The effect of fertility treatment on adverse perinatal outcomes in women aged at least 40 years

Facilitation of Ovarian Response by Mechanical Force-Latest Insight on Fertility Improvement in Women with Poor Ovarian Response or Primary Ovarian Insufficiency

The decline in fertility in aging women, especially those with poor ovarian response (POR) or primary ovarian insufficiency (POI), is a major concern for modern IVF centers. Fertility treatments have traditionally relied on gonadotropin- and steroid-hormone-based IVF practices, but these methods have limitations, especially for women with aging ovaries. Researchers have been motivated to explore alternative approaches. Ovarian aging is a complicated process, and the deterioration of oocytes, follicular cells, the extracellular matrix (ECM), and the stromal compartment can all contribute to declining fertility. Adjunct interventions that involve the use of hormones, steroids, and cofactors and gamete engineering are two major research areas aimed to improve fertility in aging women. Additionally, mechanical procedures including the In Vitro Activation (IVA) procedure, which combines pharmacological activators and fragmentation of ovarian strips, and the Whole Ovary Laparoscopic Incision (WOLI) procedure that solely relies on mechanical manipulation in vivo have shown promising results in improving follicle growth and fertility in women with POR and POI. Advances in the use of mechanical procedures have brought exciting opportunities to improve fertility outcomes in aging women with POR or POI. While the lack of a comprehensive understanding of the molecular mechanisms that lead to fertility decline in aging women remains a major challenge for further improvement of mechanical-manipulation-based approaches, recent progress has provided a better view of how these procedures promote folliculogenesis in the fibrotic and avascular aging ovaries. In this review, we first provide a brief overview of the potential mechanisms that contribute to ovarian aging in POI and POR patients, followed by a discussion of measures that aim to improve ovarian folliculogenesis in aging women. At last, we discuss the likely mechanisms that contribute to the outcomes of IVA and WOLI procedures and potential future directions.

Association between Abortion History and Perinatal and Neonatal Outcomes of Singleton Pregnancies after Assisted Reproductive Technology

IMPORTANCE

At present, few people have studied the associations between abortion history before pregnancy on the outcomes of women and their infants after assisted reproductive technology (ART).

OBJECTIVE

To explore the association between the history of abortion and the outcomes of singleton pregnancies after ART.

DESIGN

This was a retrospective study in a hospital from 2015 to 2020 in Shanghai, China. Pregnant women with live singleton births through ART were included (n = 3043). Abortion was classified into spontaneous abortion (SAB) and induced abortion. We compared the maternal and fetal outcomes of singleton pregnancies obtained through ART with different abortion histories. Logistic regression analysis was used to evaluate the associations between the history of pre-pregnancy abortion with perinatal complications and neonatal outcomes.

RESULTS

We observed that compared with those who had no abortion history and obtained singleton pregnancies through ART, women who had an abortion history before pregnancy (including SAB or induced abortion history) and only SAB history were more likely to have gestational diabetes mellitus (GDM), thyroid-related diseases, and placenta-related diseases. After adjusting the potential confounding factors, these differences still existed. The adjusted odds ratios (ORs) and 95% confidence interval (CI) of GDM, thyroid-related diseases, and placenta-related diseases in women with a history of abortion and only a history of SAB were 1.239 (1.030-1.492) and 1.240 (1.010-1.522), 1.589 (1.261-2.002) and 1.724 (1.344-2.213), 1.465 (1.183-1.815) and 1.433 (1.132-1.814), respectively. However, we did not observe the association between the history of induced abortion and GDM and thyroid-related diseases.

CONCLUSIONS AND RELEVANCE

Our research showed that pregnant women with singleton pregnancies through ART who had a history of abortion or only a history of SAB were more likely to have GDM, thyroid-related diseases, and placenta-related diseases. Pregnant women who had both SAB and induced abortion before pregnancy had a higher risk of thyroid-related diseases and placenta-related diseases, while women who had only a history of induced abortion had a higher risk of placenta-related diseases. Further research is needed to explore the biological mechanism of different types of abortion related to subsequent pregnancy.

The vitrification system may affect preterm and cesarean delivery rates after single vitrified blastocyst transfer

The purpose of this study was to investigate the possible effects of different vitrification systems on single vitrified blastocyst transfer cycles. The clinical and birth outcomes of 412 patients who underwent single vitrified blastocyst transfer between January 2018 and June 2020 were retrospectively analyzed and compared between patients who underwent blastocyst vitrification with kit A (group A, 196 patients) and those who underwent blastocyst vitrification with kit B (group B, 216 patients). Clinical outcomes, including the clinical pregnancy rate, ongoing pregnancy rate, early miscarriage rate, late miscarriage rate, ectopic pregnancy rate, twin pregnancy rate, and induced labor rate due to fetal malformation, were not significantly different between the two groups (P > 0.05). The preterm delivery rate among singleton newborns (11.57% vs. 3.23%, P < 0.05) and the cesarean delivery rate were significantly higher in group B than in group A (70.25% vs. 57.26%, P < 0.05). Birth outcomes, including the male-to-female ratio, low-birth-weight rate, macrosomia rate, birth defect rate, newborn gestational age, neonatal body weight, and singleton neonatal body length, were not significantly different (P > 0.05). Our findings suggest that different vitrification systems might differentially affect birth outcomes. Such disparity could reflect differences in kit composition and/or protocol.ABBREVIATIONS: DMSO: dimethyl sulfoxide; ES: equilibration solution; VS: vitrification solution; BMI: body mass index; ICSI: intracytoplasmic sperm injection; OR: odds ratio; CI: confidence interval.

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

Background

Caesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.

Methods

We searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I²) test > 75% was considered as high heterogeneity.

Results

One thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.

Conclusions

The odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03711-x.

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.

Perinatal complications and live-birth outcomes following assisted reproductive technology: a retrospective cohort study

Background

With the development of assisted reproductive technology (ART) and its increasing success rate in the mainland of China, more attention has been paid to the safety of ART. In this study, we explored the associations between conception by ART and pregnancy/perinatal complications, and neonatal outcomes compared with similar outcomes following spontaneous conception.

Methods

This retrospective cohort study of pregnancies over a 3-year period (2013–2015) was performed at Beijing Obstetrics and Gynecology Hospital, Beijing, China. Subjects were divided into two groups: conception by ART (n = 2256) or spontaneous conception (n = 6768). According to different fertilization modes, the ART group was divided into in vitro fertilization (IVF, n = 1873) and intracytoplasmic sperm injection (ICSI, n = 383) subgroups. The ART group was also divided into two different embryo transfer methods; fresh embryo transfer (ET, n = 1583) and frozen embryo transfer (FET, n = 673) subgroups. Pregnancy complications, perinatal complications, and neonatal outcomes of the enrolled subjects were investigated and analyzed by univariate analysis and multivariate logistic regression.

Results

After adjustment for maternal age, gravidity, parity, maternal education, smoking, alcohol consumption, and body mass index (BMI), pregnancies conceived by ART were associated with a significantly increased incidence of gestational diabetes mellitus (GDM; OR 1.88, 95% CI 1.56–2.27), gestational hypertension (OR 2.18, 95% CI 1.83–2.60), and intrahepatic cholestasis of pregnancy (ICP) (OR 2.79, 95% CI 2.15–3.64), compared with spontaneous conception. These associations were similar for the singleton group. In the twin group, only the incidence of ICP was significantly higher than in controls. We found that pregnancies conceived by ART were associated with perinatal complications, including placental abruption (OR 2.14, 95% CI 1.33–3.45), premature rupture of membranes (PROM; OR 1.24, 95% CI 1.06–1.45), postpartum hemorrhage (OR 2.89, 95% CI 2.33–3.59) and polyhydramnios (OR 2.01, 95% CI 1.29–3.16). The singleton group had a similar result with placental abruption, but not with fetal membranes ruptures before labor and polyhydramnios. There were no significant differences in the incidence of these perinatal complications in the twin group. Some neonatal outcomes, including preterm labor (OR 4.29, 95% CI 3.84–4.80) and low birth weight (OR 1.72, 95% CI 1.42–2.08), were more likely to occur with singleton births after ART. However, there were no significant differences for these outcomes from twin pregnancies. Perinatal complications and neonatal outcomes were consistent between the IVF and ICSI subgroups. The FET and ET subgroups showed a similar increase in complications, except for the incidence of placental abruption. After taking into account the effects of parity, birth plurality and maternal age, the ART group still exhibited increased maternal and neonatal complications, although some differences narrowed or disappeared.

Conclusions

This retrospective cohort study demonstrated that patients who underwent ART were at increased risk of several adverse pregnancy outcomes compared with women who conceived spontaneously. These complications may be attributed in part to the relatively high multiple pregnancy rate after ART. Elective single embryo transfer should be promoted in China to reduce the obstetrical risks of ART pregnancy. Singletons of ART pregnancy exhibited increased maternal and neonatal complications as well, suggesting that underlying infertility or other maternal or parental factors may contribute to the adverse outcomes.

Does parity affect pregnancy outcomes in the elderly gravida?

PURPOSE

To identify whether older primiparas have more complications than do women who continue to deliver children into their late reproductive age. Patients of at least 35 years of age at delivery were included. Within this cohort, data from primiparous and multiparous women were compared.

METHODS

This retrospective study was based on electronic medical records from a single academic center, with more than 7000 deliveries annually. The impact of parity on maternal complications was assessed using a multivariate logistic regression model that adjusted for baseline maternal characteristics and medical history.

RESULTS

During the study period, there were 54 283 deliveries in our medical center. A total of 13,982 (25.7%) patients were at least 35 years old at delivery. The rate of twin pregnancy was higher in the primiparous group (1.9%) as compared to the multiparous group (0.8%, 95% CI 0.30-0.64, P < 0.001), as was the incidence of delivery prior to 34 weeks (6.1% of the primiparas versus 2.9% of the multiparas, P < 0.001, OR 2.16, 95% CI 1.75-2.68); hypertensive disorders (3.9% versus 1.7%, P < 0.001, 95% CI 0.33-0.57); diabetes (4.6% versus 3.2%, P = 0.003, 95% CI 0.55-0.88); and IUGR (10.5% versus 4.7%, P < 0.001, 95% CI 0.35-049), respectively. The increased risk for pre-term delivery, hypertensive disorders, diabetes, and IUGR was maintained after logistic regression analysis.

CONCLUSION

We found that pregnancy complications typical to older parous women are significantly more common among primiparas, indicating that not only older age, but also having a first child relatively late in the reproductive period contributes to adverse pregnancy outcomes.

Uses of dietary supplements and herbal medicines during pregnancy in women undergoing assisted reproductive technologies- A study of taiwan birth cohort

OBJECTIVE

This study aimed to assess the efficacy of dietary supplements and herbal medicines for the care of pregnant women undergoing assisted reproductive technologies (ART).

MATERIALS AND METHODS

A total of 366 women undergoing ART and their children from the dataset of Taiwan Birth Cohort Study (TBCS, 2005) were enrolled in this study. Structured questionnaires were applied to collect the health information at 6-month follow-up after their delivery. The related use patterns were analyzed to investigate the final birth outcomes.

RESULTS

Comparing with those of non-ART group, the women undergoing ART consumed more supplements of multivitamin, fish oil, and calcium than herbal medicines during pregnancy. This study revealed that the consumptions of multivitamin, calcium pills, Genseng, and Suz-Wu-Tang were associated with low birth weight, whereas the intake of Huanglian was associated with birth weight. Besides, the uses of multivitamin and Suz-Wu-Tang were related to lower gestational age of infants.

CONCLUSIONS

Physicians and nurses must educate themselves in dietary supplements and herbal/alternative medicines for offering accurate advices for pregnant women to optimize their care. The results could be of reference for further investigation on longitudinal effects of dietary supplements and herbal medicines during pregnancy in women undergoing ART continuously followed with TBCS.