Assisted reproductive technology (ART) and epigenetic modifications in the placenta

Assisted reproductive technology (ART) has become common amongst couples with infertility issues. ART is known to be successful, but epidemiological data indicates that ART is associated with placental disorders. Additionally, reports show increased risks of short- and long-term complications in children born to mothers undergoing ART. However, the mechanisms responsible for these events are obscure. The placenta is considered as a key organ for programming of diseases and ART procedures are suggested to alter the placental function and intrauterine growth trajectories. Epigenetic changes in maternal and foetal tissues are suggested to be the underlying mechanisms for these outcomes. Epigenetic regulation is known to evolve following fertilisation and before implantation and subsequently across gestation. During these critical periods of epigenetic 'programming', DNA methylation and chromatin remodelling influence the placental structure and function by regulating the expression of various genes. ART treatment coinciding with epigenetic 'programming' events during gametogenesis and early embryo development may alter the programming phases leading to long-term consequences. Thus, disruptions in placental development observed in ART pregnancies could be associated with altered epigenetic regulation of vital genes in the placenta. The review summarises available literature on the influence of ART procedures on epigenetic changes in the placenta.

The Consequences of Assisted Reproduction Technologies on the Offspring Health Throughout Life: A Placental Contribution

The use of assisted reproductive technologies (ART) worldwide has led to the conception and birth of over eight million babies since being implemented in 1978. ART use is currently on the rise, given growing infertility and the increase in conception age among men and women in industrialized countries. Though obstetric and perinatal outcomes have improved over the years, pregnancies achieved by ART still bear increased risks for the mother and the unborn child. Moreover, given that the first generation of ART offspring is now only reaching their forties, the long-term effects of ART are currently unknown. This is important, as there is a wealth of data showing that life-long health can be predetermined by poor conditions during intrauterine development, including irregularities in the structure and functioning of the placenta. In the current review, we aim to summarize the latest available findings examining the effects of ART on the cardiometabolic, cognitive/neurodevelopmental, and behavioral outcomes in the perinatal period, childhood and adolescence/adulthood; and to examine placental intrinsic factors that may contribute to the developmental outcomes of ART offspring. Altogether, the latest knowledge about life outcomes beyond adolescence for those conceived by ART appears to suggest a better long-term outcome than previously predicted. There are also changes in placenta structure and functional capacity with ART. However, more work in this area is critically required, since the potential consequences of ART may still emerge as the offspring gets older. In addition, knowledge of the placenta may help to foresee and mitigate any adverse outcomes in the offspring.

Predicting singleton antepartum stillbirth by the demographic Fetal Medicine Foundation Risk Calculator-A retrospective case-control study

OBJECTIVE

To assess the risk of singleton intrauterine fetal death (IUFD) in women by the demographic setting of the online Fetal Medicine Foundation (FMF) Stillbirth Risk Calculator.

METHODS

Retrospective single-centre case-control study involving 144 women having suffered IUFD and 247 women after delivery of a live-born singleton. Nonparametric receiver operating characteristics (ROC) analyses were performed to predict the prognostic power of the FMF Stillbirth risk score and to generate a cut-off value to discriminate best between the event of IUFD versus live birth.

RESULTS

Women in the IUFD cohort born a significantly higher overall risk with a median FMF risk score of 0.45% (IQR 0.23-0.99) compared to controls [0.23% (IQR 0.21-0.29); p<0.001]. Demographic factors contributing to an increased risk of IUFD in our cohort were maternal obesity (p = 0.002), smoking (p<0.001), chronic hypertension (p = 0.015), antiphospholipid syndrome (p = 0.017), type 2 diabetes (p<0.001), and insulin requirement (p<0.001). ROC analyses showed an area under the curve (AUC) of 0.72 (95% CI 0.67-0.78; p<0.001) for predicting overall IUFD and an AUC of 0.72 (95% CI 0.64-0.80; p<0.001), respectively, for predicting IUFD excluding congenital malformations. The FMF risk score at a cut-off of 0.34% (OR 6.22; 95% CI 3.91-9.89; p<0.001) yielded an 82% specificity and 58% sensitivity in predicting IUFD with a positive and negative predictive value of 0.94% and 99.84%, respectively.

CONCLUSION

The FMF Stillbirth Risk Calculator based upon maternal demographic and obstetric characteristics only may help identify women at low risk of antepartum stillbirth.

Assisted reproductive technologies and the risk of stillbirth in singleton pregnancies: a systematic review and meta-analysis

OBJECTIVE

To identify the risk of stillbirth from in vitro types of assisted reproductive technologies compared with spontaneous conception (SC), limited to singleton births.

DESIGN

Systematic literature search and search chaining on online databases: PubMed, Embase, and Scopus.

SETTING

Not applicable.

PATIENT(S)

Singleton pregnancies from in vitro fertilization (IVF) or fertilization by IVF and intracytoplasmic sperm injection (IVF-ICSI).

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Adjusted odds ratio for stillbirth or prevalence of stillbirth in case-control groups of IVF/IVF-ICSI singletons and SCs, respectively, in matched studies.

RESULT(S)

A total of 19 studies were included, and study quality was mixed. Ten studies qualified for inclusion to the meta-analysis, which revealed a significantly increased risk of stillbirth in IVF/IVF-ICSI compared with that in SC (odds ratio [95% confidence interval]: 1.82 [1.37-2.42]), and there was no evidence of publication bias.

CONCLUSION(S)

In vitro fertilization and IVF-ICSI treatment increases the risk of stillbirth compared with natural conception.

CLINICAL TRIAL REGISTRATION NUMBER

PROSPERO 216768.

Risk of stillbirth in singleton gestations following in vitro methods of conception: a systematic review and meta-analysis

BACKGROUND

In vitro methods of conception are associated with adverse perinatal outcomes. It is unclear if the risk of stillbirth is increased also.

OBJECTIVE

This systematic review and meta-analysis aimed to estimate the risk of stillbirth in singleton gestations following in vitro methods of conception compared to non-in vitro conceptions.

SEARCH STRATEGY

A comprehensive search in PubMed, Embase, CINAHL, and Cochrane Library was undertaken from database inception to February 2021, with backward citation tracking.

SELECTION CRITERIA

Eligible studies included randomized controlled trials, cohort studies, or case-control studies that assessed stillbirth following in vitro fertilisation and/or intracytoplasmic sperm injection in comparison to non-in vitro methods of conception, including spontaneous conceptions, intrauterine insemination, and ovarian stimulation.

DATA COLLECTION AND ANALYSIS

The Newcastle-Ottawa Scale was used to assess risk of bias. A summary odds ratio (OR) for stillbirth following in vitro methods of conception compared to non-in vitro methods was calculated using a random-effects model for meta-analysis.

MAIN RESULTS

Thirty-three cohort studies met inclusion criteria. There was an increased risk of stillbirth with in vitro methods: OR 1.41 (95% CI 1.20-1.65); however, the crude baseline risk of stillbirth was low (4.44/1000 total births). Subgroup analysis did not demonstrate an increased risk when in vitro methods were compared to conception without in vitro methods in the context of subfertility.

CONCLUSIONS

Compared to non-in vitro conceptions, in vitro conceptions have an increased risk of stillbirth. However, there is insufficient evidence to demonstrate whether this risk is associated with in vitro techniques or underlying subfertility.

TWEETABLE ABSTRACT

This meta-analysis found an increased risk of stillbirth in singletons from in vitro methods of conception.

Risk of gestational diabetes mellitus in women achieving singleton pregnancy spontaneously or after ART: a systematic review and meta-analysis

BACKGROUND

Women who achieve pregnancy by ART show an increased risk of obstetric and perinatal complications compared with those with spontaneous conception (SC).

OBJECTIVE AND RATIONALE

The purpose of this systematic review and meta-analysis was to synthesize the best available evidence regarding the association between ART and gestational diabetes mellitus (GDM) in women with singleton pregnancies. The research question asked was whether the risk of GDM is higher in women achieving singleton pregnancy by ART compared with those achieving singleton pregnancy spontaneously.

SEARCH METHODS

A literature search, in MEDLINE, Scopus and Cochrane databases, covering the period 1978–2019, was performed aiming to identify studies comparing the risk of GDM in singleton pregnancies after ART versus after SC. Both matched and unmatched studies were considered eligible. Meta-analysis of weighted data was performed using the random effects model. Results were reported as risk ratio (RR) with 95% CI. Heterogeneity was quantified with the I² index.

OUTCOMES

The study reports on 63 760 women who achieved a singleton pregnancy after ART (GDM was present in 4776) and 1 870 734 women who achieved a singleton pregnancy spontaneously (GDM in 158 526). Women with singleton pregnancy achieved by ART showed a higher risk of GDM compared with those with singleton pregnancy achieved spontaneously (RR 1.53, 95% CI 1.39–1.69; I² 78.6%, n = 37, 1 893 599 women). The direction or the magnitude of the effect observed did not change in subgroup analysis based on whether the study was matched (n = 17) or unmatched (n = 20) (matched: RR 1.42, 95% CI 1.17–1.72; I² 61.5%—unmatched: RR 1.58, 95% CI 1.40–1.78; I² 84.1%) or whether it was prospective (n = 12) or retrospective (n = 25) (prospective studies: RR 1.52, 95% CI 1.27–1.83, I² 62.2%—retrospective studies: RR 1.53, 95% CI 1.36–1.72, I² 82.5%). Regarding the method of fertilization, a higher risk of GDM after ART versus SC was observed after IVF (n = 7), but not after ICSI (n = 6), (IVF: RR 1.95, 95% CI 1.56–2.44, I² 43.1%—ICSI: RR 1.42, 95% CI 0.94–2.15, I² 73.5%). Moreover, regarding the type of embryo transfer (ET), a higher risk of GDM after ART versus SC was observed after fresh (n = 14) but not after frozen (n = 3) ET (fresh ET: RR 1.38, 95% CI 1.03–1.85, I² 75.4%—frozen ET: RR 0.46, 95% CI 0.10–2.19; I² 73.1%). A higher risk of GDM was observed after ART regardless of whether the eligible studies included patients with polycystic ovary syndrome (RR 1.49, 95% CI 1.33–1.66, I² 75.0%) or not (RR 4.12, 95% CI 2.63–6.45, I² 0%), or whether this information was unclear (RR 1.46, 95% CI 1.22–1.75, I² 77.7%).

WIDER IMPLICATIONS

The present systematic review and meta-analysis, by analysing 1 893 599 women, showed a higher risk of GDM in women achieving singleton pregnancy by ART compared with those achieving singleton pregnancy spontaneously. This finding highlights the importance of early detection of GDM in women treated by ART that could lead to timely and effective interventions, prior to ART as well as during early pregnancy.

Monochorionic twins after in-vitro fertilization: do they have poorer outcomes?

OBJECTIVE

To compare the outcome of monochorionic diamniotic (MCDA) twin pregnancies conceived by in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) with that of spontaneously conceived MCDA twins.

METHODS

This was a retrospective cohort study of MCDA twin pregnancies conceived after IVF/ICSI or spontaneously, followed from the first trimester onwards at a single center between January 2002 and September 2018. The primary outcome was survival per fetus from the first trimester until 28 days after birth. Secondary outcome measures were number of survivors, miscarriage, termination of pregnancy, intrauterine and neonatal death, major congenital anomalies, twin-twin transfusion syndrome, selective fetal growth restriction, gestational age at birth, delivery before 32 weeks' gestation, mode of delivery, admission to the neonatal intensive care unit, birth weight and birth-weight discordance.

RESULTS

Of the 654 MCDA pregnancies included in the analysis, 80 were conceived by IVF/ICSI and 574 spontaneously. Overall fetal and neonatal survival was significantly lower in the IVF/ICSI group than in the spontaneous-conception group (79% vs 90%; P = 0.001). In the IVF/ICSI group, compared with the spontaneous-conception group, loss of one or both twins occurred twice as often (29% vs 14%; P = 0.001) and there was a higher risk of second-trimester miscarriage (8% vs 1%; P = 0.002).

CONCLUSIONS

MCDA twins conceived after IVF/ICSI have lower overall survival rates and higher rates of second-trimester miscarriage than do spontaneously conceived MCDA twins. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Risk of gestational diabetes mellitus following assisted reproductive technology: systematic review and meta-analysis of 59 cohort studies

OBJECTIVE

The use of assisted reproductive technology (ART) has been associated with an increased risk of gestational diabetes mellitus (GDM) in previous studies, but its risk has not been consistent. Therefore, we aimed to estimate the risk of GDM in women who conceived with ART via a systematic review and meta-analysis of cohort studies.

METHODS

ISI Web of Knowledge, Medline/PubMed, Scopus, and Embase databases were searched to identify studies that evaluated the risk of GDM through May 2017 using the relevant keywords. Two reviewers independently performed the screening, data extraction, and quality assessment. Meta-analysis was performed with a random effects model.

RESULTS

The search yielded 957 records relating to GDM and use of ART, from which 59 eligible cohorts were selected for meta-analysis (n = 96,785). There was evidence of substantial heterogeneity among these studies (χ₍₅₈₎² = 3072.34, p < .001; I²=98.1%). The pooled estimate of GDM risk using the random effects model was 9.00% (95% CI: 7.90-10.20). Visual inspection of the funnel plot indicated the presence of low publication bias, but Egger's test did not reveal publication bias.

CONCLUSIONS

The findings revealed that the risk of GDM was very high among women who conceived with ART treatment. GDM screening, management, and improved care are vital in ART pregnancy.

Risk of miscarriage in women conceiving after medically assisted reproduction with an ultrasound-verified viable pregnancy at 6-8 weeks' gestation

RESEARCH QUESTION

What is the risk of miscarriage after a viable fetus verified on ultrasound at 6-8 weeks' gestation among women who conceive with medically assisted reproduction (MAR), stratified by type of fertility treatment?

DESIGN

A nationwide register-based cohort study of women identified in the Danish ART-Registry with a viable singleton pregnancy at 6-8 weeks' gestation between 2007 and 2010 (n = 10,011). Women were identified from The Danish Fetal Medicine Database (DFMD), which holds information on early (between 6-8 and 11-14 weeks) and late (between 11-14 and 22 weeks) miscarriages. The late miscarriage rate was compared with a control group of naturally conceived pregnancies with a viable fetus at 11-14 weeks' gestation from 2008 to 2010, identified in the DFMD (n = 146,932).

RESULTS

In the MAR1 cohort, the overall miscarriage rate was 11.8% (1091/9261) after an ultrasound verified viable pregnancy at 6-8 weeks' gestation. Most miscarriages occurred before the 11-14-week scan (1035/1091 [94.9%]). The early miscarriage rate was slightly higher in women who conceived with frozen embryo transfer compared with intrauterine insemination (IUI), corresponding to an adjusted OR of 1.31 (1.02 to 1.68). We found no significant risk associated with IVF and intracytoplasmic sperm injection compared with IUI pregnancies. The late miscarriage rate was 0.8% in women conceiving with MAR and 0.6% among controls (P = 0.013).

CONCLUSIONS

After adjustment for maternal characteristics, none of the fertility treatment types were associated with an increased risk of miscarriage compared with naturally conceiving women.

First-trimester screening for trisomies by cfDNA testing of maternal blood in singleton and twin pregnancies: factors affecting test failure

OBJECTIVE

To examine factors affecting the rate of failure to obtain a result from cell-free DNA (cfDNA) testing of maternal blood for fetal trisomies 21, 18 and 13 in singleton and twin pregnancies in the first trimester.

METHODS

This was a prospective study of 23 495 singleton and 928 twin pregnancies undergoing screening for fetal trisomy by targeted cfDNA testing at 10 + 0 to 14 + 1 weeks' gestation. Multivariate logistic regression analysis was used to determine significant predictors of failure to obtain a result after first sampling.

RESULTS

There was no result from cfDNA testing after first sampling in 3.4% (798/23 495) of singletons, 11.3% (91/806) of dichorionic twins and 4.9% (6/122) of monochorionic twins. Multivariate logistic regression analysis demonstrated that the risk of test failure, first, increased with increasing maternal age (odds ratio (OR), 1.02; 95% CI, 1.01-1.04) and weight (OR, 1.05; 95% CI, 1.04-1.05), decreasing gestational age (OR, 0.85; 95% CI, 0.79-0.91), serum pregnancy-associated plasma protein-A (PAPP-A) multiples of the median (MoM) (OR, 0.56; 95% CI, 0.49-0.65) and free β-human chorionic gonadotropin (β-hCG) MoM (OR, 0.67; 95% CI, 0.60-0.74), second, was higher in women of black (OR, 1.72; 95% CI, 1.33-2.20) and South Asian (OR, 1.99; 95% CI, 1.56-2.52) than those of white racial origin, in dichorionic twin than in singleton pregnancy (OR, 1.75; 95% CI, 1.34-2.26) and in pregnancies conceived by in-vitro fertilization than in those conceived naturally (OR, 3.82; 95% CI, 3.19-4.55) and, third, was lower in parous than in nulliparous women (OR, 0.63; 95% CI, 0.55-0.74).

CONCLUSIONS

Maternal age, weight, racial origin and parity, gestational age, dichorionicity, method of conception and serum levels of free β-hCG and PAPP-A are independent predictors of cfDNA test failure. The risk of test failure is higher in dichorionic twin than in singleton pregnancies, mainly because a higher proportion of twins are conceived by in-vitro fertilization and more of the women are nulliparous. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Maternal serum anti-Müllerian hormone in Sudanese women with preeclampsia

Objectives

A case–control study was conducted at Omdurman Maternity Tertiary Hospital, Sudan, during the period from May to August 2014 to investigate AMH level in women with preeclampsia compared to healthy controls. The cases were women with preeclampsia and healthy pregnant women were the controls. The obstetrics and medical history was gathered using a questionnaire. AMH level was measured using ELISA.

Results

There was no significant difference between the two groups (40 in each arm of the study) in the age, parity and gestational age. Thirty-three of the 40 cases were patients with severe preeclampsia. There was no significant difference in median inter-quartile of the AMH level between the women with preeclampsia and the controls [0.700 (0.225–1.500) vs. 0.700 (0.400–1.275) ng/ml, P = 0.967]. In a linear regression model there was no association between the log of AMH and age, parity, gestational age, BMI, hemoglobin level and preeclampsia.

Dydrogesterone support following assisted reproductive technique (ART) reduces the risk of pre-eclampsia

BACKGROUND

Pre-eclampsia (PE) contributes to poor maternal morbidity and mortality. Progesterone is hypothesised to reduce the risk of PE.

AIM

To determine the effect of progestogen supplementation during assisted reproductive technique (ART) in reducing the incidence of PE.

METHOD

A retrospective comparative analysis among 1140 pregnancies between January 2006 and March 2015 conducted in a tertiary centre. A total of 570 pregnancies who conceived following ART with progesterone supplementation (study group) and an age-matched spontaneous pregnancies, without progesterone supplementation (control group, n=570) were included in the analysis. The study group received progesterone support following ART or intrauterine insemination (IUI) until 14-16 weeks' gestation.

RESULTS

The rate of PE was significantly lower in the study group compared to control group (8.4% vs. 14.2%, p<0.05). Women supplemented with dydrogesterone only showed a lower PE incidence as compared to women received a combination of dydrogesterone and hydroxyprogesterone caproate, however, it was not statistically significant (6.9% vs. 9.9%; 6.9%; p=0.2).

Prediction of stillbirth from maternal demographic and pregnancy characteristics

OBJECTIVES

To develop a model for prediction of stillbirth based on maternal characteristics and components of medical history and to evaluate the performance of screening with this model for all stillbirths and those due to impaired placentation and to unexplained causes.

METHODS

This was a prospective screening study of 113 415 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation and at 19 + 0 to 24 + 6 weeks. The study population included 113 019 live births and 396 (0.35%) antepartum stillbirths; 230 (58%) were secondary to impaired placentation and 166 (42%) were due to other or unexplained causes. Multivariable logistic regression analysis was used to determine the factors from maternal characteristics and medical history which provided a significant contribution to the prediction of stillbirth.

RESULTS

The risk for stillbirth increased with maternal weight (odds ratio (OR), 1.01 per kg above 69 kg), was higher in women of Afro-Caribbean racial origin (OR, 2.01), those with assisted conception (OR, 1.79), cigarette smokers (OR, 1.71), and in those with a history of chronic hypertension (OR, 2.62), systemic lupus erythematosus/antiphospholipid syndrome (OR, 3.61) or diabetes mellitus (OR, 2.55) and was increased in women with a history of previous stillbirth (OR, 4.81). Screening with the model predicted 26% of unexplained stillbirths and 31% of those due to impaired placentation, at a false-positive rate of 10%; within the impaired-placentation group the detection rate of stillbirth < 32 weeks' gestation was higher than that of stillbirth ≥ 37 weeks (38% vs 28%).

CONCLUSIONS

A model based on maternal characteristics and medical history recorded in early pregnancy can potentially predict one-third of subsequent stillbirths. The extent to which such stillbirths could be prevented remains to be determined. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Prospective first-trimester screening for trisomies by cell-free DNA testing of maternal blood in twin pregnancy

OBJECTIVES

First, to examine in twin pregnancies the performance of first-trimester screening for fetal trisomies 21, 18 and 13 by cell-free (cf) DNA testing of maternal blood and, second, to compare twin and singleton pregnancies regarding the distribution of fetal fraction of cfDNA and rate of failure to obtain a result.

METHODS

This was a prospective study in 438 twin and 10 698 singleton pregnancies undergoing screening for fetal trisomies by cfDNA testing at 10 + 0 to 13 + 6 weeks' gestation. Chromosome-selective sequencing of cfDNA was used and, in twin pregnancies, an algorithm was applied that relies on the lower fetal fraction contributed by the two fetuses. Multivariate regression analysis was used to determine significant predictors of fetal fraction and a failed result.

RESULTS

In twin pregnancies, the median fetal fraction was lower (8.0% (interquartile range (IQR), 6.0-10.4%) vs 11.0% (IQR, 8.3-14.4%); P < 0.0001) and failure rate after first sampling was higher (9.4% vs 2.9%; P < 0.0001) compared to in singletons. Multivariate logistic regression analysis demonstrated that the risk of test failure increased with increasing maternal age and body mass index and decreased with fetal crown-rump length. The risk was increased in women of South Asian racial origin and in pregnancies conceived by in-vitro fertilization (IVF). The main contributor to the higher rate of failure in twins was conception by IVF which was observed in 9.5% of singletons and 56.2% of twins. In the 417 twin pregnancies with a cfDNA result after first or second sampling, the detection rate was 100% (8/8) for trisomy 21 and 60% (3/5) for trisomies 18 or 13, at a false-positive rate (FPR) of 0.25% (1/404). In the 10 530 singleton pregnancies with a cfDNA result after first or second sampling, the detection rate was 98.7% (156/158) for trisomy 21 and 80.3% (49/61) for trisomies 18 or 13, at a FPR of 0.22% (23/10 311).

CONCLUSIONS

In twin pregnancies undergoing first-trimester screening for trisomies by cfDNA testing, the fetal fraction is lower and failure rate higher compared to in singletons. The number of trisomic twin pregnancies examined was too small for an accurate assessment of performance of screening, but it may be similar to that in singleton pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Screening for trisomies by cell-free DNA testing of maternal blood: consequences of a failed result

OBJECTIVES

First, to report the distribution of the fetal fraction of cell-free (cf) DNA and the rate of a failed cfDNA test result in trisomies 21, 18 and 13, by comparison with pregnancies unaffected by these trisomies, second, to examine the possible effects of maternal and fetal characteristics on the fetal fraction, and third, to consider the options for further management of pregnancies with a failed result.

METHODS

This was a cohort study of 10 698 singleton pregnancies undergoing screening for fetal trisomies 21, 18 and 13 by cfDNA testing at 10-14 weeks' gestation. There were 160 cases of trisomy 21, 50 of trisomy 18, 16 of trisomy 13 and 10 472 were unaffected by these trisomies. Multivariate regression analysis was used to determine significant predictors of fetal fraction and a failed cfDNA test result amongst maternal and fetal characteristics.

RESULTS

Fetal fraction decreased with increasing body mass index and maternal age, was lower in women of South Asian racial origin than in Caucasians and in assisted compared to natural conceptions. It increased with fetal crown-rump length and higher levels of serum pregnancy-associated plasma protein-A and free β-human chorionic gonadotropin. The median fetal fraction was 11.0% (interquartile range (IQR), 8.3-14.4%) in the unaffected group, 10.7% (IQR, 7.8-14.3%) in trisomy 21, 8.6% (IQR, 5.0-10.2%) in trisomy 18 and 7.0% (IQR, 6.0-9.4%) in trisomy 13. There was a failed result from cfDNA testing after first sampling in 2.9% of the unaffected group, 1.9% of trisomy 21, 8.0% of trisomy 18 and 6.3% of trisomy 13. In the cases with a failed result, 7% of women had invasive testing, mainly because of high risk from the combined test and/or presence of sonographic features suggestive of trisomies 18 and 13. All cases of trisomies were detected prenatally.

CONCLUSIONS

In cases of a failed cfDNA test, the rate of trisomies 18 and 13, but not trisomy 21, is higher than in those with a successful test. In the management of such cases, the decision in favor of invasive testing should depend on the risk of prior screening and the results of detailed ultrasound examination. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Fertility problems and risk of gestational diabetes mellitus: a nationwide cohort study

OBJECTIVE

To determine whether women with a history of fertility problems have a higher risk of gestational diabetes mellitus (GDM) than women without a history of fertility problems after adjustment for maternal factors.

DESIGN

Nationwide population-based cohort study.

SETTING

Not applicable.

PATIENT(S)

All live and stillbirths during 2004-2010 among women with fertility problems (n = 49,616) and women without fertility problems (n = 323,061) were identified by linkage between the Danish Medical Birth Registry and the Danish Infertility Cohort. Information on GDM was obtained from the Danish National Patient Registry.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Odds ratios and 95% confidence intervals for the association between fertility problems and risk of GDM after adjustment for potentially confounding factors, including maternal age, prepregnancy BMI, parity, parental history of diabetes, level of education, and smoking during pregnancy.

RESULT(S)

In total, 7,433 (2%) pregnant women received a diagnosis of GDM. Multivariate analysis showed that pregnant women with a history of fertility problems had a statistically significantly higher risk of GDM than pregnant women without fertility problems. In stratified analyses, the association between fertility problems and risk of GDM attenuated with increasing age and was more pronounced among primiparous women and women with polycystic ovary syndrome.

CONCLUSION(S)

Our findings suggest that pregnant women with a history of fertility problems are at increased risk of GDM.

Differential effect of mode of conception and infertility treatment on fetal growth and prematurity

Objectives To examine perinatal outcomes in pregnancies conceived by different methods: fertile women with spontaneous pregnancies, infertile women who achieved pregnancy without treatment, pregnancies achieved by ovulation induction (OI) and in vitro fertilization or intra-cytoplasmic sperm injection (IVF/ICSI). Methods Retrospective single-center cohort study including 200 fertile and 748 infertile women stratified according to infertility treatment. The outcome measurements were preterm delivery (PTD), small-for-gestational-age (SGA), gestational diabetes, placenta previa or preeclampsia. Results The overall rate of pregnancy complications was significantly increased in all infertility groups regardless of the infertility treatment (adjusted odds ratio (OR): infertile without treatment 2.3 versus OI 2.2 versus IVF/ICSI 3.4). While PTD was mainly associated to IVF/ICSI (adjusted OR: infertile without treatment 1.3 versus OI 1.6 versus IVF/ICSI 3.3), SGA was significantly associated to both OI and IVF/ICSI (adjusted OR: infertile without treatment 1.9 versus OI 2.7 versus IVF/ICSI 2.6). All these associations remained statistically significant after adjusting by maternal age and twin pregnancy. Conclusions This study confirms the higher prevalence of pregnancy complications in infertile women irrespectively of receiving infertility treatment or not, and further describes a preferential association of prematurity with IVF/ICSI, and SGA with treated infertility (OI and IVF/ICSI).

The placenta: phenotypic and epigenetic modifications induced by Assisted Reproductive Technologies throughout pregnancy

Today, there is growing interest in the potential epigenetic risk related to assisted reproductive technologies (ART). Much evidence in the literature supports the hypothesis that adverse pregnancy outcomes linked to ART are associated with abnormal trophoblastic invasion. The aim of this review is to investigate the relationship between epigenetic dysregulation caused by ART and subsequent placental response. The dialogue between the endometrium and the embryo is a crucial step to achieve successful trophoblastic invasion, thus ensuring a non-complicated pregnancy and healthy offspring. However, as described in this review, ART could impair both actors involved in this dialogue. First, ART may induce epigenetic defects in the conceptus by modifying the embryo environment. Second, as a result of hormone treatments, ART may impair endometrial receptivity. In some cases, it results in embryonic growth arrest but, when the development of the embryo continues, the placenta could bring adaptive responses throughout pregnancy. Amongst the different mechanisms, epigenetics, especially thanks to a finely tuned network of imprinted genes stimulated by foetal signals, may modify nutrient transfer, placental growth and vascularization. If these coping mechanisms are overwhelmed, improper maternal-foetal exchanges occur, potentially leading to adverse pregnancy outcomes such as abortion, preeclampsia or intra-uterine growth restriction. But in most cases, successful placental adaptation enables normal progress of the pregnancy. Nevertheless, the risks induced by these modifications during pregnancy are not fully understood. Metabolic diseases later in life could be exacerbated through the memory of epigenetic adaptation mechanisms established during pregnancy. Thus, more research is still needed to better understand abnormal interactions between the embryo and the milieu in artificial conditions. As trophectoderm cells are in direct contact with the environment, they deserve to be studied in more detail. The ultimate goal of these studies will be to render ART protocols safer. Optimization of the environment will be the key to improving the dialogue between the endometrium and embryo, so as to ensure that placentation after ART is similar to that following natural conception.

Performance of screening for aneuploidies by cell-free DNA analysis of maternal blood in twin pregnancies

OBJECTIVES

To report clinical implementation of cell-free DNA (cfDNA) analysis of maternal blood in screening for trisomies 21, 18 and 13 in twin pregnancies and examine variables that could influence the failure rate of the test.

METHODS

cfDNA testing was performed in 515 twin pregnancies at 10-28 weeks' gestation. The failure rate of the test to provide results was compared with that in 1847 singleton pregnancies, and logistic regression analysis was used to determine which factors among maternal and pregnancy characteristics were significant predictors of test failure.

RESULTS

Failure rate of the cfDNA test at first sampling was 1.7% in singletons and 5.6% in twins. Of those with a test result, the median fetal fraction in twins was 8.7% (range, 4.1-30.0%), which was lower than that in singletons (11.7% (range, 4.0-38.9%)). Multivariable regression analysis demonstrated that twin pregnancy, higher maternal weight and conception by in-vitro fertilization provided significant independent prediction of test failure. Follow-up was available in 351 (68.2%) of the twin pregnancies and comprised 334 with euploid fetuses, 12 discordant for trisomy 21 and five discordant for trisomy 18. In all 323 euploid cases with a result, the risk score for each trisomy was < 1:10 000. In 11 of the 12 cases with trisomy 21 and in the five with trisomy 18, the cfDNA test gave a high-risk result, but in one case of trisomy 21, the score was < 1:10 000.

CONCLUSION

In twin pregnancies screening by cfDNA testing is feasible, but the failure rate is higher and detection rate may be lower than in singletons.

First trimester trophoblast and placental bed vascular volume measurements in IVF or IVF/ICSI pregnancies

STUDY QUESTION

Are first trimester trophoblast volume (TV) and placental bed vascular volume (PBVV) different in IVF or IVF/ICSI pregnancies in comparison with spontaneously conceived pregnancies?

SUMMARY ANSWER

Any possible abnormal placentation in IVF or IVF/ICSI pregnancies in comparison with spontaneously conceived pregnancies is not detected by a difference in PBVV or TV at an early gestational age (GA).

WHAT IS KNOWN ALREADY

Assisted reproductive technology pregnancies have been associated with an increased risk of placenta-related adverse pregnancy outcomes. It is unclear whether these effects originate from infertility or from the technique itself.

STUDY DESIGN, SIZE, DURATION

We performed a retrospective cohort study in which 154 pregnant patients qualified for participation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Out of 154 pregnant patients, 84 conceived spontaneously and 70 conceived after IVF or IVF/ICSI. We determined the TV at 10 weeks GA by Virtual Organ Computer-aided AnaLysis measuring application and the PBVV at 12 weeks GA by the virtual reality operating system of BARCO I-Space in both subgroups. The investigators were blinded to the mode of conception during the measurements. Analysis was limited to singleton pregnancies with only one sac ever detectable.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in TV (mean 42.7, SD 15.9 versus mean 41.2, SD 13.9, P = 0.70) and PBVV (mean 27.6, SD 16.9 versus mean 24.8, SD 19.9, P = 0.20) between IVF or IVF/ICSI pregnancies and spontaneously conceived pregnancies. There was a significant correlation between TV and PBVV (rs = 0.283, P = 0.004).

LIMITATIONS, REASONS FOR CAUTION

The limitations of the present study concern the small size of the study groups.

WIDER IMPLICATIONS OF THE FINDINGS

IVF or IVF/ICSI does not seem to be associated with abnormal placentation.

STUDY FUNDING/COMPETING INTERESTS

This study was financially supported by the Erasmus Trustfonds, the Meindert de Hoop foundation and the Fonds NutsOhra. No competing interests are declared.

Maternal serum anti-Müllerian hormone at 11-13 weeks' gestation in the prediction of preeclampsia

OBJECTIVE

To investigate the potential value of maternal serum anti-Müllerian hormone (AMH) at 11-13 weeks' gestation in the prediction of preeclampsia (PE).

METHODS

The serum concentration of AMH was measured at 11-13 weeks' gestation in cases of PE (n = 50) and normotensive controls (n = 150). Backward stepwise multiple regression analysis was used to determine which of the factors amongst the maternal characteristics and gestation were significant predictors of the serum AMH in the control group and from the regression model the value in each case and control was expressed as a multiple of the expected median (MoM).

RESULTS

In normotensive pregnancies, the maternal serum concentration of AMH is higher in Afro-Caribbean than in Caucasian women and in smokers than in non-smokers. In the PE group, the median serum concentration of AMH was significantly higher than in the controls (2.140 ng/L, IQR 1.968-2.273 versus 2.062 ng/L, IQR 1.938-2.181; p = 0.025), but the median MoM value of AMH was not significantly different between the PE group and the controls (1.040, IQR 0.941-1.081 versus 0.995, IQR 0.939-1.065, p = 0.147).

CONCLUSIONS

Maternal serum AMH is not an effective early predictor for PE.

Assisted conception, maternal age and breastfeeding: an Australian cohort study

AIM

To establish the relationships between age, mode of conception and breastfeeding.

METHOD

Consecutive cohorts of nulliparous women >25 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age groups ≤30, 31-36 and ≥37 years were recruited. Data were obtained via telephone interviews and postal questionnaires in late pregnancy and 4 months postpartum. Sociodemographic characteristics, reproductive health, birth and breastfeeding experiences were assessed by study-specific questions. Self-rated general health and symptoms of depression and anxiety were assessed with standardized psychometric instruments. Main outcomes were exclusive breastfeeding at discharge from maternity hospital and 4 months postpartum.

RESULTS

Of 1179 eligible women, 791 (67%) participated; 549 (93%) had singleton infants, provided complete data and were included in analyses. Overall, 37.2% of participants aged ≤30, 33% aged 31-36 and 55.1% aged ≥37 years experienced Caesarean births. Regardless of age, compared with the SC group, ARTC women had twice the rate of Caesareans prior to labour. Controlling for other factors, exclusive breastfeeding rates at hospital discharge and 4 months postpartum were lowest amongst ARTC women who experienced Caesarean prior to labour (p < .001).

CONCLUSION

Independent of age, assisted conception increases the risk conferred by Caesarean birth to breastfeeding initiation and maintenance.

Birthweight with gestation and maternal characteristics in live births and stillbirths

OBJECTIVE

To establish a normal range of birthweight with gestational age (GA) at delivery and examine the contribution of maternal characteristics in defining growth restriction in stillbirths.

METHODS

In 69,895 normal singleton pregnancies, regression analysis was used to determine the association of birthweight with GA and maternal characteristics. The proportion of 290 stillbirths classified as small for GA depending on inclusion or exclusion of maternal characteristics was determined.

RESULTS

In normal pregnancies, there was a polynomial association between birthweight and GA. Birthweight increased with maternal weight, height and parity and was lower in Africans and South Asians than in Caucasians. Birthweight for GA was reduced in antepartum stillbirths (n = 243; p < 0.0001) but not in intrapartum stillbirths (n = 47; p = 0.334). There was no significant difference in the proportion of antepartum stillbirths with birthweight below the 10th percentile when birthweight was corrected for GA only compared to correction for GA and maternal characteristics (53.1 vs. 54.3%). The birthweight was below the 10th percentile in 71.8% of antepartum stillbirths at <32 weeks' gestation, in 47.2% at 33-36 weeks and in 31.5% at ≥37 weeks.

CONCLUSION

Correction of birthweight for maternal characteristics does not alter the proportion of stillbirths that are small for GA.