How to avoid multiple pregnancies in assistive reproductive technologies

The use of a prostacyclin analog, iloprost, as an adjunct to uterus preservation with histidine-tryptophan-ketoglutarate solution

INTRODUCTION

Although assisted reproductive techniques have made most causes of both male and female infertility treatable, uterine factor infertility is not able to therapy. Therefore, transplantation of the uterus has been suggested as a future possible cure. Organ preservation solutions seek to reduce reperfusion injury. Since iloprost is an antioxidant with cytoprotective properties, we investigated its potential positive effects in histidine-tryptophan-ketoglutarate (HTK) solution after 4 or 24 h cold storage period of the rat uterus.

METHODS

We divided 24 female Wistar-albino rats into four groups: Group 1 had the uterus tissue stored in HTK solution at 4 °C for 4h. Group 2, the tissue was stored in HTK solution combined with iloprost (10(-8) M) for 4h at 4 °C. The same procedures were repeated for 24 h for Groups 3 and 4 respectively. Tissue levels of malondialdehyde (MDA) and nitric oxide (NO), as indicators of oxidative stress were determined with histopathological evaluations.

RESULTS

MDA and NO levels were compared between the group 1 vs 3; and 2 vs 4. No significant difference was observed between the groups. Cold storage for 24 h produced alterations in histological appearances that were mitigated by the addition of iloprost to HTK solution.

CONCLUSION

In conclusion, addition of iloprost to HTK solution reversed the histological alterations after 24h-cold storage of the rat uterus.

The application and impact of cryopreservation of early cleavage stage embryos in assisted reproduction

The contribution of cryopreserved embryos to the overall outcomes achieved by a clinical assisted reproduction programme has increased in importance with the trend towards reducing the numbers of fresh embryos transferred following in vitro fertilisation. Although cryopreservation appears to fully preserve developmental potential in early cleavage stage embryos that survive intact, it results in a reduction in potential when blastomere loss occurs during freezing and thawing. Overall, it can be estimated that cryopreservation results in approximately a 30% reduction in the potential for pregnancy in a population of embryos. Both blastomere survival and post-thaw resumption of mitosis can act as markers of implantation potential in frozen/thawed embryos. Application of strict criteria for freezing embryos and transferring thawed embryos may enhance apparent success rates, but may also result in some pregnancy potential being discarded. The role of embryo cryopreservation in minimising the incidence of multiple pregnancy must be balanced with the need for efficiency in the quest to establish pregnancy.

Preimplantation genetic diagnosis of skin fragility-ectodermal dysplasia syndrome

Skin fragility-ectodermal dysplasia syndrome is an autosomal recessive disorder caused by loss-of-function mutations in the desmosomal protein, plakophilin 1. Clinically, there may be considerable morbidity from extensive skin erosions and painful fissures on the palms and soles. In the absence of any specific treatment, prenatal diagnosis is an option for couples at reproductive risk of recurrence. In 2000, we developed and applied a single cell nested polymerase chain reaction protocol to test one couple for compound heterozygous plakophilin 1 gene mutations by preimplantation genetic diagnosis (PGD). Although pregnancy was established, an unrelated trisomy 22 led to a spontaneous abortion. However, eight embryos of known genetic status were cryopreserved at that stage, and we planned to undertake subsequent frozen embryo replacement cycles that might lead to the birth of an unaffected child in this family. Embryo cryopreservation was carried out in June 2000 using standard protocols in a three-step freezing procedure. Four embryos were thawed in March 2003, one of which was viable and was used in a frozen embryo replacement cycle, but pregnancy did not occur. The remaining four embryos were thawed in February 2004, two of which were viable (both carriers of the paternal mutation) and these were used in a second frozen embryo replacement cycle, and a singleton pregnancy was established. The child's plakophilin 1 genotype was assessed by direct nucleotide sequencing across the site of both potential mutations. Following two frozen embryo replacement cycles, and almost 4 years after the initial embryo biopsy and mutation analysis, a pregnancy was achieved that progressed to term with the birth of a healthy baby girl. Nucleotide sequencing of cord blood DNA, taken immediately after delivery, showed that the child was a heterozygous carrier of the paternal mutation but not of the maternal mutation. This case demonstrates the value of embryo cryopreservation, which can increase the number of embryo replacement procedures and hence the cumulative pregnancy rate per retrieval cycle. Moreover, this is the first report of successful full-term pregnancy and birth of a healthy baby following exclusion of a severe genodermatosis by PGD. The successful outcome of PGD in this case illustrates what is technically possible for couples at risk of recurrence of a severe inherited skin disease.

Prevention of triplets and higher order multiples: trends in reproductive medicine

In the United States and throughout the world, today's healthcare providers are challenged by the risks of multiple gestation pregnancy. Assisted reproductive technologies (ARTs) often used to treat infertility raise ethical issues including informed consent, veracity, and nonmalificence. In the United States, there is the need to improve maternal and fetal/neonatal mortality and morbidity by proposing legislation regulating ART and supporting single embryo transfers with no more than 2 such transfers. Beginning with the diagnosis of infertility, providers have a responsibility to educate, inform, and treat infertile couples. From the moment pregnancy with multiples is confirmed, these families are faced with incredible stressors including decision making on multifetal or selective reduction. Full disclosure of risks involved throughout the course of care should be discussed and documented in the record and plan of care. Currently in the United States, legislation does not regulate ART, including ovulation induction/enhancement and in vitro fertilization. Although the United States does have self-regulation via limited reporting through their professional organization and the Centers for Disease Control and Prevention, an unlimited number of embryos may be transferred. Unfortunately, many healthcare providers have not recognized the responsibility and burden placed on families and society as a whole. Lack of regulation means women may become pregnant with high order multiples, which raises serious moral and ethical issues.

Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.

Outcome of assisted reproductive technologies after different embryo transfer strategies

The outcomes of 1028 assisted reproductive technology cycles were studied retrospectively, considering two different periods of embryo transfer. In the first period, 262 cycles in women < 36 years old were studied, in which three embryos were transferred, followed by 157 cycles in women > or = 36 years, in which four embryos were transferred. In the second period, 332 cycles were evaluated in women < 36 years and 277 cycles in women > or = 36 years old, reducing the number of embryos transferred to two and three respectively. Embryos were only scored morphologically, and the best embryos were chosen for transfer. In the first period, in women < 36 years old, a clinical pregnancy rate of 55.7% was achieved, compared with 42.5% in the second period (P < 0.01). In women > or = 36 years old, the first period of embryo transfer showed a clinical pregnancy rate of 39.5%, compared with 28.5% in the second period (P < 0.01). The number of twin pregnancies in the three groups of patients in whom one to four embryos were transferred was not significantly different (24.2, 28.4, 24.8%). It is concluded that even with the biases induced by a retrospective study, the reduction in the number of embryos transferred, from three to two in women < 36 years of age, and from four to three in women > or = 36 years of age, without any selection other than pre-transfer morphological score, adversely affects the outcome of treatment, without a significant reduction in twin gestation rate. Other strategies are to be implemented in gametes and embryo selection, and patients must be aware that, even with a reduction in pregnancy rate, the goal is to achieve a high cumulative pregnancy rate, reducing the complications induced by multiple pregnancies.

Do multiple gestations raise the risk of cerebral palsy?

There is an increased risk of CP in multiple as compared with singleton pregnancies, and the higher the number of fetuses the greater is the prevalence of CP. Although LBW and preterm birth are the most significant risk factors for CP, the disadvantage of twins is apparent near term. Moreover, the excessive risk is not only the result of over-representation of multiples among premature babies, but seems to be associated with circumstances that are unique to the twinning process. The risk of CP should be acknowledged not only when a multiple pregnancy is diagnosed, but also when counseling infertility patients in whom iatrogenic multiple pregnancies are an actual risk.

Survival and developmental potential of stored human early cleavage stage embryos

Human early cleavage stage embryos which survive cryopreservation and thawing fully intact demonstrate similar developmental potential to equivalent non frozen embryos when returned to the in vivo environment, whereas blastomere loss is directly related to the loss of potential for subsequent implantation in thawed embryos. This suggests that blastomere lysis during freezing and thawing does not occur preferentially in non viable blastomeres. Prefreeze growth rate rather than prefreeze blastomere number per se correlates with the developmental potential of stored embryos. When blastomere loss occurs as a consequence of cryopreservation, development of thawed early cleavage stage embryos to the blastocyst stage in vitro is impaired and the resultant blastocysts have a reduced total cell content. Blastomere loss is more prevalent in embryos which have been biopsied for preimplantation genetic diagnosis but this increased sensitivity can be circumvented by modification of the standard cryopreservation protocol.

Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial

OBJECTIVE

To compare the effectiveness of an electrocautery strategy with ovulation induction using recombinant follicle stimulating hormone in patients with polycystic ovary syndrome.

DESIGN

Randomised controlled trial.

SETTING

Secondary and tertiary hospitals in the Netherlands.

PARTICIPANTS

168 patients with clomiphene citrate resistant polycystic ovary syndrome: 83 were allocated electrocautery and 85 were allocated recombinant follicle stimulating hormone.

INTERVENTION

Laparoscopic electrocautery of the ovaries followed by clomiphene citrate and recombinant follicle stimulating hormone if anovulation persisted, or induction of ovulation with recombinant follicle stimulating hormone.

MAIN OUTCOME MEASURE

Ongoing pregnancy within 12 months.

RESULTS

. The cumulative rate of ongoing pregnancy after recombinant follicle stimulating hormone was 67%. With only electrocautery it was 34%, which increased to 49% after clomiphene citrate was given. Subsequent recombinant follicle stimulating hormone increased the rate to 67% at 12 months (rate ratio 1.01, 95% confidence interval 0.81 to 1.24). No complications occurred from electrocautery with or without clomiphene citrate. Patients allocated to electrocautery had a significantly lower risk of multiple pregnancy (0.11, 0.01 to 0.86).

CONCLUSION

The ongoing pregnancy rate from ovulation induction with laparoscopic electrocautery followed by clomiphene citrate and recombinant follicle stimulating hormone if anovulation persisted, or recombinant follicle stimulating hormone, seems equivalent to ovulation induction with recombinant follicle stimulating hormone, but the former procedure carries a lower risk of multiple pregnancy.

Role of fertility treatments in multiple pregnancy at National Women's Hospital from 1996 to 2001

OBJECTIVE

To determine the influence of fertility treatments on multiple pregnancy rates.

STUDY DESIGN

A retrospective audit of women with multiple pregnancies from 1996 to 2001 at National Women's Hospital (NWH), Auckland, New Zealand was conducted. Information was collected regarding the demographics, fertility treatment, outcome of the pregnancy and complications experienced by women discharged with multiple births as an discharge diagnosis.

RESULTS

For the years 1996-2001 there were 1136 multiple births at NWH. Of these births, 201 (18%) were conceived following fertility treatment. Seventeen percent of twin births and 44% of triplet births were conceived following fertility treatment. There was a statistically significant increase in the number of births conceived following fertility treatment, from 9%, in 1996 to 24%, in 2001, although the proportion of births that were multiple overall did not change (20% in 1996 and 2.3%, in 2001). Sixty-three percent of all fertility conceived multiple births were following in vitro fertilization/intracytoplasmic sperm injection treatment. Sixty percent of these women had two embryos transferred and 31% had three embryos transferred. Ovulation induction with follicle-stimulating hormone accounted for 19% of all fertility conceived multiple births. Nineteen percent of fertility conceived multiple births followed clomiphene treatment alone.

CONCLUSIONS

The proportion of multiple pregnancies as a result of fertility treatments has increased over the 6 years studied.