Pregnancy and birth outcomes in couples with infertility with and without assisted reproductive technology: with an emphasis on US population-based studies

The rationale, design of the Assisted reproductive technology cohort nested in a pre-pregnancy family cohort (APP-Cohort)

INTRODUCTION

Infertility has become a major global issue due to the trend of delaying marriage and advanced maternal age. Family/Birth cohort studies are essential for exploring ways to enhance health outcomes at both the individual and societal levels. However, there is a shortage of cohorts that include families who have utilized assisted reproductive technology (ART), particularly initiated at the early stages before pregnancy. The Assisted Reproductive Technology Cohort (APP-Cohort) is a prospective study aiming to investigate the epidemiology and risk factors of adverse gestational outcomes and other health issues in couples who have conceived through ART or naturally.

METHODS

The cohort study's baseline survey commenced in January 2022 at several locations in Beijing, and enrollment is currently in progress. Both spouses filled out a questionnaire covering demographic, socio-economic, and various modifiable risk factors to gather information on their lifestyle. Physical examinations and biochemical tests were carried out, alongside regular yearly health check-ups throughout pregnancy and childhood. The survey data will be connected to electronic medical records to compile health information on the couples, newborns, and children.

DISCUSSION

The APP-Cohort study collected data from both wives and husbands before conception, allowing for early assessment of environmental risk factors for maternal and offspring health. With a focus on various types of risk factors such as genetic, environmental, and shared familial traits, the ongoing follow-up of this study will enable researchers to evaluate and distinguish the impacts of these factors on pregnancy outcomes, perinatal health, and children's health for individuals conceived naturally versus those conceived through ART. By utilizing practical experience and advanced mathematical analysis of the extensive data, the APP-Cohort study will provide valuable insights to promote the administration and success rate of ART in China.

Characteristics of Births Conceived Through Medically Assisted Reproduction by Parental Structure in Louisiana (2016-2023)

Objective: To examine the risk of pregnancy complications and adverse delivery outcomes among births conceived using medically assisted reproduction (MAR) in same-sex, different-sex, and single-parent households. Methods: We conducted a cross-sectional population-based analysis of all MAR births in Louisiana from 2016 to 2023. Based on the sex of both parents listed on the child's birth certificate, we classified births as occurring in different-sex (reference category), same-sex, and single-parent households. We used modified Poisson regression with robust standard errors to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CIs) for all study outcomes including gestational diabetes mellitus (GDM), gestational hypertension (gHTN), induced labor, cesarean delivery, breech delivery, preterm birth, and low birth weight. Results: Among 2,934 MAR-conceived births, 177 (6.0%) were in same-sex relationships, 93 (3.2%) were in single-parent households, and 2,664 (90.8%) were in different-sex relationships. After adjusting for sociodemographic, preexisting health, and pregnancy risk factors, birthing people in same-sex relationships experienced higher risks of labor induction (aRR: 1.23; 95% CI: 1.06, 1.43) and lower risks of cesarean delivery (aRR: 0.89; 95% CI: 0.81, 0.98) compared to those in different-sex relationships. Single-parent households exhibited higher risks of gHTN (aRR: 1.56; 95% CI: 1.10, 2.21). Conclusions: Birthing people in same-sex relationships were at higher risk for labor induction and lower risk of cesarean delivery, while single parents were at greater risk for gHTN. These findings underscore the importance of considering family structure in research and clinical care to address disparities in reproductive health.

COVID-19 vaccination and pregnancy-induced hypertension risk in women undergoing assisted reproduction

STUDY QUESTION

Does COVID-19 vaccination affect the risk of pregnancy-induced hypertension (PIH) in women undergoing ARTs, and does this risk differ based on vaccine type (inactivated vs recombinant) and timing relative to embryo transfer?

SUMMARY ANSWER

Women who received inactivated COVID-19 vaccines before undergoing ART had a significantly increased risk of developing PIH, particularly when vaccinated with two or more doses or when embryo transfer occurred within 1 month of vaccination.

WHAT IS KNOWN ALREADY

COVID-19 vaccination during pregnancy reduces the risk of severe COVID-19 illness with no significant safety concerns for the mother or fetus. PIH is a common complication in ART pregnancies, particularly in older women and those with higher BMI, but the effects of different COVID-19 vaccine types on PIH risk in ART pregnancies remain unclear.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study analyzing 3911 women undergoing ART after receiving COVID-19 vaccines. The study period spanned from 1 December 2020 to 30 September 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were categorized based on COVID-19 vaccination status, vaccine type (inactivated vs recombinant), and the timing of vaccination relative to embryo transfer. The primary outcome was the development of PIH. Multivariate robust Poisson regression was used to assess the association between vaccination and PIH, while subgroup analyses explored the risk across variables like age, BMI, and embryo transfer type.

MAIN RESULTS AND THE ROLE OF CHANCE

Women vaccinated with an inactivated COVID-19 vaccine prior to embryo transfer had a significantly higher incidence of PIH compared to unvaccinated counterparts (relative risk [RR] = 1.45; 95% CI 1.10-1.92; P = 0.009). In contrast, recombinant vaccines did not show a significant association with increased PIH risk (RR = 1.19; 95% CI 0.69-2.05; P = 0.537). The risk was particularly pronounced among women receiving two or more doses of the inactivated vaccines and those who had embryo transfers within 1 month of vaccination. Subgroup analyses showed elevated PIH risk in women aged ≥30 years old, those with BMI ≥22 kg/m2, individuals with secondary infertility, and those undergoing cleavage-stage or fresh embryo transfers.

LIMITATIONS, REASONS FOR CAUTION

The study's retrospective design limits causal inference. The sample is from a single ethnic background, and familial hypertension history was not available, potentially introducing residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

The study suggests that the type and timing of COVID-19 vaccination may influence PIH risk in ART pregnancies. These findings underscore the need for careful consideration of vaccination type and timing in ART protocols and highlight the importance of further prospective studies to validate these results before influencing clinical decision-making.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Hunan High-Level Talent Aggregation Project [2022RC4007]; the National Natural Science Foundation of China [72004148]; the Hunan Provincial Enterprise Joint Fund [2024JJ9093]; the Hunan Provincial Grant for Innovative Province Construction [2019SK4012]; the Deutschlandstipendium of the Charite; the non-restricted research grant of Boehringer Ingelheim Ltd.; and the Research Grant of CITIC-Xiangya [YNXM-202304, 202217]. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Parkinson's Spectrum Mechanisms in Pregnancy: Exploring Hypothetical Scenarios for MSA in the Era of ART

Multiple System Atrophy (MSA) is a rare, rapidly progressive neurodegenerative disorder marked by autonomic dysfunction, parkinsonism, and cerebellar ataxia. While predominantly affecting individuals in their fifth or sixth decade, advancements in assisted reproductive technologies (ART) have created new clinical scenarios involving pregnancies in women within MSA's typical onset range. Given the scarcity of documented MSA pregnancies, this review leverages insights from related Parkinson's spectrum mechanisms to explore hypothetical scenarios for how pregnancy-induced physiological changes might influence MSA progression. Pregnancy-induced hormonal fluctuations, including elevated estrogen and progesterone levels, may modulate α-synuclein aggregation and neuroinflammatory pathways. Immune adaptations, such as fetal microchimerism and Th2-biased immune profiles, introduce additional complexities, particularly in donor embryo pregnancies involving complex microchimerism. Metabolic demands and oxidative stress further intersect with these mechanisms, potentially accelerating disease progression. We analyze existing literature and theoretical models, emphasizing the need for interdisciplinary research. Clinical implications are discussed to propose evidence-based strategies for optimizing maternal-fetal outcomes. This paper identifies critical knowledge gaps and proposes avenues for future investigation to optimize maternal-fetal outcomes in this unique and underexplored clinical intersection.

Safety of Fertility Treatments in Women With Systemic Lupus Erythematosus: Data From a Prospective Population-Based Study

OBJECTIVE

To assess safety of fertility treatments in women with systemic lupus erythematosus (SLE).

DESIGN

Data from the multicentre French observational GR2 (Groupe de Recherche sur la Grossesse et les Maladies Rares) study (2014-ongoing).

SETTING

Seventy-six centres in France.

POPULATION

All pregnancies in women with SLE enrolled in the GR2 study, conceived before 1 August 2022, with available end-of-pregnancy data and known conception type, were included; that is, 577 spontaneous and 53 assisted pregnancies.

METHODS

A comparative analysis of spontaneous and assisted pregnancies was conducted. Logistic regression was used to determine if fertility treatments were independently associated with live birth prognosis, adjusting for confounders (e.g., maternal age). Kaplan-Meier analysis compared cumulative incidences of disease flares and adverse pregnancy outcomes (APOs), with confounding factors adjusted using a Cox regression model.

MAIN OUTCOME MEASURES

Live birth, disease flares, and APOs.

RESULTS

The mean age was older (35.8 vs. 32.3 years, p < 1 × 10-4), and twins were more frequent in assisted pregnancies (5/50, 10.0% vs. 20/554, 3.6%; p = 0.047). Lupus disease was clinically inactive at baseline in 51 (96.2%) assisted pregnancies (vs. n = 511, 89.6%; p = 0.15), with 35 of 45 (77.8%) having no chronic damage (vs. 448/513, 87.3%; p = 0.07). The live birth rate was similar between assisted and spontaneous pregnancies (n = 46, 86.8% vs. n = 505, 87.5%; p = 0.83), with no statistical difference in the incidence of lupus flares and APOs. These results remained consistent after adjusting for confounding factors.

CONCLUSIONS

Fertility treatments in women with mostly well-controlled SLE did not appear to increase risks of maternal and neonatal complications, supporting current recommendations. Trial Registration ClinicalTrials.gov identifier: NCT02450396.

Newborn screening for primary congenital hypothyroidism: past, present and future

This manuscript reviews the evolution of newborn screening for primary congenital hypothyroidism (CH) and explores future strategies to enhance diagnostic accuracy. Over the past few decades, newborn screening has expanded globally, significantly reducing the incidence of severe forms of the disease. However, challenges persist, especially regarding the overdiagnosis of mild cases of primary CH, which may not require treatment. Omic sciences may help researchers to enhance the understanding of primary CH and to uncover new biomarkers to identify mild cases with altered proteomic and/or metabolic profiles associated with the need for treatment. Record-linkage studies can help deepen knowledge on the long-term outcomes of affected children identified through newborn screening. Nevertheless, despite 50 years of newborn screening for primary CH, a minority of newborns currently benefit from this critically important public health intervention. Efforts should be done to expand access to newborn screening globally, especially for those born in developing countries.

Fetal Cardiac Function and Remodeling in In Vitro Fertilization Pregnancies: A Tertiary Center Experience

PURPOSE

To investigate fetal cardiac functions and remodeling in pregnancies conceived via in vitro fertilization (IVF).

METHODS

This prospective case-control study included 40 singleton IVF pregnancies and 46 uncomplicated control pregnancies at 28-36 weeks of gestation. The IVF group consisted of pregnancies applied to the outpatient clinic, excluding those with anatomical or chromosomal abnormalities. Fetal cardiac morphological measurements, left myocardial performance index (MPI), cardiac output, spectral, tissue Doppler, and M-mode measurements were recorded. Ventricular and great vessel size were assessed for fetal cardiac morphology, while MPI, spectral Doppler, and tissue Doppler parameters were assessed for cardiac function.

RESULTS

The right atrial area was statistically increased and the right ventricular basal sphericity index was statistically decreased in the IVF group. The mitral and aortic valves were smaller in the IVF group, while tricuspid and pulmonary valve measurements were similar. Left ventricular ejection time was statistically lower in the IVF group, although the MPI was similar. The IVF group had a higher right fetal MPI on tissue Doppler imaging, but the difference was not statistically significant.

CONCLUSION

This study suggests that IVF pregnancies may demonstrate some effects of fetal cardiac remodeling and mild systolic dysfunction.

Effects of Assisted Reproductive Technology on Genetics, Obstetrics, and Neonatal Outcomes

The prevalence of infertility has increased in the United States over the past decade with 1 in 5 reproductive-aged women suffering from this diagnosis. The use of assisted reproductive technology (ART) to achieve pregnancy has correspondingly steadily increased. After examining the outcomes of ART births, clear trends of increased preterm birth rate, higher-order multiples, and imprinting disorders have been established among ART-related outcomes. However, the relationship between ART and birth defects, abnormal placentation, and stillbirth require further investigation. This review aims to highlight current literature surrounding ART and its relationship with key obstetrical outcomes, neonatal outcomes, and medical genetics.

Resveratrol: potential application in safeguarding testicular health

Factors such as increasing mental pressure and poor living habits in modern society have led to an increase in the incidence of male reproductive diseases, including poor semen quality, testicular malignancy, and congenital developmental defects. The decline of male fertility deserves our attention. Resveratrol (3,4', 5-trihydroxy-trans-Stilbene, 3,4',5-trihydroxy), a polyphenol widely found in plant foods, is expected to enhance testicular function and promote breakthroughs in the treatment of diseases related to the male reproductive system. A large number of studies have shown that in male animals, resveratrol can enhance testicular function and spermatogenesis by activating SIRT1 expression and resist the damage of the testicular system by adverse factors. This article reviews the basic protective pathways of resveratrol against testicular and sperm damage, which involve oxidative stress, cell apoptosis, inflammatory damage, and mitochondrial function. The healthcare framework of predictive, preventive, and personalized medicine (PPPM/3PM) is by far the most beneficial for healthcare and is suitable for the management of chronic diseases. This review also summarizes the health benefits of resveratrol on male reproduction in the context of PPPM/3PM by comprehensively collecting and reviewing the available evidence, thus leading to a working hypothesis that resveratrol can personalize prevention and protection of male reproductive function. It provides a new perspective and direction for future research on the health effects of resveratrol in improving male reproductive function.

Maternal and Neonatal Perinatal Outcomes of Singleton Pregnancies in Advanced-Age Women Undergoing IVF/ICSI-ET Compared with Spontaneous Conception: A Retrospective Propensity Score Matched Cohort Study

Objective

To assess the safety and efficiency of in vitro fertilization/ intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) on maternal and neonatal perinatal outcomes in women (≥40y) with singleton pregnancies.

Methods

This multi-center retrospective cohort study, carried out from January 2018 to June 2023, enrolled 1762 women (≥40y) with singleton pregnancies of at least 28 weeks. Participants were divided into two groups: the IVF/ICSI-ET group (204 cases) and the spontaneous conception (SC) group (1558 cases). After 1:2 propensity score matching (PSM), the two groups were compared for maternal and neonatal outcomes. The SC group (1558 cases) was further divided by age into the <43 years group (1195 cases) and the ≥43 years group (363 cases) for subgroup analysis.

Results

Adverse maternal and neonatal outcomes were comparable between the IVF/ICSI-ET group and the SC group, with a higher cesarean section rate (78% vs 67.5%, P =0.013), an increased maternal ICU admissions rate (5.5% vs 1.3%, P =0.008), and a lower birth defects rate (1.1% vs 4.6%, P =0.037) in the IVF/ICSI-ET group. Subgroup analysis showed that women aged ≥43 years had higher incidences of gestational diabetes, gestational hypertension, cesarean section, and neonatal asphyxia compared to women aged <43 years.

Conclusion

This study indicated IVF/ICSI-ET is relatively safe for women ≥40 years with singleton pregnancies. However, advanced maternal age deteriorated maternal and neonatal outcomes, and IVF/ICSI-ET further heightened the risk of cesarean section and maternal ICU admissions. Therefore, enhanced care and vigilance are crucial for women over 40 undergoing IVF/ICSI-ET.

Internet-Based Abnormal Chromosomal Diagnosis During Pregnancy Using a Noninvasive Innovative Approach to Detecting Chromosomal Abnormalities in the Fetus: Scoping Review

BACKGROUND

Chromosomal abnormalities are genetic disorders caused by chromosome errors, leading to developmental delays, birth defects, and miscarriages. Currently, invasive procedures such as amniocentesis or chorionic villus sampling are mostly used, which carry a risk of miscarriage. This has led to the need for a noninvasive and innovative approach to detect and prevent chromosomal abnormalities during pregnancy.

OBJECTIVE

This review aims to describe and appraise the potential of internet-based abnormal chromosomal preventive measures as a noninvasive approach to detecting and preventing chromosomal abnormalities during pregnancy.

METHODS

A thorough review of existing literature and research on chromosomal abnormalities and noninvasive approaches to prenatal diagnosis and therapy was conducted. Electronic databases such as PubMed, Google Scholar, ScienceDirect, CENTRAL, CINAHL, Embase, OVID MEDLINE, OVID PsycINFO, Scopus, ACM, and IEEE Xplore were searched for relevant studies and articles published in the last 5 years. The keywords used included chromosomal abnormalities, prenatal diagnosis, noninvasive, and internet-based, and diagnosis.

RESULTS

The review of literature revealed that internet-based abnormal chromosomal diagnosis is a potential noninvasive approach to detecting and preventing chromosomal abnormalities during pregnancy. This innovative approach involves the use of advanced technology, including high-resolution ultrasound, cell-free DNA testing, and bioinformatics, to analyze fetal DNA from maternal blood samples. It allows early detection of chromosomal abnormalities, enabling timely interventions and treatment to prevent adverse outcomes. Furthermore, with the advancement of technology, internet-based abnormal chromosomal diagnosis has emerged as a safe alternative with benefits including its cost-effectiveness, increased accessibility and convenience, potential for earlier detection and intervention, and ethical considerations.

CONCLUSIONS

Internet-based abnormal chromosomal diagnosis has the potential to revolutionize prenatal care by offering a safe and noninvasive alternative to invasive procedures. It has the potential to improve the detection of chromosomal abnormalities, leading to better pregnancy outcomes and reduced risk of miscarriage. Further research and development in this field is needed to make this approach more accessible and affordable for pregnant women.

Season, household registry and isolated birth defects: a population-based case-control study in Danyang, China

BACKGROUND

A birth population-based study was conducted in Danyang, Jiangsu Province, to evaluate major birth defects in emerging regions in China with similar maternal and neonatal care conditions.

METHODS

We conducted a population-based study in a cohort of infants born in Danyang from 2014 to 2021, including 55 709 perinatal infants. Four categories of isolated birth defects were defined as cases: congenital heart defects (CHDs; n=2138), polydactyly (n=145), cleft lip with or without palate (CL/P; n=76) and accessory auricles (n=93). Infants with congenital malformations were identified by the Chinese Birth Defects Monitoring Network.

RESULTS

Compared with autumn, conception in spring (OR=1.31 [1.16-1.48]) and winter (OR=1.39 [1.23-1.58]) was associated with an increased risk of CHD. Increased risk of CHD, CL/P and accessory auricles was significantly associated with non-local registered residence (OR=1.17 [1.07-1.28], OR=2.73 [1.52-4.88] and OR=2.11 [1.20-3.71], respectively). Individuals of Han nationality were less likely to have polydactyly (OR=0.23 [0.05-0.98]).

CONCLUSIONS

The season of pregnancy was significantly associated with CHDs. Offspring of mothers with non-local registered hometown had greater risks of CHDs, CL/P and accessory auricles.

The impact of assisted reproductive technologies on ADHD: A systematic review and meta-analysis

BACKGROUND

The escalating utilization of assisted reproductive technology (ART) in response to global infertility rates has spurred research into its complications. Short-term and long-term outcomes have been extensively studied, particularly the neurological concerns surrounding attention-deficit/hyperactivity disorder (ADHD) among ART-conceived children. This study aims investigate the association between ART and ADHD.

METHODS

Medline, Embase, Scopus, and Web of Science databases were searched through April 4, 2023. Cohort, case-control, and cross-sectional studies were eligible for inclusion. primary summary measures included the unadjusted relative risk (RR) and adjusted hazard ratio (HR) with 95 % confidence intervals. Both fixed-effects and random-effects models were utilized for meta-analysis data pooling to determine the overall effect size. The onset of ADHD in children conceived through ART compared to those conceived naturally.

RESULTS

The systematic search yielded 8 studies with 10,176,148 individuals included in the meta-analysis. The meta-analysis revealed a pooled RR of 0.93 (0.68-1.26) for cohort studies and a pooled RR of 0.97 (0.41-2.29) for cross-sectional studies, along with a pooled HR of 1.08 (1.03-1.13) for ADHD in the ART group compared to the non-ART group.

CONCLUSION

While this study identifies some potential association between ART and ADHD, the limited effect size and inherent heterogeneity underscore the need for cautious interpretation.

Comparison of obstetric and perinatal complications in intracytoplasmic sperm injection cycles with autologous oocytes and donated oocytes

OBJECTIVE

The aim of this study was to compare the obstetric and perinatal complications in women who became pregnant with autologous oocytes and those who received donated oocytes (DO) in intracytoplasmic sperm injection cycles (ICSI).

METHODS

A retrospective cohort study was carried out by collecting data from medical records between 2019 and 2022. Only patients who underwent ICSI in an induced cycle using their own or freshly DO, with male infertility factor and tubal factor, were included.

RESULTS

A total of 120 patients were assessed, comprising 51 cases utilizing their own oocytes (control group) and 69 cases employing DO (study group). Patients receiving DO (n=69) exhibited a significantly higher mean age compared to those utilizing their own oocytes (n=51) (41.96±2.16 vs 38.54±1.42 years, p<0.001). There was no significant association between the source of oocytes and gestational age at delivery (p=0.296), birth weight (p=0.836), admission to neonatal intensive care unit (ICU) (p=0.120), or maternal admission to adult ICU (p=0.767). Additionally, the origin of oocytes did not demonstrate any significant association with the risk of pre-eclampsia (p=0.357), gestational diabetes mellitus (p=0.187), premature rupture of membranes (p=0.996), uterine atony (p=0.996), placenta previa (p=0.393), oligohydramnios (p=0.393), or gestational hypertension (p=0.393)."

CONCLUSION

An increase in obstetric and perinatal complications was not observed in pregnancies with DO compared to pregnancies with autologous oocytes in women undergoing ICSI without prior comorbidities. Further studies with larger sample sizes are required to validate our findings.

The Effect of Nutrient Supplementation on Female Fertility: A Systematic Review

Assisted reproductive technologies (ART) have improved infertility treatment but reproductive outcomes remain challenging. Nutrient supplementation is being explored to enhance pregnancy rates, increase live birth rates, and reduce miscarriage rates in females undergoing ART. Nutrients like folic acid, omega-3 fatty acids, and antioxidants have shown potential benefits, yet conflicting results exist. Live birth rates may also be influenced by nutrient supplementation, with coenzyme Q10 and vitamin D showing promise. Miscarriage rates may be reduced with nutrients such as vitamin D, omega-3 fatty acids, and antioxidants, although more research is needed for definitive conclusions. Scientific and medical literature databases such as Cochrane Library, PubMed, and Web of Science were queried to identify relevant English publications adhering to predetermined inclusion and exclusion criteria. Various reproductive metrics, encompassing biochemical pregnancy rate, clinical pregnancy rate, ongoing pregnancy rate, implantation rate, live birth rates, and miscarriage rates, were assessed as clinical endpoints. The study population included 996 female subjects receiving ART. Two studies performed investigations on subjects diagnosed with unexplained infertility, two studies specifically included polycystic ovary syndrome patients, and five studies did not provide any specific information on the type of infertility or subfertility. All studies reported on the clinical/ongoing pregnancy rate, among which four included studies observed a significantly higher rate. Out of the four studies that reported on implantation rates, three found significantly higher rates in treatment groups. Out of the three studies that reported on biochemical pregnancy rates, two studies found significantly higher rates in treatment groups. With respect to the clinical outcomes that were studied in this analysis, variable effects of nutritional supplementation on reproductive parameters were observed. Some studies reported significantly higher rates of clinical/ongoing pregnancy, implantation, biochemical pregnancy, and live birth, while no significant difference was found in miscarriage rates.

Hispanic Ethnicity and Fertility Outcomes

OBJECTIVE

To assess the association between ethnicity and fertility outcomes for men in a statewide cohort.

METHODS

We linked data from the Utah Population Database and Subfertility Health Assisted Reproduction and Environment database, to comprise a cohort of sub-fertile men who underwent semen analysis between 1998 and 2017 in Utah. A multivariable Cox proportional hazard model was constructed to understand the impact of ethnicity on fertility outcomes in our cohort.

RESULTS

A total of 11,363 men were included. 1039 (9.1%) were Hispanic. 39.7% of men in the lowest socioeconomic status group were Hispanic (P <.001). When controlling for demographic and clinical factors, the number of live births was reduced for Hispanic men (hazard ratios [HR] = 0.62 [0.57-0.67], P <.001). Though fertility treatment had a positive effect (HR 1.242 [1.085-1.421], P <.001), in competing risks models, Hispanic men were less likely to use fertility treatment (HR = 0.633 [0.526-0.762], P <.001).

CONCLUSION

Hispanic ethnicity is significantly associated with a lower likelihood of successful fertility outcomes in Utah. Hispanic men had nearly a 40% reduced likelihood of live births when controlling for sociodemographic factors. Our results indicate that, depending on age, Hispanic men have up to approximately 14 fewer live births per 100 men per year, pointing to a significant disparity in fertility outcomes in the state of Utah. Given 15.1% of Utah's population identifies as Hispanic and 18.7% of the United States population identifies as Hispanic on the 2020 Census, a better understanding of the association of ethnicity and fertility outcomes is imperative.

The effect of supportive counseling on self-esteem of infertile women after in vitro fertilization (IVF) failure: a randomized controlled trial study

BACKGROUND

The unsuccessful treatment of infertility can lead to heightened levels of negative emotions, which are often associated with various psychological consequences. These consequences may include a decrease in self-confidence, feelings of loneliness, reduced self-esteem, and even discontinuation of treatment. Therefore, it is crucial to implement interventions that can help improve these consequences for women who have experienced IVF failure. The present study aimed to examine the effect of supportive counseling on self-esteem of infertile women after IVF failure.

METHODS

this randomized clinical trial study was conducted on 63 infertile women after IVF failure, referred to Milad Infertility Center in Mashhad in 2021. In the intervention group, the researcher provided individual supportive counseling sessions. These sessions took place over a span of four weeks, with each session lasting 60 min (One session every week). Data collection was conducted both before and one month after the study using Eysenck self-esteem Questionnaire. Data were analyzed using SPSS25, as well as statistical tests such as chi-square, independent t-test, Paired t-test and Mann-Whitney tests. A significance level of less than 5% was considered.

RESULTS

The study found no significant difference in mean scores of self-esteem between the two groups before the study (p = 0.823). However, after one month, the intervention group had significantly higher self-esteem scores (24.3 ± 18.55) compared to the control group (21.74 ± 5.62) (p = 0.043) Moreover, Based on the Within-group comparison, there was a 2.43 ± 3.24 point increase in self-esteem scores of the intervention group after one month, while the control group showed a -0.33 ± 3.72 point decrease.

CONCLUSION

Supportive counseling was found to be effective in improving self-esteem following IVF failure. As a result, it can be recommended as an effective, affordable, and low-risk counseling approach for women who have experienced IVF failure. By offering supportive counseling, it is possible to help prevent and alleviate the psychological consequences associated with IVF failure.

TRIAL REGISTRATION

This research project was registered at the Iranian Registry of Clinical Trials with code IRCT20210407050883N1- Date of registration 2021-05-25.

Comparison of pregnancy outcomes between 4th day morula and 5th day blastocyst after embryo transfer: a retrospective cohort study

BACKGROUND

This study was designed to evaluate pregnancy outcomes between morulae transferred on day 4 (D4) and blastocysts transferred on day 5 (D5).

METHODS

From September 2017 to September 2020, 1963 fresh transfer cycles underwent early follicular phase extra-long protocol for assisted conception in our fertility center were divided into D4 (324 cases) and D5 (1639 cases) groups, and the general situation and other differences of patients in both groups were compared. To compare the differences in pregnancy outcomes, the D4 and D5 groups were further divided into groups A and B based on single and double embryo transfers. Furthermore, the cohort was divided into two groups: those with live births (1116 cases) and those without (847 cases), enabling a deeper evaluation of the effects of D4 or D5 transplantation on assisted reproductive outcomes.

RESULTS

In single embryo transfer, there was no significant difference between groups D4A and D5A (P > 0.05). In double embryo transfer, group D4B had a lower newborn birthweight and a larger proportion of low birthweight infants (P < 0.05). The preterm delivery rate, twin delivery rate, cesarean delivery rate, and percentage of low birthweight infants were lower in the D5A group than in the D5B group (P < 0.05). Analysis of factors influencing live birth outcomes further confirmed the absence of a significant difference between D4 and D5 transplantation in achieving live birth (P > 0.05).

CONCLUSION

When factors such as working life and hospital holidays are being considered, D4 morula transfer may be a good alternative to D5 blastocyst transfer. Given the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) success rate and risk of twin pregnancy, D4 morula transfer requires an adapted decision between single and double embryo transfer, although a single blastocyst transfer is recommended for the D5 transfer in order to decrease the twin pregnancy rate. In addition, age, endometrial thickness and other factors need to be taken into account to personalize the IVF program and optimize pregnancy outcomes.

Assisted reproductive technologies and postpartum depressive symptoms: A meta-analysis

BACKGROUND

Assisted reproductive technologies (ARTs) have become the main treatment for infertility. ART treatment can be a stressful life event for infertile females. Whether there is an association between ARTs and postpartum depressive symptoms (PDS) has not been established.

METHODS

PubMed, MEDLINE, EMBASE, PsycINFO, and CNKI were searched. The pooled outcome was the difference in incidence of PDS within 1 year postpartum between ARTs and the spontaneous pregnancy group.

RESULTS

A total of 12 cohort studies, which were conducted in eight developed countries and two developing countries, were involved. In total, 106,338 pregnant women, including 4990 infertile females with ARTs treatment and 101,348 women with spontaneous pregnancy, were enrolled in our final analysis. ARTs women had a lower incidence of PDS compared to the spontaneous pregnancy group according to a random effect model (OR = 0.83, 95 % CI: 0.71-0.97, p = 0.022, I2 = 62.0 %). Subgroup analyses indicated that studies on late PDS (follow-up: 3-12 months postpartum) were more heterogeneous than those on early PDS (follow-up: <3 months postpartum) (I2 = 24.3 % vs. I2 = 0 %, interaction p-value < 0.001). There was a strong relationship between ARTs and late PDS (OR = 0.65, 95 % CI: 0.55-0.77, p < 0.001). Therefore, the possible source of heterogeneity was the postpartum evaluation time, which was confirmed by post-hoc meta-regression.

LIMITATIONS

Some underlying confounders, such as previous psychiatric illness, the limited availability of ARTs, and ethnic disparities, cannot be ignored and may have biased interpretation of the results.

CONCLUSION

The available data suggested that ARTs were associated with lower incidence of PDS, especially when follow-up lasted over 3 months. However, these findings should be interpreted with caution. Better-designed trials are needed to confirm this association.

Mental health in children conceived by Assisted Reproductive Technologies (ARTs): Insights from a longitudinal study of Australian children

BACKGROUND

The mental health of children conceived using Assisted Reproductive Technologies (ARTs) such as In-Vitro-Fertilization (IVF) is a subject of significant controversy. Existing studies suggest children conceived through ART meet physical and cognitive developmental milestones at similar rates to their spontaneously conceived peers, however, a significant number of studies have connected ART conception with mental health conditions, particularly depression and attention-deficit hyperactivity disorder (ADHD) in adolescence. This study, therefore, aimed to determine whether maternal use of ARTs to achieve pregnancy is associated with an increased risk of mental disorders in these children, and whether these effects are sex-dependent or confounded by known covariates in the ART population.

METHODS

Secondary data analysis was performed using Growing Up in Australia: The Longitudinal Study of Australian Children (LSAC) data; a nationally representative population-based cross-sequential cohort study. Multivariate logistic regression models examined the impact of ART (including IVF and other fertility drugs, from LSAC wave-1 and wave-2 conducted in 2004 and 2006, respectively) on mental health outcomes (i.e., autism, ADHD, anxiety and/or depression, from LSAC waves 8 conducted in 2018) in Australian adolescents aged 18-19 years in 2018 (n = 1735). Known sociological and obstetric covariates including maternal age, birth weight, smoking and drinking alcohol during pregnancy, maternal gestational diabetes, postnatal depression, hypertension, and socioeconomic status were considered to generate an adjusted logistic model. Variables with a p-value of <0.05 in the regression models were considered statistically significant.

RESULTS

Of the 1735 mother-child dyads analysed, the maternal mean age was 35.6 years (Standard deviation = ±4.75), approximately 5% of mothers (n = 89) used ART to become pregnant, and 22% of adolescents (n = 384) had a mental disorder. Longitudinal analysis revealed no relationship between ART and children developing a mental disorder in the LSAC population.

CONCLUSION

These results should reassure parents considering ART that there is no increased risk of psychological or neurodevelopmental problems in their ART conceived offspring.

Perinatal outcomes between immediate vs deferred selective termination in dichorionic twin pregnancies with fetal congenital anomalies: a French multicenter study

BACKGROUND

Because selective termination for discordant dichorionic twin anomalies carries a risk of pregnancy loss, deferring the procedure until the third trimester can be considered in settings where it is legal.

OBJECTIVE

To determine whether perinatal outcomes were more favorable following deferred rather than immediate selective termination.

STUDY DESIGN

A French multicenter retrospective study from 2012 to 2023 on dichorionic twin pregnancies with selective termination for fetal conditions, which were diagnosed before 24 weeks gestation. Pregnancies with additional risk factors for late miscarriage were excluded. We defined 2 groups according to the intention to perform selective termination within 2 weeks after the diagnosis of the severe fetal anomaly was established (immediate selective termination) or to wait until the third trimester (deferred selective termination). The primary outcome was perinatal survival at 28 days of life. Secondary outcomes were pregnancy losses before 24 weeks gestation and preterm delivery.

RESULTS

Of 390 pregnancies, 258 were in the immediate selective termination group and 132 in the deferred selective termination group. Baseline characteristics were similar in both groups. Overall survival of the healthy co-twin was 93.8% (242/258) in the immediate selective termination group vs 100% (132/132) in the deferred selective termination group (P<.01). Preterm birth <37 weeks gestation was lower in the immediate than in the deferred selective termination group (66.7% vs 20.2%; P<.01); preterm birth <28 weeks gestation and <32 weeks gestation did not differ significantly (respectively 1.7% vs 0.8%; P=.66 and 8.26% vs 11.4%; P=.36). In the deferred selective termination group, an emergency procedure was performed in 11.3% (15/132) because of threatened preterm labor, of which 3.7% (5/132) for imminent delivery.

CONCLUSION

Overall survival after selective termination was high regardless of the gestational age at which the procedure was performed. Postponing selective termination until the third trimester seems to improve survival, whereas immediate selective termination reduces the risk of preterm delivery. Furthermore, deferred selective termination requires an expert center capable of performing the selective termination procedure on an emergency basis if required.

The relationship between cesarean delivery and fecundability: a population-based cohort study

BACKGROUND

Previous studies have found that women who undergo cesarean delivery have fewer pregnancies. Cesarean delivery is also more common among women with lower fecundability. The potential role of cesarean delivery in reduced fecundability is not known.

OBJECTIVE

This study aimed to assess the bidirectional relationship between cesarean delivery and fecundability.

STUDY DESIGN

This was a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥12 months) by mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a cesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,024 women.

RESULTS

The proportion of women with infertility was 7.3% (2707/37,226) among women with a previous vaginal delivery and 9.9% (508/5153) among women with a previous cesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval, 1.10-1.33). Women with a previous cesarean delivery also had a lower fecundability ratio (0.90; 95% confidence interval, 0.88-0.93) than women with a previous vaginal delivery. When assessing the reverse association between fecundability and cesarean delivery, we found that women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery (adjusted relative risk, 1.57; 95% confidence interval, 1.48-1.66) than women who conceived within the first 2 cycles. The associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups.

CONCLUSION

Among women with more than 1 child, those who had a previous cesarean delivery subsequently had a lower fecundability ratio and an increased infertility risk than those who had a vaginal delivery. However, women who needed a longer time to conceive were also more prone to be delivered by cesarean delivery, indicating a bidirectional relationship between cesarean delivery and fecundability. This could suggest a common underlying explanatory mechanism and that the surgical procedure itself may not or only partly directly influence fecundability.

Surgical repair of post-cesarean vesicouterine fistula: A systematic review and a plea for prevention

BACKGROUND

Vesicouterine fistula (VUF) is a iatrogenic injury in the vast majority of cases. The worldwide increase of cesarean delivery rates is expected to lead to increased complications.

OBJECTIVES

To assess current evidence on VUF pathogenesis and surgical management.

SEARCH STRATEGY

Pubmed and Embase databases were searched from January 2000 to January 2023 using relevant key words.

SELECTION CRITERIA

Only original articles including either transabdominal or transvaginal surgical routes for post-cesarean VUF repair, in English language, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the references for eligibility, data extraction, and assessment of methodologic quality. All available surgical outcomes were recorded.

MAIN RESULTS

Of the 1160 studies retrieved, 67 were selected for analysis. Most of these were case reports, case series, or observational cohort studies including a total of 284 patients. The majority (78.6%) of patients had more than one cesarean section, and approximately 10% of them experienced an overt bladder injury and/or uterine rupture at the time of cesarean delivery. The supratrigonal part of the bladder was most commonly involved (92.5%). The majority of patients (88.8%) underwent delayed VUF repair through laparotomy. Length of stay and blood loss were significantly less in patients treated via a minimally invasive approach (P < 0.001 and P = 0.02, respectively). Most patients had double-layer bladder repair and single-layer uterine repair. The overall success rate was 100% on first attempt for each independent combination of different surgical approaches and techniques. Live birth following VUF repair was reported in 23 patients.

CONCLUSIONS

Paying close attention to surgical details is crucial to reduce the incidence of this complication and recurrence rates. Double-layer bladder closure and delayed timing of repair of VUF are recommended.

Magnetic-Assisted Control of Eggs and Embryos via Zona Pellucida-Linked Nanoparticles

Eggs and embryo manipulation is an important biotechnological challenge to enable positioning, entrapment, and selection of reproductive cells to advance into a new era of nature-like assisted reproductive technologies. Oviductin (OVGP1) is an abundant protein in the oviduct that binds reversibly to the zona pellucida, an extracellular matrix that surrounds eggs and embryos. Here, the study reports a new method coupling OVGP1 to magnetic nanoparticles (NP) forming a complex (NPOv). NPOv specifically surrounds eggs and embryos in a reversible manner. Eggs/embryos bound to NPOv can be moved or retained when subjected to a magnetic force, and interestingly only mature-competent eggs are attracted. This procedure is compatible with normal development following gametes function, in vitro fertilization, embryo development and resulting in the birth of healthy offspring. The results provide in vitro proof-of-concept that eggs and embryos can be precisely guided in the absence of physical contact by the use of magnets.

Is large for gestational age in singletons born after frozen embryo transfer associated with freezing technique or endometrial preparation protocol? A longitudinal national French study

STUDY QUESTION

Is large for gestational age (LGA) observed in babies born after frozen embryo transfer (FET) associated with either the freezing technique or the endometrial preparation protocol?

SUMMARY ANSWER

Artificial cycles are associated with a higher risk of LGA, with no difference in rate between the two freezing techniques (vitrification versus slow freezing) or embryo stage (cleaved embryo versus blastocyst).

WHAT IS KNOWN ALREADY

Several studies have compared neonatal outcomes after fresh embryo transfer (ET) and FET and shown that FET is associated with improved neonatal outcomes, including reduced risks of preterm birth, low birthweight, and small for gestational age (SGA), when compared with fresh ET. However, these studies also revealed an increased risk of LGA after FET. The underlying pathophysiology of this increased risk remains unclear; parental infertility, laboratory procedures (including embryo culture conditions and freezing-thawing processes), and endometrial preparation treatments might be involved.

STUDY DESIGN, SIZE, DURATION

A multicentre epidemiological data study was performed through a retrospective analysis of the standardized individual clinical records of the French national register of IVF from 2014 to 2018, including single deliveries resulting from fresh ET or FET that were prospectively collected in fertility centres. Complementary data were collected from the participating fertility centres and included the vitrification media and devices, and the endometrial preparation protocols.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were collected from 35 French ART centres, leading to the inclusion of a total of 72 789 fresh ET, 10 602 slow-freezing FET, and 39 062 vitrification FET. Main clinical outcomes were presented according to origin of the transferred embryos (fresh, slow frozen, or vitrified embryos) and endometrial preparations for FET (ovulatory or artificial cycles), comparing five different groups (fresh, slow freezing-ovulatory cycle, slow freezing-artificial cycle, vitrification-ovulatory cycle, and vitrification-artificial cycle). Foetal growth disorders were defined in live-born singletons according to gestational age and sex-specific weight percentile distribution: SGA and LGA if <10th and ≥90th percentiles, respectively. Analyses were performed using linear mixed models with the ART centres as random effect.

MAIN RESULTS AND THE ROLE OF CHANCE

Transfers led to, respectively, 19 006, 1798, and 9195 deliveries corresponding to delivery rates per transfer of 26.1%, 17.0%, and 23.5% after fresh ET, slow-freezing FET, and vitrification FET, respectively. FET cycles were performed in either ovulatory cycles (n = 21 704) or artificial cycles (n = 34 237), leading to 5910 and 10 322 pregnancies, respectively, and corresponding to pregnancy rates per transfer of 31.6% and 33.3%. A significantly higher rate of spontaneous miscarriage was observed in artificial cycles when compared with ovulatory cycles (33.3% versus 21.4%, P < 0.001, in slow freezing groups and 31.6% versus 21.8%, P < 0.001 in vitrification groups). Consequently, a lower delivery rate per transfer was observed in artificial cycles compared with ovulatory cycles both in slow freezing and vitrification groups (15.5% versus 18.9%, P < 0.001 and 22.8% versus 24.9%, P < 0.001, respectively). Among a total of 26 585 live-born singletons, 16 413 babies were born from fresh ET, 1644 from slow-freezing FET, and 8528 from vitrification FET. Birthweight was significantly higher in the FET groups than in the fresh ET group, with no difference between the two freezing techniques. Likewise, LGA rates were higher and SGA rates were lower in the FET groups compared with the fresh ET group whatever the method used for embryo freezing. In a multivariable analysis, the risk of LGA following FET was significantly increased in artificial compared with ovulatory cycles. In contrast, the risk of LGA was not associated with either the freezing procedure (vitrification versus slow freezing) or the embryo stage (cleaved embryo versus blastocyst) at freezing. Regarding the vitrification method, the risk of LGA was not associated with either the vitrification medium used or the embryo stage.

LIMITATIONS, REASONS FOR CAUTION

No data were available on maternal context, such as parity, BMI, infertility cause, or maternal comorbidities, in the French national database. In particular, we cannot exclude that the increased risk of LGA observed following FET with artificial cycles may, at least partially, be associated with a confounding effect of some maternal factors. No information about embryo culture and incubation conditions was available. Most of the vitrification techniques were performed using the same device and with two main vitrification media, limiting the validity of a comparison of risk for LGA according to the device or vitrification media used.

WIDER IMPLICATIONS OF THE FINDINGS

Our results seem reassuring, since no potential foetal growth disorders following embryo vitrification in comparison with slow freezing were observed. Even if other factors are involved, the endometrial preparation treatment seems to have the greatest impact on LGA risk following FET. FET during ovulatory cycles could minimize the risk for foetal growth disorders.

STUDY FUNDING/COMPETING INTEREST(S)

This work has received funding from the French Biomedicine Agency (Grant number: 19AMP002). None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Do IVF culture conditions have an impact on neonatal outcomes? A systematic review and meta-analysis

PURPOSE

Are embryo culture conditions, including type of incubator, oxygen tension, and culture media, associated with obstetric or neonatal complications following in vitro fertilization (IVF)?

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane Library was performed from January 01, 2008, until October 31, 2021. The studies reporting quantitative data on at least one of the primary outcomes (birthweight and preterm birth) for the exposure group and the control group were included. For oxygen tension, independent meta-analysis was performed using Review Manager, comparing hypoxia/normoxia. For culture media, a network meta-analysis was carried out using R software, allowing the inclusion of articles comparing two or more culture media.

RESULTS

After reviewing 182 records, 39 full-text articles were assessed for eligibility. A total of 28 studies were kept for review. Meta-analysis about the impact of incubator type on perinatal outcomes could not be carried out because of a limited number of studies. For oxygen tension, three studies were included. The pairwise meta-analysis comparing hypoxia/normoxia did not show any statistical difference for birthweight and gestational age at birth. For culture media, 18 studies were included. The network meta-analysis failed to reveal any significant impact of different culture media on birthweight or preterm birth.

CONCLUSION

No difference was observed for neonatal outcomes according to the embryo culture conditions evaluated in this review. Further research is needed about the safety of IVF culture conditions as far as future children's health is concerned.

The risk of perinatal and cardiometabolic complications in pregnancies conceived by medically assisted reproduction

PURPOSE

To examine the impact of medically assisted fertility treatments on the risk of developing perinatal and cardiometabolic complications during pregnancy and in-hospital deliveries.

METHODS

We conducted a retrospective cohort study using medical health records of deliveries occurring in 2016-2022 at a women's specialty hospital in a southern state of the Unites States (US). Pregnancies achieved using medically assisted reproductive (MAR) techniques were compared with unassisted pregnancies using propensity score matching (PSM), based on demographic, preexisting health, and reproductive factors. Study outcomes included cesarean delivery, gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), delivery complications, and postpartum readmission. We used Poisson regression with robust standard errors to generate risk ratios (RRs) and 95% confidence intervals (CIs) for all study outcomes.

RESULTS

Among 57,354 deliveries, 586 (1.02%) pregnancies were achieved using MAR and 56,768 (98.98%) were unassisted ("non-MAR"). Compared to the non-MAR group, MAR pregnancies had significantly higher prevalence of all study outcomes, including GDM (15.9% vs. 11.2%, p < 0.001), HDP (28.2% vs. 21.1%, p < 0.001), cesarean delivery (56.1% vs. 34.6%, p < 0.001), delivery complications (10.9% vs. 6.8%, p = 0.03), and postpartum readmission (4.3% vs. 2.7%, p = 0.02). In a PSM sample of 584 MAR and 1,727 unassisted pregnancies, MAR was associated with an increased risk of cesarean delivery (RR = 1.11, 95% CI = 1.01-1.22); whereas IVF was associated with an increased risk of cesarean delivery (RR = 1.15, 95% CI = 1.03-1.28) and delivery complications (RR = 1.44, 95% CI = 1.04-2.01).

CONCLUSIONS

Women who conceived with MAR were at increased risk of cesarean deliveries, and those who conceived with IVF were additionally at risk of delivery complications.

Effect of small follicles on clinical pregnancy and multiple pregnancy rates in intrauterine insemination: a cohort study

STUDY QUESTION

What is the effect of small follicles on clinical pregnancy and multiple pregnancy rates in women undergoing IUI with ovarian stimulation (IUI-OS)?

SUMMARY ANSWER

The presence of ≥2 small follicles with a diameter of 10-12 or 12-14 mm was associated with an increased chance of clinical pregnancy and the presence of any 12-14 mm or larger follicles, but not smaller follicles, was statistically significantly associated with an increased risk for multiple pregnancy.

WHAT IS KNOWN ALREADY

IUI-OS is widely used as the first-line treatment for unexplained or mild male factor infertility. However, IUI is associated with the risk of multiple pregnancy. While the positive association between the number of follicles ≥14 mm and the chance of pregnancy and the risk of multiple pregnancy is known, the impact of smaller follicles is uncertain.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study that included women undergoing IUI cycles from January 2007 to May 2021 in one assisted reproduction center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the impact of the number and size of follicles on trigger day on clinical pregnancy and multiple pregnancy rates. Generalized estimation equation regression models were used to compute unadjusted and adjusted odds ratios and 95% CI in all women and only women who achieved clinical pregnancy separately. The chance of clinical pregnancy and multiple pregnancy for different numbers of small follicles in cycles with one >18-mm follicle was calculated using marginal effects estimate.

MAIN RESULTS AND THE ROLE OF CHANCE

This cohort included 12 933 IUI cycles in 7504 women. The overall clinical pregnancy rate was 16.1% (2081/12 933), with a multiple pregnancy rate of 10.5% (218/2081). In the adjusted analysis, the chance of clinical pregnancy increased significantly with the increase in the number of follicles with the diameter of 14-16, 16-18, and 18-20 mm. As for 10-12 mm [adjusted odds ratio (aOR) 1.22, 95% CI 1.02-1.46] and 12-14 mm (aOR 1.29, 95% CI 1.07-1.56) follicles, only groups with ≥2 follicles of those sizes showed significantly increased chance of clinical pregnancy. In cycles that led to pregnancy, follicles with the diameter of 12-14 mm were associated with an increased risk of multiple pregnancy (aOR 1.73, 95% CI 1.19-2.53 for one such follicle; aOR 2.27, 95% CI 1.44-3.56 for ≥2 such follicles), while 10- to 12-mm follicles were not significantly associated with multiple pregnancy (aOR 1.18, 95% CI 0.72-1.95 for ≥2 such follicles). The associations of multiple pregnancy were similar when including all cycles.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective observational study from a single center. The records of follicle diameter in our center were of a 2-mm interval which limited our ability to analyze the size of follicle as a continuous variable. Also, the number of cycles with a high number of small follicles was still limited which impeded more detailed analysis on the ≥2 follicles subgroup. Similarly, the value of some parts of the marginal probability estimation for multiple pregnancy versus pregnancy according to size and number of follicles was also limited by the low sample size of certain combinations.

WIDER IMPLICATIONS OF THE FINDINGS

Follicles larger than 10 mm, especially those ≥12 mm, may need to be clearly recorded during transvaginal ultrasound surveillance and their potential effects on both pregnancy and multiple pregnancy can be discussed with couples undergoing IUI.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (Grant numbers 82201912, 82371651, and 82071615) and Shanghai Sailing Program (21YF1423200). B.W.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Investigating the Association of Assisted Reproduction Techniques and Adverse Perinatal Outcomes

BACKGROUND

Infertility affects about 80 million individuals worldwide and 10-15% of couples at reproductive age will seek medical assistance. There is increasing evidence that pregnancies after Assisted Reproduction Techniques (ART) are associated with pre-term birth, low birthweight, congenital defects, and increased mortality rates. The aim of this review is to assess all the published literature and provide an updated review on the effect of assisted conception and perinatal and neonatal outcomes.

METHODS

Comprehensive research on Pubmed/Medline, Scopus, and Google scholar electronic databases was conducted from July 2023 up to September 2023, using the terms assisted reproductive techniques, ART, in vitro fertilization, IVF, intracytoplasmic sperm injection, ICSI, preterm birth, PTB, low birth weight, LBW, chromosomal defects, congenital defects, and hypospadias. In total, 87 full text articles were retrieved and after a careful evaluation, 31 studies were selected for data extraction.

RESULTS

Our review demonstrated a higher risk of congenital and chromosomal defects, and a higher incidence of male genital tract defects and heart defects in ART pregnancies. Regarding pre-term birth, our results were contradictory.

CONCLUSIONS

Although assisted reproduction techniques are associated with increased risks, they are safe regarding perinatal outcomes and couples should not be discouraged from utilizing them. Our results aim to alert clinicians to these specific outcomes and offer more personalized care and counseling to infertile couples and their children.

Type of infertility and prevalence of congenital malformations

BACKGROUND

Children conceived with assisted reproductive technologies (ART) or after a long waiting time have a higher prevalence of congenital malformations, but few studies have examined the contribution of type of infertility.

OBJECTIVES

To quantify the association between causes of infertility and prevalence of malformations.

METHODS

We compared the prevalence at birth of all and severe malformations diagnosed up to age 2 between 6656 children born in 1996-2017 to parents who had previously been assessed for infertility a an academic fertility clinic ("exposed") and 10,382 children born in the same period to parents with no recent medical history of infertility ("reference"). We estimated prevalence ratios (PR) and prevalence differences (PD), by infertility status, type of treatment (non-ART, ART), and infertility diagnosis, in all children and among singletons.

RESULTS

Compared with children of parents with no infertility, children of parents with infertility had a higher prevalence of malformations (both definitions), particularly following ART conceptions. After accounting for treatment, ovulatory disorders were associated with a higher prevalence of both all (PR 1.49, 95% confidence interval (CI) 1.15, 1.93; PD 3.8, 95% CI 1.0, 6.6) and severe (PR 1.53, 95% CI 1.02, 2.29; PD 1.8, 95% CI -0.2, 3.7) malformations (the estimates refer to exposed children conceived without treatment). Unexplained and male factor infertility were associated with all and severe malformations, respectively. Estimates among singletons were similar. A diagnosis of ovulatory disorders was associated with all malformations also in analyses restricted to exposed children, regardless of treatment (we did not examine severe malformations, due to limited power).

CONCLUSIONS

In this study, ovulatory disorders were consistently associated with a higher prevalence of congenital malformations (including severe malformations) among live births, regardless of mode of conception.

No major differences in perinatal and maternal outcomes between uninterrupted embryo culture in time-lapse system and conventional embryo culture

STUDY QUESTION

Is embryo culture in a closed time-lapse system associated with any differences in perinatal and maternal outcomes in comparison to conventional culture and spontaneous conception?

SUMMARY ANSWER

There were no significant differences between time-lapse and conventional embryo culture in preterm birth (PTB, <37 weeks), low birth weight (LBW, >2500 g) and hypertensive disorders of pregnancy for singleton deliveries, the primary outcomes of this study.

WHAT IS KNOWN ALREADY

Evidence from prospective trials evaluating the safety of time-lapse incubation for clinical use show similar embryo development rates, implantation rates, and ongoing pregnancy and live birth rates when compared to conventional incubation. Few studies have investigated if uninterrupted culture can alter risks of adverse perinatal outcomes presently associated with IVF when compared to conventional culture and spontaneous conceptions.

STUDY DESIGN, SIZE, DURATION

This study is a Swedish population-based retrospective registry study, including 7379 singleton deliveries after fresh embryo transfer between 2013 and 2018 from selected IVF clinics. Perinatal outcomes of singletons born from time-lapse-cultured embryos were compared to singletons from embryos cultured in conventional incubators and 71 300 singletons from spontaneous conceptions. Main perinatal outcomes included PTB and LBW. Main maternal outcomes included hypertensive disorders of pregnancy (pregnancy hypertension and preeclampsia).

PARTICIPANTS/MATERIALS, SETTING, METHODS

From nine IVF clinics, 2683 singletons born after fresh embryo transfer in a time-lapse system were compared to 4696 singletons born after culture in a conventional incubator and 71 300 singletons born after spontaneous conception matched for year of birth, parity, and maternal age. Patient and treatment characteristics from IVF deliveries were cross-linked with the Swedish Medical Birth Register, Register of Birth Defects, National Patient Register and Statistics Sweden. Children born after sperm and oocyte donation cycles and after Preimplantation Genetic testing cycles were excluded. Odds ratio (OR) and adjusted OR were calculated, adjusting for relevant confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

In the adjusted analyses, no significant differences were found for risk of PTB (adjusted OR 1.11, 95% CI 0.87-1.41) and LBW (adjusted OR 0.86, 95% CI 0.66-1.14) or hypertensive disorders of pregnancy; preeclampsia and hypertension (adjusted OR 0.99, 95% CI 0.67-1.45 and adjusted OR 0.98, 95% CI 0.62-1.53, respectively) between time-lapse and conventional incubation systems. A significantly increased risk of PTB (adjusted OR 1.31, 95% CI 1.08-1.60) and LBW (adjusted OR 1.36, 95% CI 1.08-1.72) was found for singletons born after time-lapse incubation compared to singletons born after spontaneous conceptions. In addition, a lower risk for pregnancy hypertension (adjusted OR 0.72 95% CI 0.53-0.99) but no significant difference for preeclampsia (adjusted OR 0.87, 95% CI 0.68-1.12) was found compared to spontaneous conceptions. Subgroup analyses showed that some risks were related to the day of embryo transfer, with more adverse outcomes after blastocyst transfer in comparison to cleavage stage transfer.

LIMITATIONS, REASONS FOR CAUTION

This study is retrospective in design and different clinical strategies may have been used to select specific patient groups for time-lapse versus conventional incubation. The number of patients is limited and larger datasets are required to obtain more precise estimates and adjust for possible effect of additional embryo culture variables.

WIDER IMPLICATIONS OF THE FINDINGS

Embryo culture in time-lapse systems is not associated with major differences in perinatal and maternal outcomes, compared to conventional embryo culture, suggesting that this technology is an acceptable alternative for embryo incubation.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financed by a research grant from Gedeon Richter. There are no conflicts of interest for all authors to declare.

TRIAL REGISTRATION NUMBER

N/A.

Serum Cu, Zn and IL-1β Levels May Predict Fetal Miscarriage Risk After IVF Cycles: A Nested Case-Control Study

To explore the association between serum-related indicators (levels of inflammatory cytokines and essential trace elements) and miscarriage risk among infertile women undergoing assisted reproductive techniques (ART) on the 14th day after embryo transfer, and to develop and establish a multivariable algorithm model that might predict pregnancy outcome. According to a nested case-control study design, a total of 100 miscarriage cases and 100 live birth controls were included in this study, and women in both groups were infertile and have underwent in vitro fertilization (IVF). Pregnancy tests were performed and serum levels of five essential trace elements (vanadium (V), copper (Cu), zinc (Zn), selenium (Se) and molybdenum (Mo)) and five inflammatory cytokines (interleukin-1β (IL-1β), IL-6, IL-8, IL-10 and tumor necrosis factor-α (TNF-α)) of the participants were measured on the 14th day after embryo transfer. The serum levels of five inflammatory cytokines were determined by multiple magnetic bead enzyme immunity analyzer; and the serum concentrations of five elements were determined simultaneously by inductively coupled plasma‒mass spectrometry (ICP ‒ MS). The logistic regression was used to evaluate the relationship between these serum indices and miscarriage risk among women undergoing ART, and a predictive model of pregnancy outcome based on these indices was established. The levels of IL-10, IL-1β and TNF-α of infertile women in the live birth group were significantly higher than those in the miscarriage group (p = 0.009, p < 0.001, p = 0.006), and the levels of V, Cu, Zn and Se of infertile women in the live birth group were also significantly higher than those in the miscarriage group (all p < 0.001). Through logistic regression analyses, we found that serum levels of IL-1β, TNF-α, V, Cu, Zn and Se were significantly and negatively associated with miscarriage risk. Different combination prediction models were generated according to the results of logistic regression analyses, and the combination of IL-1β, Cu and Zn had the best prediction performance. The area under the curve (AUC) was 0.776, the sensitivity of the model was 60% and the specificity was 84%. In conclusion, the serum-related indicators of women undergoing ART on the 14th day after embryo transfer, including the inflammatory cytokines such as IL-1β and TNF-α and the essential trace metal elements such as V, Cu, Zn and Se, were negatively correlated with miscarriage risk. A multivariate algorithm model to predict pregnancy outcome among women undergoing ART was established, which showed that IL-1β, Cu and Zn might synergistically predict pregnancy outcome.

The associations of cola intake with adverse birth outcomes among pregnant women after assisted reproductive technology treatment and women naturally conceived: a birth cohort study

The influence of cola intake on birth outcomes is unclear. This study sought to describe and compare the associations between cola intake and adverse birth outcomes among women following assisted reproductive technology (ART) and women spontaneously conceived (SC). Participants (736 ART women and 1,270 SC women) were from the Chinese National Birth Cohort collected in Anhui province. Cola intake was assessed by self-reported questionnaires at each trimester. Outcome measures including preterm birth (PTB) and low birth weight (LBW) were extracted from medical records. The association between cola intake during pregnancy and PTB was found using multivariable log-binomial regression in combined ART and SC women. Separately, for ART women, cola intake during pregnancy increased the risk of PTB (risk ratios were 2.10, 1.65, and 1.81 for all three trimesters, respectively, all p < 0.05), and cola intake in the 1st trimester increased the risk of LWB (risk ratio 2.58, 95% confidence interval 1.29 to 5.16). Cola intake during pregnancy was not associated with PTB or LBW for SC women. Our findings indicate a detrimental effect of cola intake during pregnancy on birth outcomes for ART women. Thus, avoidance of cola intake should be counselled by medical doctors in women prescribed with ART treatment.

Maternal education and its association with maternal and neonatal adverse outcomes in live births conceived using medically assisted reproduction (MAR)

BACKGROUND

To examine the association between maternal education and adverse maternal and neonatal outcomes in women who conceived using medically assisted reproduction, which included fertility medications, intrauterine insemination, or in vitro fertilization.

METHODS

We conducted a retrospective cohort study utilizing the US Vital Statistics data set on national birth certificates from 2016 to 2020. Women with live, non-anomalous singletons who conceived using MAR and had education status of the birthing female partner recorded were included. Patients were stratified into two groups: bachelor's degree or higher, or less than a bachelor's degree. The primary outcome was a composite of maternal adverse outcomes: intensive care unit (ICU) admission, uterine rupture, unplanned hysterectomy, or blood transfusion. The secondary outcome was a composite of neonatal adverse outcomes: neonatal ICU admission, ventilator support, or seizure. Multivariable modified Poisson regression models with robust error variance adjusted for maternal age, race, marital status, prenatal care, smoking during pregnancy, neonatal sex, and birth year estimated the relative risk (RR) of outcomes with a 95% confidence interval (CI).

RESULTS

190,444 patients met the inclusion criteria: 142,943 had a bachelor's degree or higher and 47,501 were without a bachelor's degree. Composite maternal adverse outcomes were similar among patients with a bachelor's degree (10.1 per 1,000 live births) and those without a bachelor's degree (9.4 per 1,000 live births); ARR 1.05, 95% CI (0.94-1.17). However, composite adverse neonatal outcomes were significantly lower in women with a bachelor's degree or higher (94.1 per 1,000 live births) compared to women without a bachelor's degree (105.9 per 1,000 live births); ARR 0.91, 95% CI (0.88-0.94).

CONCLUSIONS

Our study demonstrated that lower maternal education level was not associated with maternal adverse outcomes in patients who conceived using MAR but was associated with increased rates of neonatal adverse outcomes. As access to infertility care increases, patients who conceive with MAR may be counseled that education level is not associated with maternal morbidity. Further research into the association between maternal education level and neonatal morbidity is indicated.

Relationships between birth weight discordance and maternal and perinatal risks among twin pregnancies conceived following frozen embryo transfer

STUDY QUESTION

Is intertwin birth weight discordance associated with adverse maternal and perinatal outcomes following frozen embryo transfer (FET)?

SUMMARY ANSWER

For twins conceived following FET, intertwin birth weight discordance is related to elevated risks of neonatal mortality irrespective of chorionicity, and the risk of hypertensive disorders of pregnancy (HDP) is elevated for the mothers of dichorionic twins affected by such birth weight discordance.

WHAT IS KNOWN ALREADY

While the relationships between intertwin birth weight discordance and adverse maternal or fetal outcomes have been studied for naturally conceived twins, similarly comprehensive analyses for twins conceived using ART remain to be performed.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study of all twin births from 2007 to 2021 at Shanghai Ninth People's Hospital in Shanghai, China that were conceived following FET (N = 6265).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Intertwin birth weight discordance was defined as a 20% difference in neonatal birth weights. The primary study outcome was the incidence of HDP and neonatal death while secondary outcomes included gestational diabetes, placenta previa, placental abruption, intrahepatic cholestasis of pregnancy, preterm premature rupture of the membranes, Cesarean delivery, gestational age, birth weight, stillbirth, birth defect, neonatal jaundice, necrotizing enterocolitis, and pneumonia incidence. Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% CIs for maternal and neonatal outcomes. Subgroup analyses were conducted, and Kaplan-Meier survival analysis was used to estimate the survival probability. The sensitivity analysis was performed with a propensity score-based patient-matching model, an inverse probability weighting model, a restricted cubic spline analysis, and logistic regression models using other percentage cutoffs for discordance.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 6101 females that gave birth to dichorionic twins during the study interval, birth weight discordance was observed in 797 twin pairs (13.1%). In this cohort, intertwin birth weight discordance was related to an elevated risk of HDP (aOR 1.56; 95% CI 1.21-2.00), and this relationship was confirmed through sensitivity analyses. Hypertensive disease risk rose as the severity of this birth weight discordance increased. Discordant birth weight was also linked to increased odds of neonatal mortality (aOR 2.13; 95% CI 1.03-4.09) and this risk also increased with the severity of discordance. Of the 164 women with monochorionic twins, the discordant group exhibited an elevated risk of neonatal death compared to the concordant group (crude OR 9.00; 95% CI 1.02-79.3).

LIMITATIONS, REASONS FOR CAUTION

The limitations of this study are its retrospective nature and the fact that the available data could not specify which twins were affected by adverse outcomes. There is a lack of an established reference birth weight for Chinese twins born at a gestational age of 24-41 weeks.

WIDER IMPLICATIONS OF THE FINDINGS

These findings suggest that twins exhibiting a birth weight discordance are related to an elevated risk of adverse maternal and perinatal outcomes, emphasizing a potential need for higher levels of antenatal surveillance in these at-risk pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

Authors declare no conflict of interest. This study was funded by the Clinical Research Program of Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYLJ202118) and the National Natural Science Foundation of China (Grant Nos 82271693 and 82273634).

TRIAL REGISTRATION NUMBER

N/A.

Interpregnancy Interval After Clinical Pregnancy Loss and Outcomes of the Next Frozen Embryo Transfer

Importance

The optimal interpregnancy interval (IPI) after a clinical pregnancy loss (CPL) remains controversial. Few studies have addressed the role of the IPI after a preceding CPL during in vitro fertilization (IVF) treatment.

Objective

To evaluate the association between different IPI lengths after a preceding CPL and pregnancy outcomes of the next frozen embryo transfer (FET).

Design, Setting, and Participants

This retrospective cohort study was conducted using data from the Center for Reproductive Medicine of Shandong University in China. The study included women who underwent frozen-thawed blastocyst transfer between July 1, 2017, and June 30, 2022, within 1 year after a preceding CPL during IVF treatment. Follow-up for pregnancy outcomes was completed for all participants on March 31, 2023. Data analysis was performed from April to May 2023.

Exposures

Interpregnancy interval length was classified as less than 3 months, 3 to less than 6 months, or 6 to 12 months.

Main Outcomes and Measures

Outcomes included live birth, conception, clinical pregnancy, pregnancy loss, preterm birth, small or large for gestational age, and low birth weight. Multivariable logistic regression analysis was conducted to evaluate the association between IPI and pregnancy outcomes by adjusted odds ratios (AORs).

Results

This study included 2433 women (mean [SD] age, 31.8 [4.6] years) who received IVF treatment. There were 338 women (13.9%) with an IPI of less than 3 months, 1347 (55.4%) with an IPI of 3 to less than 6 months, and 748 (30.7%) with an IPI of 6 to 12 months. The median (IQR) IPI lengths for the 3 groups were 77 (65-85), 128 (109-152), and 234 (202-288) days, respectively. Compared with an IPI of 6 to 12 months, shorter IPIs (<3 and 3 to <6 months) were associated with decreased odds of clinical pregnancy (AOR, 0.70 [95% CI, 0.53-0.92] and 0.79 [0.65-0.95]), live birth (AOR, 0.64 [95% CI, 0.48-0.85] and 0.74 [0.61-0.90]), and healthy live birth (AOR, 0.63 [95% CI, 0.46-0.87] and 0.79 [0.64-0.98]). Compared with women with an IPI of 6 to 12 months, women with shorter IPIs (<3 and 3 to <6 months) had a higher risk of total pregnancy loss (AOR, 1.87 [95% CI, 1.31-2.67] and 1.29 [1.00-1.66], respectively).

Conclusions and Relevance

The results of this study suggest that delaying the next FET for at least 6 months after a preceding CPL was associated with beneficial pregnancy outcomes, considering that a decreased likelihood of achieving clinical pregnancy and live birth was observed among women with shorter IPIs. Further prospective studies are needed to confirm these findings.

AI, Borges Jr. E. Beetroot, watermelon and ginger juice supplementation may increase the clinical outcomes of Intracytoplasmic Sperm Injection cycles

OBJECTIVE

To prove the hypothesis that beetroot, watermelon and ginger juice supplementation improves the endometrial receptivity and clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles.

METHODS

This prospective randomized study enrolled 436 female patients undergoing ICSI cycles from January/2018 to June/2021, in a private university-affiliated IVF center. Female patients were randomized in a 1:3 ratio to either Control (n=109) or Supplementation Group (n=327). All patients received nutritional orientation before the beginning of the treatment. Participants in the Supplementation Group were instructed to intake a daily dose of homemade juice, prepared with fresh beetroot, watermelon and ginger, from the day of embryo transfer until the day of pregnancy test, while patients in Control Group did not follow the juice protocol. Generalized Linear Models, adjusted for potential confounders (female age, body mass index - BMI, endometrial thickness upon embryo transfer, and number of transferred embryos), followed by Bonferroni post hoc test for the comparison of means between groups, were used to investigate the impact of juice supplementation on the clinical outcomes of ICSI.

RESULTS

Patients and cycles characteristics were equally distributed among Supplementation and Control groups. Implantation rate (25.2% vs. 20.5%, p<0.001) and clinical pregnancy rate (41.0% vs. 22.0%, p=0.039) were significantly higher in the Supplementation compared to the Control group.

CONCLUSIONS

The use of beetroot, watermelon and ginger juice may be considered a promising strategy for improving clinical outcomes in assisted reproductive technology (ART), without any side effects.

Higher risk of pre-eclampsia and other vascular disorders with artificial cycle for frozen-thawed embryo transfer compared to ovulatory cycle or to fresh embryo transfer following in vitro fertilization

Background

Risks of maternal morbidity are known to be reduced in pregnancies resulting from frozen embryo transfer (FET) compared to fresh-embryo transfer (fresh-ET), except for the risk of pre-eclampsia, reported to be higher in FET pregnancies compared to fresh-ET or natural conception. Few studies have compared the risk of maternal vascular morbidities according to endometrial preparation for FET, either with ovulatory cycle (OC-FET) or artificial cycle (AC-FET). Furthermore, maternal pre-eclampsia could be associated with subsequent vascular disorders in the offspring.

Methods

A 2013-2018 French nationwide cohort study comparing maternal vascular morbidities in 3 groups of single pregnancies was conducted: FET with either OC or AC preparation, and fresh-ET. Data were extracted from the French National Health System database. Results were adjusted for maternal characteristics and infertility (age, parity, smoking, obesity, history of diabetes or hypertension, endometriosis, polycystic ovary syndrome and premature ovarian insufficiency).

Results

A total of 68025 single deliveries were included: fresh-ET (n=48152), OC-FET (n=9500), AC-FET (n=10373). The risk of pre-eclampsia was higher in AC-FET compared to OC-FET and fresh-ET groups in univariate analysis (5.3% vs. 2.3% and 2.4%, respectively, P<0.0001). In multivariate analysis the risk was significantly higher in AC-FET compared to fresh-ET: aOR=2.43 [2.18-2.70], P<0.0001). Similar results were observed for the risk of other vascular disorders in univariate analysis (4.7% vs. 3.4% and 3.3%, respectively, P=0.0002) and in multivariate analysis (AC-FET compared to fresh-ET: aOR=1.50 [1.36-1.67], P<0.0001). In multivariate analysis, the risk of pre-eclampsia and other vascular disorders were comparable in OC-FET and fresh-ET: aOR=1.01 [0.87-1.17, P= 0.91 and aOR=1.00 [0.89-1.13], P=0.97, respectively).Within the group of FET, the risks of pre-eclampsia and other vascular disorders in multivariate analysis were higher in AC-FET compared to OC-FET (aOR=2.43 [2.18-2.70], P<0.0001 and aOR=1.5 [1.36-1.67], P<0.0001, respectively).

Conclusion

This nationwide register-based cohort study highlights the possibly deleterious role of prolonged doses of exogenous estrogen-progesterone supplementation on gestational vascular pathologies and the protective role of the corpus luteum present in OC-FET for their prevention. Since OC-FET has been demonstrated not to strain the chances of pregnancy, OC preparation should be advocated as first-line preparation in FET as often as possible in ovulatory women.

Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review

OBJECTIVE

This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines.

METHOD

A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations.

RESULTS

Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise.

CONCLUSIONS

Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.

Postpartum hemorrhage among twin pregnancies - Medically assisted versus spontaneously conceived

INTRODUCTION

In singleton pregnancies, an increased risk of Postpartum hemorrhage (PPH) have been linked with assisted reproductive technology (ART) and abnormal placentation. It is unknown wheather such association exists in twin pregnancies conceived by Medically assisted reproduction (MAR). The aim of the current study was to compare maternal blood loss among twin pregnancies conceived by different types of MAR treatments to spontaneously conceived twins and to identify the cycle characteristics if an association exits.

METHODS

Retrospective study conducted on data collected between 2011 and 2020. The study cohort included all twin pregnancies conceived by MAR and born at our institution. Controls were spontaneously conceived twins matched for maternal age on a 1:2 (study: controls) ratio.

RESULTS

Overall 113 MAR twin births categorized into three groups; 25 ovulation induction, 59 fresh ART, 29 frozen-thawed ART cycles, and 226 controls were included. The incidence of PPH was higher among MAR twin pregnancies (5.3%) compared to the controls (4%). The highest incidence was observed among women in the frozen-thawed group (13.8%) which differed significantly compared with the controls (p = 0.024). A significant difference was also observed in the mean decrease of postpartum hemoglobin levels between these two groups (2.13 g/dL versus 1.3 g/dL respectively, p = 0.002). Blood transfusion was nearly 2.5 times more common in the frozen-thawed group (3.4%) compared to the control group (1.3%).

DISCUSSION

The present study demonstrates that frozen embryo transfer (FET) ART-conceived twin pregnancies are associated with a markedly increased rate of PPH compared to spontaneously conceived twins.

Risk factors associated with preterm birth in singletons born after IVF: a national cohort study

RESEARCH QUESTION

What are the risk factors for prematurity other than intrauterine growth restriction in singletons after IVF?

DESIGN

Data were collected from a national registry, based on an observational prospective cohort of 30,737 live births after assisted reproductive technology (fresh embryo transfers: n = 20,932 and frozen embryo transfer [FET] n = 9805) between 2014 and 2015. A population of not-small for gestational age singletons conceived after fresh embryo transfers and FET, and their parents, was selected. Data on a number of variables were collected, including type of infertility, number of oocytes retrieved and vanishing twins.

RESULTS

Preterm birth occurred in 7.7% (n = 1607) of fresh embryo transfers and 6.2% (n = 611) of frozen-thawed embryo transfers (P < 0.0001; adjusted odds ratio [aOR] = 1.34 [1.21-1.49]). Endometriosis and vanishing twin increased the risk of preterm birth after fresh embryo transfer (P < 0.001; aOR 1.32 and 1.78, respectively). Polycystic ovaries or more than 20 oocytes retrieved also increased preterm birth risk (aOR 1.31 and 1.30; P = 0.003 and P = 0.02, respectively); large oocyte cohort (>20) was no longer associated with the risk of prematurity in FET.

CONCLUSION

Endometriosis remains a risk for prematurity even in the absence of intrauterine growth retardation, which suggests a dysimmune effect. Large oocyte cohorts obtained by stimulation, without clinical polycystic ovary syndrome diagnosed before attempts, do not affect FET outcomes, reinforcing the idea of a phenotypic difference in the clinical presentation of polycystic ovary syndrome.

Fetal growth disorders following medically assisted reproduction: due to maternal context or techniques? A national French cohort study

RESEARCH QUESTION

What part do maternal context and medically assisted reproduction (MAR) techniques play in the risk of fetal growth disorders?

DESIGN

This retrospective nationwide cohort study uses data available in the French National Health System database and focuses on the period from 2013 to 2017. Fetal growth disorders were divided into four groups according to the origin of pregnancy: fresh embryo transfer (n = 45,201), frozen embryo transfer (FET, n = 18,845), intrauterine insemination (IUI, n = 20,179) and natural conceptions (n = 3,412,868). Fetal growth disorders were defined from the percentiles of the weight distribution according to gestational age and sex: small and large for gestational age (SGA and LGA) if <10th and >90th percentiles, respectively. Analyses were performed using univariate and multivariate logistic models.

RESULTS

Compared with births following natural conception, multivariate analysis showed that the risk of SGA was higher for births following fresh embryo transfer and IUI (adjusted odds ratio [aOR] 1.26 [1.22-1.29] and 1.08 [1.03-1.12], respectively) and significantly lower following FET (aOR 0.79 [0.75-0.83]). The risk of LGA was higher for births following FET (aOR 1.32 [1.27-1.38]), especially in artificial cycles when compared with ovulatory cycles (aOR 1.25 [1.15-1.36]). In the subgroup of births without any obstetrical or neonatal morbidity, the same increased risk of SGA and LGA were observed following fresh embryo transfer or IUI and FET (aOR 1.23 [1.19-1.27] or 1.06 [1.01-1.11] and aOR 1.36 [1.30-1.43], respectively).

CONCLUSIONS

An effect of MAR techniques on the risks for SGA and LGA is suggested independently from maternal context and obstetrical or neonatal morbidities. Pathophysiological mechanisms remain poorly understood and should be further evaluated, as well as the influence of embryonic stage and freezing techniques.

The impact of maternal ABO blood type on obstetric and perinatal outcomes after frozen embryo transfer

RESEARCH QUESTION

Does the maternal ABO blood type affect obstetric and perinatal outcomes following frozen embryo transfer (FET)?

DESIGN

A retrospective study was performed at a university-affiliated fertility centre, involving women with singleton and twin deliveries conceived by FET. Subjects were divided into four groups based on ABO blood type. The primary end-points were obstetric and perinatal outcomes.

RESULTS

A total of 20,981 women were involved, with 15,830 having singletons and 5151 delivering twins. In singleton pregnancies, women with blood group B had a slight but significantly increased risk of gestational diabetes mellitus compared to women with blood group O (adjusted odds ratio [aOR] 1.16; 95% confidence interval [CI] 1.01-1.34). Furthermore, singletons born to women with the B antigen (blood type B or AB) were more likely to be large for gestational age (LGA) and with macrosomia. In twin pregnancies, blood type AB was related to a decreased risk of hypertensive diseases of pregnancy (aOR 0.58; 95% CI 0.37-0.92), while blood type A was associated with a higher risk of placenta praevia (aOR 2.04; 95% CI 1.15-3.60). When compared with the O blood group, twins from the AB blood group had a lower risk of low birthweight (aOR 0.83; 95% CI 0.71-0.98) but a higher risk of LGA (aOR 1.26; 95% CI 1.05-1.52).

CONCLUSIONS

This study demonstrates that the ABO blood group may influence the obstetric and perinatal outcomes for both singletons and twins. These findings emphasize that patient characteristics could be, at least partly, responsible for adverse maternal and birth outcomes following IVF.

Assisted reproductive technology: Short- and long-term outcomes

Assisted reproductive technology (ART) includes fertility treatment in which either eggs or embryos are handled outside a female's body to promote successful pregnancies and healthy offspring. Current ART procedures encompass in vitro fertilization with or without intracytoplasmic sperm injection. The most common complication of ART is related to the consequences of multiple pregnancy, which can be prevented or minimized by reducing the number of embryos transferred to the uterus, commonly single embryo transfer. ART has been shown to be variably associated with adverse short- and long-term perinatal outcomes, including cerebral palsy, autism, neurodevelopmental imprinting disorders, and cancer. However, there is uncertainty as to whether reported problems are related to the ART procedure itself, to factors related to infertility, to other medical and environmental factors, or a combination thereof. From a pathophysiological perspective, whether ART alters epigenetic mechanisms of gene expression, leading to later developmental, medical, and behavioral disorders, is an area of active investigation. With the meticulously conducted short- and long-term outcome studies completed so far, overall, and after controlling for multiple gestations and preterm delivery, the results suggest that ART is a safe procedure, offering hope to many parent(s) wishing for a healthy child. This paper highlights ART methods and the risk factors and confounders in the interpretation of short- and long-term outcome data, providing the reader with a means to evaluate findings and conclusions of outcome studies. WHAT THIS PAPER ADDS: Assisted reproductive technology (ART) is a relatively safe procedure. Single embryo implantation optimizes outcome. Informed consent, including the risks and benefits of ART, should be required. Ongoing longitudinal studies are necessary to fully understand ART outcomes.

The use of IVF/ICSI and risk of postpartum hemorrhage: A retrospective cohort study of 153,765 women in China

Objective

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. Identifying women who are at high risk of PPH is crucial for implementing early preventive and interventive strategies. This study aimed to examine whether there is an association between the use of in vitro fertilization (IVF) /intracytoplasmic sperm injection (ICSI) and increased risk of PPH.

Method

This retrospective cohort study was conducted using medical record data from women who delivered at a tertiary hospital in Shanghai, China, between January 1, 2013 and April 30, 2019. Logistic regression analysis was used to estimate the associations between the use of IVF/ICSI and the risk of PPH.

Results

A total of 153,765 pregnant women were included, of which 6,484 conceived through IVF/ICSI and147,281 conceived naturally. The incidence of PPH was 1.9% in this cohort. The incidence of PPH in women who conceived through IVF/ICSI was significantly higher than those in women who conceived naturally (3.4% vs. 1.7%, p < 0.01). The use of IVF/ICSI was associated with an increase in the amount of postpartum blood loss. Compared to women who conceived naturally, the average amount of postpartum blood loss increased by 42.1 mL (β = 42.1, 95% CI, 38.2-46.0) for women who conceived through IVF/ICSI. In addition, women who conceived through IVF/ICSI were at higher risk of maternal PPH. The adjusted odds ratio (OR) of PPH in women who conceived through ART was 2.7 (OR = 2.7, 95% CI, 2.3-3.1).

Conclusion

Our findings demonstrated that women who conceived through IVF/ICSI were at higher risk of PPH and suggested to obstetricians and midwives to identify and implement early preventative strategies for PPH among pregnant women who conceived through IVF/ICSI.

Application of Single-Cell RNA Sequencing in Ovarian Development

The ovary is a female reproductive organ that plays a key role in fertility and the maintenance of endocrine homeostasis, which is of great importance to women's health. It is characterized by a high heterogeneity, with different cellular subpopulations primarily containing oocytes, granulosa cells, stromal cells, endothelial cells, vascular smooth muscle cells, and diverse immune cell types. Each has unique and important functions. From the fetal period to old age, the ovary experiences continuous structural and functional changes, with the gene expression of each cell type undergoing dramatic changes. In addition, ovarian development strongly relies on the communication between germ and somatic cells. Compared to traditional bulk RNA sequencing techniques, the single-cell RNA sequencing (scRNA-seq) approach has substantial advantages in analyzing individual cells within an ever-changing and complicated tissue, classifying them into cell types, characterizing single cells, delineating the cellular developmental trajectory, and studying cell-to-cell interactions. In this review, we present single-cell transcriptome mapping of the ovary, summarize the characteristics of the important constituent cells of the ovary and the critical cellular developmental processes, and describe key signaling pathways for cell-to-cell communication in the ovary, as revealed by scRNA-seq. This review will undoubtedly improve our understanding of the characteristics of ovarian cells and development, thus enabling the identification of novel therapeutic targets for ovarian-related diseases.

Female fertility treatment and adverse birth outcomes: a multistate analysis of pregnancy risk assessment monitoring system data

OBJECTIVE

The popularity of fertility treatments has continued to rise, however, the potential health risks of these treatments for both mother and infant are not fully known. Our objective was to determine the association between fertility treatments and adverse birth outcomes of intended pregnancies using the Pregnancy Risk Assessment Monitoring System (PRAMS) data.

METHODS

Data from 27,018 intended pregnancies, collected from 2009 to 2018 in the United States, were included in our analysis. PRAMS data consisted of questionnaire and birth certificate data. SAS 9.4 was used for analyses accounting for complex survey weights. All analyses were conducted separately for singleton and twin births. Weighted percentages with 95% confidence intervals (CIs) were estimated for maternal characteristics and birth outcomes. Multivariable logistic regression was used to determine adjusted odds ratios (OR) and 95% CIs for associations of fertility treatment use and adverse birth outcomes.

RESULTS

Close to 12% of women reported the use of any fertility treatment. Among those using fertility treatments, the most common type was assisted reproductive technology (ART) for both twin (68.7%, 95% CI: 62.3, 75.2) and singleton births (45.1%, 95% CI: 42.0, 48.1). Use of any type of fertility treatment for singleton births was associated with increased odds of a cesarean delivery (OR: 1.31, 95% CI: 1.16, 1.47), preterm birth (OR: 1.42, 95% CI: 1.20, 1.67), a small-for-gestational age infant (OR: 1.20, 95% CI: 1.00, 1.44), and an infant hospital stay >5 days (OR: 1.34, 95% CI: 1.11, 1.62). Use of fertility treatment for twin births was associated with cesarean delivery only. In analyses examining associations for specific types of treatment (medication alone, ART, insemination) with birth outcomes, results varied by treatment type.

CONCLUSIONS

In this large population-based sample of women who intended to become pregnant and had a live birth, fertility treatment was associated with adverse birth outcomes. Patients seeking fertility treatment should be appropriately counseled on the risks of adverse maternal and infant birth outcomes overall and by treatment type. Maternal support and resources to prevent adverse birth outcomes among women using fertility treatments are warranted.

Duration of infertility and assisted reproductive outcomes in non-male factor infertility: can use of ICSI turn the tide?

Background

Intracytoplasmic sperm injection (ICSI) is increasingly used among in vitro fertilization (IVF) cycles without male factor infertility. For couples with prolonged infertility duration, the preferred insemination method may vary across laboratories and clinics. We analyzed whether ICSI is effective for non-male factor infertility with long infertility duration.

Methods

Seventeen thousand four hundred seventy-seven IVF/ICSI cycles from women with non-male factor infertility were included, of these 4177 women with infertility duration ≥ 5 years were in the final analysis. Primary outcome was the live birth rate after first embryo transfer. Secondary outcomes were rates of clinical pregnancy and fertilization.

Results

A nonlinear relationship was observed between infertility duration and IVF fertilization rate, which decreased with infertility years up to the turning point (4.8 years). 4177 women with infertility ≥ 5 years were categorized by IVF (n = 3806) or ICSI (n = 371). Live birth rate after first embryo transfer was 43.02% in ICSI and 47.85% in IVF group (adjusted odds ratio (aOR), 0.91; 95% confidence interval (CI), 0.72–1.15). Fertilization rate per metaphaseII (aOR, 1.10; 95% CI, 0.86–1.40) and clinical pregnancy rate (aOR, 0.89; 95% CI, 0.71–1.13) were similar between the two groups. Sensitive analyses (women ≥ 35 years) did not show a benefit of ICSI over IVF.

Conclusions

Women with infertility exceeding 4.8 years had decreased incidence of IVF fertilization. The use of ICSI showed no significant improvement in fertilization and live birth rates for non-male factor couples with ≥ 5 years of infertility.

Mental health and behavioural problems in adolescents conceived after ART

STUDY QUESTION

Does mental health and behaviour differ between those conceived with and those conceived without ART?

SUMMARY ANSWER

Our study observed less externalizing behaviour (delinquent/aggressive), and more parent-reported internalizing behaviour, as well as more (clinical) depression at age 14 years, in adolescents conceived after ART compared to their non-ART counterparts.

WHAT IS KNOWN ALREADY

Health outcomes of ART-conceived offspring may differ from those conceived without ART, and previous studies have reported differences in behaviour and mental health, particularly in childhood.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective cohort study, investigating the long-term health of offspring conceived after ART (aged 14, 17 and 20 years), in the two operational fertility clinics in Western Australia 1991-2001 (n = 303). Their long-term health outcomes were compared to those of offspring conceived without ART from the Raine Study Generation 2 (Gen2) born 1989-1991 (n = 2868). Both cohorts are representative of the local adolescent population.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mental health parameters and behaviour were assessed at ages 14 and 17 years, through the parent completed 'Child Behaviour Checklist' (CBCL; ART versus non-ART: age 14 years: N = 150 versus N = 1781, age 17 years: N = 160 versus N = 1351), and the adolescent completed equivalent 'Youth Self-Report' (YSR; age 14 years: by N = 151 versus N = 1557, age 17 years: N = 161 and N = 1232). Both tools generate a T-score (standardized for age and sex) for internalizing (withdrawn, somatic complaints, anxious/depressed), externalizing (delinquent/aggressive behaviour) and total behaviour. Adolescents also completed the 'Beck Depression Inventory for Youth' (BDI-Y; age 14 years: N = 151 versus N = 1563, age 17 years: N = 161 versus N = 1219). Higher scores indicate poorer mental health and behaviour on all the above tools. Parent-reported doctor-diagnosed conditions (anxiety, behavioural problems, attention problems and depression) were also univariately compared between the cohorts. In addition, univariate comparisons were conducted between the GUHS adolescents and Gen2 adolescents born to subfertile parents (time to pregnancy >12 months), as well as between offspring born to subfertile versus fertile parents within the Gen2 cohort. A subgroup analysis excluding offspring born preterm (<37 weeks' gestation) or at low birthweight (<2500 g) was also performed. Generalized estimating equations that account for correlated familial data were adjusted for the following covariates: non-singleton, primiparity, primary caregiver smoking, family financial problems, socio-economic status and both maternal and paternal ages at conception.

MAIN RESULTS AND THE ROLE OF CHANCE

At both 14 and 17 years of age, ART versus non-ART-conceived adolescents reported lower mean T-scores for externalizing problems (age 14 years: 49 versus 51, P = 0.045, age 17 years: 49 versus 52, P < 0.001). A similar effect was reported by parents, although not significant (age 14 years: P = 0.293, age 17 years: P = 0.148). Fewer ART-conceived adolescents reported a T-score above the clinical cut-off for externalizing behaviour (≥60; age 14 years: 7.3% versus 16.3%, P = 0.003, age 17 years: 8.1% versus 19.7%, P < 0.001). At both ages, no differences in internalizing behaviour were reported by adolescents (age 14 years: P = 0.218, age 17 years: P = 0.717); however, higher mean scores were reported by parents of the ART-conceived adolescents than by parents of the non-ART conceived adolescents (age 14 years: 51 versus 48, P = 0.027, age 17 years: 50 versus 46, P < 0.001). No differences in internalizing behaviour above the clinical cut-off (T-score ≥ 60) were observed. At age 17 years, parents who conceived through ART reported higher total behaviour scores than those parents who conceived without ART (48 versus 45, P = 0.002). At age 14 years, ART versus non-ART-conceived adolescents reported significantly higher mean scores on the BDI-Y (9 versus 6, P = 0.005); a higher percentage of adolescents with a score indicating clinical depression (≥17; 12.6% versus 8.5%, aOR 2.37 (1.18-4.77), P = 0.016), as well as more moderate/severe depression (≥21; 9.3% versus 4.0%, P = 0.009). At age 17 years, no differences were reported on the BDI-Y. There was also a higher percentage of parent-reported doctor-diagnosed anxiety in the ART cohort (age 14 years: 8.6% versus 3.5%, P = 0.002, at age 17 years: 12.0% versus 4.5%, P < 0.001). Removing adolescents born preterm or at low birthweight did not alter the above results. Comparing outcomes between GUHS adolescents and Gen2 adolescents born to subfertile parents, as well as between those born to subfertile versus fertile parents within Gen2, did not alter results for CBCL and YSR outcomes. Those born to subfertile parents showed higher rates of clinical depression than those born to fertile parents at age 14 years (13.7% versus 6.9%, P = 0.035).

LIMITATIONS, REASONS FOR CAUTION

The main limitation of the study is the time difference between the GUHS and Gen2 assessments. Even though we have adjusted for covariates, additional socio-economic and lifestyle factors affecting behaviour and mental well-being could have changed. We were unable to differentiate between different types of ART (e.g. IVF versus ICSI), owing to the low number of ICSI cycles at the time of study. Fertility sub-analyses need to be replicated in larger cohorts to increase power, potentially using siblingship designs. Lastly, selection bias may be present.

WIDER IMPLICATIONS OF THE FINDINGS

The reported lower prevalence of externalizing behaviour (delinquent/aggressive), and higher prevalence of internalizing behaviour, as well as more (clinical) depression at age 14 years, in ART versus non-ART-conceived adolescents, is in line with some previous studies, mostly conducted in childhood. It is reassuring that differences in the rates of depression were not observed at age 17 years, however, these findings require replication. As the use of ART is common, and mental health disorders are increasing, knowledge about a potential association is important for parents and healthcare providers alike.

STUDY FUNDING/COMPETING INTEREST(S)

This project was funded by an NHMRC Grant (Hart et al., ID 1042269). R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director of PIVET Medical Centre, Perth, Western Australia.

TRIAL REGISTRATION NUMBER

N/A.

Neurodevelopmental Outcomes of Pregnancies Resulting from Assisted Reproduction: A Review of the Literature

The term infertility is defined as the lack of conception within 1 year of unprotected intercourse. It affects more than 80 million individuals worldwide. It is estimated that 10-15% of couples of reproductive age are challenged by reproductive issues. Assisted reproduction techniques (ART) are responsible for more than 4% of live births. Our aim is to review the research on neurodevelopmental outcomes of newborns born after the implementation of assisted reproduction methods compared to those conceived naturally. We conducted a comprehensive search of the PubMed, Crossref and Google Scholar electronic databases for related articles up to June 2022 using the PRISMA guidelines. Our research revealed a large number of long term follow-up studies between 2 and 18 years of age, with comparable developmental outcomes. Many studies compared the effects of different infertility treatments against natural conception. The review of the literature revealed that ART is safe, as the majority of studies showed no effect on the neurodevelopmental outcomes of the offspring. In most cases when such an effect was observed, it could be attributed to confounding factors such as subfertility, multiple pregnancies and gestational age at delivery. Finally, the increase in the prevalence of neurodevelopmental disorders after ART, as described in studies with statistically significant results, is predominantly marginal, and given the low incidence of neurodevelopmental disorders in the general population, its clinical significance is debatable.