Fertility treatments and pediatric neoplasms of the offspring: results of a population-based cohort with a median follow-up of 10 years

Long-term gastrointestinal morbidity among twins conceived by assisted reproductive technology

BACKGROUND

Assisted reproductive technologies (ART) increased the incidence of multiple pregnancies, which has a negative effect on offspring health outcomes. The long-term health outcomes for singletons born after ART is well studied, however, studies on ART twin's long-term morbidities are scarce.

OBJECTIVE

This study aimed to investigate a possible association between ART resulting in twin pregnancy and long-term gastrointestinal (GI) morbidity of the offspring.

STUDY DESIGN

A population-based cohort study was performed in a tertiary medical center including twin deliveries born between 1991-2021. Long-term GI morbidities among twins conceived via ART including ovulation induction (OI) and in-vitro fertilization (IVF) were compared with twins born following spontaneous pregnancies. The diagnoses of GI morbidities were defined based on ICD-9 codes as recorded in community clinics and hospitalization files. A Kaplan-Meier survival curve was used to compare the cumulative incidence of GI morbidity among the study group and a Cox proportional hazards model was constructed to control for possible confounders.

RESULTS

A total of 7,790 twins met the inclusion criteria: 2,076 twins (26.6 %) were conceived by ART. The total GI morbidity rate was significantly higher in twins conceived by ART as compared with twins from spontaneous pregnancies (34.9 % for IVF, 34.3 % for OI and 27.0 % for spontaneous twins, p < 0.001). In addition, the cumulative incidence of GI morbidity over time was elevated for twins conceived by ART (log-rank test, p < 0.001). The Cox model, controlling for confounders such as maternal age, gestational age, hypertensive disorders and diabetes mellitus found that using ART resulting in twin pregnancy is an independent risk factor for long-term GI morbidity of twin offspring (adjusted hazards ratio (aHR) for IVF vs. spontaneous = 1.42 (95 %CI 1.27-1.58, p < 0.001; aHR for OI vs spontaneous = 1.38 (95 %CI 1.20-1.60, p < 0.001).

CONCLUSION

In our cohort, twins conceived by ART exhibited a higher risk for long-term GI morbidity compared with spontaneously conceived twins. This association remained after adjustment for confounders although part of the increased risk may be mediated by perinatal complications such as prematurity and cesarean delivery.

Assisted Reproductive Technology and Risk of Childhood Cancer Among the Offspring of Parents With Infertility: Systematic Review and Meta-Analysis

Background

The relationship between assisted reproductive technology (ART) and childhood cancer risk has been widely debated. Previous meta-analyses did not adequately account for the impact of infertility, and this study addresses this gap.

Objective

Our primary objective was to assess the relative risk (RR) of childhood cancer in infertile populations using ART versus non-ART offspring, with a secondary focus on comparing frozen embryo transfer (FET) and fresh embryo transfer (fresh-ET).

Methods

A literature review was conducted through PubMed, Embase, Cochrane, and Web of Science, with a cutoff date of July 10, 2024. The study was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY 202470119). Inclusion criteria were based on the PICOS (Population, Intervention, Comparison, Outcomes, and Study Design) framework: infertile or subfertile couples (population), ART interventions (in vitro fertilization [IVF], intracytoplasmic sperm injection [ICSI], FET, and fresh-ET), non-ART comparison, and childhood cancer risk outcomes. Data abstraction focused on the primary exposures (ART vs non-ART and FET vs fresh-ET) and outcomes (childhood cancer risk). The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale, and the evidence quality was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Pooled estimates and 95% CIs were calculated using random effects models.

Results

A total of 18 studies were included, published between 2000 and 2024, consisting of 14 (78%) cohort studies and 4 (22%) case-control studies, all of which were of moderate to high quality. The cohort studies had follow-up periods ranging from 3 to 18 years. Compared with non-ART conception, ART conception was not significantly associated with an increased risk of childhood overall cancer (RR 0.95, 95% CI 0.71-1.27; GRADE quality: low to moderate). Subgroup analyses of IVF (RR 0.86, 95% CI 0.59-1.25), ICSI (RR 0.76, 95% CI 0.26-2.2), FET (RR 0.98, 95% CI 0.54-1.76), and fresh-ET (RR 0.75, 95% CI 0.49-1.15) showed similar findings. No significant differences were found for specific childhood cancers, including leukemia (RR 0.99, 95% CI 0.79-1.24), lymphoma (RR 1.22, 95% CI 0.64-2.34), brain cancer (RR 1.22, 95% CI 0.73-2.05), embryonal tumors (RR 1, 95% CI 0.63-1.58), retinoblastoma (RR 1.3, 95% CI 0.73-2.31), and neuroblastoma (RR 1.02, 95% CI 0.48-2.16). Additionally, no significant difference was observed in a head-to-head comparison of FET versus fresh-ET (RR 0.99, 95% CI 0.86-1.14; GRADE quality: moderate).

Conclusions

In conclusion, this study found no significant difference in the risk of childhood cancer between offspring conceived through ART and those conceived through non-ART treatments (such as fertility drugs or intrauterine insemination) in infertile populations. While infertility treatments may elevate baseline risks, our findings suggest that whether individuals with infertility conceive using ART or non-ART methods, their offspring do not face a significantly higher risk of childhood cancer. Further research, especially comparing infertile populations who conceive naturally, is needed to better understand potential long-term health outcomes.

Use of signal detection methods to identify associations between prenatal medication exposure and subsequent childhood cancers: a Nordic hypothesis-generating registry-based study

BACKGROUND

Childhood cancer is an important contributor to childhood mortality in high-income countries. Information on associations between childhood cancer and in-utero exposure is absent or limited for most medications. Signal detection methods identify medications where research should be focused but have not been applied to datasets containing prenatal medication exposures and childhood cancers.

RESEARCH DESIGN AND METHODS

The aim of this study was to apply and evaluate four signal detection methods - odds ratios (OR), the information component (IC), sequential probability ratio testing (SPRT), and Bayesian hierarchical models (BHM) - for identification of associations between medications dispensed during pregnancy and subsequent, incident diagnosis of childhood cancer <10 years, using linked Nordic registry data. Signal detection results were compared to propensity score adjusted odds ratios from generalized linear models.

RESULTS

Analysis was performed for 117 medication-cancer pairs with 5 or more observations. The OR had the greatest sensitivity (0.75). The IC had a greater specificity (0.98) than the OR (0.95).

CONCLUSIONS

The IC may be the most appropriate method for identifying signals within this type of data. Reported signals should not be considered sufficient evidence of causal association and must be followed-up by tailored investigations that consider confounding by indication.

ART altered DNA methylation of the imprinted gene H19 in fetal tissue after multifetal pregnancy reduction

PURPOSE

This study aimed to assess whether assisted reproductive technology alters DNA methylation levels at the H19 promoter and H19 imprinting control element (ICE) in fetal tissues obtained after multifetal pregnancy reduction.

METHODS

Fetal tissues from multiple pregnancies were obtained, including fresh and frozen-thawed embryos: nine from conventional in vitro fertilization (c-IVF), four from intracytoplasmic sperm injection (ICSI), ten from cryopreserved IVF embryos (cryo-IVF), and six from cryopreserved ICSI (cryo-ICSI) embryos. Next-generation sequencing-based bisulfite PCR was used to determine the DNA methylation status of three CpG islands (H19-1, H19-2, and H19-3) in the H19 promoter and H19 ICE. The primary outcome was H19-1 DNA methylation status, whereas secondary outcomes assessed H19-2, H19-3, and ICE methylation.

RESULTS

The ICSI (β = -3.189, 95% CI = -5.034 to -1.345, p = 0.0026), cryo-IVF (β = -2.150, 95% CI = -3.706 to -0.593, p = 0.0129), and cryo-ICSI (β = -2.238, 95% CI = -3.817 to -0.659, p = 0.0110) groups exhibited significantly lower methylation levels in the primary outcome H19-1 region than the c-IVF group after adjustment. For the secondary outcome H19-2 region, significant decreases were observed in the cryo-IVF (β = -2.132, 95% CI = -4.071 to -0.192, p = 0.0425) and cryo-ICSI groups (β = -2.598, 95% CI = -4.566 to -0.630, p = 0.0168).

CONCLUSIONS

These findings further indicate that embryo cryopreservation and potentially ICSI can lower the methylation level of the H19 promoter, advocating for careful use of these techniques when necessary.

Medically Assisted Reproduction and Risk of Cancer Among Offspring

Importance

Cancer is a leading cause of death among children worldwide. Treatments used for medically assisted reproduction (MAR) are suspected risk factors because of their potential for epigenetic disturbance and associated congenital malformations.

Objective

To assess the risk of cancer, overall and by cancer type, among children born after MAR compared with children conceived naturally.

Design, Setting, and Participants

For this cohort study, the French National Mother-Child Register (EPI-MERES) was searched for all live births that occurred in France between January 1, 2010, and December 31, 2021 (and followed up until June 30, 2022). The EPI-MERES was built from comprehensive data of the French National Health Data System. Data analysis was performed from December 1, 2021, to June 30, 2023.

Exposure

Use of assisted reproduction technologies (ART), such as fresh embryo transfer (ET) or frozen ET (FET), and artificial insemination (AI).

Main Outcomes and Measures

The risk of cancer was compared, overall and by cancer type, among children born after fresh ET, FET, or AI and children conceived naturally, using Cox proportional hazards regression models adjusted for maternal and child characteristics at birth.

Results

This study included 8 526 306 children with a mean (SD) age of 6.4 (3.4) years; 51.2% were boys, 96.4% were singletons, 12.1% were small for gestational age at birth, and 3.1% had a congenital malformation. There were 260 236 children (3.1%) born after MAR, including 133 965 (1.6%) after fresh ET, 66 165 (0.8%) after FET, and 60 106 (0.7%) after AI. A total of 9256 case patients with cancer were identified over a median follow-up of 6.7 (IQR, 3.7-9.6) years; 165, 57, and 70 were born after fresh ET, FET, and AI, respectively. The overall risk of cancer did not differ between children conceived naturally and those born after fresh ET (hazard ratio [HR], 1.12 [95% CI, 0.96 to 1.31]), FET (HR, 1.02 [95% CI, 0.78 to 1.32]), or AI (HR, 1.09 [95% CI, 0.86 to 1.38]). However, the risk of acute lymphoblastic leukemia was higher among children born after FET (20 case patients; HR 1.61 [95% CI, 1.04 to 2.50]; risk difference [RD], 23.2 [95% CI, 1.5 to 57.0] per million person-years) compared with children conceived naturally. Moreover, among children born between 2010 and 2015, the risk of leukemia was higher among children born after fresh ET (45 case patients; HR, 1.42 [95% CI, 1.06 to 1.92]; adjusted RD, 19.7 [95% CI, 2.8 to 43.2] per million person-years).

Conclusions and Relevance

The findings of this cohort study suggest that children born after FET or fresh ET had an increased risk of leukemia compared with children conceived naturally. This risk, although resulting in a limited number of cases, needs to be monitored in view of the continuous increase in the use of ART.

Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016-2021)

OBJECTIVES

We set out to compare adverse pregnancy and neonatal outcomes in singleton gestations conceived via in vitro fertilization (IVF) to those conceived spontaneously.

METHODS

Retrospective, population-based cohort using the CDC Natality Live Birth database (2016-2021). All singleton births were stratified into two groups: those conceived via IVF, and those conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes was compared between the two groups using Pearson's chi-square test with Bonferroni adjustments. Multivariate logistic regression was used to adjust outcomes for potential confounders.

RESULTS

Singleton live births conceived by IVF comprised 0.86 % of the cohort (179,987 of 20,930,668). Baseline characteristics varied significantly between the groups. After adjusting for confounding variables, pregnancies conceived via IVF were associated with an increased risk of several adverse pregnancy and neonatal outcomes compared to those conceived spontaneously. The maternal adverse outcomes with the highest risk in IVF pregnancies included maternal transfusion, unplanned hysterectomy, and maternal intensive care unit admission. Increased rates of hypertensive disorder of pregnancy, preterm birth (delivery <37 weeks of gestation), and cesarean delivery were also noted. The highest risk neonatal adverse outcomes associated with IVF included immediate and prolonged ventilation, neonatal seizures, and neonatal intensive care unit admissions, among others.

CONCLUSIONS

Based on this large contemporary United States cohort, the risk of several adverse pregnancy and neonatal outcomes is increased in singleton pregnancies conceived via IVF compared to those conceived spontaneously. Obstetricians should be conscious of these associations while caring for and counseling pregnancies conceived via IVF.

Maternal particulate matter exposure and gestational diabetes mellitus: a population-based cohort study

BACKGROUND

Gestational diabetes mellitus prevalence is steadily increasing worldwide, posing a significant threat to the short-term and long-term health of both mother and offspring. Because particulate matter air pollution has been reported to affect glucose metabolism, it was suggested that maternal particulate matter exposure may be associated with the development of gestational diabetes mellitus; however, the evidence is limited and inconsistent.

OBJECTIVE

This study aimed to determine the association between maternal exposure to particulate matter of diameter ≤2.5 µm and of diameter of ≤10 µm and the risk of gestational diabetes mellitus, to identify critical windows of susceptibility and to evaluate effect modification by ethnicity.

STUDY DESIGN

A retrospective cohort study was conducted including pregnancies of women who delivered at a large tertiary medical center in Israel between 2003 and 2015. Residential particulate matter levels were estimated by a hybrid spatiotemporally resolved satellite-based model at 1 km spatial resolution. Multivariable logistic analyses were applied to study the association between maternal particulate matter exposure in different pregnancy periods and gestational diabetes mellitus risk, while adjusting for background, obstetrical, and pregnancy characteristics. Analyses were also stratified by ethnicity (Jewish and Bedouin).

RESULTS

The study included 89,150 pregnancies, of which 3245 (3.6%) were diagnosed with gestational diabetes mellitus. First trimester exposure to both particulate matter of diameter ≤2.5 µm (adjusted odds ratio per 5 μg/m3, 1.09; 95% confidence interval, 1.02-1.17) and particulate matter of diameter of ≤10 µm (adjusted odds ratio per 10 μg/m3, 1.11; 95% confidence interval, 1.06-1.17) was significantly associated with increased risk for gestational diabetes mellitus. In the stratified analyses, the association with first trimester particulate matter of diameter of ≤10 µm exposure was consistent among pregnancies of both Jewish and Bedouin women, whereas the association with first trimester particulate matter of diameter ≤2.5 µm exposure was significant among pregnancies of Jewish women only (adjusted odds ratio per 5 μg/m3, 1.09; 95% confidence interval, 1.00-1.19), as well as association with preconception particulate matter of diameter of ≤10 µm exposure (adjusted odds ratio per 10 μg/m3, 1.07; 95% confidence interval, 1.01-1.14). No association was found between second trimester particulate matter exposure and gestational diabetes mellitus risk.

CONCLUSION

Maternal exposure to both particulate matter of diameter ≤2.5 µm and diameter of 10 µm or less during the first trimester of pregnancy is associated with gestational diabetes mellitus, suggesting that the first trimester is a particular window of susceptibility to the effect of particulate matter exposure on gestational diabetes mellitus risk. The effects found in this study differed by ethnic group, emphasizing the importance of addressing ethnic disparities when assessing environmental impacts on health.

Infertility Treatments Resulting in Twin Pregnancy: Does It Increase the Risk for Future Childhood Malignancy

Background: Controversy exists in the literature regarding the possible association between infertility treatments in singleton pregnancies and long-term risk for childhood malignancy. Data regarding infertility treatments in twins and long-term childhood malignancies are scarce. Objective: We sought to investigate whether twins conceived following infertility treatments are at an increased risk for childhood malignancy. Study design: A population-based retrospective cohort study, comparing the risk for future childhood malignancy in twins conceived by infertility treatments (in vitro fertilization and ovulation induction) and those who were conceived spontaneously. Deliveries occurred between the years 1991 and 2021 in a tertiary medical center. A Kaplan-Meier survival curve was used to compare the cumulative incidence of childhood malignancies, and a Cox proportional hazards model was constructed to control for confounders. Results: During the study period, 11,986 twins met the inclusion criteria; 2910 (24.3%) were born following infertility treatments. No statistically significant differences were noted between the groups comparing the rate (per 1000) of childhood malignancies (2.0 in the infertility treatments group vs. 2.2 in the comparison group, OR 1.04, 95% CI 0.41-2.62; p = 0.93). Likewise, the cumulative incidence over time was comparable between the groups (log-rank test, p = 0.87). In a Cox regression model, controlling for maternal and gestational age, no significant differences in childhood malignancies were noted between the groups (adjusted HR = 0.82, 95% CI 0.49-1.39, p = 0.47). Conclusions: In our population, twins conceived following infertility treatments are not at an increased risk for childhood malignancies.

The Use of Assisted Reproductive Technology by European Childhood Cancer Survivors

CCS often wish to have biological children yet harbour concerns about fertility impairment, pregnancy risks and the general health risks of prospective offspring. To clarify these concerns, health outcomes in survivor offspring born following ART (n = 74, 4.5%) or after spontaneous conception (n = 1585) were assessed in our European offspring study by descriptive and bivariate analysis. Outcomes were compared to a sibling offspring cohort (n = 387) in a 4:1 matched-pair analysis (n = 1681). (i) Survivors were more likely to employ ART than their siblings (4.5% vs. 3.7%, p = 0.501). Successful pregnancies were achieved after a median of one cycle with, most commonly, intracytoplasmic sperm injection (ICSI) using non-cryopreserved oocytes/sperm. (ii) Multiple-sibling births (p < 0.001, 29.7% vs. 2.5%), low birth weight (p < 0.001; OR = 3.035, 95%-CI = 1.615−5.706), and preterm birth (p < 0.001; OR = 2.499, 95%-CI = 1.401−4.459) occurred significantly more often in survivor offspring following ART utilisation than in spontaneously conceived children. ART did not increase the prevalence of childhood cancer, congenital malformations or heart defects. (iii) These outcomes had similar prevalences in the sibling population. In our explorative study, we could not detect an influence on health outcomes when known confounders, such as multiple births, were taken into account.

Assisted Reproductive Technology and Risk of Childhood Cancers

IMPORTANCE

The number of children born through the use of assisted reproductive technology (ART) has been increasing. These children may have higher risks for epigenetic alteration and adverse perinatal outcomes, which may be associated with childhood cancers.

OBJECTIVE

To determine the associations between different modes of conception and childhood cancers and potential mediation by preterm birth and low birth weight.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, population-based cohort study included registry data from 2 308 016 eligible parents-child triads in Taiwan from January 1, 2004, to December 31, 2017. A total of 1880 children with incident childhood cancer were identified. Data were analyzed between September 1, 2020, and June 30, 2022.

EXPOSURE

Mode of conception, defined as (1) natural conception, (2) subfertility and non-ART (ie, infertility diagnosis but no ART-facilitated conception), or (3) ART (ie, infertility diagnosis and ART-facilitated conception).

MAIN OUTCOMES AND MEASURES

Diagnosis of childhood cancer according to the International Classification of Childhood Cancers, Third Edition.

RESULTS

The mean (SD) paternal and maternal ages were 33.28 (5.07) and 30.83 (4.56) years, respectively. Of the 2 308 016 children, 52.06% were boys, 8.16% were born preterm, and 7.38% had low birth weight. During 14.9 million person-years of follow-up (median, 6 years [IQR, 3-10 years]), ART conception was associated with an increased risk of any type of childhood cancers compared with natural conception (hazard ratio, 1.58; 95% CI, 1.17-2.12) and subfertility with non-ART conception (hazard ratio, 1.42; 95% CI, 1.04-1.95). The increased cancer risk of children conceived with ART was mainly owing to leukemia and hepatic tumor. The increased cancer risk associated with ART conception was not mediated by preterm birth or low birth weight.

CONCLUSIONS AND RELEVANCE

In this cohort study, children conceived via ART had a higher risk of childhood cancers than those conceived naturally and those born to parents with an infertility diagnosis did not use ART. The increased risk could not be explained by preterm birth or low birth weight.

Atypical Teratoid Rhabdoid Tumor in a Newborn: Can IVF Be a Risk Factor?

BackgroundIn recent years, with the widespread use of assisted reproductive technologies, questions have arisen regarding the possible relationship between these infertile parents with assisted conception procedures and childhood cancers. Case report: We present a 23-day-old newborn conceived by in vitro fertilization (IVF) with a 53 × 46 × 38 mm intracranial mass detected by magnetic resonance imaging on the 15th postnatal day. The mass, removed on 23rd postnatal day, was an Atypical Teratoid Rhabdoid Tumor (ATRT), WHO grade 4. Conclusions: As far as we know, this is the only neonatally detected ATRT. Further studies are needed to investigate whether there is a causal relationship between IVF and childhood cancers.

Maternal Medication Use and Childhood Cancer in Offspring-Systematic Review and Considerations for Researchers

Cancer is an important cause of childhood mortality, yet the etiology is largely unknown. A combination of pre- and postnatal factors is thought to be implicated, including maternal medication use. We aimed to provide: 1) a systematic review of peer-reviewed publications on associations between maternal medication use and childhood cancer, with a focus on study design and methodology; and 2) suggestions for how to increase transparency, limit potential biases, and improve comparability in studies on maternal medication use and childhood cancer. We conducted a systematic search in the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to June 8, 2020. Altogether, 112 studies were identified. The reviewed studies were heterogeneous in study design, exposure, and outcome classification. In 21 studies (19%), the outcome was any childhood cancer. Of the 91 papers that reported on specific types of cancer, 62% did not report the cancer classification system. The most frequently investigated medication groups were sex hormones (46 studies, excluding fertility medications), and antiinfectives (37 studies). Suggestions for strengthening future pharmacoepidemiologic studies on maternal medication use and childhood cancer relate to choice of cancer classification system, exposure windows, and methods for identification of, and control for, potential confounders.

Oxidative damage-induced hyperactive ribosome biogenesis participates in tumorigenesis of offspring by cross-interacting with the Wnt and TGF-β1 pathways in IVF embryos

In vitro fertilization (IVF) increases the risk of tumorigenesis in offspring. The increased oxidative damage during IVF may be involved in tumor formation. However, the molecular mechanisms underlying this phenomenon remain largely unclear. Using a well-established model of oxidatively damaged IVF mouse embryos, we applied the iTRAQ method to identify proteins differentially expressed between control and oxidatively damaged zygotes and explored the possible tumorigenic mechanisms, especially with regard to the effects of oxidative damage on ribosome biogenesis closely related to tumorigenesis. The iTRAQ results revealed that ribosomal proteins were upregulated by oxidative stress through the Nucleolin/β-Catenin/n-Myc pathway, which stimulated ribosomes to synthesize an abundance of repair proteins to correct the damaged DNA/chromosomes in IVF-derived embryos. However, the increased percentages of γH2AX-positive cells and apoptotic cells in the blastocyst suggested that DNA repair was insufficient, resulting in aberrant ribosome biogenesis. Overexpression of ribosomal proteins, particularly Rpl15, which gradually increased from the 1-cell to 8-cell stages, indicated persistent hyperactivation of ribosome biogenesis, which promoted tumorigenesis in offspring derived from oxidatively damaged IVF embryos by selectively enhancing the translation of β-Catenin and TGF-β1. The antioxidant epigallocatechin-3-gallate (EGCG) was added to the in vitro culture medium to protect embryos from oxidative damage, and the expression of ribosome-/tumor-related proteins returned to normal after EGCG treatment. This study suggests that regulation of ribosome biogenesis by EGCG may be a means of preventing tumor formation in human IVF-derived offspring, providing a scientific basis for optimizing in vitro culture conditions and improving human-assisted reproductive technology.

Impact of interpregnancy interval on long-term childhood neoplasm of the offspring

BACKGROUND

The possible impact of interpregnancy interval (IPI) on perinatal outcomes has long been studied, however, a definition of the optimal interval is still not clear. Both short and long IPIs have been associated with obstetrical syndromes and short and long-term complications. In this study, we sought to explore the impact of IPI on the hazard for neoplasm of the offspring, thus contribute to the present literature in determining the preferred birth spacing.

OBJECTIVE

We aim to investigate the association between short and long IPIs and the hazard for childhood neoplasm of the offspring.

METHODS

A population-based retrospective cohort analysis comparing offspring neoplasm hazard following three different IPIs. Exposure was defined as short (<6 months), or long (>60 months) IPIs, whereas intermediate IPI (6 months - 60 months) served as the comparison group. The study included singleton live births in a tertiary regional hospital between 1991 and 2014. Offspring were followed for 18 years, and all hospitalization records for neoplasm diagnoses were collected. Kaplan-Meier survival curves were used for the cumulative incidence of neoplasm morbidity, and Cox proportional hazards models were used to control for confounders.

RESULTS

During the study period, 144,397 deliveries met the inclusion criteria. Of those, 18,947 (13.1%) occurred in women with short IPI, 114,012 (79%) in women with intermediate IPI, and 11,438 (7.9%) in women with long IPI. 61 benign neoplasms and 80 malignant neoplasms were registered in offspring born after long IPI. The total percentage of neoplasm were the highest in the long IPI group versus the intermediate and short IPI groups (malignant - 0.7%, 0.6%, 0.5% respectively, benign - 0.5%, 0.4%, 0.3% respectively). Controlling for maternal age, diabetes mellitus, preterm delivery, birth weight, smoking, cesarean section, and fertility treatments, long IPI was found to be independently associated with high hazard for long-term pediatric neoplasm related hospitalizations (adjusted HR 1.39, 95% CI 1.09, 1.77). Short IPI may be associated to decreased hazard for childhood neoplasms (adjusted HR 0.74, 95% Cl 0.59, 0.92).

CONCLUSIONS

Long IPI is associated with a high hazard for childhood neoplasms, compared with intermediate and short IPIs. Short IPI may be associated with decreased hazard for childhood neoplasms.

The Association between Ovarian Hyperstimulation Syndrome and Pregnancy Complications following Fertility Treatments

OBJECTIVE

 This study was aimed to assess the association between ovarian hyperstimulation syndrome (OHSS) and pregnancy complications among women who conceived following fertility treatment.

STUDY DESIGN

 A retrospective population-based cohort study, including all singleton deliveries of patients conceived following ovulation induction (OI) or in vitro fertilization (IVF) between 1988 and 2016, was conducted. All births occurred in a single tertiary medical center. A comparison was performed between deliveries of women who had experienced OHSS at early gestation and subsequently had a pregnancy and women without OHSS. Women lacking prenatal care, multiple gestations, and stillbirths were excluded from the analyses. A multivariable logistic regression model was used to control for confounders.

RESULTS

 During the study period, 351,373 deliveries met the inclusion criteria, of which 6,748 were deliveries of infants who were conceived by either IVF or OI. Of this study population, 105 cases (1.6%) composed the exposed group, that is, women who had experienced OHSS with a subsequent live birth. In the multivariate analyses, after controlling for confounders, OHSS was not found as an independent risk factor for preeclampsia, gestational diabetes mellitus (GDM), intrauterine growth restriction (IUGR), preterm delivery (both <37 and <34 weeks), low birth weight (LBW), very LBW (VLBW), small for gestational age (SGA), and caesarean delivery. In a subanalysis conducted solely on the IVF population, similar results were found, aside from the association between OHSS and preterm delivery before 34 weeks of gestation which was statistically significant (adjusted odds ratio [AOR] = 2.3 95% confidence interval [CI]: 1.0-5.3, p = 0.049).

CONCLUSION

 In our population, OHSS was not found as a risk factor for adverse pregnancy and perinatal outcome. In IVF patients, OHSS is a risk factor for preterm delivery before 34 weeks of gestation.

KEY POINTS

· OHSS is not a risk factor for pregnancy complications.. · Complications investigated were preeclampsia, GDM, prematurity, and others.. · In IVF patients, OHSS is a risk factor for preterm delivery..

Association between exposure during pregnancy and the risk of developing solid tumors in second children: Results from a Chinese matched case-control study

BACKGROUND

Even though many studies have proven the risk factors for cancer in children, studies focusing exclusively on second children are absent. This study is designed to examine the association between maternal exposure during pregnancy and the risk of developing solid tumors (STs) in second children.

METHODS

This retrospective matched case-control study included 80 s children with STs and 160 s children without STs matched in terms of birth weight, gestational age, pregnancy body mass index (BMI), and residence from a medical center. Exposure during pregnancy and birth characteristics of these children were investigated through structured questionnaires.

RESULTS

A univariate analysis suggested that birth spacing (OR, 12.70; CI, 4.44-36.34), maternal smoking (OR, 6.00; CI, 1.62-22.16), paternal smoking (OR, 2.20; CI, 1.23-3.93), and common cold (OR,1.94; CI, 1.02-3.69) were associated with an increased risk of second children STs. A multivariate analysis demonstrated that birth spacing (OR, 12.45; CI, 4.00-38.78) and paternal smoking (OR, 2.04; CI, 1.04-3.99) were the main risk factors for STs in second-born children.

CONCLUSION

Long birth spacing (>10 years) and paternal smoking could significantly increase the risk of developing STs in second-born children. Despite the fact that the effects of maternal smoking and the common cold were not significant, it is still recommended to quit smoking, take necessary self-protective measures to reduce the risk of infection.

Maternal Smoking during Pregnancy and the Risk for Childhood Infectious Diseases in the Offspring: A Population-Based Cohort Study

OBJECTIVE

Infectious diseases account for up to 43% of childhood hospitalizations. Given the magnitude of infection-related hospitalizations, we aimed to evaluate the effect of maternal smoking during pregnancy on the risk for long-term childhood infectious morbidity.

STUDY DESIGN

This is a population-based cohort analysis comparing the long-term risk for infectious diseases, in children born to mothers who smoked during pregnancy versus those who did not. Infectious diseases were predefined based on International Classification of Diseases, Ninth Revision codes. Deliveries occurred between the years 1991 and 2014.

RESULTS

A total of 246,854 newborns met the inclusion criteria; 2,986 (1.2%) were born to mothers who smoked during pregnancy. Offspring of smokers had significantly higher risk for several infectious diseases during childhood (upper respiratory tract, otitis, viral infections, and bronchitis) as well as increased risk for total infection-related hospitalizations (odds ratio = 1.5, 95% confidence interval [CI]: 1.3-1.7; p = 0.001). Cumulative incidence of infection-related hospitalizations was significantly higher in offspring of smokers (log-rank test, p = 0.001). Controlling for maternal age, diabetes, hypertensive disorders, and gestational age at index delivery, smoking remained an independent risk factor for infectious diseases during childhood (adjusted hazard ratio = 1.5, 95% CI: 1.3-1.6; p = 0.001).

CONCLUSION

Intrauterine exposure to maternal smoking may create an environment leading to an increased future risk for long-term pediatric infectious morbidity of the offspring.

Inter-pregnancy interval and later pediatric cardiovascular health of the offspring - a population-based cohort study

Recent evidence suggests that a long inter-pregnancy interval (IPI: time interval between live birth and estimated time of conception of subsequent pregnancy) poses a risk for adverse short-term perinatal outcome. We aimed to study the effect of short (<6 months) and long (>60 months) IPI on long-term cardiovascular morbidity of the offspring. A population-based cohort study was performed in which all singleton live births in parturients with at least one previous birth were included. Hospitalizations of the offspring up to the age of 18 years involving cardiovascular diseases and according to IPI length were evaluated. Intermediate interval, between 6 and 60 months, was considered the reference. Kaplan-Meier survival curves were used to compare the cumulative morbidity incidence between the groups. Cox proportional hazards model was used to control for confounders. During the study period, 161,793 deliveries met the inclusion criteria. Of them, 14.1% (n = 22,851) occurred in parturient following a short IPI, 78.6% (n = 127,146) following an intermediate IPI, and 7.3% (n = 11,796) following a long IPI. Total hospitalizations of the offspring, involving cardiovascular morbidity, were comparable between the groups. The Kaplan-Meier survival curves demonstrated similar cumulative incidences of cardiovascular morbidity in all groups. In a Cox proportional hazards model, short and long IPI did not appear as independent risk factors for later pediatric cardiovascular morbidity of the offspring (adjusted HR 0.97, 95% CI 0.80-1.18; adjusted HR 1.01, 95% CI 0.83-1.37, for short and long IPI, respectively). In our population, extreme IPIs do not appear to impact long-term cardiovascular hospitalizations of offspring.

Assisted reproductive technology and long-term ophthalmic morbidity of the offspring

In this study, we investigate if children born following assisted reproduction technologies (ARTs) are at an increased risk for long-term ophthalmic complications. For this purpose, a population-based cohort analysis was conducted which included all deliveries between 1991 and 2014 at a single tertiary medical center. Offspring were classified relative to conception method as ART or spontaneous pregnancies. Offspring hospitalizations up to the age of 18 years involving ophthalmic morbidities were evaluated according to a predefined set of ICD-9 codes. A Kaplan-Meier survival curve was used to compare cumulative hospitalization rates in exposed (ART) and unexposed offspring (spontaneous), and a Cox proportional hazards model was used to control for potential confounders. A total of 243,682 deliveries were included in the study. In that, 1.8% of the deliveries (4364) were of mothers who underwent fertility treatments and 98.2% (239,318) were conceived spontaneously. Offspring born to mothers who underwent fertility treatments had a significantly higher hospitalization rate involving ophthalmic morbidity, as compared to spontaneously conceived offspring (1.2% vs. 1.0%, p = 0.04). The Kaplan-Meier survival curve pointed to a significantly higher cumulative incidence of ophthalmic morbidity following ART (log rank p = 0.02). Cox proportional hazards model was adjusted for maternal age, preterm delivery, maternal hypertensive disorders, diabetes, and mode of delivery which demonstrated ART as an independent risk factor for long-term pediatric ophthalmic morbidity (adjusted hazard ratio = 1.37, CI 1.04-1.80, p-value = 0.02). We concluded that ART is an independent risk factor for long-term ophthalmic morbidity of the offspring.

Long-term endocrine disorders in children born from pregnancies conceived following fertility treatments

BACKGROUND

Despite the endocrine basis of several infertility etiologies, data on long-term endocrine consequences in offspring conceived following fertility treatments remain limited.

AIM

To determine the risk of long-term endocrine disorders among children born after in-vitro fertilization (IVF) and ovulation induction (OI) as compared with spontaneous pregnancies.

STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES

A population-based cohort study including all singleton deliveries occurring between 1991 and 2014 at a single tertiary medical center was performed. Hospitalization rates up to the age of 18 years involving endocrine disorders were compared between children delivered following pregnancies achieved by IVF, OI, and spontaneous pregnancies. A Kaplan-Meier survival curve was used to compare cumulative morbidity incidence. A Cox regression model was used to control for confounders.

RESULTS

During the study period, 242,187 singleton deliveries met the inclusion criteria; 1.0% were following IVF (n = 2603), 0.7% following OI (n = 1721), and the remaining (n = 237,863) were following spontaneous conceptions. Hospitalizations up to the age of 18 years involving endocrine disorders were comparable in children delivered following IVF (0.4%), OI (0.8%) and spontaneous pregnancies (0.5%; p = 0.09). The Kaplan-Meier survival curve demonstrated comparable cumulative incidence of endocrine morbidity following IVF and OI (log-rank p = 0.30). Using the Cox regression model while controlling for confounders, no significant association was noted between IVF (adjusted HR = 0.95, CI 0.51-1.87), or OI (adjusted HR = 1.32, CI 0.78-2.24) conceived pregnancies, and long-term pediatric endocrine morbidity.

CONCLUSIONS

Singletons conceived via fertility treatment do not appear to be at an increased risk for long-term endocrine disorders.

Frequent and mild scrotal heat stress in mice epigenetically alters glucose metabolism in the male offspring

Several studies have reported that health problems occur in assisted reproductive technology (ART)-conceived offspring. Recently, investigations have demonstrated that paternal environmental conditions influence offspring health. However, it is unclear whether the factors that cause male infertility per se affect offspring health and contribute to health problems in ART-born children. Scrotal heat stress represents a common cause for oligoasthenozoospermia, and in these cases, in vitro fertilization-embryo transfer (IVF-ET) is typically recommended for those individuals trying to conceive. We exposed C57BL/6J male mice to frequent and mild scrotal heat stress (fmSHS) (39°C for 30 min once weekly for 5 consecutive wk). Sperm was subjected to IVF-ET with oocytes of untreated C57BL/6J females to produce offspring mice. Glucose intolerance and insulin resistance was observed in the male offspring mice derived from fmSHS-exposed fathers. Islets, after evaluation, remained unchanged. Genes involved in glucose metabolism, especially, those in insulin signaling pathways, showed dysregulation in the liver of the fmSHS-derived male offspring. Differentially methylated regions were found in the sperm of fmSHS-exposed mice by whole genome bisulfite sequencing. Interestingly, abnormal methylation of some genes with altered expression in offspring was observed in both the sperm of fmSHS fathers and the liver of their male offspring. Our results suggest that the factors that cause male infertility can affect male offspring health by an epigenetic mechanism.

Early Life Oxidative Stress and Long-Lasting Cardiovascular Effects on Offspring Conceived by Assisted Reproductive Technologies: A Review

Assisted reproductive technology (ART) has rapidly developed and is now widely practised worldwide. Both the characteristics of ART (handling gametes/embryos in vitro) and the infertility backgrounds of ART parents (such as infertility diseases and unfavourable lifestyles or diets) could cause increased oxidative stress (OS) that may exert adverse influences on gametogenesis, fertilisation, and foetation, even causing a long-lasting influence on the offspring. For these reasons, the safety of ART needs to be closely examined. In this review, from an ART safety standpoint, the origins of OS are reviewed, and the long-lasting cardiovascular effects and potential mechanisms of OS on the offspring are discussed.

The risk for childhood malignancies in the offspring of mothers with previous gestational diabetes mellitus: a population-based cohort study

The hyperglycemic intrauterine environment has been shown to have long-term effects on offspring. We aimed to evaluate its effect on the long-term risk of childhood malignancies. This was a population-based cohort analysis comparing the risk for long-term childhood malignancies (≤18 years) in children born to mothers with and without gestational diabetes mellitus (GDM). Childhood malignancies were diagnosed by physicians and recorded in hospital medical files according to predefined codes based on ICD-9. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. Children to mothers with pre-GDM, with fetal congenital malformations, and with benign tumors were excluded from the analysis. Kaplan-Meier survival curve was constructed to compare cumulative oncological morbidity in both groups over time. Cox proportional hazards model was used to control for confounders. During the study period, 236 893 infants met the inclusion criteria; 10 294 (4.3%) of whom were born to mothers with GDM. Hospitalizations involving malignancy diagnoses were comparable between the groups (0.11 vs. 0.12%; P=0.424), as were the cumulative incidences of total oncological morbidity using a Kaplan-Meier survival curve (log-rank P=0.820). In the Cox regression model, maternal GDM was not associated with increased childhood oncological hospitalizations while controlling for maternal age, gestational age, and hypertensive disorders (adjusted hazard ratio: 1.02, 95% confidence interval: 0.58-1.82, P=0.932). Exposure to intrauterine hyperglycemic environment due to maternal GDM does not increase the risk for childhood malignancies.

Fertility treatments and offspring pediatric infectious morbidities: results of a population-based cohort with a median follow-up of 10 years

OBJECTIVE

To study the association between mode of conception and offspring infectious morbidity risk.

DESIGN

Population-based cohort study.

SETTING

Regional university medical center.

PATIENT(S)

All singleton infants born between the years 1991 and 2014 and discharged alive from the hospital.

INTERVENTION(S)

Follow-up time in the study was calculated from birth to an event, defined as the first offspring hospitalization with any infectious morbidity. All infectious diagnoses were compared between the study groups, and a multivariable survival model was created to study the association between mode of conception and offspring pediatric hospitalization with infectious morbidity, and adjusting for confounding or clinically significant variables.

MAIN OUTCOME MEASURE(S)

First offspring pediatric hospitalization with infectious morbidity.

RESULT(S)

During the study period, 242,187 newborns met the inclusion criteria: 2,603 (1.1%) of which were conceived after undergoing IVF, 1,172 (0.7%) after ovulation induction (OI), and 237,863 (98.3%) were conceived spontaneously. Mothers receiving fertility treatments were older and with higher rates of preterm births and low birthweights. The hospitalizations rates per 1,000 person years of follow-up were 16.34/1,000 person years, 11.61/1,000 person years, and 10.19/1,000 person years, among the IVF, OI, and spontaneously conceived offspring, respectively. The adjusted hazard ratios were 1.26 (95% confidence interval 1.13-1.42) and 1.14 (95% confidence interval 1.00-1.38), for the IVF and OI compared with the spontaneously conceived offspring, respectively. The model adjusted for preterm delivery, birthweight, maternal age, hypertension, diabetes, and cesarean section.

CONCLUSION(S)

Higher risk for infectious morbidity was found among offspring conceived after fertility treatments compared with spontaneously conceived offspring.

Fertility treatments and gastrointestinal morbidity of the offspring

BACKGROUND

Prevalence of pregnancies conceived following fertility treatments is high worldwide. While the impact of fertility treatments on short-term perinatal outcome is well established, long-term consequences are yet to be determined.

OBJECTIVE

To study the association between mode of conception and long-term gastrointestinal morbidity among children born following fertility treatments.

STUDY DESIGN

A population-based cohort analysis including all singleton deliveries occurring between 1991 and 2014 at a single regional tertiary medical center was performed. Fetuses with congenital malformations were excluded. A comparison was performed between children delivered following IVF, OI and spontaneous pregnancies. Hospitalizations up to the age of 18 years involving gastrointestinal morbidity were evaluated. Kaplan-Meier survival curve was used to compare cumulative morbidity incidence. A Cox regression model was used to control for confounders.

RESULTS

During the study period 242,187 singleton deliveries met the inclusion criteria; 1.1% following IVF (n = 2603), and 0.7% following OI (n = 1721). Hospitalization rates involving gastrointestinal morbidity were significantly higher in children conceived following IVF and OI (5.7%, 7.1% respectively) as compared with children conceived spontaneously (5.4%; p = 0.005). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of gastrointestinal morbidity following IVF and OI (log rank p = 0.001). Using a Cox proportional hazards model, controlling for maternal age, preterm delivery, birthweight, maternal diabetes and hypertensive disorders in pregnancy, IVF (adjusted HR = 1.27, CI 1.08-1.50, p = 0.004), was noted as an independent risk factor for long-term pediatric gastrointestinal morbidity.

CONCLUSION

Singletons conceived by IVF appear to be at an increased risk for long-term gastrointestinal morbidity.

Prenatal Exposure to Preeclampsia and Long-Term Ophthalmic Morbidity of the Offspring

The aim of this population-based study was to evaluate whether prenatal exposure to preeclampsia poses a risk for long-term ophthalmic morbidity. A population-based cohort analysis compared the risk of long-term ophthalmic morbidity among children who were prenatally exposed to preeclampsia and those who were not. The study population was composed of children who were born between the years 1991 and 2014 at a single tertiary medical center. Total ophthalmic hospitalization and time-to-event were both evaluated. A Kaplan-Meier survival curve was conducted to compare cumulative ophthalmic hospitalization incidence based on the severity of preeclampsia. Confounders were controlled using a Cox regression model. A total of 242,342 deliveries met the inclusion criteria, of which 7279 (3%) were diagnosed with mild preeclampsia and 2222 (0.92%) with severe preeclampsia or eclampsia. A significant association was found between severe preeclampsia or eclampsia and the risk of long-term vascular-associated ophthalmic morbidity in the offspring (no preeclampsia 0.3%, mild preeclampsia 0.2% and severe preeclampsia or eclampsia 0.5%, p = 0.008). This association persisted after controlling for maternal age and ethnicity (adjusted hazard ratio (HR) 1.861, 95% CI 1.051-3.295). In conclusion, within our population, prenatal exposure to severe preeclampsia or eclampsia was found to be a risk factor for long-term vascular-associated ophthalmic morbidity in the offspring.

Ist unerfüllter Kinderwunsch ein Leiden? – Der Leidensbegriff im Kontext der Kinderwunschtherapie

Der Begriff Leiden ist in der Medizin und in der Bioethik bisher kaum reflektiert und dahingehend in normativer Hinsicht wenig bestimmt. Dennoch bildet das Leiden an einer Unfruchtbarkeit den Ausgangspunkt für die medizintechnischen Interventionen der assistierten reproduktionsmedizinischen Behandlung. Dabei wird implizit angenommen, dass der unerfüllte Kinderwunsch ein Leiden ist. Ob der unerfüllte Kinderwunsch allerdings ein Leiden darstellt, ist bisher nicht eindeutig geklärt worden.

Ziel dieses Beitrages ist es, die Annahme, dass es sich beim unerfüllten Kinderwunsch um ein Leiden handelt, zu überprüfen. Anhand der Darstellung einiger gängiger Leidenskonzeptionen werden Merkmale von Leiden herausgearbeitet, die als treffende Grundannahmen für eine Leidensbestimmung gelten können. Es wird sich zeigen, dass der unerfüllte Kinderwunsch, entsprechend der Leidenskonzeptionen, als ein Leiden angesehen werden sollte, und ihm somit ein normativer Stellenwert zukommt. In einem weiteren Schritt ist zu klären, ob das Leiden an einem unerfüllten Kinderwunsch als ein Rechtfertigungsgrund für reproduktionsmedizinische Interventionen gelten kann. Dafür wird zum einen der Stellenwert von Leiden, als eine anthropologische Grundbedingung, im Zusammenhang mit dem Leidenslinderungsauftrag der Medizin diskutiert. Zum anderen werden die Risiken der reproduktionsmedizinischen Therapien sowie deren Bedeutung als Gesundheitsressourcen erörtert. Dabei wird deutlich, dass Leiden an einem unerfüllten Kinderwunsch immer ein psychosomatischer Komplex ist. Nur unter Berücksichtigung der psychoexistenziellen Dimension des Leidens ergibt sich eine Legitimation für eine angemessene somatische Intervention.

Melatonin and Caffeine Supplementation Used, Respectively, as Protective and Stimulating Agents in the Cryopreservation of Human Sperm Improves Survival, Viability, and Motility after Thawing compared to Traditional TEST-Yolk Buffer

Cryopreservation processes can damage spermatozoa and impair structural and functional cell characteristics. Plasma, nuclear membranes, and cellular organelles can suffer from the freeze and thaw process. This study evaluates the protective and stimulant effect of melatonin and caffeine supplementation on the functional characteristics of human spermatozoa before and after freezing. Thirty seminal samples from normozoospermic men aged 19–45 years old collected between October 2012 and May 2017 were included. Semen samples were supplemented with either 2 mM melatonin (MEL) prior to cryopreservation, 2 mM caffeine (CAF) in postthaw, or CAF and MEL (CM) in precryopreservation and postthaw, respectively. Kinetics and seminal parameters, mitochondrial activity, DNA fragmentation, and reactive oxygen species (ROS) levels were analyzed before and after cryopreservation. A significant reduction in sperm concentration, total and progressive motility, sperm kinetics, and mitochondrial activity, as well as a significant increase in DNA fragmentation and ROS production in postthaw samples compared to fresh samples, was identified. After administration of a caffeine and/or melatonin supplement, there was a significant increase in progressive motility in the CAF (p = 0.005) and CM (p = 0.048) groups, as well as mitochondrial activity in the CM group (p < 0.05). Cryopreservation has negative effects on overall sperm quality and increases ROS production. A combination of caffeine and melatonin in prefreeze and postthaw sperm samples has proven to be a very effective and simple way to improve semen quality. This will be particularly useful for initial low-quality semen samples, those which suffer the most from the freezing/thawing process.

Cancer Risk in Children and Young Adults (Offspring) Born after Medically Assisted Reproduction: A Systematic Review and Meta-Analysis

Many studies have investigated the relationship between medically assisted reproduction (MAR) and health outcomes, particularly cancer, in the offspring. This meta-analysis investigated the association between MAR and childhood cancer. Data sources were PubMed, Scopus, and Web of Science up until June 2018. From the selected studies, we extracted the cancer risk estimates of the exposure of interest (MAR, assisted reproductive technology—ART, and in fitro fertilization—IVF). We conducted the meta-analysis using a random effects model. The outcomes of interest were childhood cancers, classified according to the international classification of childhood cancer (ICCC-3). In our meta-analysis (18 cohort and 15 case-control studies) the overall cancer risk was significantly increased in children conceived by MAR, ART, or IVF. MAR and ART significantly increased the risk for hematological tumors, hepatic tumors, and sarcomas (odds ratio (OR) 1.54; 95% CI 1.18–2.02 and OR 1.92; 95% CI 1.34–2.74, respectively). MAR increased acute myeloid leukemia risk (OR 1.41; 95% CI 1.02–1.95) and ART increased neural cancer risk (OR 1.21; 95% CI 1.01–1.46). Our results suggest an increased risk of cancer in children conceived by MAR. Further studies are needed to investigate the impact of fertility treatments, parental subfertility status, and their association on health outcomes in the offspring.

Fertility treatments and the risk of pediatric obstructive sleep apnea in the offspring-Results from a population-based cohort study

OBJECTIVE

While the impact of fertility treatments on the perinatal outcome is well established, the long-term effects on offspring are yet to be determined. The current study aimed to investigate the risk of long-term obstructive sleep apnea (OSA) among children born following in vitro fertilization (IVF) and ovulation induction (OI) as compared with spontaneously conceived pregnancies.

STUDY DESIGN

A retrospective population-based cohort study was performed. Exposure was defined as delivery following pregnancies conceived by IVF or OI. Incidence of OSA related hospitalizations of the offspring, up to the age of 18 years, was evaluated. A Kaplan-Meier survival curve and multivariable Cox regression models were used to assess the association.

RESULTS

During the study period, 242 187 singleton deliveries met the inclusion criteria; 1.1% were conceived following IVF (n = 2603), and 0.7% following OI (n = 1721). Offspring hospitalization rates, involving OSA (n = 1607), were higher among children conceived following IVF and OI pregnancies as compared with the rate in children conceived spontaneously (1.4% vs 1.2% vs 0.7%, respectively; P < .001). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of OSA related hospitalizations following IVF and OI (log-rank P < .001). Using multiple Cox regression models, controlled for gestational age, maternal age, maternal smoking, maternal obesity, birthweight, offspring gender and obesity, IVF as well as OI exhibited a significant and independent association with pediatric OSA in all models with adjusted hazard ratios of 2.25, (95% confidence interval [CI] = 1.6-3.1) and 1.63 (95% CI = 1.1-2.5), respectively.

CONCLUSION

Both IVF and OI treatments appear to be independently associated with OSA in the offspring.

Risk of cancer in children and young adults conceived by assisted reproductive technology

STUDY QUESTION

Do children conceived by ART have an increased risk of cancer?

SUMMARY ANSWER

Overall, ART-conceived children do not appear to have an increased risk of cancer.

WHAT IS KNOWN ALREADY

Despite the increasing use of ART, i.e. IVF or ICSI worldwide, information about possible long-term health risks for children conceived by these techniques is scarce.

STUDY DESIGN, SIZE, DURATION

A nationwide historical cohort study with prospective follow-up (median 21 years), including all live-born offspring from women treated with subfertility treatments between 1980 and 2001.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All offspring of a nationwide cohort of subfertile women (OMEGA study) treated in one of the 12 Dutch IVF clinics or two fertility clinics. Of 47 690 live-born children, 24 269 were ART-conceived, 13 761 naturally conceived and 9660 were conceived naturally or through fertility drugs, but not by ART. Information on the conception method of each child and potential confounders were collected through the mothers' questionnaires and medical records. Cancer incidence was ascertained through linkage with The Netherlands Cancer Registry from 1 January 1989 until 1 November 2016. Cancer risk in ART-conceived children was compared with risks in naturally conceived children from subfertile women (hazard ratios [HRs]) and with the general population (standardized incidence ratios [SIRs]).

MAIN RESULTS AND THE ROLE OF CHANCE

The median follow-up was 21 years (interquartile range (IQR): 17-25) and was shorter in ART-conceived children (20 years, IQR: 17-23) compared with naturally conceived children (24 years, IQR: 20-30). In total, 231 cancers were observed. Overall cancer risk was not increased in ART-conceived children, neither compared with naturally conceived children from subfertile women (HR: 1.00, 95% CI 0.72-1.38) nor compared with the general population (SIR = 1.11, 95% CI: 0.90-1.36). From 18 years of age onwards, the HR of cancer in ART-conceived versus naturally conceived individuals was 1.25 (95% CI: 0.73-2.13). Slightly but non-significantly increased risks were observed in children conceived by ICSI or cryopreservation (HR = 1.52, 95% CI: 0.81-2.85; 1.80, 95% CI: 0.65-4.95, respectively). Risks of lymphoblastic leukemia (HR = 2.44, 95% CI: 0.81-7.37) and melanoma (HR = 1.86, 95% CI: 0.66-5.27) were non-significantly increased for ART-conceived compared with naturally conceived children.

LIMITATIONS, REASONS FOR CAUTION

Despite the large size and long follow-up of the cohort, the number of cancers was rather small for subgroup analyses as cancer in children and young adults is rare.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, ART-conceived children do not appear to have an increased cancer risk after a median follow-up of 21 years. This large study provides important results, enabling physicians to better inform couples considering ART about the long-term safety of ART for their children. However, larger studies with prolonged follow-up are needed to investigate cancer risk in adults and in children conceived by ICSI and/or from cryopreserved embryos.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by The Dutch Cancer Society (NKI 2006-3631) which funded the OMEGA-women's cohort and Children Cancer Free (KIKA;147) which funded the OMEGA-offspring cohort. We declare no competing interests.

Periconceptional environment and the developmental origins of disease

The concept emerging from Professor David Barker’s seminal research on the developmental origins of later-life disease has progressed in many directions since it was first published. One critical question being when during gestation might environment alter the developmental programme with such enduring consequences. Here, we review the growing consensus from clinical and animal research that the period around conception, embracing gamete maturation and early embryogenesis might be the most vulnerable period. We focus on four types of environmental exposure shown to modify periconceptional reproduction and offspring development and health: maternal overnutrition and obesity; maternal undernutrition; paternal diet and health; and assisted reproductive technology. These conditions may act through diverse epigenetic, cellular and physiological mechanisms to alter gene expression and cellular signalling and function in the conceptus affecting offspring growth and metabolism leading to increased risk for cardiometabolic and neurological disease in later life.

Cancer risk among children conceived by fertility treatment

Prior studies on the association between fertility treatment and childhood cancer risk have generated inconsistent results. We performed a systematic review and meta-analysis of observation studies to summarize the evidence regarding the relation of fertility treatment with childhood cancer risk. A systematic literature search of several databases was conducted through April 2018 to identify relevant studies. The outcomes of interest included overall cancer, haematological malignancies, neural tumours, other solid tumours, and eight specific cancers. The overall risk estimates and corresponding 95% confidence intervals (CIs) were pooled using random-effects meta-analysis. Sixteen cohort and thirteen case-control studies were included. Results showed that children conceived by fertility treatment had significantly higher risk for developing overall cancer (relative risk [RR]: 1.16, 95% CI: 1.01, 1.32), haematological malignancies (RR: 1.39, 95% CI: 1.21, 1.60) and other solid tumours (RR: 1.57, 95% CI: 1.14, 2.16). For specific cancers, fertility treatment was associated with a significantly increased risk of leukaemia (RR: 1.31, 95% CI: 1.09, 1.57) and hepatic tumours (RR: 2.26, 95% CI: 1.32, 3.85). Sensitivity analysis validated evidence of the robustness of the findings. The results may demonstrate a possible association between fertility treatment and an increased risk of cancer among the offspring. However, the findings cannot say whether this increased risk is due to the subfertility itself or to the fertility treatment. Further research is needed to address the underlying mechanisms.

Long-Term Cardiovascular Morbidity in Children Born Following Fertility Treatment

OBJECTIVE

To determine the risk of long-term cardiovascular disease (CVD) among children born following in vitro fertilization (IVF) and compared with spontaneous pregnancies.

STUDY DESIGN

A population-based cohort study including all singleton deliveries occurring between 1991and 2014 at a tertiary medical center was performed. Hospitalizations up to the age of 18 years involving CVD were evaluated in children delivered following IVF, ovulation induction, and spontaneous pregnancies. CVD included valvular disorders, hypertension, arrhythmias, rheumatic disease, cardiomyopathy, ischemic heart disease, and heart failure. Kaplan-Meier survival curves were used to compare cumulative morbidity incidence, and a Cox regression model controlled for confounders.

RESULTS

During the study period, 242 187 singleton deliveries met the inclusion criteria; 1.1% following IVF (n = 2603), and 0.7% following ovulation induction (n = 1721). Hospitalizations up to the age of 18 years involving CVD (n = 1503) were comparable in children delivered following IVF (0.6%), ovulation induction (0.7%), and spontaneous pregnancies (0.6%; P = .884). No significant difference in the cumulative incidence of CVD was noted between the groups (log rank P = .781). Controlling for maternal age, gestational age, birthweight, maternal diabetes, and hypertensive disorders in pregnancy, fertility treatment was not noted as a risk factor for long-term pediatric CVD (IVF adjusted hazard ratio 1.05, 95% CI 0.63-1.74, P = .86; ovulation induction adjusted hazard ratio 0.97, CI 95% 0.55-1.71, P = .92).

CONCLUSIONS

Singletons conceived via fertility treatments do not appear to be at an increased risk of long-term pediatric CVD.

Advanced maternal age during pregnancy and the risk for malignant morbidity in the childhood

In the past several decades, rates of delayed childbearing have increased, and as a result, maternal age has advanced. Our objective was to evaluate whether advanced maternal age is independently associated with an increased risk of childhood cancers in the offspring. A retrospective cohort study of women who delivered between the years 1991 and 2014 was conducted. Elderly parturients (≥ 35 years) were divided into two sub-categories: 35-39 and 40-50 years. The comparison group consisted of parturients aged 20-34 years. All hospitalizations of offspring up to the age of 18 years involving malignant morbidity were compared between the groups. A Kaplan-Meier survival curve was used to compare cumulative malignant morbidity incidence of the offspring. A Weibull regression model was used to control for confounders. During the study period, 201,738 deliveries met the inclusion criteria. Of them, 16.3% (n = 32,804) occurred in mothers aged 35 years or more (35-39 years old n = 26,145, 79.7%; 40-50 years old n = 6659, 20.3%). In the Weibull regression model, advanced maternal age exhibited no association with general malignant morbidity in the offspring up to 18 years of age (mothers aged 35-39: adjusted HR 1.06, 95% CI 0.76-1.48, p = 0.727; mothers aged 40-50: adjusted HR 0.73, 95% CI 0.36-1.46, p = 0.373). For leukemia, the regression model exhibited an independent association in maternal ages of 35-39 (adjusted HR 2.23, 95% CI 1.34-3.69, p = 0.002).

CONCLUSION

Advanced maternal age does not appear to raise the risk for future malignancy in the offspring up to the age 18 years. The specific nature of the association between maternal age and leukemia of the offspring necessitates further investigation. What is Known: • Advanced maternal age is associated with a marked elevation in the risk of different pregnancy complications and adverse pregnancy outcomes. What is New: • Advanced maternal age does not appear to raise the risk for future malignancy in the offspring up to the age 18 years. • Leukemia of the offspring may be associated with advanced maternal age although the specific nature of the association necessitates further investigation.

[Culture conditions for gametes and embryos: Which culture medium? Which impact on newborn?]

Many studies have examined the impact of cell/embryo culture media on the development of human embryo during IVF process, but few studies have followed up and compared the effects of these culture media on the developmental outcome of children conceived by IVF. As recurrent experimental evidence from animal studies suggests potential long-term effects of embryo culture media on the health outcome of IVF-conceived children, more studies are needed to clarify the role of the culture media and mechanisms underlying such effects. In human, however, the effects of culture media are difficult to pinpoint due to complications stem from both the influence of maternal nutrition during the gestational period and the parental genetic. Based on a simple review of the literature integrating animal experimentations and human clinic studies, we suggest that the composition of culture medium should be considered beyond the character of unique or sequential medium, corresponding to "let embryo choose" or "back to nature" respectively. Instead, we suggest that the main components of embryo culture media should be considered from the point of view of metabolic consequences and potential epigenetic effects. Given that energetic metabolites can regulate epigenetic machinery, we hypothesize that metabolic abnormalities linked to morphological abnormalities could reveal epigenetic defects in embryos.

Transplacental exposure to environmental carcinogens: Association with childhood cancer risks and the role of modulating factors

Biological responses to carcinogens from environmental exposure during adulthood are modulated over years or decades. Conversely, during transplacental exposure, the effects on the human foetus change within weeks, intertwining with developmental mechanisms: even short periods of transplacental exposure may be imprinted in the organism for a lifetime. The pathways leading to childhood and juvenile cancers, such as leukaemias, neuroblastoma/brain tumours, hepatoblastoma, and Willm's tumour involve prenatally-induced genomic, epigenomic and/or non-genomic effects caused by xenobiotics. Pregnant women most often live in complex environmental settings that cause transplacental exposure of the foetus to xenobiotic mixtures. Mother-child biomonitoring should integrate the analysis of chemicals/radiation present in the living and workplace environment with relevant risk modulators related to life style. The interdisciplinary approach for transplacental cancer risk assessment in high-pressure areas should be based on an integrated model for mother-child exposure estimation via profiling the exposure level by water quality analysis, usage of emission grids, and land use maps.