Guidelines for the number of embryos to transfer following in vitro fertilization

The Association between the Burden of PM2.5-Related Neonatal Preterm Birth and Socio-Demographic Index from 1990 to 2019: A Global Burden Study

BACKGROUND

Preterm birth (PTB) leads to short-term and long-term adverse effects on newborns. Exposure to fine particulate matter (PM_2.5) was positively related to PTB. However, the global annual average PM_2.5 was three times than the recommended value in 1998-2014. Socio-demographic index (SDI) is a new indicator that comprehensively reflects the overall development level of a country, partly because of "the epidemiological transition". Among other countries with higher and similar SDI levels, policy makers have the opportunity to learn from their successful experiences and avoid their mistakes by identifying whether their burdens of disease are higher or lower than the expected. However, it is unclear about the trends of the burden of PM_2.5-related preterm birth in different countries and different levels of SDI regions. Additionally, the relationship between the SDI and the burden in 1990-2019 is also unclear.

METHODS

This was a retrospective study based on the Global Burden of Disease Study 2019 (GBD2019) database from 1990 to 2019. The burden of PM_2.5-related PTB was measured by the age-standardized mortality rate (ASMR), age-standardized disability-adjusted life years rate (ASDR), mortality rate, and the disability-adjusted life years (DALYs). The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) were used to reflect the trends over the past 30 years, which were calculated using a joinpoint model. The relationships between the ASMR, ASDR, and SDI were calculated using a Gaussian process regression.

FINDINGS

In 2019, the entire burden of PM_2.5-related PTB was relatively high, where the ASMR and the ASDR were 0.76 and 67.71, increasing by 7.04% and 7.12%, respectively. It mainly concentrated on early neonates, boys, and on low-middle SDI regions. The increase in the burden of PM_2.5-related PTB in low and low-middle SDI regions is slightly higher than the decrease in other SDI regions. In 2019, the burden varied greatly among different levels of SDI regions where ASMRs varied from 0.13 in high SDI regions to 1.19 in low-middle regions. The relationship between the expected value of the burden of PM_2.5-related PTB and SDI presented an inverted U-shape, and it reached the maximum when SDI is around 0.50. The burdens in four regions (South Asia, North Africa and the Middle East, western sub-Saharan Africa, and southern sub-Saharan Africa) were much higher than the mean value. Boys bore more burden that girls. The sex ratio (boys:girls) of the burden showed a dramatically increasing trend in low SDI regions and a decreasing trend in middle SDI regions and high-middle SDI regions. These differences reflect the huge inequality among regions, countries, ages, and sex in the burden of PM_2.5-related PTB.

CONCLUSION

The overall burden of PM_2.5-related PTB in 2019 was relatively high, mainly concentrated on early neonates, boys, and on low-middle SDI regions. It showed an increasing trend in low-middle and low SDI regions. The association between the burden and the SDI presented an inverted U-shape. It is very necessary to promulgate policies to prevent and control air pollution in countries with large and increasing exposure to PM_2.5 pollution because it does not need action at an individual level. Focusing on public educational interventions, public and professional policies, and improving accessibility of prenatal care are other feasible ways for low and low-middle SDI countries. Policy makers should also appropriately allocate medical resources to boys and early newborns.

First-time mothers' experiences of foetal reduction in pregnancy following assisted reproductive technology treatment in Taiwan: a qualitative study

BACKGROUND

Foetal reduction-removal of one or more foetuses to reduce the number of foetuses in multiple conceptions-is a procedure used for improving pregnancy outcomes following assisted reproductive technology (ART) treatment. While there is a recognition of the importance of understanding the experiences of women who undergo foetal reduction to offer appropriate help and support, studies that provide relevant insights are sparse. Our aim was to gain an in-depth understanding about first-time mothers' experiences of foetal reduction following ART treatment in Taiwan.

METHODS

We adopted a qualitative design based on a phenomenological approach for this study. In-depth semi-structured interviews were conducted with seven first-time mothers who underwent foetal reduction following ART treatment at a fertility centre in Taipei, Taiwan. All interviews were recorded, transcribed and analysed using the Colaizzi strategy.

RESULTS

The views and experiences relating to foetal reduction reflected five key themes: hesitation, ambivalence and distress; the guilt of knowingly terminating a life; rituals and ceremonies to ease the sense of guilt; persuading oneself to consider the 'big picture'; and wishing for a reunion in next pregnancy. Mothers often regretted that they took clinical advice to implant multiple embryos and then having had to resort to foetal reduction. There was a sense of hesitation, ambivalence and distress reflected in the views from all participants. They believed that they ended the fetuses' lives knowingly and expressed strong feelings of guilt. Mothers often tried to persuade themselves to look at foetal reduction within the 'big picture' of the overall pregnancy outcome. Losing their unborn babies was as an unforgettable incident for most mothers, and they wished for a reunion with the lost baby in the next pregnancy.

CONCLUSION

Findings indicate the need for ART providers to undertake a more sensitive approach that involves detailed discussions with women and their families to tailor the embryo transfer processes to suit individual needs. Women who undergo foetal reduction should be provided with tailored interventions towards enhancing their coping strategies before and after foetal reduction taking into account the cultural and religious context.

The effect of oral melatonin supplementation on MT-ATP6 gene expression and IVF outcomes in Iranian infertile couples: a nonrandomized controlled trial

This study aims to evaluate the effect of melatonin supplementation on the outcomes of in vitro fertilization (IVF) and mitochondrial adenosine triphosphate production (MT-ATP6) gene expression in Iranian infertile couples. A single-blind nonrandomized controlled trial was conducted, recruiting 90 infertile couples who underwent IVF at an infertility center in Tehran, Iran. Patients who were assigned to the intervention group received melatonin as a supplementation to the standard controlled ovarian stimulation (COS). The control group received a COS protocol only. Primary outcome was the mRNA level of the MT-ATP6 gene in cumulus cells of ovarian follicles. Secondary outcomes were the mean number of mature oocytes retrieved, the embryo quality, and biochemical and clinical pregnancy rates. The mRNA level of the MT-ATP6 gene in cumulus cells between intervention and control groups was not statistically different (0.931 vs.1; P ˃ 0.05). The mean number of poor-quality embryos was significantly lower in the intervention group than that in the control group (0.27 vs. 0.80; P = 0.028). The biochemical and clinical pregnancy rates were higher in the intervention group (24% vs. 14%, P = 0.089, and 14% vs. 7%, P = 0.302, respectively); however, the difference was not significant. Melatonin supplementation did not increase the odds of clinical pregnancy and the number of mature oocytes retrieved, but significantly reduced the number of low-quality embryos. More extensive studies focusing on the level of MT-ATP6 gene expression in the oocyte or blastomere cells may further elucidate the effect of supplementation with melatonin in infertile couples who have poor clinical outcomes. Trial registration: Current Controlled Trials: IRCT2015042912307N4.

Factors affecting the live-birth rate in women with diminished ovarian reserve undergoing IVF-ET

PURPOSE

The occurrence of diminished ovarian reserve (DOR) in women was growing in recent years. Although in vitro fertilization and embryo transfer (IVF-ET) became an effective treatment for DOR, the live-birth (LB) rate remains unsatisfactory. This study aimed to investigate the impact factors of LB rate in women with DOR undergoing assisted reproduction.

METHODS

This was a single-center retrospective cohort study. A total of 2277 IVF-ET or ICSI cycles from 1957 DOR women were analysed. Impact factors of LB rate were explored via Student's t test, Pearson's Chi-square test, and multivariate logistic regression models.

RESULTS

There were statistically significant differences in maternal age (P < 0.001), duration of infertility (P < 0.001), female body mass index (P = 0.039), first IVF cycle (P = 0.004), poor ovarian response (P < 0.001), paternal age (P < 0.001), total gonadotropin dose (P = 0.010), endometrial thickness (P = 0.021), number of follicles ≥ 14 mm (P = 0.007), number of oocytes retrieved (P < 0.001), number of frozen embryos (P = 0.014), and the stage (P < 0.001) and number (P < 0.001) of embryos transferred between the non-live-birth (NLB) and LB groups. However, only factors of maternal age, the stage and number of embryos transferred remained different after adjusting for potential confounders.

CONCLUSIONS

Maternal age, the stage and number of embryos transferred were independent impact factors affecting the live-birth rate in women with DOR seeking for assisted conception.

Born too soon: care during pregnancy and childbirth to reduce preterm deliveries and improve health outcomes of the preterm baby

Pregnancy and childbirth represent a critical time period when a woman can be reached through a variety of mechanisms with interventions aimed at reducing her risk of a preterm birth and improving her health and the health of her unborn baby. These mechanisms include the range of services delivered during antenatal care for all pregnant women and women at high risk of preterm birth, services provided to manage preterm labour, and workplace, professional and other supportive policies that promote safe motherhood and universal access to care before, during and after pregnancy. The aim of this paper is to present the latest information about available interventions that can be delivered during pregnancy to reduce preterm birth rates and improve the health outcomes of the premature baby, and to identify data gaps. The paper also focuses on promising avenues of research on the pregnancy period that will contribute to a better understanding of the causes of preterm birth and ability to design interventions at the policy, health care system and community levels. At minimum, countries need to ensure equitable access to comprehensive antenatal care, quality childbirth services and emergency obstetric care. Antenatal care services should include screening for and management of women at high risk of preterm birth, screening for and treatment of infections, and nutritional support and counselling. Health workers need to be trained and equipped to provide effective and timely clinical management of women in preterm labour to improve the survival chances of the preterm baby. Implementation strategies must be developed to increase the uptake by providers of proven interventions such as antenatal corticosteroids and to reduce harmful practices such as non-medically indicated inductions of labour and caesarean births before 39 weeks of gestation. Behavioural and community-based interventions that can lead to reductions in smoking and violence against women need to be implemented in conjunction with antenatal care models that promote women's empowerment as a strategy for reducing preterm delivery. The global community needs to support more discovery research on normal and abnormal pregnancies to facilitate the development of preventive interventions for universal application. As new evidence is generated, resources need to be allocated to its translation into new and better screening and diagnostic tools, and other interventions aimed at saving maternal and newborn lives that can be brought to scale in all countries.

Temporal trends in the frequency of twins and higher-order multiple births in Canada and the United States

BACKGROUND

The dramatic increase in multiple births is an important public health issue, since such births have elevated risks for adverse perinatal outcomes. Our objective was to explore the most recent temporal trends in rates of multiple births in Canada and the United States.

METHODS

Live birth data from Canada (excluding Ontario) and the United States from 1991-2009 were used to calculate rates of twins, and triplet and higher-order multiples (triplet+). Temporal trends were assessed using tests for linear trend and absolute and relative changes in rates.

RESULTS

Twin live births in the United States increased from 23.1 in 1991 to 32.2 per 1,000 live births in 2004, remained stable between 2004 and 2007, and then increased slightly to an all-time high of 33.2 per 1,000 live births in 2009. In Canada, rates also increased from 20.0 in 1991 to 28.3 per 1,000 live births in 2004, continued to increase modestly between 2004 and 2007, and rose to a high of 31.4 per 1,000 in 2009. Rates of triplet+ live births in the United States increased dramatically from 81.4 in 1991 to 193.5 per 100,000 live births in 1998, remained stable between 1998 and 2003 and then decreased to 148.9 per 100,000 in 2007. The rate declined marginally in 2008, but then rose again in 2009 to 153.5 per 100,000. Rates of triplet+ live births were much lower in Canada, although the temporal pattern of change was similar.

CONCLUSION

The rate of twin live births in the United States and Canada continues to increase, though more modestly than during the 1990s. Recent declines in rates of triplet+ live births in both countries have been followed by unstable trends.

Multiple births associated with assisted human reproduction in Canada

OBJECTIVE

Assisted human reproduction has been associated with increased rates of multiple births. Data suggest that twins and higher order multiple pregnancies are at risk for pre- and postnatal health complications that contribute to stress on both the family and the Canadian health care system. No published Canadian data estimate the contribution of assisted human reproduction to multiple birth rates. This study was designed to determine the contributions of age and assisted human reproduction to multiple birth rates in Canada.

METHODS

We performed analyses of existing Canadian databases, using a mathematical model from the Centers for Disease Control and Prevention. More specifically, data from the Canadian Vital Statistics: Births and Stillbirths database were combined with data from the Canadian Assisted Reproductive Technologies Register collected by the Canadian Fertility and Andrology Society. Datasets were standardized to age distributions of mothers in 1978.

RESULTS

RESULTS suggest that in vitro fertilization, ovulation induction, and age each contribute more to the rates of triplets than to twins. As expected, the contribution of natural factors was higher to twins than to triplets.

CONCLUSION

These are the first Canadian data analyzed to separate and measure the contributions of age and assisted reproductive technologies to multiple birth rates. Our findings are important for guiding physician and patient education and informing the development of treatment protocols that will result in lower-risk pregnancies and improved long-term health for women and their offspring.

Goals and strategies for prevention of preterm birth: an obstetric perspective

Complications of prematurity surpass congenital malformations as the leading cause of infant mortality in the United States. Since 1990, there has been a steady rise in preterm birth, alarming health professionals from all disciplines. This review from a prenatal perspective confirms those concerns and describes the risks and opportunities that may attend efforts to improve the health of fetuses, newborns, and infants. Fetal and live-born outcomes are included.

Assisted reproductive technologies (ART) in Canada: 2006 results from the Canadian ART Register

OBJECTIVE

To present a report on assisted reproductive technologies (ART) cycles performed in 2006 in Canada and show trends in outcomes over time. This is the sixth annual report from the Canadian ART Register (CARTR).

DESIGN

Prospective cohort study.

SETTING

Twenty-five of 25 ART centers in Canada.

PATIENT(S)

Couples undergoing ART treatment in Canada during 2006.

INTERVENTION(S)

ART treatments, including in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and frozen embryo transfer (FET).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, live birth, and multiple birth rates.

RESULT(S)

A total of 12,052 ART cycles was reported to CARTR. In 8278 IVF/ICSI cycles using the woman's own oocytes, the clinical pregnancy rate per cycle started was 33.7% (38.6% per ET), and the live birth rate was 27.1%; the multiple birth rate per delivery was 30.3%, with a high-order multiple birth rate of 1.5%. In 64% of cycles, ICSI was performed. One or two embryos were transferred in 67% of cycles. In 350 IVF/ICSI cycles using donor oocytes, the clinical pregnancy rate was 42.3%, and the live birth rate was 33.6%; the multiple birth rate was 37.3%, with no triplet birth. In 2838 FET cycles using the woman's own oocytes, the clinical pregnancy rate was 24.3%, and the live birth rate was 18.6%; the multiple birth rate was 22.5%, with a triplet birth rate of 0.6%. Birth outcomes were unknown for 3.6% of ongoing pregnancies.

CONCLUSION(S)

For 2006, CARTR achieved 100% voluntary participation from Canadian ART centers for the fourth consecutive year. Clinical pregnancy and live birth rates continued to increase in 2006 compared with previous years, but multiple birth rates decreased only slightly.

Distributive justice and infertility treatment in Canada

An exploration of distributive justice in Canadian infertility treatment requires the integration of ethical, clinical, and economic principles. In 1971, American philosopher John Rawls proposed a theoretical model for fair decision-making in which "rational" and "self-interested" citizens are behind a "veil of ignorance" with respect to both their own position and the position of other decision-makers. Rawls proposed that these self-interested decision-makers, fearing that they are among the least advantaged persons who could be affected by the decision, will agree only upon rules that encode equality of opportunity and that bestow the greatest benefit on the least advantaged citizens. Regarding health policy decision-making, Rawls' model is best illustrated by Canadian philosopher Warren Bourgeois in his panel of "volunteers." These rational and self-interested volunteers receive an amnestic drug that renders them unaware of their health, social, and financial position, but they know that they are representative of diverse spheres of citizens whose well-being will be affected by their decision. After describing fair decision-making, Bourgeois considers the lack of a distributive justice imperative in Canada's Assisted Human Reproduction Act, in contrast to legislation in European nations and Australia, summarizes the economic and clinical considerations that must be provided to the decision-makers behind the "veil of ignorance" for fair decisions to occur, and considers altruism in relation to equality of access. He concludes by noting that among countries with legislation governing assisted reproduction Canada is alone in having legislation that is void of distributive justice in providing access to clinically appropriate infertility care.

Assisted reproductive technologies in Canada: 2005 results from the Canadian Assisted Reproductive Technologies Register

OBJECTIVE

To present a report on assisted reproductive technologies (ART) cycles performed in 2005 in Canada. This is the fifth annual report from the Canadian ART Register (CARTR).

DESIGN

Prospective cohort study.

SETTING

Twenty-five of 25 ART centers in Canada.

PARTICIPANT(S)

Couples undergoing ART treatment in Canada during 2005.

INTERVENTION(S)

ART treatments, including IVF, intracytoplasmic sperm injection (ICSI), and frozen ET (FET).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, live birth, and multiple birth rates.

RESULT(S)

A total of 11,414 ART cycles was reported to CARTR. In 8195 IVF/ICSI cycles using the women's own oocytes, the clinical pregnancy rate per cycle started was 32.1% (37.5% per ET procedure), and the live birth rate was 25.6%; the multiple birth rate per delivery was 30.8%, with a triplet birth rate of 1.4%. IVF was performed in 40% of cycles and ICSI in 60% with similar pregnancy rates. One or two embryos were transferred in 68% of cycles; transferring more embryos did not increase the pregnancy rate. In 301 IVF/ICSI cycles using donor oocytes, the clinical pregnancy rate was 46.5%, and the live birth rate was 35.2%; the multiple birth rate was 33.3%, with no triplet birth. In 2498 FET cycles using the woman's own oocytes, the clinical pregnancy rate was 22.8%, and the live birth rate was 17.4%; the multiple birth rate was 24.5%, with a triplet birth rate of 1.6%. Compared with singletons, babies from multiple births had higher risks for preterm birth, low birth weight, and perinatal death.

CONCLUSION(S)

For 2005, CARTR achieved 100% voluntary participation from Canadian ART centers for the third consecutive year. Clinical pregnancy and live birth rates continued to increase in 2005 compared with previous years.

Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.

Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics

For women aged 41-43 years old, success rates in IVF are generally poor. This study aimed to assess cumulative live birth rate related to treatment costs over a maximum of three IVF cycles in selected women who were considered to still have adequate ovarian reserve. Fifty-five patients (38% of the total cohort, n = 144) were excluded from IVF treatment based on low antral follicle count (<5 follicles) and/or elevated basal FSH (>15 IU/l). Of those admitted, 66 (74%) actually started and completed a total of 125 IVF/intracytoplasmic sperm injection cycles. Treatment resulted in 10 live births (8% per cycle). Kaplan-Meier survival analysis revealed a realistic cumulative live birth rate after three cycles of 17%. The direct medical costs per live birth were calculated to be approximately 44,000 euro. These results show that selection towards favourable ovarian reserve status in the female age group 41-43 years yielded disappointing results in terms of cumulative live birth rates after IVF. In view of the costs raised per live birth, improvement of selection parameters for treatment in this age group is warranted.

Incidence and complications of multiple gestation in Canada: proceedings of an expert meeting

This paper reports the proceedings of a consensus meeting on the incidence and complications of multiple gestation in Canada. In addition to background presentations about current and possible future practice in Canada, the expert panel also developed a set of consensus points. The need for infertility to be understood, and funded, as a healthcare problem was emphasized, along with recognition of the emotional impact of infertility. It was agreed that the goal of assisted reproduction treatment is the delivery of a single healthy infant and that even though many positive outcomes have resulted from twin or even triplet pregnancies, the potential risks associated with multiple pregnancy require that every effort be made to achieve this goal. The evidence shows that treatments other than IVF (such as superovulation and clomiphene citrate) contribute significantly to the incidence of multiple pregnancy. There is an urgent need for studies to understand better the usage and application of these other fertility technologies within Canada, as well as the non-financial barriers to treatment. The final consensus of the expert panel was that with adequate funding and good access to treatment, it will be possible to achieve the goal of reducing IVF-related multiple pregnancy rates in Canada by 50%.