early establishment of in vitro insemination, it became clear that one of the limiting steps is the achievement of fertilization. Among the different assisted fertilization methods, intracytoplasmic sperm injection emerged as the ultimate technique to allow fertilization with ejaculated, epididymal, and testicular spermatozoa. This work describes the early steps that brought forth the development of intracytoplasmic sperm injection and its role in assisted reproductive techniques. The current methods to select the preferential male gamete will be elucidated and the concerns related to the offspring of severe male factor couples will be discussed.

Outcomes for offspring of men having ICSI for male factor infertility

Since the introduction of intracytoplasmic sperm injection (ICSI) using single sperm isolated from testicular tissue in men with obstructive and non-obstructive azoospermia, or using ejaculated sperm in those with poor semen quality, there have been concerns that this might have adverse effects on the offspring compared to conventional in vitro fertilisation (IVF) and natural conceptions. ICSI is done for reasons other than male factor infertility, and on the whole has not been shown to have any more negative effects than those seen with IVF. There have however, been very few studies of ICSI with a focus on, or large enough numbers to examine, the specific outcomes associated with male factor infertility. From the limited information available in relation to the source of the sperm and aetiology of infertility in the presence of ICSI, there appears to be no increased risk of congenital malformations. There is, however, a small increase in both de novo and inherited chromosome abnormalities. In terms of growth and neurodevelopment, there are very few studies, and so far, no adverse outcomes have been found in young children whose fathers have a sperm defect. The origin of the sperm used in ICSI does not have a major influence on the early life outcomes for the offspring, but transgenerational and epigenetic effects remain unknown. When the male factor infertility is known or thought to be due to a Y-chromosome deletion, this information should be given to the young male offspring at a time that will ensure his own reproductive health and plans are optimized.

Assessment of vision and hearing in children conceived spontaneously and by ICSI: a prospective controlled, single-blinded follow-up study

Long-term follow-up studies on the health of children born after assisted reproduction technologies are mandatory. Vision and hearing are the most important senses that continue to develop during childhood. There are few reports on vision and hearing in preschool children born after assisted conception. This prospective controlled blinded follow-up study examined 276 term-born singleton intracytoplasmic injection (ICSI) children and 273 spontaneously conceived controls at a mean age of 5.5 years and performed detailed vision and hearing test and clinically examined eyes and ears. There was no significant difference between ICSI and control children regarding the occurrence of vision or hearing impairments. Unsurprisingly, children with abnormalities in otoscopy were more likely to have an abnormal hearing test compared with children without abnormalities. Only 8.5% of ICSI parents and 25.4% of control parents whose children showed an abnormal hearing test knew about the hearing problems of their child. In conclusion, there was no difference in the development of hearing and vision in ICSI children and spontaneously conceived controls. But only few parents knew about hearing problems of their child after undergoing routine screening examinations. Parental interviews would therefore not be sufficient in order to assess vision and hearing in follow-up studies.

Infant outcomes of assisted reproduction

Assisted reproductive technologies (ART) have become widely used in the treatment of subfertility over the last 30 years. Currently 1.7% of all births in the UK occur after assisted conception. This review summarises work that has been undertaken to investigate health outcomes of these children and summarises areas where uncertainty continues to exist. Much of the adverse health outcomes of children born after ART are related to higher order birth; however evidence suggests adverse perinatal outcomes in singletons as well as twins and triplets. The cause of adverse health outcomes in ART conceived children is as yet unclear and studies investigating causal factors such as underlying subfertility are discussed.

[ICSI with non-ejaculated sperm: what about children?]

For men presenting azoospermia, the development of ICSI with epidydimal (MESA) or testicular (TESE) sperm, allowed them to father their own progeny. Little is known about the issue of these ICSI, in terms of efficiency and quality of the conceptus, and many controversies remain. Some studies emphasized that children born after Assisted Reproductive Technology (ART) with surgically sperm retrieved were at increased risk of birth defects. In this context, we proposed a retrospective analysis of pregnancy issues with non-ejaculated sperm.

Genetic and epigenetic characteristics of ICSI children

The outcome of pregnancy and the developmental wellbeing of children conceived from 12,866 consecutive intracytoplasmic sperm injection (ICSI) cycles was assessed. A total of 3277 couples delivered 5891 neonates. There was a higher than normal incidence of de-novo chromosomal abnormalities in a small sample of ICSI offspring. Controlling for maternal age showed that the incidence of low birth weight and gestational length were comparable with the naturally conceived counterpart. Rates of malformation in ICSI offspring ranged from 3.5 to 6.2%. At 3 years of age (n = 811), the proportion of children at risk for developmental delays was 10.4% in ICSI and 10.7% in IVF singletons. However, high order gestations were characterized by 19.4% of the children having compromised development. Epigenetic analysis of assisted reproductive technique conceptuses found minor imprinted gene expression imbalances. ICSI offspring presented with genetic defects that were inherited or arose de novo. Obstetric and neonatal outcomes of singleton pregnancies appeared to be dependent upon maternal age. ICSI and IVF appeared to exert a negative effect on the wellbeing of offspring mainly because of the association with multiple gestations. All assisted reproduction procedures should be monitored for the eventual effect of environmental aggressors on offspring epigenesis.

Follow-up of children born after ART

Assisted reproductive therapies (ART), namely in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), have become widely used in the treatment of human infertility. Children conceived using ART represent a substantial proportion of the population. Follow-up of these children is necessary in order to evaluate the risks of infertility treatment upon subsequently conceived offspring. In recent years there has been considerable work in this field. This review summarises current evidence regarding the health of children conceived following ART, encompassing neonatal outcomes, the risk of congenital malformations, neurodevelopmental outcome, physical health, psychosocial well being, and the risk of cancer. The main risks for the future well being of ART children remain multiple pregnancies and low birth weight. Evidence regarding the outcome of singletons born at term following ART is generally reassuring. It is essential that follow-up of ART children continues as they progress through adolescence into adulthood.

Abnormal vessel morphology in boys born after intracytoplasmic sperm injection

AIM

Children born after intracytoplasmic sperm injection (ICSI) are at risk of preterm birth, low birth weight and perinatal morbidity which may predispose for diseases of the central nervous and vascular systems. Our aim was to investigate the ocular fundus morphology in children born after ICSI.

METHOD

Children born after ICSI (n = 82) had ocular fundus photographs taken at the age of 5 years and results were compared with those of a control group (n = 203). The ocular fundus morphology with the central retinal vessels was evaluated by digital image analysis.

RESULTS

Children born after ICSI (n = 57) had abnormal retinal vascularization as evidenced by a lower number of vascular branching points compared with the control group (n = 181) (p = 0.0002). A gender difference was found whereby the ICSI boys (n = 35) had significantly fewer retinal branching points (median 24, range 19-29.5) compared with the control boys (median 27.5, range 20-37) (p < 0.0001).

CONCLUSION

Our findings showed that ICSI boys have abnormal vessel morphology as demonstrated by a reduced number of central retinal branching points. The difference still remained after elimination of factors earlier shown to be associated with a low number of vascular branching points, i.e. low birth weight and preterm, suggesting other mechanisms responsible for the low number of vascular branching points.

The Bertarelli Foundation's actions in the field of multiple gestations

The Bertarelli Foundation aims to promote understanding of infertility. Two international conferences in 1999 and 2002 have highlighted the importance of multiple gestations, which have been recognized as a major problem associated with assisted reproductive technologies and ovulation induction therapies. For this reason, the Bertarelli Foundation has, since 2002, decided to focus its efforts on multiple gestations: the final aim of this programme is to make the medical population more aware of this public health problem, its psychosocial implications, and the high costs of any attitude that leads to an unacceptably high rate of multiple gestations. Conclusions and consensus statements have been widely published from the first expert meeting 2003 and used as the basis for the following actions: (i) organization of national conferences and consensus meetings with the aim of establishing gold standards in managing the ongoing epidemic of multiple gestations; (ii) funding research projects focused on different aspects of multiple gestations; (iii) supporting the European Society of Human Reproduction and Embryology's multiple gestations working group's (European IVF Monitoring) registry; and (iv) promoting understanding of the human face of infertility by promoting publications, development of websites, exhibitions in the field of infertility.

Physical health at 5.5 years of age of term-born singletons after intracytoplasmic sperm injection: results of a prospective, controlled, single-blinded study

OBJECTIVE

To study the health of children born after ICSI and of spontaneously conceived control children at the age of 4-6 years.

DESIGN

Prospective, controlled, blinded study.

SETTING

Tertiary-care center.

PATIENT(S)

Two hundred seventy-six term-born singletons conceived by ICSI and 273 matched spontaneously conceived singletons at the age of 5.5 years.

INTERVENTION(S)

Detailed physical examination, interview of the parents, and collection of data from each child's examination booklet.

MAIN OUTCOME MEASURE(S)

Biometrical data; current health status; acute, chronic and childhood illnesses; hospitalizations; and surgeries.

RESULT(S)

Detailed physical examination did not reveal any relevant differences between ICSI and spontaneously conceived children. There were no relevant differences regarding the incidence of childhood illnesses, acute or chronic illnesses, accidents, and surgeries up to the age of 5.5 years. However, a history of undescended testicles was found significantly more often in boys born after ICSI (5.4% vs. 0.7%), with the consequence that they had significantly more urogenital surgery (19.2% vs. 8.9%). Significantly more ICSI children had been hospitalized (37.6% vs. 27.2%), although we did not find any specific reason for the increased hospitalization rate.

CONCLUSION(S)

Other than an increased risk of undescended testicles and therefore an increase in urogenital surgeries in ICSI boys, the physical health of ICSI children was comparable to that of spontaneously conceived children at the age of 5.5 years.

Long-term effects of mouse intracytoplasmic sperm injection with DNA-fragmented sperm on health and behavior of adult offspring

Genetic and environmental factors produce different levels of DNA damage in spermatozoa. Usually, DNA-fragmented spermatozoa (DFS) are used with intracytoplasmic sperm injection (ICSI) treatments in human reproduction, and use of DFS is still a matter of concern. The purpose of the present study was to investigate the long-term consequences on development and behavior of mice generated by ICSI with DFS. Using CD1 and B6D2F1 mouse strains, oocytes were injected with fresh spermatozoa or with frozen-thawed spermatozoa without cryoprotector. This treatment increased the percentage of TUNEL-positive spermatozoa, tail length as measured by comet assay, and loss of telomeres as measured by quantitative PCR. The ICSI-generated embryos were cultured for 24 h in KSOM, and 2-cell embryos were transferred into CD1 females. The DFS reduced both the rate of preimplantation embryo development and number of offspring. Immunofluorescence staining with an antibody against 5-methylcytosine showed a delay of 2 h on the active demethylation of male pronucleus in the embryos produced by ICSI. Moreover, ICSI affected gene transcription and methylation of some epigenetically regulated genes like imprinting, X-linked genes, and retrotransposon genes. At 3 and 12 mo of age, ICSI with DFS-produced animals and in vivo-fertilized controls were submitted to behavioral tests: locomotor activity (open field), exploratory/anxiety behavior (elevated plus maze, open field), and spatial memory (free-choice exploration paradigm in Y maze). Females produced by ICSI showed increased anxiety, lack of habituation pattern, deficit in short-term spatial memory, and age-dependent hypolocomotion in the open-field test (P<0.05). Postnatal weight gain of mice produced by ICSI with fresh or frozen sperm was higher than that of their control counterparts from 16 wk on (P<0.01). Anatomopathological analysis of animals at 16 mo of age showed some large organs and an increase in pathologies (33% of CD1 females produced with DFS presented some solid tumors in lungs and dermis of back or neck). Moreover, 20% of the B6D2F1 mice generated with DFS died during the first 5 mo of life, with 25% of the surviving animals showing premature aging symptoms, and 70% of the B6D2F1 mice generated with DFS died earlier than controls with different kind of tumors. We propose that depending on the level of DFS, oocytes may partially repair fragmented DNA, producing blastocysts able to implant and produce live offspring. The incomplete repair, however, may lead to long-term pathologies. Our data indicate that use of DFS in ICSI can generate effects that only emerge during later life, such as aberrant growth, premature aging, abnormal behavior, and mesenchymal tumors.

The risk of malformation following assisted reproduction

INTRODUCTION

Intracytoplasmatic sperm injection (ICSI) is currently the most frequently used human reproductive technology in Germany. ICSI was introduced as routine, insurance-funded medical care in 2002 by the Federal Joint Committee. A re-evaluation of published literature on malformation rates in children born of ICSI pregnancies within a period of three years formed part of the committee's decision. The analysis investigated whether ICSI increases the risk of malformation in the offspring, compared to in vitro fertilization (IVF) and natural conception.

METHODS

Systematic literature review.

RESULTS

929 studies were identified. Three meta-analyses, 15 studies investigating malformations, and 12 studies analyzing imprinting disorders were included. The risk of malformation was not significantly different in nine studies comparing ICSI versus IVF. Two meta-analyses and three of eight cohort studies and retrospective analysis showed significantly more severe malformations after assisted reproduction than after natural conception. The remaining five studies displayed no significant results. Current evidence does not show a higher risk of major malformations in the offspring resulting from the use of ICSI compared to IVF. However, there is evidence that both techniques increase the risk for major malformations considerably, compared to natural conception, and further research is needed. The validity of the results is low since the studies were heterogeneous and the cohorts used in the studies had limited comparability.

Perinatal outcome, health, growth, and medical care utilization of 5- to 8-year-old intracytoplasmic sperm injection singletons

OBJECTIVE

To evaluate short- and long-term health in intracytoplasmic sperm injection (ICSI) singletons.

DESIGN

Follow-up study.

SETTING

University medical center, assessments between March 2004 and May 2005.

PATIENT(S)

Singletons born between June 1996 and December 1999 after ICSI in the Leiden University Medical Center laboratory were compared with matched singletons born after IVF and natural conception.

INTERVENTION(S)

Mode of conception.

MAIN OUTCOME MEASURE(S)

An examiner blinded to the conception mode of the child assessed congenital malformations and growth. Information on pregnancy, perinatal period, birth defects, general health, and medical consumption was obtained through questionnaires.

RESULT(S)

Outcomes of children conceived by ICSI and IVF (n = 81/81, preterm infants excluded) were comparable or even more positive for ICSI. Perinatal outcomes were poorer after ICSI than natural conception: prematurity: P=.014; low birth weight: odds ratio = 7.4, 95% confidence interval (CI) [0.9; 62.5]; mean birth weight: Delta = 186 g, 95% CI [21; 351]. The ICSI mothers had more pregnancy complications (n = 33 vs. 18) and in-hospital deliveries (prevalence ratio 1.36, 95% CI 1.17; 1.48). No further differences were found between ICSI and natural conception children on congenital malformations, health, growth, and medical consumption (n = 87/85, preterm infants included).

CONCLUSION(S)

No adverse health outcomes were identified in ICSI singletons up to age 5-8 years compared to IVF and natural conception singletons, besides poorer perinatal outcomes after ICSI versus natural conception.

[Children born of ICSI]

Studies on children born as a result of IVF or ICSI present significant methodological differences and have been conducted on highly heterogeneous populations. Regarding perinatal data, there is a consensus of opinion on the increased risk of prematurity, growth retardation and perinatal mortality, even after maternal factors and the presence or absence of multiple pregnancies have been taken into account. There is no significant difference in the studies between ICSI and IVF, which are often not individualised. The results of birth defects following IVF treatment are contradictory in the literature. The risk of birth defects following ICSI can be caused by male infertility (chromosome abnormality rate, microdeletion of the Y chromosome, genetic fingerprint) or by the technique used (no selection of the fertilising spermatozoon, disturbance of the meiotic spindle, risk of introduction of foreign materials, risk of infection). Analysis of the literature is complicated because of methodological biases. Thus, according to the studies, the risks of defects following ICSI are identical or increased compared with those following IVF. In the long term, synthesis of the studies does not allow any certainty regarding the growth of children, their cognitive or psychomotor development, the risk of cancers or epigenetic diseases. The current data is more reassuring than worrying, but the good current studies on child development should be developed in terms of number, cohort size and monitoring period.

In vitro spermatogenesis as a method to bypass pre-meiotic or post-meiotic barriers blocking the spermatogenetic process: genetic and epigenetic implications in assisted reproductive technology

Pregnancies achieved by assisted reproduction technologies and particularly by ooplasmic injections of either in vivo or in vitro generated immature male germ cells are susceptible to genetic risks inherent to the male population treated with assisted reproduction and additional risks inherent to these innovative procedures. The documented, as well as the theoretical risks, are discussed in this review. These risks represent mainly the consequences of genetic abnormalities underlying male infertility and may become stimulators for the development of novel approaches and applications in the treatment of infertility. Recent data suggest that techniques employed for in vitro spermatogenesis, male somatic cell haploidization, stem cell differentiation in vitro and assisted reproductive technology may also affect the epigenetic characteristics of the male gamete, the female gamete, or may have an impact on early embryogenesis. They may be also associated with an increased risk for genomic imprinting abnormalities. Production of haploid male gametes in vitro may not allow the male gamete to undergo all the genetic and epigenetic alterations that the male gamete normally undergoes during in vivo spermatogenesis.

Genetic and epigenetic risks of intracytoplasmic sperm injection method

Pregnancies achieved by assisted reproduction technologies, particularly by intracytoplasmic sperm injection (ICSI) procedures, are susceptible to genetic risks inherent to the male population treated with ICSI and additional risks inherent to this innovative procedure. The documented, as well as the theoretical, risks are discussed in the present review study. These risks mainly represent that consequences of the genetic abnormalities underlying male subfertility (or infertility) and might become stimulators for the development of novel approaches and applications in the treatment of infertility. In addition, risks with a polygenic background appearing at birth as congenital anomalies and other theoretical or stochastic risks are discussed. Recent data suggest that assisted reproductive technology might also affect epigenetic characteristics of the male gamete, the female gamete, or might have an impact on early embryogenesis. It might be also associated with an increased risk for genomic imprinting abnormalities.

Serum insulin-like growth factor-I (IGF-I) and growth in children born after assisted reproduction

CONTEXT

Concern has been raised about the safety of assisted reproduction techniques for the offspring.

OBJECTIVES

The objective of the study was to investigate postnatal growth and growth factors in children born after intra-cytoplasmatic sperm injection (ICSI) and in vitro fertilization (IVF).

DESIGN

The study had two cohorts: a population-based longitudinal infant cohort 0-36 months [236 ICSI, 173 IVF, 1530 naturally conceived (NC)], and a cross-sectional child cohort at 5 yr (68 ICSI, 67 IVF, 70 NC).

INTERVENTION

Anthropometrical measurements were made at birth, 3, 18, 36 (infant cohort), and 60 months (child cohort), and blood samples were collected at 3 or 60 months.

MAIN OUTCOME MEASURES

Serum IGF-I, IGFBP-3, height, weight, head and abdominal circumference, body mass index, and fat folds were the main outcome measures.

RESULTS

Anthropometrical measurements showed no significant differences between ICSI and IVF children and controls in either cohort. However, singleton ICSI girls [3.4 (0.6) kg, P = 0.008] had a slightly lower birth weight than IVF [3.5 (0.5) kg] and NC girls [3.5 (0.5) kg]. Birth weights of singleton boys [3.6 (0.5) kg], twin boys [2.6 (0.6) kg], and twin girls [2.4 (0.5) kg] did not differ between types of conception. In the infant cohort in 3-month-old singletons, serum IGF-I was lower in ICSI [78 (26) ng/ml] than NC boys [94 (27) ng/ml, P < 0.001] and IVF [74 (34) ng/ml], compared with NC girls [93 (43) ng/ml, P = 0.011]. ICSI children were also smaller than their target height (sd score) at 3 yr of age [mean -0.91 (1.2)], compared with NC children [-0.61 (0.9), P = 0.033]. In the child cohort, target height attainment (sd score) and growth factors did not differ among the three groups.

CONCLUSIONS

The overall growth pattern of ICSI and IVF children in both cohorts was normal. Our findings of subtle differences in target height attainment and serum IGF-I levels between infants born after assisted reproduction techniques and controls may not be clinically significant. However, these observations indicate that further systematic follow-up of growth and puberty in these children is needed.

Ex vivo early embryo development and effects on gene expression and imprinting

The environment to which the mammalian embryo is exposed during the preimplantation period of development has a profound effect on the physiology and viability of the conceptus. It has been demonstrated that conditions that alter gene expression, and in some instances the imprinting status of specific genes, have all previously been shown to adversely affect cell physiology. Thus, questions are raised regarding the aetiology of abnormal gene expression and altered imprinting patterns, and whether problems can be averted by using more physiological culture conditions. It is also of note that the sensitivity of the embryo to its surroundings decreases as development proceeds. Post compaction, environmental conditions have a lesser effect on gene function. This, therefore, has implications regarding the conditions used for IVF and the culture of the cleavage stage embryo. The developmental competence of the oocyte also impacts gene expression in the embryo, and therefore superovulation has been implicated in abnormal methylation and imprinting in the resultant embryo. Furthermore, the genetics and dietary status of the mother have a profound impact on embryo development and gene expression. The significance of specific animal models for human assisted reproductive technologies (ART) is questioned, given that most cattle data have been obtained from in vitro-matured oocytes and that genes imprinted in domestic and laboratory animals are not necessarily imprinted in the human. Patients treated with ART have fertility problems, which in turn may predispose their gametes or embryos to greater sensitivities to the process of ART. Whether this is from the drugs involved in the ovulation induction or from the IVF, intracytoplasmic sperm injection or culture procedures themselves remains to be determined. Alternatively, it may be that epigenetic alterations are associated with infertility and symptoms are subsequently revealed through ART. Whatever the aetiology, continued long-term monitoring of the children conceived through ART is warranted.