Monitoring of IVF birth outcomes in Finland: a data quality study

Probability of live birth after IVF/ICSI treatments in female early onset cancer survivors: a Finnish population-based registry study

STUDY QUESTION

Does the probability of a live birth after fresh IVF/ICSI cycles with autologous oocytes differ in early onset female cancer survivors compared to their siblings?

SUMMARY ANSWER

The probability of a live birth was similar in female cancer survivors and siblings after four fresh IVF/ICSI cycles.

WHAT IS KNOWN ALREADY

Fertility preservation strategies are rapidly being developed to help female cancer patients who wish to have children later. However, there are only a few studies available on fertility treatments and following live births in female cancer survivors before fertility preservation strategies became available. In one of them, the probability of a live birth was reduced after assisted reproductive technology with autologous oocytes in cancer survivors compared to siblings.

STUDY DESIGN, SIZE, DURATION

In this retrospective, register-based study, data from Finnish registers on cancer, birth and prescribed medications were merged to identify 8944 female cancer survivors (diagnosed with cancer between 1953 and 2012 at the age of 0-40 years) and 9848 female siblings of survivors eligible for IVF/ICSI treatments between January 1993 and December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fresh IVF/ICSI cycles and following live birth rates (LBRs) within 22-48 weeks in cancer survivors and siblings at the age of 20-41 years were identified. A binomial regression model with log-link function was used to calculate risk ratio (RR) for live births after fresh IVF/ICSI cycles in survivors compared to siblings, adjusting for attained age and calendar time. A Poisson regression model was used to estimate incidence rate ratios (IRRs) for an IVF/ICSI treatment, as well as overall live births, including both pregnancies after fertility treatments and spontaneous pregnancies, in survivors compared to siblings.

MAIN RESULTS AND THE ROLE OF CHANCE

We observed an overall decreased LBR, irrespective of IVF/ICSI treatments, in cancer survivors compared to siblings (IRR 0.68, 95% CI 0.64-0.71). All in all, 179 (2.0%) survivors and 230 (2.3%) siblings were prescribed fertility drugs for IVF/ICSI treatments (IRR 0.72, 95% CI 0.62-0.84). For the first fresh IVF/ICSI cycle, the LBR was 17.2% among survivors and 15.7% among siblings (RR 1.13, 95% CI 0.72-1.87). The mean LBR after four fresh IVF/ICSI cycles was not statistically different in survivors compared to siblings.

LIMITATIONS, REASONS FOR CAUTION

In this study, only IVF/ICSI treatments with autologous oocytes were included. The probability of a live birth after a frozen embryo transfer or oocyte donation could not be evaluated in this study. Information on miscarriages, extrauterine pregnancies or termination of pregnancies was not available.

WIDER IMPLICATIONS OF THE FINDINGS

For those early onset cancer survivors, who received IVF/ICSI treatments, the probability of live birth was not different from siblings who received IVF/ICSI treatments. However, an overall decreased LBR, irrespective of IVF/ICSI treatments, was observed in cancer survivors compared to siblings, indicating that cancer survivors receiving IVF/ICSI treatments in our study consisted of a selected group with at least a moderate ovarian reserve.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a grant from the Cancer Foundation (Finland) (grant number 130079) and by a grant from LähiTapiola. The authors have no potential conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

A systematic review of database validation studies among fertility populations

STUDY QUESTION

Are routinely collected data from fertility populations adequately validated?

SUMMARY ANSWER

Of the 19 studies included, only one validated a national fertility registry and none reported their results in accordance with recommended reporting guidelines for validation studies.

WHAT IS KNOWN ALREADY

Routinely collected data, including administrative databases and registries, are excellent sources of data, particularly for reporting, quality assurance, and research. However, these data are subject to misclassification bias due to misdiagnosis or errors in data entry and therefore need to be validated prior to using for clinical or research purposes.

STUDY DESIGN SIZE DURATION

We conducted a systematic review by searching Medline, Embase, and CINAHL from inception to 6 October 2016 to identify validation studies of databases that contain routinely collected data in an ART setting. Webpages of international ART centers were also searched.

PARTICIPANTS/MATERIALS SETTING METHODS

We included studies that compared at least two data sources to validate ART population data. Key words and MeSH terms were adapted from previous systematic reviews investigating routinely collected data (e.g. administrative databases and registries), measures of validity (including sensitivity, specificity, and predictive value), and ART (including infertility, IVF, advanced reproductive age, and diminished ovarian reserve). Only full-text studies in English were considered. Results were synthesized qualitatively. The electronic search yielded 1074 citations, of which 19 met the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

Two studies validated a fertility database using medical records; seven studies used an IVF registry to validate vital records or maternal questionnaires, and two studies failed to adequately describe their reference standard. Four studies investigated the validity of mode of conception from birth registries; two studies validated diagnoses or treatments in a fertility database; four studies validated a linkage algorithm between a fertility registry and another administrative database; one study created an algorithm in a single database to identify a patient population. Sensitivity was the most commonly reported measure of validity (12 studies), followed by specificity (9 studies). Only three studies reported four or more measures of validation, and five studies presented CIs for their estimates. The prevalence of the variable in the target population (pre-test prevalence) was reported in seven studies; however, only four of the studies had prevalence estimates from the study population (post-test prevalence) within a 2% range of the pre-test estimate. The post-test estimate was largely discrepant from the pre-test value in two studies.

LIMITATIONS REASONS FOR CAUTION

The search strategy was limited to the studies and reports published in English, which may not capture validation studies from countries that do not speak English. Furthermore, only three specific fertility-based diagnostic variables (advanced reproductive age, diminished ovarian reserve, and chorionicity) were searched in Medline, Embase, and CINAHL. Consequently, published studies with other diagnoses or conditions relevant to infertility may not have been captured in our review.

WIDER IMPLICATIONS OF THE FINDINGS

There is a paucity of literature on validation of routinely collected data from a fertility population. Furthermore, the prevalence of the markers that have been validated are not being presented, which can lead to biased estimates. Stakeholders rely on these data for monitoring outcomes of treatments and adverse events; therefore, it is essential to ascertain the accuracy of these databases and make the reports publicly available.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Canadian Institutes of Health Research (CIHR) (FDN-148438). There are no competing interests for any of the authors.

REGISTRATION NUMBER

International Prospective Register of Systematic Reviews ID: CRD42016048466.

Quality of IVF status registration in the Estonian Medical Birth Registry: a national record linkage study

Background

Information regarding in vitro fertilization (IVF) as a pregnancy risk factor (yes/ no) is stored in each birth record of the Estonian Medical Birth Registry (EMBR). This study aimed to assess the validity of registration of newborns’ IVF status in the EMBR.

Methods

To identify the newborns conceived by IVF, the birth records in the EMBR were compared to individual records on the embryo transfer procedures in the Estonian Health Insurance Fund (EHIF) database as a reference. Maternal age was restricted to 40 years, the age limit for IVF treatment covered by the EHIF. The embryo transfer procedures, that dated up to eight weeks before pregnancy, were additionally checked in the infertility treatment clinics. The validity of IVF status was measured by sensitivity, specificity, positive and negative predictive values (PPV and NPV). Relative risk (RR) of unrecorded IVF status among IVF mothers by socio-demographic characteristics and birth plurality was estimated using modified Poisson regression models.

Results

There were 3198 newborns identified as conceived by IVF in the EMBR in 2005–2014. Eight of them were incorrectly entered as born after IVF. The record linkage with the EHIF database revealed 1014 newborns with unrecorded IVF status in the EMBR. A total of 4204 newborns were verified as conceived by IVF, 24.1% of them were not categorized as born after IVF. The sensitivity of the IVF status registration was poor (75.9%), specificity (100.0%), PPV (99.8%) and NPV (99.3%) were high. The misclassifications were significantly more common among mothers of younger age or non-Estonians or with singleton birth.

Conclusion

Information based on mother’s self-report or her antenatal chart does not accurately identify the newborn’s IVF status. The lack of a specialized country-wide assisted reproductive technology register in Estonia requires routine record linkage of the EMBR, EHIF and the infertility treatment clinics’ databases to obtain adequate information regarding IVF status in the EMBR. Electronic record linkages between databases would help considerably to improve the validity of data to be used in medical decision making, in research and for statistical purposes.

Fertility treatments among female cancer survivors giving birth - a Finnish register-based study

BACKGROUND

Long-term survival rates for most types of childhood cancers have improved dramatically over the past decades. However, because of advances in multimodality treatments, cancer survivors nowadays more often face long-term complications, including diminished gonadal and reproductive function. The aim of this study was to identify whether the use of fertility treatments among early onset (0-34 years) cancer survivors giving birth differed from that among siblings giving birth and to identify the subgroups of cancer survivors that were most likely to require fertility treatments.

MATERIAL AND METHODS

Nationwide cancer and birth registries were merged to identify 1974 post-diagnosis deliveries of cancer survivors and 6107 deliveries of female siblings in 2004-2013. Unconditional multivariate logistic regression models were used to estimate the risk for different fertility treatments namely assisted reproductive technology, intrauterine insemination and ovulation induction. We adjusted for maternal age, year of delivery, parity and smoking.

RESULTS

We found overall significantly increased odds for use of any fertility treatments in survivors compared to siblings (OR 1.84, 95% CI 1.18-2.86). As time from cancer treatment increased, the odds for need of fertility treatments increased, being highest at 11 to 15 years post cancer treatment (OR 2.88, 95% CI 1.13-7.30). Survivors diagnosed at ages 25-34 years had the highest odds for use of fertility treatments compared to siblings (OR 2.31, 95% CI 1.01-5.32).

CONCLUSIONS

Our study supports previous findings indicating that cancer survivors have an increased risk for subfertility. Survivors diagnosed in their childhood had the lowest risk for fertility treatment and seemed to get pregnant with less extensive fertility treatments than survivors diagnosed as adults. Time elapsed from cancer treatment played a central role, increasing the need for fertility treatments compared to siblings, suggesting that cancer therapies might lead to diminished ovarian reserve.

Utilization of Large Data Sets in Maternal Health in Finland: A Case for Global Health Research

In recent years, the use of large data sets, such as electronic health records, has increased. These large data sets are often referred to as "Big Data," which have various definitions. The purpose of this article was to summarize and review the utilization, strengths, and challenges of register data, which means a written record containing regular entries of items or details, and Big Data, especially in maternal nursing, using 4 examples of studies from the Finnish Medical Birth Register data and relate these to other international databases and data sets. Using large health register data is crucial when studying and understanding outcomes of maternity care. This type of data enables comparisons on a population level and can be utilized in research related to maternal health, with important issues and implications for future research and clinical practice. Although there are challenges connected with register data and Big Data, these large data sets offer the opportunity for timely insight into population-based information on relevant research topics in maternal health. Nurse researchers need to understand the possibilities and limitations of using existing register data in maternity research. Maternal child nurse researchers can be leaders of the movement to utilize Big Data to improve global maternal health.

Linking databases on perinatal health: a review of the literature and current practices in Europe

Background: International comparisons of perinatal health indicators are complicated by the heterogeneity of data sources on pregnancy, maternal and neonatal outcomes. Record linkage can extend the range of data items available and thus can improve the validity and quality of routine data. We sought to assess the extent to which data are linked routinely for perinatal health research and reporting. Methods: We conducted a systematic review of the literature by searching PubMed for perinatal health studies from 2001 to 2011 based on linkage of routine data (data collected continuously at various time intervals). We also surveyed European health monitoring professionals about use of linkage for national perinatal health surveillance. Results: 516 studies fit our inclusion criteria. Denmark, Finland, Norway and Sweden, the US and the UK contributed 76% of the publications; a further 29 countries contributed at least one publication. Most studies linked vital statistics, hospital records, medical birth registries and cohort data. Other sources were specific registers for: cancer (70), congenital anomalies (56), ART (19), census (19), health professionals (37), insurance (22) prescription (31), and level of education (18). Eighteen of 29 countries (62%) reported linking data for routine perinatal health monitoring. Conclusion: Research using linkage is concentrated in a few countries and is not widely practiced in Europe. Broader adoption of data linkage could yield substantial gains for perinatal health research and surveillance.

Autism spectrum disorders in IVF children: a national case-control study in Finland

STUDY QUESTION

Does IVF increase the risk of autism spectrum disorders (ASDs)?

SUMMARY ANSWER

No association between IVF and ASDs or any of its subtypes was found in this sample.

WHAT IS KNOWN ALREADY

Certain prenatal factors may increase the risk of ASDs. Studies on the association between IVF and ASDs have shown inconsistent results. IVF is known to increase the risk of perinatal problems but many of them are related to multiple pregnancies.

STUDY DESIGN, SIZE, DURATION

This case-control study included 4164 autistic cases and 16 582 matched controls born in Finland in 1991-2005. The cases were diagnosed with ASDs by the year 2007. The maximum age at diagnosis was 16 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Four controls were matched to each case. For singletons the matching criteria were date of birth, place of birth, sex and residency in Finland. For twins the birth order within a twin pair was included as well. In the whole sample, there were 63 cases (1.51%) and 229 controls (1.38%) born after IVF.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant association was found between IVF and ASDs (adjusted odds ratio (OR): 0.9, 95% confidence interval (CI): 0.7-1.3) or its subtypes childhood autism (OR: 0.8, 95% CI: 0.4-1.5), Asperger's syndrome (OR: 0.9, 95% CI: 0.5-1.6) or other pervasive developmental disorder (OR: 1.0, 95% CI: 0.6-1.6). When only singletons were included, there was an association between IVF and Asperger's syndrome in an unadjusted analysis (OR: 2.0, 95% CI: 1.1-3.5) but this was not significant when adjusted for mother's socioeconomic status or parity. When the analyses were conducted separately for boys and girls, there was a significant association between IVF and Asperger's syndrome for boys in an unadjusted analysis (OR: 2.1, 95% CI: 1.2-3.7) but this was not significant in the final adjusted model.

LIMITATIONS, REASONS FOR CAUTION

Information both on IVF and on ASDs was based on registers and it is possible that there is some misclassification. No information on different subtypes of IVF or other assisted reproduction techniques was available. Statistical power may have been insufficient.

WIDER IMPLICATIONS OF THE FINDINGS

This study showed no increased risk of ASDs in children born after IVF but studies with larger sample sizes and information on different subtypes of IVF are needed to confirm the finding.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by Autism Speaks, NIMH 1K02-MH65422 and NIEHS 1R01ES019004. There are no competing interests.

[Morbidity and mortality of premature neonates after introduction of national in vitro fertilisation programme--our experience]

INTRODUCTION

Infertility occurs in approximately 10% of couples and in vitro fertilisation (IVF) is its most efficient treatment method. The National IVF Programme started in October 1st, 2006.

OBJECTIVE

Examination of morbidity and mortality of premature neonates conceived by IVF after initiation of the National IVF Programme.

METHODS

Retrospective analysis of history charts of IVF premature neonates treated at the Neonatal Intensive Care Unit (NICU) of the Institute of Child and Youth Healthcare of Vojvodina, Novi Sad, Serbia, from March 1st, 2007 to March 1st, 2008.

RESULTS

Of 189 treated premature neonates, 25 (13.23%) were IVF conceived, with mean gestational age (GA) of 29.46 +/- 3.28 gestational weeks (GW), one-minute Apgar score 5.44 +/- 2.45, five-minute Apgar score 7.16 +/- 1.92 and birth weight (BW) 1299 +/- 484.35 g; from singleton 12 (48%), twin 10 (40%), and trigeminal 3 (12%) gestations. The largest number of neonates were of GA between 29 and 31.9 GW (12; 48%) and BW between 1500 and 2499 g (9; 36%). All of them were treated due to respiratory distress syndrome, complicated in 2 (8%) with air leak syndromes and in 4 (16%) with pulmonary haemorrhage. Congenital anomalies were detected in 2 (8%) and intracranial haemorrhage developed subsequently in 21 (84%) neonates. Lethal outcome occurred in 7 (28%) neonates, in all cases in lower gestation groups (<29 GW). Variable analysis showed significantly higher incidence of chorioamnionitis (p = 0.0004) and lower GA (p approximately 0.00), BW (p approximately 0.00), one-minute Apgar score (p = 0.0007) as well as significant difference in prophylactic surfactant application (p approximately 0.00) and mean arterial pressure on admission (p = 0.002).

CONCLUSION

Morbidity and mortality of IVF premature neonates does not differ significantly from that of other premature neonates treated at NICU. Prematurity and low BW are important factors in pathology of these neonates and final outcome is influenced by perinatal asphyxia, risk of systemic infection, prophylactic surfactant application and arterial hypotension.

Validation of self-reported data on assisted conception in The Danish National Birth Cohort

BACKGROUND

An increasing number of children are born after assisted conception and in surveillance programmes information on mode of conception is often achieved via maternal self-report. We assessed the validity of self-reported assisted conception in The Danish National Birth Cohort (DNBC), a prospective pregnancy cohort. Here, the term assisted conception refers to IVF, ICSI, ovulation induction and insemination.

METHODS

We compared self-reported assisted conception in the DNBC to corresponding data from Danish national registers; the IVF Register and Danish Drug Prescription Register, providing method of conception in the entire population. In the DNBC, 101,042 women accepted the invitation in early pregnancy from 1996 to 2002. Our final study population comprised 88,151 DNBC women aged 20 years and older who participated in the first DNBC interview with a pregnancy resulting in a live born child.

RESULTS

In the DNBC, assisted conception was reported with a sensitivity of 83% and positive predictive value of 88%. Misclassification was largely explained by ambiguous phrasing of the DNBC interview question and interview skip patterns. Women with false negative reporting were more often multipara (P < 0.001) and older (P = 0.027 for IVF/ICSI and P = 0.002 for ovulation induction). The risk ratio (RR) for being born preterm in IVF/ICSI children was lower for children identified via the DNBC, RR 3.61 (95% confidence interval (CI) 3.31-3.94), than the IVF Register, RR 4.36 (95% CI 4.02-4.74).

CONCLUSIONS

There was a high positive predictive value of self-reported assisted conception in the DNBC, but the structure of the DNBC interview represented a problem and misclassification could introduce bias.

Success of infertility treatments in Finland in the period 1992-2005

OBJECTIVES

The objective was to study the success rates of infertility treatments in the period 1992-2005 in public and private clinics.

STUDY DESIGN

Aggregate IVF statistics (1992-2005) and nationally representative cross-sectional survey (2002).

RESULTS

The success rates of infertility treatments remained stable, despite a substantial increase in single-embryo transfers. In 2005, the clinical pregnancy rate was 23/100 initiated cycles and a live birth rate of 17/100 cycles. The proportions of term singletons and singletons weighing at least 2500g improved over time and both rates were 14/100 in 2005. Pregnancy rates improved most among older women during the study period. The success rate in the private sector was significantly better than that in the public sector among women younger than 35 years.

CONCLUSION

The single-embryo policy has not decreased pregnancy and birth rates. The proportions of term singletons per initiated cycle and singletons weighing at least 2500g per initiated cycle have improved over time. The higher success rate in the private sector may be because of different clientele.

Health of children born after ovulation induction

OBJECTIVE

To study the health of children born after ovulation induction (OI).

DESIGN

Nationwide register-based study.

SETTING

The OI children were followed up to the age of 4 years and compared with other children.

PATIENT(S)

The OI children (N = 4,467). Two control groups: all other children (excluding children born after IVF, N = 190,398) and a random sample of those children (n = 26,877).

INTERVENTION(S)

Ovulation induction treatment in ordinary practice.

MAIN OUTCOME MEASURE(S)

Mortality rates and adjusted odds ratios for perinatal outcomes, hospitalizations, health-related benefits, and long-term medication use.

RESULT(S)

A total of 12% of OI and 2% of control children were multiples. Even after stratifying for multiplicity and adjusting for the available confounding factors (region, smoking, maternal age, socioeconomic position, and parity for perinatal health and mother's socioeconomic position for other indicators), most indicators showed worse health among OI children compared with control children. The OI children had poorer perinatal health and more episodes of long hospitalization than the control children. Singleton OI children had more long-term illnesses in childhood, as measured by child disability allowance, long-term medication use, and hospital care episodes.

CONCLUSION(S)

Either OI treatment or the reasons for the treatment increase the risk of health problems in early childhood.

Health of children born as a result of in vitro fertilization

OBJECTIVE

The purpose of this study was to use nationwide registries to examine the health of children up to 4 years of age who were born as a result of in vitro fertilization.

METHODS

Children born after in vitro fertilization (N = 4559) from 1996 to 1999 were monitored until 2003. Two control groups were selected from the Finnish Medical Birth Register as follows: all other children (excluding children born after ovulation induction) from the same period (N = 190,398, for study of perinatal health and hospitalizations) and a random sample of those children (n = 26,877, for study of health-related benefits). Mortality rates and odds ratios for perinatal outcomes, hospitalizations, health-related benefits, and long-term medication use were calculated.

RESULTS

Although the health of most in vitro fertilization children was good, such children had more health problems than other children. A total of 35.7% of in vitro fertilization children and 2.2% of control children were multiple births, and the health of multiple births was worse than that of singletons. Perinatal outcomes of in vitro fertilization children were worse and hospital episodes were more common than among control children. Risks for cerebral palsy and psychological and developmental disorders were increased. Among in vitro fertilization singletons, worse results for perinatal outcomes and hospitalizations, but no increased risk for specific diseases, were found. The health of in vitro fertilization multiple births was comparable to the health of control multiple births.

CONCLUSIONS

Reducing the number of transferred embryos would improve the health of in vitro fertilization children. Additional studies are needed to explain the poorer health of in vitro fertilization singletons, as well as follow-up studies to examine the health of in vitro fertilization children from 4 years onward.

Practitioner reporting of birth defects in children born following assisted reproductive technology: Does it still have a role in surveillance of birth defects?

BACKGROUND

National assisted reproductive technology (ART) data collections that rely on practitioners' reports of birth defects have consistently reported lower proportions of children with birth defects than record linkage studies that link ART infants to birth and malformation registers.

METHODS

We compared the birth defect data reported to the national Australian Assisted Conception Data Collection (ACDC) by practitioners at three Western Australian ART clinics with the birth defect data identified on the Western Australian Birth Defects Registry (WABDR) through record linkage of all the pregnancies conceived at these clinics to the WABDR. Cases are reported to the WABDR by multiple statutory and voluntary sources.

RESULTS

We found that the national ACDC significantly underestimated the prevalence of birth defects in WA-born ART infants. Less than one-third of ART children identified with a major birth defect on the WABDR were reported to the ACDC.

CONCLUSIONS

Although national ART data collections provide valuable information on pregnancy rates and short-term pregnancy outcomes such as multiple birth and birth weight, we strongly recommend that birth defect information used for patient counselling is preferentially drawn from large studies that have used record linkage to high-quality birth defect registers.

An update on antenatal screening for Down's syndrome and specific implications for assisted reproduction pregnancies

Since the introduction of antenatal serum screening for Down's syndrome (DS) more than two decades ago, several screening approaches have been utilized in routine clinical practice. The current DS screening strategies involve mid-trimester serum biochemistry tests, first trimester tests combining sonographic markers and serum biochemistry and integration of first and second trimester markers. In this review, we evaluate the performance of DS screening strategies according to the Serum, Urine and Ultrasound Screening Study (SURUSS), the First and Second Trimester Evaluation of Risks (FASTER) Trial and the Serum Biochemistry and Fetal Nuchal Translucency Screening (BUN) Study. We also evaluate the performance of first trimester screening in studies and meta-analyses by other groups. Specific issues related to assisted reproduction technology (ART) pregnancies are also addressed in this review.

Children born after assisted fertilization have an increased rate of major congenital anomalies

OBJECTIVE

To study the occurrence of major congenital anomalies (CAs) among children born after IVF (IVF, microinjections, and frozen embryo transfers) and after ovulation inductions with or without insemination (other assisted reproductive technologies [ART]).

DESIGN

Register-based study.

SETTING

Data regarding CAs were obtained from the Register of Congenital Malformations.

PATIENT(S)

Children from IVF (n = 4,559), children from other ART (n = 4,467), and controls (n = 27,078, a random sample of naturally conceived children) from the Medical Birth Register.

INTERVENTION(S)

In vitro fertilization and other ART treatment in ordinary practice.

MAIN OUTCOME MEASURE(S)

Rate of major CAs. Children from IVF and other ART were compared with control children, both overall and by plurality, controlling for confounding factors by logistic regression.

RESULT(S)

For IVF children, the adjusted odds ratio (OR) was 1.3 (95% confidence interval [CI], 1.1-1.6). Stratifying by gender and plurality showed that the risk was only increased for boys, and the risk was decreased for multiple IVF girls (OR = 0.5, 95% CI 0.2-0.9). The crude OR of major CA for other ART children was 1.3 (95% CI 1.1-1.5), but adjusted differences by gender and plurality were statistically insignificant.

CONCLUSION(S)

In vitro fertilization was associated with an increased risk for major CAs among singleton boys and a decreased risk among multiple girls. The risk after other ART was only slightly increased.