Increased frequency of severe major anomalies in children conceived by intracytoplasmic sperm injection

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.

Comprehensive meta-analysis reveals association between multiple imprinting disorders and conception by assisted reproductive technology

PURPOSE

To determine whether a history of conception by assisted reproductive technology (ART) is associated with occurrence of one or more imprinting disorders of either maternal or paternal origin.

METHODS

We implemented a systematic review of scholarly literature followed by comprehensive meta-analysis to quantitatively synthesize data from reports relating to use of ART to occurrence of any imprinting disorder of humans, including Beckwith-Wiedemann (BWS), Angelman (AS), Prader-Willi (PWS), and Silver-Russell (SRS) syndromes, as well as transient neonatal diabetes mellitus (TNDB) and sporadic retinoblasoma (RB).

RESULTS

The systematic review identified 13 reports presenting unique data from 23 studies that related conception following ART to occurrence of imprinting disorders. Multiple studies of four disorder were identified, for which meta-analysis yielded the following summary estimates of associations with a history of ART: AS, summary odds ratio (sOR) = 4.7 (95% confidence interval (CI) 2.6-8.5, 4 studies); BWS, sOR = 5.8 (95% CI 3.1-11.1, 8 studies); PWS, sOR = 2.2 (95% CI 1.6-3.0, 6 studies); SRS, sOR = 11.3 (95% CI 4.5-28.5, 3 studies). Only one study reported on each of TNDB and RB.

CONCLUSION

Published data reveal positive associations between history of ART conception and each of four imprinting disorders. Reasons for these associations warrant further investigation.

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.

A congenital cranial dysinnervation disorder: Möbius' syndrome

Möbius' syndrome, also known as Möbius' sequence, is a nonprogressive cranial dysinnervation disorder characterized by congenital facial and abducens nerve paralysis. Here, we report a 5-day-old girl who was conceived after in vitro fertilization with poor suck and facial paralysis. She had bilaterally ptosis and lateral gaze limitation, left-sided deviation of the tongue, dysmorphic face, hypoplastic fingers and finger nails on the left hand, and was diagnosed as having Möbius' syndrome. Involvement of other cranial nerves such as three, four, five, nine, 9 and 12, and limb malformations may accompany this syndrome. However, several factors have been proposed for the etiology, some rare cases have also been reported with artificial reproductive technologies. Feeding difficulties and aspiration are the main problems encountered in infancy. The other cranial nerves should be examined further in newborns who present with congenital facial palsy, and other cranial dysinnervation disorders should be considered in the differential diagnosis.

The influence of semen quality on male pronucleus demethylation process during ICSI cycle

There is growing evidence that the spermatozoon's epigenetic structure is of the utmost importance in the health of the future embryo. Following fertilization, sperm chromatin undergoes epigenetic reprogramming including DNA demethylation and remethylation, which resets gene expression. In some infertile patients, it is inevitable that sperm cells that are not within the range of normal human sperm parameters will be used for intracytoplasmic sperm injection. Understanding the relationship between the human sperm parameters and male pronucleus DNA demethylation seems necessary. We hypothesized that demethylation of the male pronucleus might be altered in zygotes conceived from a spermatozoa obtained from a sample exhibiting an abnormal semen analysis profile. To test the hypothesis, sperm cells from normal and abnormal human semen samples were injected into mouse oocytes. A group of cultured zygotes was fixed before the onset of DNA demethylation and the other group was fixed after DNA demethylation. Both groups were then labeled with a 5 methylcytosine antibody and the level of pronuclei methylation was detected as a function of fluorescent intensity. The level of demethylation was then determined as the difference between 5 methylcytosine fluorescent intensity before and after DNA demethylation. A negative correlation (p<0.05) was observed between sperm motility, morphology, percentage of head defects, protamine deficiency, and DNA demethylation level. However, no correlation was found between the demethylation level and sperm count. In conclusion, these observations suggest that demethylation is altered in the male pronucleus when low quality sperm samples are used.

Are children born after assisted reproductive technology at increased risk of autism spectrum disorders? A systematic review

STUDY QUESTION

Are children born after assisted reproductive technology (ART) at increased risk of autism spectrum disorders (ASD)?

SUMMARY ANSWER

There is no evidence that ART significantly increases the risk of ASD in the offspring.

WHAT IS KNOWN ALREADY

A few systematic reviews have explored the correlation between assisted conception and ASD with inconclusive results, partly due to the heterogeneity of diagnostic criteria and methodology in the different studies.

STUDY DESIGN, SIZE, DURATION

Systematic review of 7 observational studies (2 cohort and 5 case-control) encompassing 9216 subjects diagnosed with ASD published since 2000.

MATERIALS, SETTING, METHODS

Literature searches were conducted to retrieve observational studies on the risk of ASD in ART population. Databases searched included PubMed, EMBASE and PsycINFO. In order to obtain more consistent results, we only included the studies in which (i) subjects with either infantile autism or ASD could be identified according to international classification systems and (ii) the diagnosis was obtained from hospital records. Seven studies matched the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

Four out of seven studies, including the two with the best quality scores, did not show an association between ART and ASD. The two papers supporting an increased risk of autism following ART had the lowest quality scores, due to major methodological limitations. Only one paper showed a protective role of ART.

LIMITATIONS, REASONS FOR CAUTION

In spite of the strict inclusion criteria applied as to the diagnosis of ASD, the papers selected are heterogeneous in many aspects including study design, definitions of ART, data source and analysed confounders.

WIDER IMPLICATIONS OF THE FINDINGS

At present, there is no evidence that ART is significantly associated with ASD and hence that current health policies should be modified. The divergent results of some of the studies suggest that further prospective, large and high-quality studies are still needed.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported, in part, by the Italian Ministry of Health and by Tuscany Region. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Assisted reproduction and child neurodevelopmental outcomes: a systematic review

OBJECTIVE

To systematically review the existing literature on neurodevelopmental outcomes in children born after medically assisted reproduction compared with those of children born after spontaneous conception.

DESIGN

Systematic review.

SETTING

Not applicable.

PATIENT(S)

Children born after medically assisted reproduction vs. reference groups of spontaneously conceived children.

INTERVENTION(S)

Data were reviewed from worldwide published articles, without restrictions as to publication year or language. A total of 80 studies included between 31 and 2,446,044 children.

MAIN OUTCOME MEASURE(S)

Child neurodevelopmental outcomes categorized as cognitive, behavioral, emotional or psychomotor development, or diagnoses of mental disorders.

RESULT(S)

For infants, studies on psychomotor development showed no deficits, but few investigated cognitive or behavioral development. Studies on toddlers generally reported normal cognitive, behavioral, socio-emotional, and psychomotor development. For children in middle childhood, development seems comparable in children born after assisted reproduction and controls, although fewer studies have been conducted with follow-up to this age. Very few studies have assessed neurodevelopmental outcomes among teens, and the results are inconclusive. Studies investigating the risk of diagnoses of mental disorders are generally large, with long follow-up, but the results are inconsistent.

CONCLUSION(S)

It may tentatively be concluded that the neurodevelopment of children born after fertility treatment is overall comparable to that in children born after spontaneous conception.

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.

Defects in imprinting and genome-wide DNA methylation are not common in the in vitro fertilization population

OBJECTIVE

To examine an IVF cohort for imprinted and genome-wide DNA methylation abnormalities.

DESIGN

Retrospective study.

SETTING

Research laboratory.

PATIENT(S)

DNA samples from a previously described IVF cohort that comprised 66 IVF-conceived prepubertal children (IVF, n = 34; intracytoplasmic sperm injection, n = 32) and 69 matched naturally conceived controls.

INTERVENTION(S)

DNA methylation was examined at four imprinted gene loci (H19, SNRPN, KCNQ1OT1, and IGF2) and satellite 2 using methylation-sensitive quantitative polymerase chain reaction (MSQ-PCR) followed by bisulfite sequencing at H19, SNRPN, and KCNQ1OT1. Methylated DNA immunoprecipitation (MeDIP) microarray with validation using the Sequenom MassARRAY EpiTYPER(®) platform was also used.

MAIN OUTCOME MEASURE(S)

Percentage of DNA methylation by MSQ-PCR, differential methylation based on microarray signal intensity, and percentage DNA methylation as determined by Sequenom MassARRAY EpiTYPER were compared.

RESULT(S)

No differences in percentage of methylation between the IVF and control group were observed at H19, KCNQ1OT1, SNRPN, or IGF2. Absence of aberrant imprinting was confirmed using bisulfite sequencing. Methylation of satellite 2 repeats (a surrogate for global methylation) showed no difference between the IVF and control groups. MeDIP was used to screen for differences in promoter methylation. Subsequent quantification of methylation of eight candidate genes using the Sequenom MassARRAY EpiTYPER system did not reveal any differential methylation.

CONCLUSION(S)

Low-level imprinting errors are not common in the IVF population.

New insights into epididymal biology and function

BACKGROUND

The epididymis performs an important role in the maturation of spermatozoa including their acquisition of progressive motility and fertilizing ability. However, the molecular mechanisms that govern these maturational events are still poorly defined. This review focuses on recent progress in our understanding of epididymal function including its development, role of the luminal microenvironment in sperm maturation, regulation and novel mechanisms the epididymis utilizes to carry out some of its functions.

METHODS

A systematic search of Pubmed was carried out using the search term 'epididymis'. Articles that were published in the English language until the end of August 2008 and that focused on the specific topics described above were included. Additional papers cited in the primary reference were also included.

RESULTS

While the majority of these findings were the result of studies in animal models, recent studies in the human epididymis are also presented including gene profiling studies to examine regionalized expression in normal epididymides as well as in those from vasectomized patients.

CONCLUSIONS

Significant progress has been made in our understanding of epididymal function providing new insights that ultimately could improve human health. The data also indicate that the human epididymis plays an important role in sperm maturation but has unique properties compared with animal models.

Prospective evaluation of the threat related to the use of seminal fractions from hepatitis C virus-infected men in assisted reproductive techniques

BACKGROUND

The risk of hepatitis C virus (HCV) transmission during assisted reproductive techniques (ARTs) is still disputed and no report concerning its prospective evaluation is available.

METHODS

The aim of this 4-year follow-up multicentre study that enrolled 86 HCV-serodiscordant couples was to determine whether a sperm-processing method was able to reduce levels of HCV in semen and the risk of HCV transmission to the newborn. All the men were chronically infected by HCV and 10 of them by human immunodeficiency virus. A total of 181 seminal plasmas and 153 sperm fractions were tested for the presence of HCV RNA.

RESULTS

HCV RNA tested positive in 20.4% of the seminal samples. All of the 153 final sperm fractions tested negative for HCV. The detection of HCV RNA in semen was significantly correlated with a high viral load in blood (P < 0.05). The presence of HCV RNA in seminal plasma impaired neither semen parameters nor ART issue. From the 58 couples enrolled effectively in an ART programme, 24 pregnancies and 28 newborns were obtained. All of them tested negative for HCV RNA in blood.

CONCLUSION

These results emphasize the safety of the semen-processing method. The negligible risk of transmitting HCV reduces the value of the systematic analysis of HCV RNA in seminal fractions prior to ART. Since use of this analytical procedure involves the freezing of semen, its avoidance would result in an increase in sperm quality and reduce the need to perform intracytoplasmic sperm injection techniques.