Obstetric outcome and incidence of congenital anomalies in 2351 IVF/ICSI babies

Mitochondrial dysfunction in pregnancy loss: a review

A receptive endometrium, a healthy embryo, and harmonious communication between the mother and the embryo/fetus are necessary for a healthy and successful pregnancy. Pregnancy loss (PL) can be the outcome if there is a flaw in any of these critical developmental processes. Multiple risk factors contribute to PL, including genetic predispositions, uterine abnormalities, immune imbalances, endocrine dysfunctions, and environmental exposures, among others. Despite extensive investigations, more than half of women with recurrent pregnancy loss (RPL) lack identifiable risk factors, and causes of RPL remain elusive. To date, an accumulating body of evidence indicates that mitochondrial dysfunction in reproductive organs or cells is a potential underlying factor that may trigger PL. In this comprehensive review, we delve into the intricate relationship between mitochondrial dysfunction and PL, examining studies that focus on this connection in the context of diverse reproductive organs and cells, to unravel the interwoven links between these factors and gain a deeper understanding of their interconnectedness.

Congenital anomalies observed in children conceived through assisted reproductive technology-a systematic review and meta-analysis

Congenital anomalies (CAs) are a leading cause of perinatal and child mortality. With the increasing use of assisted reproductive technology (ART), there is a growing need for research on the health outcomes of children conceived through ART. This systematic review was performed to assess the incidence of CAs in ART-conceived children compared to those conceived naturally. This review followed the PRISMA 2020 guidelines and was registered with PROSPERO. A total of 113 studies were included in this meta-analysis, comprising 768,929 children in the ART group and 40,709,337 children in the control group which comprised spontaneously conceived (SC) children. The primary findings indicated that ART-conceived children have a marginally higher risk of CAs compared to the control group. Subgroup analyses showed that children conceived via ICSI, Day 3 transfer, and fresh embryo transfer (ET) had a slightly higher risk of CAs than those conceived via IVF, Day 5 transfer, or frozen embryo transfer (FET). The study highlights a slightly increased incidence of CAs among ART-conceived children over SC children, underscoring the importance of improving ART methods and closely monitoring the health of these children to reduce the risk of CAs.

Racial/ethnic disparity in severe maternal morbidity among women who conceived by in vitro fertilization

Background

In vitro fertilization (IVF) as a fertility treatment is associated with adverse perinatal outcomes. Racial/ethnic disparity in severe maternal morbidity (SMM) in women who conceived by IVF is understudied.

Objective

To examine differences in the association between race/ethnicity and SMM between women who conceived spontaneously and those who conceived using IVF.

Methods

We included all singleton live births and stillbirths in the United States, 2016-2021; data were obtained from the National Center for Health Statistics. Maternal race/ethnicity included non-Hispanic White (NHW), non-Hispanic Black (NHB), American Indian and Alaska Native (AIAN), Asian, Pacific Islander (PI), Hispanic, and mixed-race categories. The SMM composite outcome included eclampsia, uterine rupture, peripartum hysterectomy, blood transfusion, and intensive care unit (ICU) admission. We used logistic regression to adjust for potential confounders (such as age, education, parity, prepregnancy body mass index, smoking during pregnancy, chronic hypertension, and preexisting diabetes) and to assess modification of the association between race/ethnicity and SMM by IVF.

Results

The study population included 21,585,015 women: 52% were NHW, 15% NHB, 0.8% AIAN, 6% Asian, 0.2% PI, 24% Hispanic, and 2% were of mixed race. IVF was used by 183,662 (0.85%) women; the rate of the SMM composite outcome was 18.5 per 1000 deliveries and 7.9 per 1000 deliveries in the IVF and spontaneous conception groups, respectively (unadjusted rate ratio 2.34, 95% confidence interval [CI] 2.26-2.43). In women with spontaneous conception, NHB, Asian and mixed-race women had elevated odds of SMM compared with NHW women (adjusted odds ratio [aOR]=1.39, 95% CI 1.37-1.41; aOR=1.04, 95% CI 1.02-1.07; and aOR=1.42, 95% CI 1.38-1.46, respectively). Racial/ethnic disparities in SMM and its components were not different between the IVF and spontaneous conception groups for the mixed-race category. NHB and Hispanic women had significantly higher aORs for uterine rupture/intrapartum hysterectomy compared with NHW women in the IVF group, while Asian women had a higher aOR for ICU admission compared with NHW women in the IVF group.

Conclusion

Women who conceived by IVF have a greater than two-fold higher risk of SMM and this higher risk is evident across all racial/ethnic groups. However, NHB and Hispanic women who conceived by IVF had a higher risk of uterine rupture/hysterectomy, and Asian women who conceived by IVF had a higher risk of ICU admission. Our results warrant further investigation examining pregnancy and postpartum care issues among racial/ethnic minority women who conceive using IVF.

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.

Prognosis of Congenital Anomalies in Conceptions Following In Vitro Fertilization: A Multicenter Retrospective Cohort Study in China

BACKGROUND

Conceptions following in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have an increased risk of congenital anomalies. Few studies have explored the prognosis of fetuses with congenital anomalies. This study aimed to investigate the prevalence and prognosis of congenital anomalies in IVF/ICSI pregnancies, and to analyze the influencing factors contributing to poor prognosis.

METHODS

In this multicenter retrospective cohort study, we followed 405,473 embryo transfer cycles at 15 reproductive centers between January 2010 and December 2019 and enrolled 2,006 intrauterine pregnancies with congenital anomalies. The relatively positive prognosis group with one or more live births and neonatal survival for more than 7 days was compared with the poor prognosis group with poorer outcomes.

RESULTS

Among the 168,270 ongoing intrauterine pregnancy cycles, the prevalence of congenital anomalies was 1.19%, wherein the malformation rates of cycles with late abortion and delivery were 2.37% (716/30,202) and 0.93% (1,290/138,068), respectively. Among all IVF/ICSI cycles with congenital anomalies, the relatively positive prognosis rate was 61.39%. Moreover, the fertilization failure rate (2 pro-nuclei rate < 25%) in the poor prognosis group was significantly higher than that in the relatively positive prognosis group (10.89% vs. 5.09%, p < 0.001). Multivariate logistic regression analysis revealed no significant differences in the relatively positive prognosis rate among the various IVF/ICSI protocols. The relatively positive prognosis rate of fertilization failure cycles was 0.180 times that of normal fertilization cycles.

CONCLUSION

Poor fertilization rates during IVF/ICSI treatments are more likely to have poor prognosis in fetuses or neonates with congenital anomalies, and obstetric management should be strengthened in pregnant women, with which pregnant women should be recommended to strengthen obstetric management.

The Risk of Congenital Anomalies by Fertility Treatment Modality

Importance

Up to 4% of all births in developed nations involve assisted reproductive technology (ART), along with other fertility treatment modalities. Thus, ART pregnancies constitute an important epidemiologic population with a known increased risk of congenital anomalies. In this review, we summarize current fertility treatment modalities and their associated risk of congenital anomalies.

Objective

To review the risk of birth defects among pregnancies conceived with ART and other fertility treatments.

Evidence Acquisition

Articles were obtained from PubMed and the American College of Obstetricians and Gynecologists and American Society of Reproductive Medicine committee opinions.

Results

In vitro fertilization has been associated with a 25% to 50% increased risk of birth defects, including abnormalities of these organ systems: cardiovascular (25%-40% of anomalies), genitourinary (10%-60%), gastrointestinal (10%-20%), and musculoskeletal (10%-35%). Although the data are mixed, intracytoplasmic sperm injection has also been found to be associated with an increased risk of defects, particularly hypospadias, when compared with conventional in vitro fertilization. The risk among fresh versus frozen cycles and cleavage stage versus blastocyst transfers remains uncertain. There appears to be no significant added risk with preimplantation genetic testing, although more studies are needed. Ovulation induction with oral agents appears safe and not associated with an increased risk of anomalies. Oocyte cryopreservation also appears safe, but the data are still limited, requiring future investigation.

Conclusions and Relevance

While the relative risk of birth defects among ART pregnancies is increased when compared with spontaneous conceptions, the absolute risk remains low. There are no standard screening recommendations for ART pregnancies. Per the American College of Obstetricians and Gynecologists, patients who have undergone ART should be counseled regarding the risk of birth defects and available antenatal evaluation, including fetal echocardiogram and detailed ultrasound evaluation.

Association of medically assisted reproduction with offspring cord blood DNA methylation across cohorts

STUDY QUESTION

Is cord blood DNA methylation associated with having been conceived by medically assisted reproduction?

SUMMARY ANSWER

This study does not provide strong evidence of an association of conception by medically assisted reproduction with variation in infant blood cell DNA methylation.

WHAT IS KNOWN ALREADY

Medically assisted reproduction consists of procedures used to help infertile/subfertile couples conceive, including ART. Due to its importance in gene regulation during early development programming, DNA methylation and its perturbations associated with medically assisted reproduction could reveal new insights into the biological effects of assisted reproductive technologies and potential adverse offspring outcomes.

STUDY DESIGN, SIZE, DURATION

We investigated the association of DNA methylation and medically assisted reproduction using a case–control study design (N = 205 medically assisted reproduction cases and N = 2439 naturally conceived controls in discovery cohorts; N = 149 ART cases and N = 58 non-ART controls in replication cohort).

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

We assessed the association between medically assisted reproduction and DNA methylation at birth in cord blood (205 medically assisted conceptions and 2439 naturally conceived controls) at >450 000 CpG sites across the genome in two sub-samples of the UK Avon Longitudinal Study of Parents and Children (ALSPAC) and two sub-samples of the Norwegian Mother, Father and Child Cohort Study (MoBa) by meta-analysis. We explored replication of findings in the Australian Clinical review of the Health of adults conceived following Assisted Reproductive Technologies (CHART) study (N = 149 ART conceptions and N = 58 controls).

MAIN RESULTS AND THE ROLE OF CHANCE

The ALSPAC and MoBa meta-analysis revealed evidence of association between conception by medically assisted reproduction and DNA methylation (false-discovery-rate-corrected P-value < 0.05) at five CpG sites which are annotated to two genes (percentage difference in methylation per CpG, cg24051276: Beta = 0.23 (95% CI 0.15,0.31); cg00012522: Beta = 0.47 (95% CI 0.31, 0.63); cg17855264: Beta = 0.31 (95% CI 0.20, 0.43); cg17132421: Beta = 0.30 (95% CI 0.18, 0.42); cg18529845: Beta = 0.41 (95% CI 0.25, 0.57)). Methylation at three of these sites has been previously linked to cancer, aging, HIV infection and neurological diseases. None of these associations replicated in the CHART cohort. There was evidence of a functional role of medically assisted reproduction-induced hypermethylation at CpG sites located within regulatory regions as shown by putative transcription factor binding and chromatin remodelling.

LIMITATIONS, REASONS FOR CAUTIONS

While insufficient power is likely, heterogeneity in types of medically assisted reproduction procedures and between populations may also contribute. Larger studies might identify replicable variation in DNA methylation at birth due to medically assisted reproduction.

WIDER IMPLICATIONS OF THE FINDINGS

Newborns conceived with medically assisted procedures present with divergent DNA methylation in cord blood white cells. If these associations are true and causal, they might have long-term consequences for offspring health.

STUDY FUNDING/COMPETING INTERESTS(S)

This study has been supported by the US National Institute of Health (R01 DK10324), the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007-2013)/ERC Grant agreement no. 669545, European Union’s Horizon 2020 research and innovation programme under Grant agreement no. 733206 (LifeCycle) and the NIHR Biomedical Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The UK Medical Research Council and Wellcome (Grant ref: 102215/2/13/2) and the University of Bristol provide core support for ALSPAC. Methylation data in the ALSPAC cohort were generated as part of the UK BBSRC funded (BB/I025751/1 and BB/I025263/1) Accessible Resource for Integrated Epigenomic Studies (ARIES, http://www.ariesepigenomics.org.uk). D.C., J.J., C.L.R. D.A.L and H.R.E. work in a Unit that is supported by the University of Bristol and the UK Medical Research Council (Grant nos. MC_UU_00011/1, MC_UU_00011/5 and MC_UU_00011/6). B.N. is supported by an NHMRC (Australia) Investigator Grant (1173314). ALSPAC GWAS data were generated by Sample Logistics and Genotyping Facilities at Wellcome Sanger Institute and LabCorp (Laboratory Corporation of America) using support from 23andMe. The Norwegian Mother, Father and Child Cohort Study is supported by the Norwegian Ministry of Health and Care Services and the Ministry of Education and Research, NIH/NIEHS (Contract no. N01-ES-75558), NIH/NINDS (Grant nos. (i) UO1 NS 047537-01 and (ii) UO1 NS 047537-06A1). For this work, MoBa 1 and 2 were supported by the Intramural Research Program of the NIH, National Institute of Environmental Health Sciences (Z01-ES-49019) and the Norwegian Research Council/BIOBANK (Grant no. 221097). This work was partly supported by the Research Council of Norway through its Centres of Excellence funding scheme, Project no. 262700.

D.A.L. has received support from national and international government and charity funders, as well as from Roche Diagnostics and Medtronic for research unrelated to this study. The other authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Maternal and fetal safety of intravenous immunoglobulin in women with reproductive failure

PROBLEM

Intravenous immunoglobulin G (IVIG) is an emerging regimen for women with reproductive failures (RF) during- or pre-pregnancy who have aberrant cellular immune reactions. Studies investigating teratogenicity of IVIG have been limited. Herein, we evaluated the fetal teratogenicity of IVIG and IVIG-related obstetric complications.

METHOD OF STUDY

Women who used IVIG during pregnancy due to RF with cellular immune aberrances were enrolled from four medical centers in Korea. The pregnancy outcomes were collected.

RESULTS

A total of 370 RF women who used IVIG during their pregnancy were enrolled. Most of the patients started the IVIG therapy before 12 weeks of gestation and 229 women continued IVIG treatment beyond 12 weeks of gestation. The mean age of the subjects was 34.8 years and the mean total dosage of IVIG was 125.3 g. A total of 307 women had livebirths and six of them were twins. Of 301 singleton livebirths, obstetric complications were developed as follows: preterm births (12.0%), gestational diabetes (7.0%), preeclampsia (4.0%), placental abruption (1.3%), placenta previa (4.3%), and placenta accrete (1.7%). Total six cases (1.99%) had major fetal anomalies in livebirths. The incidence of birth defects is similar to those of the general population in Korea and the previous report in infertile women. No IVIG -related viral contamination was noted.

CONCLUSION

IVIG use during pregnancy did not increase obstetric complications and fetal teratogenicity. This study can be an evidence of maternal and fetal safety of IVIG administration during pregnancy.

The association between in vitro fertilization and intracytoplasmic sperm injection treatment and the risk of congenital heart defects

OBJECTIVE

Assisted reproductive technology (ART), an effective treatment modality for infertility, is associated with a higher prevalence of congenital anomalies such as congenital heart defects (CHDs). The present study aimed to evaluate data linking CHDs in infants to pregnancies resulting from in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI).

METHODS

In this study, we conducted a systematic literature search on CHDs in infants following IVF/ICSI in Google Scholar, Embase, Scopus, MEDLINE, and PubMed databases from inception to February 2020. The search strategy used combinations of search keywords that included assisted reproductive technology/ART, in vitro fertilization/IVF, intracytoplasmic sperm injection/ICSI, birth defect, congenital malformation, and congenital heart defects.

RESULTS

Fifty-six studies fulfilled the inclusion criteria and were selected in the current systematic review, which assessed the association between ART and the risk of CHDs.

CONCLUSION

Children conceived by IVF/ICSI manifested an increased risk of CHDs compared with spontaneously conceived children. Further studies are needed to assess the long-term cardiovascular safety of these techniques, which is important for the counseling of patients before the use of ART.

Polycystic ovary syndrome and offspring risk of congenital heart defects: a nationwide cohort study

STUDY QUESTION

Is maternal polycystic ovary syndrome (PCOS) associated with increased offspring risk of congenital heart defects?

SUMMARY ANSWER

This study does not support a strong association between PCOS and an increased risk of congenital heart defects.

WHAT IS KNOWN ALREADY

In addition to affecting reproductive health, PCOS may involve insulin resistance. Maternal pregestational diabetes is associated with an increased risk of congenital heart defects and therefore PCOS may increase the risk of congenital heart defects in the offspring.

STUDY DESIGN, SIZE, DURATION

In this nationwide cohort study, we used data from Danish health registers collected from 1995 to 2018. The study included 1 302 648 offspring and their mothers.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were live singleton offspring born during the study period. Information on maternal PCOS and offspring congenital heart defects was obtained from the National Patient Register. Logistic regression analysis was used to compute prevalence (odds) ratio (PR) of the association between PCOS and offspring congenital heart defects.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 1 302 648 live-born singletons, 11 804 had a mother with PCOS. Of these, 143 offspring had a congenital heart defect (prevalence 121 per 10 000) as compared with 12 832 among mothers without PCOS (prevalence 99 per 10 000). The adjusted PR was 1.22, 95% CI 1.03-1.44 comparing prevalence of congenital heart defects in offspring of women with PCOS with offspring of women without. After adjusting for the potentially mediating effect of pregestational diabetes, the PR was 1.16, 95% CI 0.98-1.37.

LIMITATIONS, REASONS FOR CAUTION

PCOS may be underdetected in the National Patient Register. However, we expect that the mothers that we identified with PCOS truly had PCOS, thus, the estimated associations are not likely to be affected by this misclassification. The study does not provide evidence to rule out a moderate or weak association.

WIDER IMPLICATIONS OF THE FINDINGS

These findings provide reassurance to clinicians counselling pregnant women with PCOS that the disease does not pose a markedly increased risk of offspring congenital heart defects.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Novo Nordisk Foundation. M.L. reports personal fees from Dansk Lægemiddel Information A/S outside the submitted work. The remaining authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Obstetric, neonatal and child development outcomes following assisted hatching treatment: a retrospective cohort study

Assisted hatching (AH) involves artificial disruption of the zona pellucida prior to embryo transfer. The purpose of this study is to examine the safety of AH technique and its effect on obstetrical, perinatal and neonatal outcomes and risk of developmental delay. This is a retrospective cohort of ART cycles using laser AH technique. The study group consisted of 120 cases of AH cycles resulting in singleton pregnancies and live births compared with 113 control cases. A current phone questionnaire was conducted to assess child development in the first year of life. AH was not associated with increased risk for all obstetrical and perinatal outcomes examined including PPROM, gestational diabetes, hypertensive diseases of pregnancy, delivery by cesarean section, gestational age at delivery, low birth weight (LBW), preterm birth and neonatal Apgar score (p>.05). No significant differences were observed between AH and control group in rates and risk of congenital malformations (5.8 vs. 4.4%, respectively, OR 1.33, 95% CI 0.41-4.34) and developmental delay (19.2 vs. 12.8%, respectively, OR 1.62, 95% CI 0.74-3.52). AH did not increase the risk of obstetrical and neonatal complications in singleton pregnancies, including congenital malformations and child developmental delay. AH may therefore be considered a safe method of ART.

Current evidence supporting a goal of singletons: a review of maternal and perinatal outcomes associated with twin versus singleton pregnancies after in vitro fertilization and intracytoplasmic sperm injection

With increasing use of in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) almost 2% of all babies born in the United States each year are now conceived with these technologies, making outcomes of IVF-ICSI extremely important not only to patients and families but to public health. Twin pregnancy rates after IVF-ICSI in the United States have declined since their peak in 2013 but remain at approximately 1 in 10 to 1 in 20 pregnancies. A review of the current international literature on twin versus singleton pregnancy outcomes after IVF-ICSI treatment confirms statistically significantly higher risks to maternal and perinatal health and statistically significantly higher health care costs. The field of infertility care should continue to work to develop practices that lower twin pregnancy rates to an absolute minimum to maximize the safety of these medical treatments.

Preimplantation Genetic Testing: Where We Are Today

BACKGROUND

Preimplantation genetic testing (PGT) is widely used today in in-vitro fertilization (IVF) centers over the world for selecting euploid embryos for transfer and to improve clinical outcomes in terms of embryo implantation, clinical pregnancy, and live birth rates.

METHODS

We report the current knowledge concerning these procedures and the results from different clinical indications in which PGT is commonly applied.

RESULTS

This paper illustrates different molecular techniques used for this purpose and the clinical significance of the different oocyte and embryo stage (polar bodies, cleavage embryo, and blastocyst) at which it is possible to perform sampling biopsies for PGT. Finally, genetic origin and clinical significance of embryo mosaicism are illustrated.

CONCLUSIONS

The preimplantation genetic testing is a valid technique to evaluated embryo euploidy and mosaicism before transfer.

Impact of contraception and IVF hormones on metabolic, endocrine, and inflammatory status

Assisted reproductive technologies (ART) represent commonly utilized management strategies for infertility with multifactorial causes (including genetically predisposed diseases). Amongst ART, in vitro fertilization (IVF) is the most popular. IVF treatment may predispose the mother to increased risks and complications during pregnancy, and there may be adverse fetal outcomes. Hormonal therapies, including oral contraceptives, may impair glucose and lipid metabolism, and promote insulin resistance and inflammation. IVF treatment involves administration of reproductive hormones, similar in composition but in much higher doses than those used for oral contraception. The provision of IVF reproductive hormones to mice associates with glucose intolerance. In addition, the physiological and hormonal changes of pregnancy can trigger an inflammatory response, and metabolic and endocrine changes. There is controversy regarding the potential effects of IVF hormonal therapies in the promotion of diabetogenic and inflammatory states, additional to those that occur during pregnancy, and which may therefore predispose women with IVF-conceived pregnancies to adverse obstetric outcomes compared with women with spontaneously conceived pregnancies. This review summarizes the limited published evidence regarding the effect of IVF-based fertility therapies on glucose homeostasis, insulin resistance, cardio-metabolic profile, and markers of inflammation.

The impact of chorionicity and assisted reproductive therapies in obstetric and neonatal outcomes

Objective: Multiple gestations' incidence have raised worldwide in the last years, much due to assisted reproductive therapies (ART). The goal of this study was to analyze obstetric and neonatal outcomes of twin pregnancies in a level 3 maternity.Methods: A retrospective study including all twins born in a period of 12 years in a level 3 maternity was conducted. Analysis comparing spontaneous monochorionic and dichorionic twins and spontaneous and ART dichorionic twins were performed. A p value < .05 was considered statistically significant.Results: The sample included 1783 newborns from 875 mothers. Mean maternal age was 31 years, with 616 spontaneous pregnancies and 259 through ART. Prematurity occurred in 77%. Congenital malformations were found in 6%, and the mortality rate was 3%. Monochorionic twins had higher prematurity (79% vs 72%) and very low birthweight (VLBW) rate (19% vs 14%). Congenital anomalies (9% vs 6%), Respiratory Distress Syndrome (23% vs 18%), patent ductus arteriosus (7% vs 4%), anemia (11% vs 5%), periventricular hemorrhage (5% vs 3%), mechanical ventilation (16% vs 10%) and mortality (4% vs 2%) were higher in monochorionic twins. Although congenital malformations were more frequent in the ART group, the difference was not statistically significant. The effect of ART in neonatal and obstetric outcomes was related to maternal age.Conclusion: Monochorionic pregnancies were associated with worst obstetric and neonatal outcomes. Although congenital malformations were more frequent in the ART group, the difference was not statistically significant. Most obstetric and neonatal complications were related to advanced maternal age.

The impact of male infertility or intracytoplasmic sperm injection technique on perinatal outcomes

Objective: The aim of this study was to evaluate the impact of male infertility or intracytoplasmic sperm injection (ICSI) technique on perinatal outcomes.Materials and methods: A retrospective cohort study included patients with singleton live births after fresh-cycle embryo transfer that occurred between 1^st January 2016 and 31^st May 2018. The patients were divided into four groups: (1) IVF treatment without male infertility; (2) ICSI treatment without male infertility; (3) ICSI treatment with male infertility; and (4) IVF treatment with male infertility.Result: In total, 2118 patients were analyzed. When comparing perinatal outcomes between the four groups, there were significant differences with regard to gender proportions of offspring and GDM. No statistically significant differences were reported in the incidence of preterm birth, gestational hypertension, placenta previa, fetal malformation, macrosomia, or low birthweight. A separate multiple logistic regression model was performed for each abnormal perinatal outcome to eliminate confounding factors, with the exception of GDM, the above abnormal perinatal outcomes still did not differ significantly when comparing the four groups. However, the incidence of GDM was higher in the third group than it was in the first group. The proportion of male births was significantly decreased in the third and fourth groups.Conclusion: The results showed that ICSI may be associated with the risk of GDM in abnormal perinatal outcomes, but the risk is not due to male infertility. However, male infertility may reduce the proportion of male births.

Safety of Follitropin Alfa/Lutropin Alfa for Stimulation of Follicular Development

Introduction

Recombinant human luteinizing hormone (r-hLH) is used in a fixed-ratio combination with recombinant human follicle-stimulating hormone (r-hFSH) for the stimulation of follicular development.

Objective

The objective of this article was to conduct a review of safety data to evaluate the risks of r-hFSH/r-hLH treatment.

Methods

Data were retrieved from the Global Safety Database (Merck KGaA, Darmstadt, Germany) including reports from healthcare professionals, patients, health authorities, clinical trials, non-interventional studies, and the literature. Reports of important risks (identified and potential) as per the risk management plan applicable at the time of data retrieval were obtained up to December 2017. The estimated patient exposure to r-hFSH/r-hLH in the post-marketing setting was 427,012 treatment cycles. Nine hundred patients received r-hFSH/r-hLH during company-sponsored clinical trials (pre- and post-marketing).

Results

We identified 72 case reports describing important risks related to r-hFSH/r-hLH use, including 46 cases of ovarian hyperstimulation syndrome (10.8 per 100,000 treatment cycles) and 24 of hypersensitivity reaction (5.6 per 100,000 treatment cycles). No thromboembolic events were reported. One congenital anomaly, not suspected to be related to r-hFSH/r-hLH use, was reported during a clinical trial; the event was resolved by corrective surgery. Two fatal cases were identified; one case of recurrent malignant melanoma (suspected to be related to r-hFSH/r-hLH use) and one case resulting from complications of ovarian hyperstimulation syndrome.

Conclusion

Cumulative reporting rates of important identified and potential risks of r-hFSH/r-hLH during a 10-year surveillance period demonstrate the benefit–risk balance is positive. This post-marketing surveillance and continued surveillance of safety events should provide reassurance about the use of r-hFSH/r-hLH in clinical practice.

Electronic supplementary material

The online version of this article (10.1007/s40264-018-0742-3) contains supplementary material, which is available to authorized users.

Preimplantation Genetic Testing for Aneuploidy Improves Clinical, Gestational, and Neonatal Outcomes in Advanced Maternal Age Patients Without Compromising Cumulative Live-Birth Rate

PURPOSE

To report the effects of blastocyst stage aneuploidy testing on clinical, gestational, and neonatal outcomes for patients of advanced maternal age undergoing IVF.

METHODS

This is a single-center observational-cohort study with 2 years follow-up. The study includes a total of 2538 couples undergoing 2905 egg collections (control group), 308 (PGT-A), and 106 (drop-out group, consenting for PGT-A but withdrawing due to poor embryological outcome) RESULTS: Compared with control group, PGT-A showed improved clinical outcomes (live-birth rate per transferred embryo, LBR 40.3% vs 11.0%) and reduced multiple pregnancy rate (MPR, 0% vs 11.1%) and pregnancy loss (PL, 3.6% vs 22.6%). Drop-out group showed the worst clinical outcomes suggesting that abandoning PGT-A due to poor response to ovarian stimulation is not a favorable option. Cytogenetic analysis of product of conceptions and CVS/amniocentesis showed higher aneuploid pregnancy rates for control group regardless of embryo transfer strategy (0%, 17.9%, and 19.9%, for PGT-A, control day 5 and day 3, respectively). Multivariate analysis showed no negative impact of PGT-A-related interventions on cumulative delivery rate (26.3%, 95% CI 21.5-31.6 vs 24.0%, 95% CI 22.5-25.6 for PGT-A and control, respectively) and on neonatal outcomes.

CONCLUSION

PGT-A improves clinical outcomes, particularly by reducing pregnancy loss and chromosomally abnormal pregnancy for patients of advanced maternal age, with no major impact on cumulative live-birth rate (CLBR) per egg retrieval.

Congenital central nervous system anomalies: Ten-year single center experience on a challenging issue in perinatal medicine

Objective

Our goal was to highlight the prenatal diagnosis and management of central nervous system (CNS) anomalies through sharing our clinic’s experience.

Material and Methods

We evaluated prenatal findings and postnatal outcomes of neonates who had a CNS anomaly diagnosis in our clinic over a ten-year period. A total of 183 cases with various CNS anomalies were included in the study. Birth or termination preferences of mothers were recorded in all cases, and postnatal diagnosis concordance and prognosis after surgical procedures were evaluated in mothers who chose to continue the pregnancy.

Results

The mean maternal age was 28.2±5.5 years, mean gravida was 2.2±1.3, and the mean gestational age at diagnosis was 30.5±5.5 weeks. Seventy-five out of 183 (41%) patients chose to terminate their pregnancy. Twenty babies (26.6%) in the termination of pregnancy group had additional anomalies. One hundred eight patients gave birth at our institution. The mean birth weight was 3060±647.5 g, the mean gestational week at delivery was 37.9±1.7 weeks, and mean APGAR score (5th minute) was 8.8±2.3. Four neonates died on the postpartum first day. The postnatal diagnosis of 60 of the 108 (55.5%) patients who gave birth was concordant with the prenatal diagnosis, and 32 of the 108 (29.6%) babies underwent surgical interventions.

Conclusion

CNS anomalies have a broad spectrum and variable prognoses. This study highlights the limitations of prenatal diagnoses, and the need for parents to have this information in order to determine the course of their pregnancy and prepare themselves for the postnatal challenging treatment/rehabilitation process.

Comparison of neonatal outcomes of very low birth weight infants by mode of conception: in vitro fertilization versus natural pregnancy

OBJECTIVE

To compare the neonatal outcomes of very low birth weight (VLBW) infants born after IVF with those of VLBW infants born after natural pregnancy (NP).

DESIGN

Prospective cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 6,871 VLBW infants born from January 2014 to December 2016.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Neonatal mortality and morbidities.

RESULT(S)

Of the 6,871 VLBW infants enrolled, 4,438 infants were born as singletons (IVF = 271; NP = 4,167), and 2,433 infants were born as multiplets (IVF = 1,301; NP = 1,132). After adjustment for maternal and neonatal baseline characteristics, infants born as singletons earlier than 28 weeks after IVF more frequently had high-stage retinopathy of prematurity than those born after NP, whereas infants born as multiplets between 28 and 31 weeks after IVF had fewer major congenital anomalies, high-grade intraventricular hemorrhage, and periventricular leukomalacia than those born after NP. Otherwise, no differences in mortality and neonatal outcomes were found.

CONCLUSION(S)

Very low birth weight infants born as singletons after IVF had comparable neonatal outcomes to those born after NP, except for an increased risk of high-stage retinopathy of prematurity. Very low birth weight infants born as multiplets after IVF had fewer neurologic morbidities than those born after NP.

Severity of congenital heart defects associated with assisted reproductive technologies: Case series and review of the literature

OBJECTIVE

Assisted reproductive technology (ART) has been associated with a higher incidence of congenital anomalies, including a specific increase in the rate of congenital heart defects (CHD). In this study, the rate of CHD in pregnancies resulting from ART at a single high-risk pregnancy referral center are compared to the published literature.

METHODS

Pregnancies were screened by fetal echocardiography for the indication of ART over a 2-year period. CHD were classified as either mild or severe based on the need for postnatal surgical intervention. Results were compared to findings from a literature review of studies examining CHD in pregnancies resulting from ART since 1980.

RESULTS

Over the course of two years, 363 fetuses in 264 pregnancies from our cohort were screened for CHD. The incidence of mild CHD in fetuses from ART pregnancies was 2.75% (10 out of 363 fetuses). None of the affected fetuses had severe CHD. Review of the literature yielded 20 studies since 1980 that examined CHD in pregnancies resulting from ART. Composite data from the studies was described based on characterization of severity of the CHD anomalies. The incidence of mild CHD in ART pregnancies was 2.2%, compared to 1% in non-ART pregnancies (out of 332,157 infants). The incidence of severe CHD in ART pregnancies and naturally conceived pregnancies was 1.4% and 1.2%, respectively (out of 661,455 infants). The incidence of unspecified CHD in ART pregnancies was 1.8%, compared to 1% in naturally conceived pregnancies (out of 1,593,277 infants).

CONCLUSION

The greatest increase in risk appears to be for mild CHD (nonsurgical), which may inform counseling of patients prior to use of assisted reproductive technologies.

Pharmacological treatment for cardiovascular disease during pregnancy and lactation

Maternal circulatory dynamics change drastically during pregnancy and delivery. Therefore, pregnancy with concomitant cardiovascular disease has risks, even for maternal death, in severe cases. This condition has tended to increase with advances in medical care and an increase in the age of pregnant women. Drug therapy during pregnancy and lactation should be administered if it is judged that this is necessary to improve the maternal pathology despite a risk of adverse effects. Fetuses and infants are exposed to maternal drugs, which is a specific concern in drug therapy for pregnant and lactating women. Care is needed because of the risk of adverse effects of teratogenicity in the organogenesis period and fetal toxicity thereafter. However, unstable maternal circulatory dynamics also inhibit fetal development and increase the risk of premature delivery, and stabilization of maternal physiologic condition by drug therapy often gives benefit to fetuses indirectly. Therefore, detailed knowledge of drug therapy during pregnancy should be acquired to manage the condition appropriately. Caution is also needed in using some obstetric drugs, such as tocolytic agents, which influence maternal circulatory dynamics. Therefore, drug therapy during pregnancy and lactation should only be used after full consideration of its benefit and possible harm to the mother and child, and after obtaining consent from the patient after giving a sufficient explanation. In this report, we review drug therapy for pregnant and lactating women with concomitant cardiovascular disease.

Congenital anomalies in infants conceived by infertile women through assisted reproductive technology: A cohort study 2004-2014

This retrospective cohort study aimed to analyse the risk of congenital anomalies (CAs) in infants conceived by infertile women through assisted reproductive technology (ART). A total of 9,013 clinical pregnancy cycles resulting in 9,101 live births between 2004 and 2014 were analysed. Congenital anomalies were evaluated and compared with spontaneous pregnancies in infertile women. A total of 9,101 infants were born following ART. Three subgroups were established: In vitro fertilisation fresh embryo transfer (IVF-ET), n=2,919, intracytoplasmic sperm injection fresh embryo transfer (ICSI), n=1,996 and frozen-thawed embryo transfer (FET), n=4,186. No significant differences in perinatal outcomes were observed between the three subgroups. A total of 105 (1.15%) infants were born with CAs. The birth defect rate was slightly higher in the IVF-ET subgroup compared with the other subgroups. Among infants in the IVF-ET and ICSI-ET subgroup, the probability of birth defects increased with increased maternal age (>35 years), male factors and diminished ovarian reserve. In the FET group, the risk of birth defects was significantly increased with multiple births and maternal age >35 years. The risk of congenital anomalies following ART was not significantly different compared with spontaneous conceptions within the infertile study population. The results of the present study may provide guidance for patients who are considering treatment for infertility in China.

Congenital heart defects according to the types of the risk factors - a single center experience

Objective: The main aim of this study was to compare the prevalence of congenital heart defects (CHDs) between pregnant women with and those without the risk factors. The secondary aim was to determine the influence of the specific risk factors, divided into subgroups, on the development of the CHD. Methods: The presented results were obtained over the course of a 15-year study between years 2002 and 2016. Fetal echocardiography was performed as a planned screening examination during the second trimester of gravidity. A total of 35,831 singleton pregnancies were examined at our center. Risk factors for the development of CHDs were analyzed and divide into the following groups: (i) maternal age ≥35 years; (ii) mother-related risk factors; (iii) pregnancy- and fetus-related risk factors; (iv) pregnancy after in vitro fertilization (IVF); (v) history of CHDs in the first-degree family member; (vi) history of CHDs in the second-degree family member; and (vii) positive genetic family history. Results: The risk factors were identified in 25% (8990/35,831) of pregnancies. In total, CHDs were detected in 1.1% (394/35,831) of fetuses. The prevalence rate of CHDs was higher in the pregnancies with than in those without the risk factors (2.5% [221/8990] versus 0.6% [173/26,841]; p < .0001). The presence of pregnancy- and fetus-related risk factors (odds ratio [OR], 6.5; 95% confidence interval [CI], 4.3-9.7) and pregnancy after IVF (OR, 2.8; 95% CI, 1.5-5.2) were found to be independent risk factors of CHDs. Conclusions: The presence of specific risk factors is related to the increasing prevalence of CHDs. Pregnancy- and fetus-related risk factors and in vitro fertilization were found to be the independent risk factors of CHD.

Multiple pregnancies achieved with IVF/ICSI and risk of specific congenital malformations: a meta-analysis of cohort studies

Studies comparing risk of specific congenital malformations (CM) between multiple pregnancies resulting from IVF/intracytoplasmic sperm injection (ICSI) and those conceived naturally report conflicting results; furthermore, there is a lack of a complete overview. This meta-analysis aimed to address which types of CM are increased in IVF/ICSI multiple pregnancies compared with those conceived naturally. All studies testing the association between IVF/ICSI multiple pregnancies and specific CM identified in various databases were considered. The literature search yielded 856 records, of which 21 cohort studies were included for analysis. Overall, multiple pregnancies achieved with IVF/ICSI experienced a significantly higher risk of chromosomal defects (relative risk [RR] = 1.36; 95% confidence interval [CI]: 1.04-1.77), urogenital (RR = 1.18; 95% CI: 1.03-1.36) and circulatory (RR = 1.22; 95% CI: 1.01-1.47) system malformations. However, the remaining specific CM, such as cleft lip and/or palate, eye, ear, face and neck, respiratory, musculoskeletal, nervous and digestive system malformations, were similar in the two groups. No substantial heterogeneity was observed for most outcomes except for digestive (P = 0.094; I² = 38.3%) and circulatory (P = 0.070; I² = 35.2%) system malformations. These findings provide additional information on risks of IVF/ICSI for use when counselling patients.

Congenital heart defects in IVF/ICSI pregnancy: systematic review and meta-analysis

OBJECTIVE

There is no consensus in current practice guidelines on whether conception by in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) techniques is an indication for performing a fetal echocardiogram. The aim of the study was to assess whether congenital heart defects (CHD) occur more often in pregnancies conceived after IVF/ICSI as compared with those conceived spontaneously.

METHODS

A systematic search for studies was conducted of PubMed/MEDLINE, EMBASE and Scopus from inception to September 2017. The search included the following medical subject heading (MeSH) terms alone or in different combinations: 'IVF', 'IVF/ICSI', 'ART pregnancy', 'assisted conception', 'birth defect', 'congenital heart defects' and 'congenital malformation or abnormalities'. Studies comparing neonatal incidence of CHD in pregnancies conceived after IVF/ICSI and those conceived spontaneously were included. Studies reporting on other types of assisted reproductive technology (ART) or lacking information concerning termination of pregnancy were excluded. Chromosomal abnormalities were excluded in all analyzed studies. A meta-analysis of selected cohort studies was conducted to estimate the pooled odds ratio (OR) with 95% CI using a random-effects model. Statistical heterogeneity among the studies was evaluated with the I2 statistic and Q-test.

RESULTS

Forty-one studies were identified for review including six case-control and 35 cohort studies. Data of eight selected cohort studies were used for meta-analysis. A total of 25 856 children conceived from IVF/ICSI techniques and 287 995 children conceived spontaneously, involving both singleton and multiple gestations, were included in the analysis. Total CHD events were 337/25 856 (1.30%) and 1952/287 995 (0.68%) in the IVF/ICSI and spontaneous conception groups, respectively. The risk of CHD was significantly increased in the IVF/ICSI group as compared with the spontaneous conception group (pooled OR, 1.45; 95% CI, 1.20-1.76; P = 0.0001; I2  = 44%; P = 0.08). In the subgroup of singleton IVF pregnancies, a significant difference was also obtained (OR, 1.55; 95% CI, 1.21-1.99; P = 0.0005; I2  = 36%; P = 0.18) and also multiple confounding factors adjusted ORs showed statistical significance (pooled OR, 1.29; 95% CI, 1.03-1.60; P = 0.02; I2  = 0%; P = 0.43).

CONCLUSION

Fetuses conceived with IVF/ICSI methods are at an increased risk of developing CHD compared with those conceived spontaneously. However, this finding deserves further investigation due to heterogeneity of both ART procedures and cardiac defects. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Which type of congenital malformations is significantly increased in singleton pregnancies following after in vitro fertilization/intracytoplasmic sperm injection: a systematic review and meta-analysis

It is inconclusive nowadays for which type of congenital malformations(CMs) is increased in singleton pregnancies following after in vitro fertilization(IVF)/intracytoplasmic sperm injection(ICSI) compared with those after spontaneous conception; furthermore, a complete overview is missing. We conducted a meta-analysis of cohort studies to assess the risk of specific CMs associated with IVF/ICSI singleton pregnancies. Unrestricted searches were conducted, with an end date parameter of 1 June 2017, of PubMed, Embase, Google Scholar, Cochrane Libraries, and Chinese databases. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. Subgroup and sensitivity analyses were performed to explore potential heterogeneity moderators when significant heterogeneity was observed. Sixteen cohort studies with a total of 129,648 IVF/ICSI and 5,491,949 spontaneously conceived singleton births fulfilled the inclusion criteria. The IVF/ICSI singleton pregnancies had a significantly increased risk of cleft lip and/or palate (OR = 1.34 [95% CI: 1.07–1.69]; I² = 0%), eye, ear, face and neck (odd ratios [OR] = 1.20 [95% CI: 1.04–1.39]; I² = 15%), chromosomal (OR = 1.23 [95% CI: 1.07–1.40]; I² = 32%), respiratory (OR = 1.28 [95% CI: 1.01–1.64]; I² = 37%), digestive (OR = 1.46 [95% CI: 1.29–1.65]; I² = 0%), musculoskeletal (OR = 1.47 [95% CI: 1.25–1.72]; I² = 64%), urogenital (OR = 1.43 [95% CI: 1.18–1.72]; I² = 62%), and circulatory (OR = 1.39 [95% CI: 1.23–1.58]; I² = 46%) system malformations. Relevant heterogeneity moderators have been identified by subgroup analysis. Sensitivity analysis yielded consistent results. No evidence of publication bias was observed. In conclusion, the IVF/ICSI singleton pregnancies are associated with higher risks for most specific CMs. Clinicians should provide appropriate information to counseling IVF/ICSI patients.

In Vitro fertilization and adverse obstetric and perinatal outcomes

Most IVF-conceived children are healthy, but IVF has also been associated with adverse obstetric and perinatal outcomes as well as congenital anomalies. There is also literature suggesting an association between IVF and neurodevelopmental disorders as well as potentially long-term metabolic outcomes. The main driver for adverse outcomes is the higher risk of multiple gestations in IVF, but as the field moves toward single embryo transfer, the rate of multiple gestations is decreasing. Studies have shown that singleton IVF pregnancies still have a higher incidence of adverse outcomes compared to unassisted singleton pregnancies. Infertility itself may be an independent risk factor. Animal models suggest that epigenetic changes in genes involved in growth and development are altered in IVF during the hormonal stimulation and embryo culture. Further animal research and prospective human data are needed to elucidate the mechanisms by which IVF may contribute to adverse outcomes and to decrease risks.

Predictive value of serum progesterone level on β-hCG check day in women with previous repeated miscarriages after in vitro fertilization

OBJECTIVE

To evaluate the predictive value of the progesterone level at the beta-human chorionic gonadotropin (β-hCG) check day for ongoing pregnancy maintenance in in vitro fertilization (IVF) cycles in women with previous unexplained repeated miscarriages.

MATERIALS AND METHODS

One hundred and forty-eight women, with visible gestational sac after IVF, were recruited in this observational study. All subjects had unexplained recurrent miscarriages in more than two previous IVF cycles. The progesterone level at the β-hCG check day (i.e. 14 days after oocyte retrieval) was assessed. The area under the curve (AUC) of the progesterone level was evaluated to predict the ongoing pregnancy or miscarriage outcomes.

RESULTS

The overall ongoing pregnancy rate was 60.8% (90/148). The cut-off value with β-hCG levels higher than 126.5 mIU/mL and with progesterone levels higher than 25.2 ng/mL could be the predictive factors for ongoing pregnancy maintenance (AUC = 0.788 and 0.826; sensitivity = 0.788 and 0.723; specificity = 0.689 and 0.833; P < 0.0001 and P < 0.0001, respectively). The miscarriage rates were 19.5% (15/77) in the women with β-hCG > 126.5 mIU/mL and 13.0% (10/77) in those with > 25.2 ng/mL. In the comparison of the ROC curves between both values, a similar significance was found. The subjects with β-hCG > 126.5 mIU/mL and progesterone > 25.2 ng/mL showed higher ongoing pregnancy rates [98.0% (49/50) vs. 41.8% (41/98)] than those with β-hCG ≤ 126.5 mIU/mL or progesterone ≤ 25.2 ng/mL.

CONCLUSIONS

The progesterone level at 14 days after oocyte retrieval can be a good predictive marker for ongoing pregnancy maintenance in women with repeated IVF failure with miscarriage, together with the β-hCG level. The combined cut-off value of progesterone > 25.2 ng/mL and β-hCG > 126.5 mIU/mL may suggest a good prognosis.