ACOG Committee opinion no. 553: multifetal pregnancy reduction

Impact of comprehensive state insurance mandates on in vitro fertilization utilization, embryo transfer practices, and outcomes in the United States

BACKGROUND

Previous studies have demonstrated that state mandated coverage of in vitro fertilization may be associated with increased utilization, fewer embryos per transfer, and lower multiple birth rates, but also lower overall live birth rates. Given new legislation and the delay between enactment and effect, a revisit of this analysis is warranted.

OBJECTIVE

This study aimed to characterize the current impact of comprehensive state in vitro fertilization insurance mandates on in vitro fertilization utilization, live birth rates, multiple birth rates, and embryo transfer practices.

STUDY DESIGN

We conducted a retrospective cohort study of in vitro fertilization cycles reported by the 2018 Centers for Disease Control and Prevention Assisted Reproductive Technology Fertility Clinic Success Rates Report in the United States. In vitro fertilization cycles were stratified according to state mandate as follows: comprehensive (providing coverage for in vitro fertilization with minimal restrictions) and noncomprehensive. The United States census estimates for 2018 were used to calculate the number of reproductive-aged women in each state. Outcomes of interest (stratified by state mandate status) included utilization rate of in vitro fertilization per 1000 women aged 25 to 44 years, live birth rate, multiple birth rate, number of embryo transfer procedures (overall and subdivided by fresh vs frozen cycles), and percentage of transfers performed with frozen embryos. Additional subanalyzes were performed with stratification of outcomes by patient age group.

RESULTS

In 2018, 134,997 in vitro fertilization cycles from 456 clinics were reported. Six states had comprehensive mandates; 32,029 and 102,968 cycles were performed in states with and without comprehensive in vitro fertilization mandates, respectively. In vitro fertilization utilization in states with comprehensive mandates was 132% higher than in noncomprehensive states after age adjustment; increased utilization was observed regardless of age stratification. Live birth rate per cycle was significantly higher in states with comprehensive mandates (35.4% vs 33.4%; P<.001), especially among older age groups. Multiple birth rate as a percentage of all births was significantly lower in states with comprehensive mandates (10.2% vs 13.8%; P<.001), especially among younger patients. Mean number of embryos per transfer was significantly lower in states with comprehensive mandates (1.30 vs 1.36; P<.001). Significantly fewer frozen transfers were performed as a percentage of all embryo transfers in states with comprehensive mandates (66.1% vs 76.3%; P<.001). Among fresh embryo transfers, significantly fewer embryos were transferred in comprehensive states among all patients (1.55 vs 1.67; P<.001).

CONCLUSION

Comprehensive state mandated insurance coverage for in vitro fertilization services is associated with greater utilization of these services, fewer embryos per transfer, fewer frozen embryo transfers, lower multiple birth rates, and higher live birth rates. These findings have important public health implications for reproductive-aged individuals in the United States and present notable opportunities for research on access to fertility care.

Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies

Twin pregnancies account for about 3.3% of all deliveries in the United States with the majority of them being dichorionic diamniotic (DCDA). Maternal physiological adaption in twin pregnancies is exaggerated and the rate of almost every maternal and fetal complication is higher when compared to singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers who are familiar with the specific challenges unique to these pregnancies, and there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation as it is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and to tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, as well as on close maternal and fetal monitoring. In this review, we summarize available evidence and current guidelines regarding antenatal care in DCDA twin pregnancies.

Pregnancy outcome following fetal reduction from dichorionic twins to singleton gestation

BACKGROUND

There are still some controversies regarding the risks and benefits of fetal reduction from twins to singletons. We aimed to evaluate if fetal reduction from twins to singleton improves pregnancy outcome.

METHODS

Retrospective analysis of all dichorionic-diamniotic twin pregnancies, who underwent fetal reduction. Pregnancy outcome was compared to ongoing, non-reduced, dichorionic-diamniotic gestations. Primary outcome was preterm birth prior to 37 gestational weeks. Secondary outcomes included: preterm birth prior to 34 gestational weeks, gestational age at delivery, birthweight, small for gestational age, hypertensive disorders, gestational diabetes and stillbirth.

RESULTS

Ninety-eight reduced pregnancies were compared with 222 ongoing twins. Preterm birth < 37 gestational weeks (39.6% vs. 57.6%, p < 0.001) was significantly lower in the reduced group compared to the ongoing twins' group. A multivariate analysis, controlling for parity and mode of conception, demonstrated that fetal reduction independently and significantly reduced the risk for prematurity (aOR 0.495, 95% CI -0.299-0.819). Subgroup analysis, similarly adjusted demonstrated lower rates of preterm delivery in those undergoing elective reduction (aOR = 0.206, 95% CI 0.065-0.651), reduction due to fetal anomalies (aOR = 0.522, 95% CI 0.295-0.926) and 1st trimester reduction (aOR = 0.297, 95% Cl 0.131-0.674) all compared to ongoing twins. A Kaplan-Meier survival curve showed a significant proportion of non-delivered women at each gestational week in the reduced group compared to non-reduced twins, after 29 gestational weeks.

CONCLUSIONS

Fetal reduction from twins to singleton reduces the risk of preterm birth < 37 gestational weeks, but not for more severe maternal and perinatal complications.

Learning to play God: a call for training OB-GYN residents in reproductive ethics

In this unique time of technological advancement in medicine and the culture of public discourse that surrounds it, trainees in obstetrics and gynecology require more intensive education in medical ethics to appropriately guide patient decision-making and to become more responsible voices in such an ethically complex field.

Care plans for women pregnant using assisted reproductive technologies: a systematic review

Background

Between 1 and 5% of children in industrialized countries are conceived through Assisted Reproductive Technologies (ART). As infertility and the use of ART may be associated with adverse perinatal outcomes, care plans specific to these pregnancies are needed. We conducted a systematic review to examine the existing care plans specific to women pregnant following Assisted Reproductive Technologies (ART).

Methods

MEDLINE, Embase and the Cochrane Library were searched by a senior information specialist. The population of interest included women becoming pregnant with ART (e.g., Intra-Uterine Insemination, In Vitro Fertilization (IVF), Intracytoplasmic Sperm Injection (ICSI), and surrogacy). All proposed care plans were sought that pertained to any aspect of care during pregnancy and delivery. Only Clinical Practice Guidelines (CPGs) addressing the recommendations and plans for the care of ART pregnant women were included. The search was restricted to the publication dates 2007 to June 12, 2017 when the search was run. The search was not restricted by language, however only English and French language guidelines were considered for inclusion.

Results

After screening 2078 citations, a total of ten CPGs were included. The following key clinical messages were prevalent: (1) although there was no supporting evidence, antenatal care for ART pregnancies should be provided by specialist with knowledge in obstetrics; (2) high-order multiple pregnancies are the greatest risk of ART and selective reduction options should be discussed; (3) there is some evidence of increased risk of congenital abnormalities and prenatal genetic and anatomic screening is recommended, especially in IVF-ICSI pregnancies; (4) due to a lack of or conflicting evidence, treatment of venous thromboembolism, antithrombotic therapy, treatment for hypothyroidism, and women with positive thyroid antibodies is recommended to be the same as in spontaneous pregnancies; and lastly (5) since an increased level of distress is a recognized feature in these pregnancies, psychosocial care and counselling should be considered.

Conclusions

There is a lack of CPGs specific to ART pregnancies. While we identified a small number of recommendations for ART pregnancies, specific interventions and models of care aiming at decreasing adverse maternal and perinatal outcomes following ART should be developed, implemented, and evaluated.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0667-z) contains supplementary material, which is available to authorized users.

Ethical considerations in the care of complicated twin pregnancies

Twin gestations are increasing in prevalence worldwide, and are potentially subject to medical complications which present uniquely complex ethical and psychosocial challenges for the pregnant patient and obstetrician to navigate. In this article, we explore these issues as they relate to medical decision-making in cases of discordant growth and discordant anomalies in both monochorionic and dichorionic twin pregnancies, including those affected by twin-twin transfusion syndrome, with particular attention to scenarios in which the individual fetuses hold competing interests. For each of these scenarios, we consider how decisions may positively or negatively impact one or both fetuses, and how familiarity with population outcomes, as well as sensitivity to the complex psychosocial circumstances surrounding these pregnancies, can support and inform shared decision-making.

Outcomes of Triplets reduced to Twins versus non-reduced Triplet Pregnancies

INTRODUCTION

This study examined the outcomes of triplet pregnancies selectively reduced to twin pregnancies, compared with non-reduced triplet pregnancies using a standardized approach.

MATERIAL AND METHODS

This study is an observational retrospective study of all women who presented to the Fetal Diagnostic Center between 1999-2009, had triplet pregnancies in the first trimester, received prenatal care and delivered at Abington Memorial Hospital. Data analysis was performed with SPPS version 15 for Windows using analysis of variance and Fisher's Exact test.

RESULTS

132 triplet pregnancies were identified. In the reduced group (n = 30) compared to the non-reduced triplet group (n = 102) average gestational age of delivery was longer 34.6 weeks versus 31.2 weeks gestation (P = <0.0005) and days in hospital were less 9.0 versus 26.7 days (P = .001). There was a significantly lower incidence of gestational diabetes and preterm labor in reduced pregnancies. Rate of loss, defined as delivery less than 24 weeks, were similar [3.3% versus 4.9%].

DISCUSSION

Women electing to reduce a triplet pregnancy to twins have higher gestational ages at delivery, lower rates of gestational diabetes and preterm labor, and spent fewer days in hospital than non-reduced triplet pregnancies.

Prepregnancy obesity and breastfeeding noninitiation in the United States: an examination of racial and ethnic differences

BACKGROUND

Prepregnancy overweight/obesity can adversely affect breastfeeding initiation, but studies examining this association among different racial/ethnic groups of U.S. women are limited. This study used a large, nationally representative sample to assess racial/ethnic differences in breastfeeding noninitiation among U.S. women of different body mass index (BMI) classifications.

MATERIALS AND METHODS

This study analyzed data from the Pregnancy Risk Assessment Monitoring System, including 95,141 women who delivered a live, singleton baby from 2009 to 2011 and provided BMI and breastfeeding information. Prepregnancy BMI was categorized as underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (≥30.0 kg/m(2)). Breastfeeding initiation was reported as having ever breastfed after delivery (yes or no). Adjusted models, which included only potential confounders resulting in a 10% or greater change in estimate, generated adjusted odds ratios (AOR) and 95% confidence intervals (CI) for breastfeeding noninitiation. Analysis was stratified by race/ethnicity.

RESULTS

Compared with normal weight non-Hispanic white women, the odds of breastfeeding noninitiation were 17% and 25% higher among overweight (AOR=1.17, 95% CI=1.07-1.29) and obese (AOR=1.25, 95% CI=1.14-1.36) non-Hispanic white women, respectively. Among non-Hispanic black women, the odds of breastfeeding noninitiation were 29% higher only in obese women compared with normal weight non-Hispanic black women. No association was observed among Hispanic women or women of other races.

CONCLUSIONS

Prepregnancy BMI is a significant predictor for breastfeeding noninitiation for non-Hispanic white and non-Hispanic black women. Further exploration of the differences underlying the association between prepregnancy BMI and breastfeeding behaviors among racial subpopulations of women in the United States is warranted.