Trends over 15 years in ART in Europe: an analysis of 6 million cycles

Maternal pre-pregnancy BMI and reproductive health in adult sons: a study in the Danish National Birth Cohort

STUDY QUESTION

Is maternal pre-pregnancy BMI associated with semen quality, testes volume, and reproductive hormone levels in sons?

SUMMARY ANSWER

Maternal pre-pregnancy BMI was associated with an altered reproductive hormone profile in young adult sons, characterized by higher levels of oestradiol, LH, and free androgen index (FAI) and lower levels of sex hormone-binding globulin (SHBG) in sons born of mothers with pre-pregnancy overweight and obesity.

WHAT IS KNOWN ALREADY

Evidence suggests that maternal pre-pregnancy BMI may influence reproductive health later in life. Only one pilot study has investigated the association between maternal pre-pregnancy BMI and reproductive health outcomes in sons, suggesting that a high BMI was associated with impaired reproductive function in the adult sons.

STUDY DESIGN, SIZE, DURATION

A population-based follow-up study of 1058 young men from the Fetal Programming of Semen Quality (FEPOS) cohort nested within the Danish National Birth Cohort (DNBC), 1998-2019, was carried out.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 1058 adult sons (median age 19 years, 2 months), born 1998-2000 by mothers included in the DNBC, participated in FEPOS. At a clinical examination, they provided a semen and blood sample, measured their testes volume, and had height and weight measured. Maternal pre-pregnancy BMI was obtained by self-report in early pregnancy. Semen characteristics, testes volume, and reproductive hormone levels were analysed according to maternal pre-pregnancy BMI categories and as restricted cubic splines using negative binomial and ordinary least square regression models. Mediation analyses examined potential mediation by the sons' birthweight, pubertal timing, fat mass, and BMI. Additional analyses investigated the role of paternal BMI in the potential associations between maternal BMI and reproductive health outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

We found no consistent associations between maternal pre-pregnancy BMI and semen characteristics or testes volume. Sons of mothers with higher pre-pregnancy BMI had higher oestradiol and lower SHBG levels, both in a dose-dependent manner. Sons of mothers with pre-pregnancy obesity (≥30 kg/m2) had higher LH levels and a higher FAI than sons born by mothers with normal pre-pregnancy BMI (18.5-24.9 kg/m2). The mediation analyses suggested that the effect of maternal pre-pregnancy BMI on higher levels of oestrogen, LH, and FAI was partly mediated by the sons' birthweight, in addition to adult fat mass and BMI measured at the clinical examination, whereas most of the effect on lower levels of SHBG was primarily mediated by the sons' own fat mass and BMI. Paternal BMI was not a strong confounder of the associations in this study.

LIMITATIONS, REASONS FOR CAUTION

This study was based in a population-based cohort with a low prevalence of overweight and obesity in both mothers and adult sons. Some men (10%) had blood for reproductive hormone assessment drawn in the evening. While several potential confounding factors were accounted for, this study's inherent risk of residual and unmeasured confounding precludes provision of causal estimates. Therefore, caution should be given when interpreting the causal effect of maternal BMI on sons' reproductive health.

WIDER IMPLICATIONS OF THE FINDINGS

Given the widespread occurrence of overweight and obesity among pregnant women, it is imperative to thoroughly examine the potential consequences for reproductive hormone levels in adult sons. The potential effects of maternal pre-pregnancy obesity on sons' reproductive hormone profile may potentially be partly avoided by the prevention of overweight and obesity in the sons.

STUDY FUNDING/COMPETING INTEREST(S)

The project was funded by the Lundbeck Foundation (R170-2014-855), the Capital Region of Denmark, Medical doctor Sofus Carl Emil Friis and spouse Olga Doris Friis's Grant, Axel Muusfeldt's Foundation (2016-491), AP Møller Foundation (16-37), the Health Foundation, Dagmar Marshall's Fond, Aarhus University, Independent Research Fund Denmark (9039-00128B), and the European Union (ERC, BIOSFER, 101071773). Views and opinions expressed are, however, those of the authors only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible. The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

ART in Europe, 2019: results generated from European registries by ESHRE†

STUDY QUESTION

What are the data and trends on ART and IUI cycle numbers and their outcomes, and on fertility preservation (FP) interventions, reported in 2019 as compared to previous years?

SUMMARY ANSWER

The 23rd ESHRE report highlights the rising ART treatment cycles and children born, alongside a decline in twin deliveries owing to decreasing multiple embryo transfers; fresh IVF or ICSI cycles exhibited higher delivery rates, whereas frozen embryo transfers (FET) showed higher pregnancy rates (PRs), and reported IUI cycles decreased while maintaining stable outcomes.

WHAT IS KNOWN ALREADY

ART aggregated data generated by national registries, clinics, or professional societies have been gathered and analyzed by the European IVF-Monitoring (EIM) Consortium since 1997 and reported in a total of 22 manuscripts published in Human Reproduction and Human Reproduction Open.

STUDY DESIGN, SIZE, DURATION

Data on medically assisted reproduction (MAR) from European countries are collected by EIM for ESHRE each year. The data on treatment cycles performed between 1 January and 31 December 2019 were provided by either national registries or registries based on initiatives of medical associations and scientific organizations or committed persons in one of the 44 countries that are members of the EIM Consortium.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall, 1487 clinics offering ART services in 40 countries reported, for the second time, a total of more than 1 million (1 077 813) treatment cycles, including 160 782 with IVF, 427 980 with ICSI, 335 744 with FET, 64 089 with preimplantation genetic testing (PGT), 82 373 with egg donation (ED), 546 with IVM of oocytes, and 6299 cycles with frozen oocyte replacement (FOR). A total of 1169 institutions reported data on IUI cycles using either husband/partner's semen (IUI-H; n = 147 711) or donor semen (IUI-D; n = 51 651) in 33 and 24 countries, respectively. Eighteen countries reported 24 139 interventions in pre- and post-pubertal patients for FP, including oocyte, ovarian tissue, semen, and testicular tissue banking.

MAIN RESULTS AND THE ROLE OF CHANCE

In 21 countries (21 in 2018) in which all ART clinics reported to the registry 476 760 treatment cycles were registered for a total population of approximately 300 million inhabitants, allowing the best estimate of a mean of 1581 cycles performed per million inhabitants (range: 437-3621). Among the reporting countries, for IVF the clinical PRs per aspiration slightly decreased while they remained similar per transfer compared to 2018 (21.8% and 34.6% versus 25.5% and 34.1%, respectively). In ICSI, the corresponding PRs showed similar trends compared to 2018 (20.2% and 33.5%, versus 22.5% and 32.1%) When freeze-all cycles were not considered for the calculations, the clinical PRs per aspiration were 28.5% (28.8% in 2018) and 26.2% (27.3% in 2018) for IVF and ICSI, respectively. After FET with embryos originating from own eggs, the PR per thawing was at 35.1% (versus 33.4% in 2018), and with embryos originating from donated eggs at 43.0% (41.8% in 2018). After ED, the PR per fresh embryo transfer was 50.5% (49.6% in 2018) and per FOR 44.8% (44.9% in 2018). In IVF and ICSI together, the trend toward the transfer of fewer embryos continues with the transfer of 1, 2, 3, and ≥4 embryos in 55.4%, 39.9%, 2.6%, and 0.2% of all treatments, respectively (corresponding to 50.7%, 45.1%, 3.9%, and 0.3% in 2018). This resulted in a reduced proportion of twin delivery rates (DRs) of 11.9% (12.4% in 2018) and a similar triplet DR of 0.3%. Treatments with FET in 2019 resulted in twin and triplet DR of 8.9% and 0.1%, respectively (versus 9.4% and 0.1% in 2018). After IUI, the DRs remained similar at 8.7% after IUI-H (8.8% in 2018) and at 12.1% after IUI-D (12.6% in 2018). Twin and triplet DRs after IUI-H were 8.7% and 0.4% (in 2018: 8.4% and 0.3%) and 6.2% and 0.2% after IUI-D (in 2018: 6.4% and 0.2%), respectively. Eighteen countries (16 in 2018) provided data on FP in a total number of 24 139 interventions (20 994 in 2018). Cryopreservation of ejaculated sperm (n = 11 592 versus n = 10 503 in 2018) and cryopreservation of oocytes (n = 10 784 versus n = 9123 in 2018) were most frequently reported.

LIMITATIONS, REASONS FOR CAUTION

Caution with the interpretation of results should remain as data collection systems and completeness of reporting vary among European countries. Some countries were unable to deliver data about the number of initiated cycles and/or deliveries.

WIDER IMPLICATIONS OF THE FINDINGS

The 23rd ESHRE data collection on ART, IUI, and FP interventions shows a continuous increase of reported treatment numbers and MAR-derived livebirths in Europe. Although it is the largest data collection on MAR in Europe, further efforts toward optimization of both the collection and the reporting, from the perspective of improving surveillance and vigilance in the field of reproductive medicine, are awaited.

STUDY FUNDING/COMPETING INTEREST(S)

The study has received no external funding and all costs are covered by ESHRE. There are no competing interests.

Cerebral palsy in children born after assisted reproductive technology in Norway: Risk, prevalence, and clinical characteristics

INTRODUCTION

The aim was to investigate the risk, prevalence, and clinical characteristics of cerebral palsy among children born after assisted reproductive technology (ART) in Norway.

MATERIAL AND METHODS

All liveborn children from 2002 to 2015 were included. Information was collected from the Medical Birth Registry of Norway, linked to the Norwegian Quality and Surveillance Registry for Cerebral Palsy as of December 31, 2022. Logistic regression analyses were used to calculate the prevalence of cerebral palsy per 1000 live births after ART and natural conception with birth year as covariate, crude odds ratios (OR) for cerebral palsy among children born after ART using children born after natural conception as reference, and OR adjusted for potential confounders, with 95% confidence intervals (CI). Potential mediators of the association were studied in stratified analyses. Descriptive statistics were used to compare proportions in clinical characteristics among children with cerebral palsy born after ART and natural conception.

RESULTS

Among 833 645 livebirths, 23 645 children were born after ART and of the latter 97 were diagnosed with cerebral palsy. The overall prevalence of cerebral palsy after ART was 4.10 per 1000 live births (95% CI 3.36-5.00), decreasing from 7.79 per 1000 in 2002 to 3.55 in 2015. Compared with children born after natural conception, the OR for cerebral palsy was 2.01 (95% CI 1.63-2.47) adjusted for mother's age at birth, parity, and pre-pregnancy health. When restricted to singletons born at term, the adjusted OR for cerebral palsy was 1.13 (95% CI 0.76-1.69). The distribution of cerebral palsy subtypes and the severity of gross and fine motor function and associated impairments did not differ significantly between children with cerebral palsy born after ART and natural conception.

CONCLUSIONS

Children born after ART had a risk of cerebral palsy that was twice that of children born after natural conception. The increased risk of cerebral palsy after ART is likely attributed to multiple pregnancies and preterm births. The prevalence of cerebral palsy after ART decreased significantly during the study period, despite an increased use of ART in the population. The distribution of clinical characteristics did not differ between children with cerebral palsy born after ART and those born after a natural conception, suggesting that the risk factors for, and causes of cerebral palsy were similar.

Sperm centriolar factors and genetic defects that can predict pregnancy

The human sperm centrosome, comprising the two morphologically distinct centrioles and associated pericentriolar materials, plays a crucial role in fertilization and early embryonic development after fertilization. Once inside the oocyte, the sperm centrosome serves as a microtubule-organizing center, orchestrating mitotic spindle formation, chromosome segregation, and syngamy. Abnormalities of the sperm centrosome can lead to abnormal embryonic development and embryonic chromosomal instability, and are associated with pregnancy loss. Recent research has shed light on the molecular composition, regulation, and function of this vital organelle. Understanding the intricacies of the sperm centrosome is crucial for elucidating the mechanisms underlying successful fertilization and early embryonic development, as well as addressing infertility and developmental disorders associated with centrosomal defects.

Mapping international research output within ethical, legal, and social implications (ELSI) of assisted reproductive technologies

PURPOSE

Research about ethical, legal, and social implications (ELSI) of assisted reproductive technologies (ART) is influenced by cultural and value-based perspectives. It impacts regulations, funding, and clinical practice, and shapes the perception of ART in society. We analyze trends in the global literature on ELSI of ART between 1999 and 2019. As most output is produced by North America, Western Europe, and Australia, we focus on international research, i.e., academic articles studying a different country than that of the corresponding author.

METHODS

The corpus, extracted from PubMed, Web of Science, and Scopus, includes 7714 articles, of which 1260 involved international research. Analysis is based on titles, abstracts and keywords, classification into ART fields and Topic Modeling, the countries of corresponding author, and countries mentioned in abstracts.

RESULTS

An absolute increase in the number of international studies, and their relative proportion. Trends of decentralization are apparent, yet geographic centralization remains, which reflects an unequal distribution of research funds across countries and may result in findings that do not reflect global diversity of norms and values. Preference for studying conceptual challenges through philosophical analysis, and for fields that concern only a portion of ART cycles. Less attention was dedicated to economic analysis and barriers to access, or to knowledge of and attitudes. International studies provide an opportunity to expand and diversify the scope of ELSI research.

CONCLUSION

We call on the research community to promote international collaborations, focus on less explored regions, and divert more attention to questions of cost, access, knowledge, and attitudes.

Main topics in assisted reproductive market: A scoping review

BACKGROUND

Infertility affects around 12% of couples, and this proportion has been gradually increasing. In this context, the global assisted reproductive technologies (ART) market shows significant expansion, hovering around USD 26 billion in 2019 and is expected to reach USD 45 billion by 2025.

OBJECTIVES

We realized a scoping review of the ART market from academic publications, market reports, and specialized media news, to identify the main terms and characterize them into the main topics in the area.

DESIGN

We apply an LDA topic modeling process to identify the main terms, and clustered them into semantic synonymous topics. We extracted the patterns and information to these topics and purposed a factor/consequence correlation to them.

RESULTS

We found 2,232 academic papers and selected 632 to include in the automatic term detection. We also included 34 market reports and seven notices produced by specialized enterprises. Were identified 121 most relevant cited terms covering 7,806 citations. These terms were manually aggregated into 10 topics based on semantic similarity: neutral terms (37.2%), economic aspects (17.6%), in vitro fertilization (IVF) commodities & cross-border reproductive care (CBRC) (10.6%), geographic distribution (9.5%), social aspects (7%), regulation (6%), trends & concerns (3.9%), accessibility (3.4%), internet influence (2.9%), and fertility preservation for non-medical reasons (2%).

DISCUSSION

The analysis indicates a market with expressive complexity. Most terms were associated with more than one topic, indicating the synergism of this market's behavior. Only seven terms related to economic aspects, surrogacy and donation represent around 50% of the citations. Except for the topic formed by generic terms, the topic of the economic aspects was the most represented, reflecting macro perspectives such as a-la-carte standard of treatments, many clinics operating on a small/medium scale, and the recent formation of conglomerates. The IVF commodities & CBRC topic brings an overview of gametes pricing and transnational surrogacy, and its regulation. The topic of geographic distribution indicates that that the Asia-Pacific (APAC) market has the most significant growth potential in all fields. Despite the increase in supply and demand for infertility treatments and technological advances in recent decades, the success rate of IVF cycles remains at around 30%. Terms referring to research and development or technical improvement were not identified in a significant way in this review.

CONCLUSIONS

The formation of topics by semantic similarity proved to be an initial path for the elaboration of in-depth studies on the dynamics between several factors, for this, we present the panel classifying main terms into factors (demand, pent-up demand, or distributive) or ART market consequences. Through this approach, it was possible to observe that most of the works addresses economic aspects, regulation and geographic aspects and that topics related to research and improvement have not been addressed. In this way, we highlight the need to deepen the analysis of market elements that may be related to increased efficiency of IVF in the technical field.

EuMAR: a roadmap towards a prospective, cycle-by-cycle registry of medically assisted reproduction in Europe

More than 20 years ago, the survey of activities in medically assisted reproduction (MAR) was initiated in Europe and resulted in cross-sectional annual reports, as issued by the European IVF Monitoring (EIM) consortium of ESHRE. Over time, these reports mirror the continuous development of the technologies and contribute to increased transparency and surveillance of reproductive care. Meanwhile, progressive changes of existing treatment modalities and the introduction of new technologies resulted in the need of a cumulative approach in the assessment of treatment outcomes, which warrants a prospective cycle-by-cycle data registry on MAR activities, including fertility preservation. This change in the paradigm of data collection in Europe towards the construction of cumulative outcome results is expected to generate additional insights into cross-institutional but also cross-border movements of patients and reproductive material. This is essential to improve vigilance and surveillance. The European monitoring of Medically Assisted Reproduction (EuMAR) project, co-funded by the European Union, will establish a registry for the transnational collection of prospective cycle-by-cycle MAR and fertility preservation data on the basis of an individual reproductive care code (IRCC). The rationale for the project and the objectives are presented here.

Hormone replacement cycles are associated with a higher risk of hypertensive disorders: Retrospective cohort study in singleton and twin pregnancies

OBJECTIVE

To elaborate the associations of different cycle regimens (natural cycle [NC], stimulated cycle [SC], hormone replacement cycle [HRC]) on maternal and neonatal adverse pregnancy outcomes after frozen-thawed embryo transfers (FET).

DESIGN

Population-based registry study.

SETTING

Swiss IVF Registry.

POPULATION OR SAMPLE

Singleton (n = 4636) and twin (n = 544) live births after NC-FET (n = 776), SC-FET (n = 758) or HRC-FET (n = 3646) registered from 2014 to 2019.

METHODS

Fifteen pregnancy pathologies were modelled for singleton and twin pregnancies using mixed models adjusted for cycle regimen, delivery, fertilisation technique, chronic anovulation, age of mother and centre.

MAIN OUTCOME MEASURES

Maternal (vaginal bleeding, isolated arterial hypertension and pre-eclampsia) and neonatal (gestational age, birthweight, mode of delivery) adverse pregnancy outcomes.

RESULTS

In singleton pregnancies, the incidences of bleeding in first trimester, isolated hypertension and pre-eclampsia were highest in HRC-FET with doubled odds of bleeding in first trimester (adjusted odds ratio [aOR] 2.23; 95% CI 1.33-3.75), isolated hypertension (aOR 2.50; 95% CI 1.02-6.12) and pre-eclampsia (aOR 2.16; 95% CI 1.13-4.12) in HRC-FET vs. NC-FET and with doubled respectively sixfold odds of bleeding (aOR 2.08; 95% CI 1.03-4.21) and pre-eclampsia (6.02; 95% CI 1.38-26.24) in HRC-FET versus SC-FET. In twin pregnancies, the incidence of pre-eclampsia was highest in HRC-FET with numerically higher odds of pre-eclampsia in HRC-FET versus NC-FET and versus SC-FET.

CONCLUSIONS

Our data implied the highest maternal risks of hypertensive disorders in HRC-FET, therefore clinicians should prefer SC-FET or NC-FET if medically possible.

Towards Automation in IVF: Pre-Clinical Validation of a Deep Learning-Based Embryo Grading System during PGT-A Cycles

Preimplantation genetic testing for aneuploidies (PGT-A) is arguably the most effective embryo selection strategy. Nevertheless, it requires greater workload, costs, and expertise. Therefore, a quest towards user-friendly, non-invasive strategies is ongoing. Although insufficient to replace PGT-A, embryo morphological evaluation is significantly associated with embryonic competence, but scarcely reproducible. Recently, artificial intelligence-powered analyses have been proposed to objectify and automate image evaluations. iDAScore v1.0 is a deep-learning model based on a 3D convolutional neural network trained on time-lapse videos from implanted and non-implanted blastocysts. It is a decision support system for ranking blastocysts without manual input. This retrospective, pre-clinical, external validation included 3604 blastocysts and 808 euploid transfers from 1232 cycles. All blastocysts were retrospectively assessed through the iDAScore v1.0; therefore, it did not influence embryologists' decision-making process. iDAScore v1.0 was significantly associated with embryo morphology and competence, although AUCs for euploidy and live-birth prediction were 0.60 and 0.66, respectively, which is rather comparable to embryologists' performance. Nevertheless, iDAScore v1.0 is objective and reproducible, while embryologists' evaluations are not. In a retrospective simulation, iDAScore v1.0 would have ranked euploid blastocysts as top quality in 63% of cases with one or more euploid and aneuploid blastocysts, and it would have questioned embryologists' ranking in 48% of cases with two or more euploid blastocysts and one or more live birth. Therefore, iDAScore v1.0 may objectify embryologists' evaluations, but randomized controlled trials are required to assess its clinical value.

Selection bias in a male-offspring cohort investigating fecundity: is there reason for concern?

STUDY QUESTION

Is there risk of selection bias in etiological studies investigating prenatal risk factors of poor male fecundity in a cohort of young men?

SUMMARY ANSWER

The risk of selection bias is considered limited despite a low participation rate.

WHAT IS KNOWN ALREADY

Participation rates in studies relying on volunteers to provide a semen sample are often very low. Many risk factors for poor male fecundity are associated with participation status, and as men with low fecundity may be more inclined to participate in studies of semen quality, a risk of selection bias exists.

STUDY DESIGN, SIZE, DURATION

A population-based follow-up study of 5697 young men invited to the Fetal Programming of Semen Quality (FEPOS) cohort nested within the Danish National Birth Cohort (DNBC), 1998-2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Young men (age range: 18 years, 9 months to 21 years, 4 months) born 1998-2000 by mothers included in the DNBC were invited to participate in FEPOS. In total, 1173 men answered a survey in FEPOS (n = 115 participated partly); of those, 1058 men participated fully by also providing a semen and a blood sample at a clinical visit. Differential selection according to parental baseline characteristics in the first trimester, the sons' own characteristics from the FEPOS survey, and urogenital malformations and diseases in reproductive organs from the Danish registers were investigated using logistic regression. The influence of inverse probability of selection weights (IPSWs) to investigate potential selection bias was examined using a predefined exposure-outcome association of maternal smoking in the first trimester (yes, no) and total sperm count analysed using adjusted negative binomial regression. A multidimensional bias analysis on the same association was performed using a variety of bias parameters to assess different scenarios of differential selection.

MAIN RESULTS AND THE ROLE OF CHANCE

Participation differed according to most parental characteristics in first trimester but did not differ according to the prevalence of a urogenital malformation or disease in the reproductive organs. Associations between maternal smoking in the first trimester and male fecundity were similar when the regression models were fitted without and with IPSWs. Adjusting for other potential risk factors for poor male fecundity, maternal smoking was associated with 21% (95% CI: -32% to -9%) lower total sperm count. In the bias analysis, this estimate changed only slightly under realistic scenarios. This may be extrapolated to other exposure-outcome associations.

LIMITATIONS, REASONS FOR CAUTION

We were unable to directly assess markers of male fecundity for non-participants from, for example an external source and therefore relied on potential proxies of fecundity. We did not have sufficient power to analyse associations between prenatal exposures and urogenital malformations.

WIDER IMPLICATIONS OF THE FINDINGS

The results are reassuring when using this cohort to identify causes of poor male fecundity. The results may be generalized to other similar cohorts. As the young men grow older, they can be followed in the Danish registers, as an external source, to examine, whether participation is associated with the risk of having an infertility diagnosis.

STUDY FUNDING/COMPETING INTEREST(S)

The project was funded by the Lundbeck Foundation (R170-2014-855), the Capital Region of Denmark, Medical doctor Sofus Carl Emil Friis and spouse Olga Doris Friis's Grant, Axel Muusfeldt's Foundation (2016-491), AP Møller Foundation (16-37), the Health Foundation, Dagmar Marshall's Fond, Aarhus University and Independent Research Fund Denmark (9039-00128B). The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Evidence-Based Pre-Pregnancy Counseling for Oocyte Donation Pregnancies: a Systematic Review and Guide for Physicians

It is well known that oocyte donation (OD) pregnancies are associated with higher complication rates compared to autologous pregnancies. However, evidence-based information for pre-pregnancy counseling designed for health care workers is scarce. Therefore, a systematic literature search was performed to find articles that address pre-pregnancy counseling before OD.A systematic search was conducted in September 2020 in various databases, including PubMed and Embase. Nine (systematic) reviews and meta-analyses were included that reported on pre-pregnancy advice in OD pregnancies.Studies are consistent in documenting a higher risk for hypertensive disorders, cesarean section, preterm birth, postpartum hemorrhage, and low birth weight. Based on these complications, pre-pregnancy advice is mentioned in all included systematic reviews to prevent complications in the next pregnancy. All studies recommend counseling women on the increased risk of complications during OD pregnancy. Other recommendations include the prophylactic use of aspirin in pregnancy and restriction to single embryo transfer. Individualized appropriate surveillance and management strategies should be considered for every patient achieving pregnancy by OD.In conclusion, we provide a summary of the most important outcomes in OD pregnancies, and thereby offer a guide for pre-pregnancy counseling.

Should we adopt a prognosis-based approach to unexplained infertility?

The treatment of unexplained infertility is a contentious topic that continues to attract a great deal of interest amongst clinicians, patients and policy makers. The inability to identify an underlying pathology makes it difficult to devise effective treatments for this condition. Couples with unexplained infertility can conceive on their own and any proposed intervention needs to offer a better chance of having a baby. Over the years, several prognostic and prediction models based on routinely collected clinical data have been developed, but these are not widely used by clinicians and patients. In this opinion paper, we propose a prognosis-based approach such that a decision to access treatment is based on the estimated chances of natural and treatment-related conception, which, in the same couple, can change over time. This approach avoids treating all couples as a homogeneous group and minimizes unnecessary treatment whilst ensuring access to those who need it early.

International Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST): enrollment and methods

STUDY QUESTION

What is the feasibility of a prospective protocol to follow subfertile couples being treated with natural procreative technology for up to 3 years at multiple clinical sites?

SUMMARY ANSWER

Overall, clinical sites had missing data for about one-third of participants, the proportion of participants responding to follow-up questionnaires during time periods when participant compensation was available (about two-thirds) was double that of time periods when participant compensation was not available (about one-third) and follow-up information was most complete for pregnancies and births (obtained from both clinics and participants).

WHAT IS KNOWN ALREADY

Several retrospective single-clinic studies from Canada, Ireland and the USA, with subfertile couples receiving restorative reproductive medicine, mostly natural procreative technology, have reported adjusted cumulative live birth rates ranging from 29% to 66%, for treatment for up to 2 years, with a mean women’s age of about 35 years.

STUDY DESIGN, SIZE, DURATION

The international Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST) was designed as a multicenter, prospective cohort study, to enroll subfertile couples seeking treatment for live birth, assess baseline characteristics and follow them up for up to 3 years to report diagnoses, treatments and outcomes of pregnancy and live birth. In addition to obtaining data from medical record abstraction, we sent follow-up questionnaires to participants (both women and men) to obtain information about treatments and pregnancy outcomes, including whether they obtained treatment elsewhere. The study was conducted from 2006 to 2016, with a total of 10 clinics participating for at least some of the study period across four countries (Canada, Poland, UK and USA).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 834 participants were subfertile couples with the woman’s age 18 years or more, not pregnant and seeking a live birth, with at least one clinic visit. Couples with known absolute infertility were excluded (i.e. bilateral tubal blockage, azoospermia). Most women were trained to use a standardized protocol for daily vulvar observation, description and recording of cervical mucus and vaginal bleeding (the Creighton Model FertilityCare System). Couples received medical and sometimes surgical evaluation and treatments aimed to restore and optimize female and male reproductive function, to facilitate in vivo conception.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age of women starting treatment was 34.0 years; among those with additional demographic data, 382/478 (80%) had 16 or more years of education, and 199/659 (30%) had a prior live birth. Across 10 clinical sites in four countries (mostly private clinical practices) with family physicians or obstetrician–gynecologists, data about clinic visits were submitted for 60% of participants, and diagnostic data for 77%. For data obtained directly from the couple, 59% of couples had at least one follow-up questionnaire, and the proportion of women and men responding to fill out the follow-up questionnaires was 69% and 67%, respectively, when participant financial compensation was available, compared to 38% and 33% when compensation was not available. Among all couples, 57% had at least one pregnancy and 44% at least one live birth during the follow-up time period, based on data obtained from clinic and/or participant questionnaires. All sites reported on female pelvic surgical procedures, and among all participants, 22% of females underwent a pelvic diagnostic and/or therapeutic procedure, predominantly laparoscopy and hysterosalpingography. Among the 643 (77%) of participants with diagnostic information, ovulation-related disorders were diagnosed in 87%, endometriosis in 31%, nutritional disorders in 47% and abnormalities of semen analysis in 24%. The mean number of diagnoses per couple was 4.7.

LIMITATIONS, REASONS FOR CAUTION

The level of missing data was higher than anticipated, which limits both generalizability and the ability to study different components of treatment and prognosis. Loss to follow-up may also be differential and introduce bias for outcomes. Most of the participating clinicians were not surgeons, which limits the opportunity to study the impact of surgical interventions. Participants were geographically dispersed but relatively homogeneous with regard to socioeconomic status, which may limit the generalizability of current and future findings.

WIDER IMPLICATIONS OF THE FINDINGS

Multicenter studies are key to understanding the outcomes of subfertility treatments beyond IVF or IUI in broader populations, and the association of different prognostic factors with outcomes. We anticipate that the iNEST study will provide insight for clinical and treatment factors associated with outcomes of pregnancy and live birth, with appropriate attention to potential biases (including adjustment for potential confounders, multiple imputation for missing data, sensitivity analysis and inverse probability weighting for potential differential loss to follow-up, and assessments for clinical site heterogeneity). Future studies will need to either have: adequate funding to compensate clinics and participants for robust data collection, including targeted randomized trials; or a scaled-down, registry-based approach with targeted data points, similar to the multiple national and regional ART registries.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the study came from the International Institute for Restorative Reproductive Medicine, the University of Utah, Department of Family and Preventive Medicine, Health Studies Fund, the Primary Children’s Medical Foundation, the Mary Cross Tippmann Foundation, the Atlas Foundation, the St. Augustine Foundation and the Women’s Reproductive Health Foundation. The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

The iNEST study is registered at clinicaltrials.gov, NCT01363596.

ART in Europe, 2018: results generated from European registries by ESHRE

STUDY QUESTION

What are the data and trends on ART and IUI cycle numbers and their outcomes, and on fertility preservation (FP) interventions, reported in 2018 as compared to previous years?

SUMMARY ANSWER

The 22nd ESHRE report shows a continued increase in reported numbers of ART treatment cycles and children born in Europe, a decrease in transfers with more than one embryo with a further reduction of twin delivery rates (DRs) as compared to 2017, higher DRs per transfer after fresh IVF or ICSI cycles (without considering freeze-all cycles) than after frozen embryo transfer (FET) with higher pregnancy rates (PRs) after FET and the number of reported IUI cycles decreased while their PR and DR remained stable.

WHAT IS KNOWN ALREADY

ART aggregated data generated by national registries, clinics or professional societies have been gathered and analysed by the European IVF-monitoring Consortium (EIM) since 1997 and reported in 21 manuscripts published in Human Reproduction and Human Reproduction Open.

STUDY DESIGN, SIZE, DURATION

Data on medically assisted reproduction (MAR) from European countries are collected by EIM for ESHRE on a yearly basis. The data on treatment cycles performed between 1 January and 31 December 2018 were provided by either national registries or registries based on initiatives of medical associations and scientific organizations or committed persons of 39 countries.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall, 1422 clinics offering ART services in 39 countries reported a total of more than 1 million (1 007 598) treatment cycles for the first time, including 162 837 with IVF, 400 375 with ICSI, 309 475 with FET, 48 294 with preimplantation genetic testing, 80 641 with egg donation (ED), 532 with IVM of oocytes and 5444 cycles with frozen oocyte replacement (FOR). A total of 1271 institutions reported data on IUI cycles using either husband/partner’s semen (IUI-H; n = 148 143) or donor semen (IUI-D; n = 50 609) in 31 countries and 25 countries, respectively. Sixteen countries reported 20 994 interventions in pre- and post-pubertal patients for FP including oocyte, ovarian tissue, semen and testicular tissue banking.

MAIN RESULTS AND THE ROLE OF CHANCE

In 21 countries (21 in 2017) in which all ART clinics reported to the registry, 410 190 treatment cycles were registered for a total population of ∼ 300 million inhabitants, allowing a best estimate of a mean of 1433 cycles performed per million inhabitants (range: 641–3549). Among the 39 reporting countries, for IVF, the clinical PR per aspiration slightly decreased while the PR per transfer remained similar compared to 2017 (25.5% and 34.1% in 2018 versus 26.8% and 34.3% in 2017). In ICSI, the corresponding rates showed similar evolutions in 2018 compared to 2017 (22.5% and 32.1% in 2018 versus 24.0% and 33.5% in 2017). When freeze-all cycles were not considered for the calculations, the clinical PRs per aspiration were 28.8% (29.4% in 2017) and 27.3% (27.3% in 2017) for IVF and ICSI, respectively. After FET with embryos originating from own eggs, the PR per thawing was 33.4% (versus 30.2% in 2017), and with embryos originating from donated eggs 41.8% (41.1% in 2017). After ED, the PR per fresh embryo transfer was 49.6% (49.2% in 2017) and per FOR 44.9% (43.3% in 2017). In IVF and ICSI together, the trend towards the transfer of fewer embryos continues with the transfer of 1, 2, 3 and ≥4 embryos in 50.7%, 45.1%, 3.9% and 0.3% of all treatments, respectively (corresponding to 46.0%, 49.2%. 4.5% and 0.3% in 2017). This resulted in a reduced proportion of twin DRs of 12.4% (14.2% in 2017) and similar triplet DR of 0.2%. Treatments with FET in 2018 resulted in twin and triplet DRs of 9.4% and 0.1%, respectively (versus 11.2% and 0.2%, respectively in 2017). After IUI, the DRs remained similar at 8.8% after IUI-H (8.7% in 2017) and at 12.6% after IUI-D (12.4% in 2017). Twin and triplet DRs after IUI-H were 8.4% and 0.3%, respectively (in 2017: 8.1% and 0.3%), and 6.4% and 0.2% after IUI-D (in 2017: 6.9% and 0.2%). Among 20 994 FP interventions in 16 countries (18 888 in 13 countries in 2017), cryopreservation of ejaculated sperm (n = 10 503, versus 11 112 in 2017) and of oocytes (n = 9123 versus 6588 in 2017) were the most frequently reported.

LIMITATIONS, REASONS FOR CAUTION

The results should be interpreted with caution as data collection systems and completeness of reporting vary among European countries. Some countries were unable to deliver data about the number of initiated cycles and/or deliveries.

WIDER IMPLICATIONS OF THE FINDINGS

The 22nd ESHRE data collection on ART, IUI and FP interventions shows a continuous increase of reported treatment numbers and MAR-derived livebirths in Europe. Although it is the largest data collection on MAR in Europe, further efforts towards optimization of both the collection and reporting, with the aim of improving surveillance and vigilance in the field of reproductive medicine, are awaited.

STUDY FUNDING/COMPETING INTEREST(S)

The study has received no external funding and all costs are covered by ESHRE. There are no competing interests.

The Impact of Culture Medium on Morphokinetics of Cleavage Stage Embryos: An Observational Study

To study the impact of culture media on preimplantation morphokinetics used for predicting clinical outcomes. All IVF and ICSI cycles performed between 2012 and 2017 with time-lapse information available were included. In November 2014, culture medium was changed from Vitrolife G-1 PLUS to SAGE 1-Step. Each embryo was retrospectively assigned a morphokinetic-based KIDScore for prediction of implantation. Clinical outcomes were retrieved from medical records. Linear mixed models were used to study differences in morphokinetic parameters, a proportional odds model for KIDScore ranking and logistic regression for differences in clinical outcomes. All analyses were adjusted for patient and treatment characteristics. In 253 (63.1%) cycles, embryos (n = 671) were cultured in Vitrolife, and in 148 (36.9%) cycles, embryos (n = 517) were cultured in SAGE. All cleavage divisions occurred earlier for SAGE embryos than for Vitrolife embryos (2-cell: -2.28 (95%CI: -3.66, -0.89), 3-cell: -2.34 (95%CI: -4.00, -0.64), 4-cell: -2.41 (95%CI: -4.11, -0.71), 5-cell: -2.54 (95%CI: -4.90, -0.18), 6-cell: -3.58 (95%CI: -6.08, -1.08), 7-cell: -5.62 (95%CI: -8.80, -2.45) and 8-cell: -5.32 (95%CI: -9.21, -1.42) hours, respectively). Significantly more embryos cultured in SAGE classified for the highest KIDScore compared to embryos cultured in Vitrolife (p < 0.001). No differences were observed in clinical outcomes. Our results demonstrate an impact of culture medium on preimplantation embryo developmental kinetics, which affects classification within the KIDScore algorithm, while pregnancy outcomes were comparable between the groups. This study underscores the need to include the type of culture medium in the development of morphokinetic-based embryo selection tools.

Personalized Nutrition in the Management of Female Infertility: New Insights on Chronic Low-Grade Inflammation

Increasing evidence on the significance of nutrition in reproduction is emerging from both animal and human studies, suggesting a mutual association between nutrition and female fertility. Different “fertile” dietary patterns have been studied; however, in humans, conflicting results or weak correlations are often reported, probably because of the individual variations in genome, proteome, metabolome, and microbiome and the extent of exposure to different environmental conditions. In this scenario, “precision nutrition”, namely personalized dietary patterns based on deep phenotyping and on metabolomics, microbiome, and nutrigenetics of each case, might be more efficient for infertile patients than applying a generic nutritional approach. In this review, we report on new insights into the nutritional management of infertile patients, discussing the main nutrigenetic, nutrigenomic, and microbiomic aspects that should be investigated to achieve effective personalized nutritional interventions. Specifically, we will focus on the management of low-grade chronic inflammation, which is associated with several infertility-related diseases.

Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology: emulating a target trial using an observational database of administrative claims

OBJECTIVE

To compare the effectiveness and safety of 1 cycle of assisted reproductive technology (ART) vs. 3 cycles of intrauterine insemination (IUI).

DESIGN

Target trial emulation using observational data.

SETTING

A healthcare claims database (2011-2015).

PATIENT(S)

The patients were 29,021 women aged 18-45 years with an infertility diagnosis and no history of IUI or ART within the past 12 months.

INTERVENTION(S)

One ART cycle immediately, with no more cycles of ART or IUI within the next 4 months; or 1 IUI cycle immediately, with 2 additional consecutive cycles of IUI within the next 4 months unless pregnancy occurred.

MAIN OUTCOME MEASURE(S)

Live births, multiple births, congenital malformations, preterm births, small-for-gestational-age newborns, large-for-gestational-age newborns, admission to neonatal intensive care unit (NICU), gestational diabetes, preeclampsia, and gestational hypertension.

RESULT(S)

The probability of live birth was 27.3% for ART and 26.3% for IUI. The observational analogue of per-protocol risk difference (95% confidence interval) for ART compared with IUI was 1.0% (-0.1%, 2.2%) for live births, 4.3% (3.7%, 4.9%) for multiple births, 3.4% (2.8%, 4.0%) for preterm births, 1.5% (0.9%, 2.1%) for NICU admissions, and 0.6% (0.2%, 1.0%) for gestational diabetes. The risk differences for the other outcomes were <0.5%. The results of the 2 strategies were similar in women ≤40 years, but in women >40 years the probability of live birth was greater for ART (14.4%) than for IUI (7.4%).

CONCLUSION(S)

Compared with 3 cycles of IUI, 1 cycle of ART was estimated to have a similar probability of live birth but slightly higher risks of multiple gestations, preterm births, and NICU admissions.

The economic burden of infertility treatment and distribution of expenditures overtime in France: a self-controlled pre-post study

Background

Recent cost studies related to infertility treatment have focused on assisted reproductive technologies. None has examined lower-intensity infertility treatments or analyzed the distribution of infertility treatment expenditures over time.

The Purpose of the study was to analyse the size and distribution of infertility treatment expenditures over time, and estimate the economic burden of infertility treatment per 10,000 women aged 18 − 50 in France from a societal perspective.

Methods

We used French National individual medico-administrative database to conduct a self-controlled before-after analytic cohort analysis with 556 incidental women treated for infertility in 2014 matched with 9,903 controls using the exact matching method. Infertility-associated expenditures per woman and per 10,000 women over the 3.5-year follow-up period derived as a difference-in-differences.

Results

The average infertility related expenditure per woman is estimated at 6,996 (95% CI: 5,755–8,237) euros, the economic burden for 10,000 women at 70.0 million (IC95%: 57.6–82.4) euros. The infertility related expenditures increased from 235 (IC95%: 98–373) euros in semester 0, i.e. before treatment, to 1,509 (IC95%: 1,277–1,741) euros in semester 1, mainly due to ovulation stimulation treatment (47% of expenditure), to reach a plateau in semesters 2 (1,416 (IC95%: 1,161–1,670)) and 3 (1,319 (IC95%: 943–1,694)), where the share of expenses is mainly related to hospitalizations for assisted reproductive technologies (44% of expenditure), and then decrease until semester 6 (577 (IC95%: 316–839) euros).

Conclusion

This study informs public policy about the economic burden of infertility estimated at 70.0 million (IC95%: 57.6–82.4) euros for 10,000 women aged between 18 and 50. It also highlights the importance of the share of drugs in infertility treatment expenditures. If nothing is done, the increasing use of infertility treatment will lead to increased expenditure. Prevention campaigns against the preventable causes of infertility should be promoted to limit the use of infertility treatments and related costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07725-9.

Fertilization and neonatal outcomes after early rescue intracytoplasmic sperm injection: a retrospective analysis of 16,769 patients

Purpose

To evaluate the efficacy and safety of short-term insemination and early-rescue intracytoplasmic sperm injection (ICSI), an approach that rescued oocytes with unclear second polar body 6 h after initial insemination by ICSI (early R-ICSI) to avoid total or near-total fertilization failure in conventional in vitro fertilization (IVF).

Methods

We performed a retrospective study in 16,769 patients (short-term IVF, n = 12,094; ICSI, n = 3452; early R-ICSI, n = 1223) who received IVF/ICSI treatment in our hospital from January 2009 to October 2018. Fertilization and clinical outcomes were compared among those three groups.

Results

When considering the R-ICSI embryos in the early R-ICSI group independently, the rates of fertilization and day-3 cleaved embryos in 2PN oocytes were comparable, the rates of fertilization (2PN) and high-quality embryos were lower, whereas the multi-PN fertilization rate (3.27%) was significantly higher than the ICSI group (1.26%). The difference of clinical pregnancy rate between the part of transferred R-ICSI embryos (40.81%) and the ICSI group (44.73%) remained nonsignificant. Furthermore, the rate of congenital birth defects in the early R-ICSI group (0.99%) was not significantly different from those in the short-term IVF (0.76%) and ICSI groups (1.07%).

Conclusion

Despite the multi-PN fertilization rate, our study highlights early R-ICSI as a safe and effective alternative in assisted reproduction to decrease complete IVF fertilization failure and reduce ICSI utilization. Additional large amount and long-term follow-up studies are needed to further validate the use of early R-ICSI.

C. elegans as a model organism to study female reproductive health

Female reproductive health has been historically understudied and underfunded. Here, we present the advantages of using a free-living nematode, Caenorhabditis elegans, as an animal system to study fundamental aspects of female reproductive health. C. elegans is a powerful high-throughput model organism that shares key genetic and physiological similarities with humans. In this review, we highlight areas of pressing medical and biological importance in the 21st century within the context of female reproductive health. These include the decline in female reproductive capacity with increasing chronological age, reproductive dysfunction arising from toxic environmental insults, and cancers of the reproductive system. C. elegans has been instrumental in uncovering mechanistic insights underlying these processes, and has been valuable for developing and testing therapeutics to combat them. Adopting a convenient model organism such as C. elegans for studying reproductive health will encourage further research into this field, and broaden opportunities for making advancements into evolutionarily conserved mechanisms that control reproductive function.

Fine-tuning IVF laboratory key performance indicators of the Vienna consensus according to female age

PURPOSE

To test the validity of the Vienna consensus laboratory key performance indicators (KPIs) to monitor the outcome of treatments involving women of different age ranges.

METHODS

The retrospective cohort study included 862 complete IVF/ICSI cycles carried out between January 2014 and May 2021. All embryos of each cycle cohort were subject to extended culture. The overall population was divided into two groups according to female age: the Vienna consensus (≤ 39 years) and older female age (≥ 40 years). We compared outcomes of a selection of the Vienna performance indicators (PIs) and KPIs, with a focus on measures relevant to embryo cleavage and blastocyst formation. A possible association between total good blastocyst development rate (TGBDR) and cumulative clinical pregnancy rate (CPR) was also assessed.

RESULTS

No differences were observed in fertilization and embryo cleavage KPIs between the Vienna consensus and the older female age group (standard IVF fertilization, 67.2 vs. 67.3; ICSI fertilization, 72.3 vs. 75.3; day 2 development, 57.6% vs 58.7%; day 3 development, 52.4% vs. 50.7%, respectively). TGBDR was lower in the older female age group (45.5% vs. 33.4% p < 0.001). Multivariate logistic regression analysis indicated female age as a factor independently associated with TGBDR. Clinical outcomes significantly decreased with increasing female age.

CONCLUSION

The study suggests that, while most laboratory outcome measures are reliably applicable irrespective of female age, KPIs describing extended embryo culture should be fine-tuned in consideration of older female age.

IMSI—Guidelines for Sperm Quality Assessment

Intracytoplasmic sperm injection (ICSI) is a widely used and accepted treatment of choice for oocyte fertilization. However, the quality of sperm selection depends on the accurate visualization of the morphology, which can be achieved with a high image resolution. We aim to correct the conviction, shown in a myriad of publications, that an ultra-high magnification in the range of 6000×–10,000× can be achieved with an optical microscope. The goal of observing sperm under the microscope is not to simply get a larger image, but rather to obtain more detail—therefore, we indicate that the optical system’s resolution is what should be primarily considered. We provide specific microscope system setup recommendations sufficient for most clinical cases that are based on our experience showing that the optical resolution of 0.5 μm allows appropriate visualization of sperm defects. Last but not least, we suggest that mixed research results regarding the clinical value of IMSI, comparing to ICSI, can stem from a lack of standardization of microscopy techniques used for both ICSI and IMSI.

Reproductive fluids, added to the culture media, contribute to minimizing phenotypical differences between in vitro-derived and artificial insemination-derived piglets

The addition of reproductive fluids (RF) to the culture media has shown benefits in different embryonic traits but its long-term effects on the offspring phenotype are still unknown. We aimed to describe such effects in pigs. Blood samples and growth parameters were collected from piglets derived from in vitro-produced embryos (IVP) with or without RF added in the culture media versus those artificially inseminated (AI), from day 0 to month 6 of life. An oral glucose tolerance test was performed on day 45 of life. We show here the first comparative data of the growth of animals produced through different assisted reproductive techniques, demonstrating differences between groups. Overall, there was a tendency to have a larger size at birth and faster growth in animals derived from in vitro fertilization and embryo culture versus AI, although this trend was diminished by the addition of RFs to the culture media. Similarly, small differences in hematological indices and glucose tolerance between animals derived from AI and those derived from IVP, with a sex-dependent effect, tended to fade in the presence of RF. The addition of RF to the culture media could contribute to minimizing the phenotypical differences between the in vitro-derived and AI offspring, particularly in males.

Comparison of outcomes of monochorionic twin pregnancies conceived by assisted reproductive technology vs. spontaneous conceptions: A systematic review and meta-analysis

BACKGROUND

This review aimed to assess if monochorionic twin pregnancies conceived by assisted conception have worse maternal and neonatal outcomes as compared to those conceived naturally.

METHODS

Datasets of PubMed, ScienceDirect, CENTRAL, Embase, and Google Scholar were searched for studies comparing maternal and neonatal outcomes of monochorionic twin pregnancies conceived by assisted vs. spontaneous methods.

RESULTS

Eight studies comparing 337 assisted with 2,711 spontaneously conceived monochorionic twin pregnancies were included. Meta-analysis revealed that the mode of conception of monochorionic twin pregnancies had no impact on the risk of hypertensive disorders of pregnancy (HDP) (OR: 1.36 95% CI, 0.73, 2.54 I ² = 9% p = 0.03), twin-twin transfusion syndrome (TTTS) (OR: 0.83 95% CI, 0.52, 1.31 I ² = 0% p = 0.42), and very preterm delivery (OR: 1.18 95% CI, 0.74, 1.88 I ² = 41% p = 0.49). We noted no statistically significant difference in the mean birth weights (MD: -17.66 95% CI, -157.23, 121.91 I ² = 82% p = 0.80), risk of intra-uterine death (OR: 0.90 95% CI, 0.51, 1.60 I ² = 36% p = 0.73) and small for gestational age between the two groups (OR: 0.92 95% CI, 0.67, 1.26 I ² = 0% p = 0.59). There was an increased risk of caesarean sections (OR: 1.34 95% CI, 1.00, 1.80 I ² = 0% p = 0.05) and neonatal death with assisted conceptions as compared to spontaneous conceptions (OR: 2.35 95% CI, 1.11, 5.01 I ² = 37% p = 0.03).

CONCLUSION

Monochorionic twin pregnancies conceived via assisted reproductive technology have a heightened risk of cesarean section and neonatal deaths. However, there is a need for further studies to supplement current evidence.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325133, identifier: CRD42022325133.

Influencing Factors of Dyadic Coping Among Infertile Women: A Path Analysis

BACKGROUND

The infertility prevalence of married couples in China is increasing gradually. The dyadic coping level and its influencing factors of infertile women in China are poorly reported. The relationship between dyadic coping and the family cohesion and adaptability in infertile women was investigated.

METHODS

A total of 482 infertile women in the reproductive clinics of three affiliated hospitals of the Lanzhou University were selected by the convenience sampling method. The self-made general information questionnaire, family adaptability and cohesion evaluation scale, and dyadic coping questionnaire were used in this study.

RESULTS

The average age of infertile women was 31.73 ± 4.57 years, the duration of infertility was 28.66 ± 27.99 months, the total score of dyadic coping was 132.66 ± 25.49, the total score of family cohesion and adaptability was 101.48 ± 20.96. A significant positive correlation between dyadic coping and family cohesion and adaptability was observed (r = 0.74, p < 0.01). The multiple linear regression analysis showed that religious belief, number of miscarriages, relationship between family members, family intimacy, and adaptability were the influencing factors of dyadic coping level in the family of infertile women (R ² = 0.566, p < 0.01).

CONCLUSIONS

The dyadic coping level of infertile women is in the medium level, which is significantly positively correlated with family intimacy and adaptability. In clinical nursing, nurses try to improve the family relationship of patients to increase the level of dyadic coping of infertile women.

Aspiration of excess follicles before intrauterine insemination in high response cycles

Purpose

To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm.

Methods

A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.

Results

EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period.

Conclusions

EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

The cognitive development from childhood to adolescence of low birthweight children born after medically assisted reproduction-a UK longitudinal cohort study

Background

Previous research has documented that children conceived through medically assisted reproduction (MAR) are at increased risk of poor birth outcomes, such as low birthweight (LBW), which are risk factors for stunted longer-term cognitive development. However, parents who undergo MAR to conceive have, on average, advantaged socioeconomic backgrounds which could compensate for the negative effects of being born LBW. Previous studies have not analysed whether the negative effects of LBW are attenuated among MAR conceived children.

Methods

We draw on the UK Millennium Cohort Study (sweeps 1–6) which contains a sub-sample of (N = 396) MAR-conceived children. The dependent variable measures cognitive ability at around ages 3, 5, 7, 11 and 14. We examine the cognitive development of four groups of children: MAR-conceived low birthweight (MAR LBW); MAR-conceived non-low birthweight (MAR NLBW); naturally conceived low birthweight (NC LBW); naturally conceived non-low birthweight (NC NLBW). We estimate the two following linear regression models for each sweep: (i) a baseline model to examine the unadjusted association between cognitive development and low birthweight by mode of conception; and (ii) a model adjusted by socio-demographic family characteristics.

Results

In baseline models, MAR LBW children [age 3: β  =  0.021, 95% confidence interval (CI): -0.198, 0.241; age 5: β  =  0.21, 95% CI: 0.009, 0.418; age 7: β  =  0.163, 95% CI: -0.148, 0.474; age 11: β  =  0.003, 95% CI: -0.318, 0.325; age 14: β  =  0.156, 95% CI: -0.205, 0.517], on average perform similarly in cognitive ability relative to NC NLBW at all ages, and display higher cognitive scores than NC LBW children until age 7. When we account for family characteristics, differences are largely attenuated and become close to zero at age 14.

Conclusions

Despite the higher incidence of LBW among MAR compared with NC children, they do not seem to experience any disadvantage in their cognitive development compared with naturally conceived children. This finding is likely explained by the fact that, on average, MAR children are born to socioeconomically advantaged parents.

Is home-based monitoring of ovulation to time frozen embryo transfer a cost-effective alternative for hospital-based monitoring of ovulation? Study protocol of the multicentre, non-inferiority Antarctica-2 randomised controlled trial

STUDY QUESTION

The objective of this trial is to compare the effectiveness and costs of true natural cycle (true NC-) frozen embryo transfer (FET) using urinary LH tests to modified NC-FET using repeated ultrasound monitoring and ovulation trigger to time FET in the NC. Secondary outcomes are the cancellation rates of FET (ovulation before hCG or no dominant follicle, no ovulation by LH urine test, poor embryo survival), pregnancy outcomes (miscarriage rate, clinical pregnancy rates, multiple ongoing pregnancy rates, live birth rates, costs) and neonatal outcomes (including gestational age, birthweight and sex, congenital abnormalities or diseases of babies born).

WHAT IS KNOWN ALREADY

FET is at the heart of modern IVF. To allow implantation of the thawed embryo, the endometrium must be prepared either by exogenous oestrogen and progesterone supplementation (artificial cycle (AC)-FET) or by using the NC to produce endogenous oestradiol before and progesterone after ovulation to time the transfer of the thawed embryo (NC-FET). During an NC-FET, women visit the hospital repeatedly and receive an ovulation trigger to time FET (i.e. modified (m)NC-FET or hospital-based monitoring). From the woman’s point of view, a more natural approach using home-based monitoring of the ovulation with LH urine tests to allow a natural ovulation to time FET may be desired (true NC-FET or home-based monitoring).

STUDY DESIGN, SIZE, DURATION

This is a multicentre, non-inferiority prospective randomised controlled trial design. Consenting women will undergo one FET cycle using either true NC-FET or mNC-FET based on randomisation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on our sample size calculation, the study group will consist of 1464 women between 18 and 45 years old who are scheduled for FET. Women with anovulatory cycles, women who need ovulation induction and women with a contra indication for pregnancy will be excluded. The primary outcome is ongoing pregnancy. Secondary outcomes are cancellation rates of FET, pregnancy outcomes (including miscarriage rate, clinical pregnancy, multiple pregnancy rate and live birth rate). Costs will be estimated by counting resource use and calculating unit prices.

STUDY FUNDING/COMPETING INTEREST(S)

The study received a grant from the Dutch Organisation for Health Research and Development (ZonMw 843002807; www.zonmw.nl). ZonMw has no role in the design of the study, collection, analysis, and interpretation of data or writing of the manuscript. F.B. reports personal fees from member of the external advisory board for Merck Serono, grants from Research support grant Merck Serono, outside the submitted work. A.E.P.C. reports and Unrestricted grant of Ferring B.V. to the Center for Reproductive medicine, no personal fee. Author up-to-date on Hyperthecosis. Congress meetings 2019 with Ferring B.V. and Theramex B.V. M.G. reports Department research and educational grants from Guerbet, Merck and Ferring (location VUMC) outside the submitted work. E.R.G. reports personal fees from Titus Health Care, outside the submitted work. C.B.L. reports grants from Ferring, grants from Merck, from Guerbet, outside the submitted work. The other authors have none to declare.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (Trial NL6414 (NTR6590), https://www.trialregister.nl/).

TRIAL REGISTRATION DATE

23 July 2017

DATE OF FIRST PATIENT’S ENROLMENT

10 April 2018

Pharmaceutical industry payments and assisted reproduction in Australia: a retrospective observational study

OBJECTIVES

To investigate the extent and nature of pharmaceutical industry payments related to fertility and assisted reproduction in Australia.

DESIGN AND SETTING

This retrospective observational study employed four databases compiled from publicly available pharmaceutical industry transparency reports on educational event sponsorship (October 2011-April 2018), payments to healthcare professionals (October 2015-April 2018) and patient group support (January 2013-December 2017). Analyses were restricted to fertility-related payments by two major manufacturers of fertility medicines in Australia: Merck Serono and Merck, Sharp and Dohme (MSD).

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive statistics on fertility-related payments and other transfers of value (counts, total and median costs in Australian dollars) for educational events and to healthcare professionals and patient groups.

RESULTS

Between October 2011 and April 2018, Merck Serono and MSD spent $A4 522 263 on 970 fertility-related events for healthcare professionals, including doctors, nurses and fertility scientists. 56.8% (551/970) events were held by fertility clinics and 29.3% (284/970) by professional medical associations. Between October 2015 and April 2018, Merck Serono spent $A403 800 across 177 payments to 118 fertility healthcare professionals, predominantly for educational event attendance. Recipients included obstetricians and gynaecologists (76.3% of payments, 135/177), nurses (11.3%, 20/177) and embryologists/fertility scientists (9.6%, 17/117). The highest paid healthcare professionals held leadership positions in major fertility clinics. Merck Serono provided $A662 850 to fertility-related patient groups for advocacy and education (January 2013-December 2017).

CONCLUSIONS

The pharmaceutical industry sponsored a broad range of fertility clinicians and organisations, including doctors, nurses, embryologists, professional medical organisations, fertility clinics and patient groups. This sponsorship may contribute to the overuse of fertility services.

Pregnancy potential and perinatal outcomes of embryos cryopreserved twice: a case-control study

RESEARCH QUESTION

What are the pregnancy and perinatal outcomes of twice-cryopreserved embryos compared with embryos cryopreserved once?

DESIGN

Retrospective register-based case-control study. The case group consisted of transfers of twice-cryopreserved embryos (n = 89), and the control group of transfers of embryos cryopreserved once (n = 304). Matching criteria were embryonic age at transfer and female age category of less than 35 years or 35 and greater.

RESULTS

The survival rate of twice-cryopreserved embryos was 92.2%, and 93.7% of the planned frozen embryo transfers (FET) could be completed. FET was performed with cleavage-stage embryos in 17 cases and 68 controls and with blastocysts in 72 cases and 238 controls. The rates of live birth (27.0% versus 31.9%, adjusted odds ratio [OR] 0.70, 95% CI 0.40-1.22, P = 0.21), clinical pregnancy (31.5% versus 36.8%, adjusted OR 0.71, 95% CI 0.42-1.21, P = 0.21) and miscarriage (4.5% versus 3.9%, adjusted OR 1.10, 95% CI 0.33-3.60, P = 0.88) in the case and the control groups were comparable. No difference was seen in the preterm delivery rate (cases 4.2% versus controls 10.3%, P = 0.69). Twenty-five children were born in the case group and 100 in the control group. No difference in birthweight was detected between the groups and there were no large for gestational age fetuses or congenital malformations in the case group.

CONCLUSIONS

Uncompromised live birth rates and neonatal outcomes may be expected after the transfer of twice-cryopreserved embryos. To avoid embryo wastage and transfer of multiple embryos, good quality surplus embryos from FET cycles may be cryopreserved again by vitrification.

Cerebral palsy in ART children has declined substantially over time: a Nordic study from the CoNARTaS group

STUDY QUESTION

Are the decreasing multiple birth rates after ART associated with a simultaneous drop in the incidence of cerebral palsy (CP) in ART children over time?

SUMMARY ANSWER

The relative odds of CP in ART children have declined in the Nordic countries over the past two decades concurrently with declining multiple birth rates.

WHAT IS KNOWN ALREADY

In the Nordic countries, the rate of twin pregnancies after ART has decreased from 30% in the early 1990s to 4-13% in 2014, following the implementation of elective single embryo transfer (SET). Consequently, preterm birth rates have declined substantially in ART pregnancies. However, whether the risk of CP, a known consequence of preterm birth, has decreased correspondingly is still unknown.

STUDY DESIGN, SIZE, DURATION

Retrospective register-based cohort study based on data on all singletons, twins, and higher-order multiples born in Denmark (birth year 1994-2010), Finland (1990-2010), and Sweden (1990-2014), corresponding to 111 844 ART children and 4 679 351 spontaneously conceived children.

PARTICIPANTS/MATERIAL, SETTING, METHODS

Data were obtained from a large Nordic cohort of children born after ART and spontaneous conception initiated by the Committee of Nordic ART and Safety-CoNARTaS. The CoNARTaS cohort was established by cross-linking national register data using the unique personal identification number, allocated to every citizen in the Nordic countries. Data from the National Medical Birth Registers, where information on maternal, obstetric, and perinatal outcomes is recorded, were cross-linked to data from the National ART- and Patients Registers to obtain information on fertility treatments and CP diagnoses. Relative risks of CP for ART compared to spontaneous conception were estimated as odds ratios from multivariate logistic regression analyses across all birth years, as well as for the following birth year categories: 1990-1993, 1994-1998, 1999-2002, 2003-2006, 2007-2010, and 2011-2014. Analyses were made for all children and for singletons and twins, separately.

MAIN RESULTS AND THE ROLE OF CHANCE

The main outcome measure was the relative odds of CP in different time periods for ART versus spontaneously conceived children. CP was diagnosed in 661 ART children and 16 478 spontaneously conceived children born between 1990 and 2014. In 1990-1993, the relative odds of CP were substantially higher in all ART children (adjusted odds ratio (aOR) 2.76 (95% CI 2.03-3.67)) compared with all spontaneously conceived children, while in 2011-2014, it was only moderately higher (aOR 1.39 (95% CI 1.01-1.87)). In singletons, the higher relative odds of CP in ART children diminished over time from 1990 to 1993 (aOR 2.02 (95% CI 1.22-3.14)) to 2003-2006 (aOR 1.18 (95% CI 0.91-1. 49)) and was not significantly increased for birth cohorts 2007-2010 and 2011-2014. For ART twins versus spontaneously conceived twins, the relative odds of CP was not statistically significantly increased throughout the study period.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of the study was a shorter follow-up time and younger age at first CP diagnosis for ART children compared with spontaneously conceived children. However, analyses ensuring a minimum of bias from differences in age at CP diagnosis and follow-up time confirmed the results, hence, we do not consider this to cause substantial bias.

WIDER IMPLICATIONS OF THE FINDINGS

A SET policy in ART treatments has the potential to reduce the increased risk of cerebral palsy in the ART population due to lower rates of multiple deliveries. At a time with high survival rates of frozen/thawed embryos, this study provides a strong argument against the continued use of multiple embryo transfer in most ART settings. Larger cohort studies including also the number of gestational sacs in early pregnancy will be preferable to show an effect of vanishing twins on the risk of CP in the ART population.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financed by grants from NordForsk (grant number 71450), Elsass Foundation (19-3-0444), the ALF-agreement (ALFGBG 70940), and The Research Fund of Rigshospitalet, Copenhagen University Hospital. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

ISRCTN11780826.

ART in Europe, 2017: results generated from European registries by ESHRE

STUDY QUESTION

What are the data on ART and IUI cycles, and fertility preservation (FP) interventions reported in 2017 as compared to previous years, as well as the main trends over the years?

SUMMARY ANSWER

The 21st ESHRE report on ART and IUI shows the continual increase in reported treatment cycle numbers in Europe, with a decrease in the proportion of transfers with more than one embryo causing an additional slight reduction of multiple delivery rates (DR) as well as higher pregnancy rates (PR) and DR after frozen embryo replacement (FER) compared to fresh IVF and ICSI cycles, while the number of IUI cycles increased and their outcomes remained stable.

WHAT IS KNOWN ALREADY

Since 1997, ART aggregated data generated by national registries, clinics or professional societies have been gathered and analyzed by the European IVF-monitoring Consortium (EIM) and communicated in a total of 20 manuscripts published in Human Reproduction and Human Reproduction Open.

STUDY DESIGN SIZE DURATION

Data on European medically assisted reproduction (MAR) are collected by EIM for ESHRE on a yearly basis. The data on treatments performed between 1 January and 31 December 2017 in 39 European countries were provided by either National Registries or registries based on personal initiatives of medical associations and scientific organizations.

PARTICIPANTS/MATERIALS SETTING METHODS

Overall, 1382 clinics offering ART services in 39 countries reported a total of 940 503 treatment cycles, including 165 379 with IVF, 391 379 with ICSI, 271 476 with FER, 37 303 with preimplantation genetic testing (PGT), 69 378 with egg donation (ED), 378 with IVM of oocytes, and 5210 cycles with frozen oocyte replacement (FOR). A total of 1273 institutions reported data on 207 196 IUI cycles using either husband/partner's semen (IUI-H; n = 155 794) or donor semen (IUI-D; n = 51 402) in 30 countries and 25 countries, respectively. Thirteen countries reported 18 888 interventions for FP, including oocyte, ovarian tissue, semen and testicular tissue banking in pre- and postpubertal patients.

MAIN RESULTS AND THE ROLE OF CHANCE

In 21 countries (20 in 2016) in which all ART clinics reported to the registry, 473 733 treatment cycles were registered for a total population of approximately 330 million inhabitants, allowing a best-estimate of a mean of 1435 cycles performed per million inhabitants (range: 723-3286).Amongst the 39 reporting countries, the clinical PR per aspiration and per transfer in 2017 were similar to those observed in 2016 (26.8% and 34.6% vs 28.0% and 34.8%, respectively). After ICSI the corresponding rates were also similar to those achieved in 2016 (24% and 33.5% vs 25% and 33.2% in 2016). When freeze all cycles were removed, the clinical PRs per aspiration were 30.8% and 27.5% for IVF and ICSI, respectively.After FER with embryos originating from own eggs the PR per thawing was 30.2%, which is comparable to 30.9% in 2016, and with embryos originating from donated eggs it was 41.1% (41% in 2016). After ED the PR per fresh embryo transfer was 49.2% (49.4% in 2016) and per FOR 43.3% (43.6% in 2016).In IVF and ICSI together, the trend towards the transfer of fewer embryos continues with the transfer of 1, 2, 3 and ≥4 embryos in 46.0%, 49.2%, 4.5% and in 0.3% of all treatments, respectively (corresponding to 41.5%, 51.9%. 6.2% and 0.4% in 2016). This resulted in a reduced proportion of twin DRs of 14.2% (14.9% in 2016) and stable triplet DR of 0.3%. Treatments with FER in 2017 resulted in a twin and triplet DR of 11.2% and 0.2%, respectively (vs 11.9% and 0.2% in 2016).After IUI, the DRs remained similar at 8.7% after IUI-H (8.9% in 2016) and at 12.4% after IUI-D (12.4.0% in 2016). Twin and triplet DRs after IUI-H were 8.1% and 0.3%, respectively (in 2016: 8.8% and 0.3%) and 6.9% and 0.2% after IUI-D (in 2016: 7.7% and 0.4%). Amongst 18 888 FP interventions in 13 countries, cryopreservation of ejaculated sperm (n = 11 112 vs 7877 from 11 countries in 2016) and of oocytes (n = 6588 vs 4907 from eight countries in 2016) were the most frequently reported.

LIMITATIONS REASONS FOR CAUTION

As the methods of data collection and levels of reporting vary amongst European countries, interpretation of results should remain cautious. Some countries were unable to deliver data about the number of initiated cycles and deliveries.

WIDER IMPLICATIONS OF THE FINDINGS

The 21st ESHRE report on ART, IUI and FP interventions shows a continuous increase of reported treatment numbers and MAR-derived livebirths in Europe. Being already the largest data collection on MAR in Europe, efforts should continue to optimize data collection and reporting with the perspective of improved quality control, transparency and vigilance in the field of reproductive medicine.

STUDY FUNDING/COMPETING INTERESTS

The study has received no external funding and all costs are covered by ESHRE. There are no competing interests.

In vitro fertilization and andrology laboratory in 2030: expert visions

The aim of this article is to gather 9 thought leaders and their team members to present their ideas about the future of in vitro fertilization and the andrology laboratory. Although we have seen much progress and innovation in the laboratory over the years, there is still much to come, and this article looks at what these leaders think will be important in the future development of technology and processes in the laboratory.

Interpregnancy intervals and adverse birth outcomes in high-income countries: An international cohort study

BACKGROUND

Most evidence for interpregnancy interval (IPI) and adverse birth outcomes come from studies that are prone to incomplete control for confounders that vary between women. Comparing pregnancies to the same women can address this issue.

METHODS

We conducted an international longitudinal cohort study of 5,521,211 births to 3,849,193 women from Australia (1980-2016), Finland (1987-2017), Norway (1980-2016) and the United States (California) (1991-2012). IPI was calculated based on the time difference between two dates-the date of birth of the first pregnancy and the date of conception of the next (index) pregnancy. We estimated associations between IPI and preterm birth (PTB), spontaneous PTB, and small-for-gestational age births (SGA) using logistic regression (between-women analyses). We also used conditional logistic regression comparing IPIs and birth outcomes in the same women (within-women analyses). Random effects meta-analysis was used to calculate pooled adjusted odds ratios (aOR).

RESULTS

Compared to an IPI of 18-23 months, there was insufficient evidence for an association between IPI <6 months and overall PTB (aOR 1.08, 95% CI 0.99-1.18) and SGA (aOR 0.99, 95% CI 0.81-1.19), but increased odds of spontaneous PTB (aOR 1.38, 95% CI 1.21-1.57) in the within-women analysis. We observed elevated odds of all birth outcomes associated with IPI ≥60 months. In comparison, between-women analyses showed elevated odds of adverse birth outcomes for <12 month and >24 month IPIs.

CONCLUSIONS

We found consistently elevated odds of adverse birth outcomes following long IPIs. IPI shorter than 6 months were associated with elevated risk of spontaneous PTB, but there was insufficient evidence for increased risk of other adverse birth outcomes. Current recommendations of waiting at least 24 months to conceive after a previous pregnancy, may be unnecessarily long in high-income countries.

Mental Health Around the Transition to First Birth: Does Medically Assisted Reproduction Matter?

Previous research has shown that childbearing is associated with short-term improvements in women's subjective well-being but that these effects depend on the timing and quantum of the birth as well as on the parents' education and socioeconomic status. These studies did not address whether and, if so, how this effect varies according to the mode of conception. This represents an important knowledge gap, given that conceptions through medically assisted reproduction (MAR) have been increasing rapidly in recent decades, exceeding 5% of live births in some European countries. Drawing on nine waves (2009/2010-2017/2018) of the UK Household Longitudinal Study, we use distributed fixed-effects linear regression models to examine changes in women's mental health before, during, and after natural and MAR conceptions. The results show that the mental health of women who conceived naturally improved around the time of conception and then gradually returned to baseline levels; comparatively, the mental health of women who conceived through MAR declined in the year before pregnancy and then gradually recovered. The findings also indicate that women's happiness decreased both two years and one year before an MAR conception and then increased above the baseline in the year of pregnancy. We further show that the deterioration in mental health and subjective well-being before an MAR conception affects both partners, which could be part of a longer process in which the partners potentially suffer from stress related not solely to the MAR treatments themselves but also to the experience of subfertility.

Frozen Embryo Transfer and Preeclampsia Risk

Worldwide, the use of Assisted Reproductive Technology (ART) has been steadily rising over recent years. With the continuous improvements in cryopreservation techniques and the growing practice of single embryo transfer, the proportion of frozen embryo transfer (FET) cycles has been increasing, therefore raising concern about the safety of this ART technique to both mothers and infants. This review aims to summarize the current evidence regarding the risk of preeclampsia in singleton pregnancies achieved by autologous FET compared to fresh embryo transfer, and to discuss the influence of different protocols used for endometrium preparation in frozen cycles on the risk of this obstetric complication. Several studies have reported a higher risk of hypertensive disorders, including preeclampsia, in pregnancies following FET compared with fresh embryo transfer. Recently, artificial FET cycles, which preclude the development of a corpus luteum, were shown to be associated with an increased preeclampsia risk in comparison with natural and stimulated cycles. Importantly, no difference was found between FET in a modified natural cycle and spontaneous conception. It has been proposed that the absence of the corpus luteum in artificial cycles may, at least partly, contribute to the observed increased risk of preeclampsia. Indeed, the corpus luteum secretes vasoactive hormones, such as relaxin, which are not replaced in artificial cycles, thereby compromising maternal cardiovascular adaptations to pregnancy, resulting in an increased risk of preeclampsia. If these findings are confirmed by a randomized controlled trial, natural, modified natural or stimulated cycles might be preferred over artificial cycles in eligible patients.

Twin Peaks: more twinning in humans than ever before

STUDY QUESTION

How many twins are born in human populations and how has this changed over recent decades?

SUMMARY ANSWER

Since the 1980s, the global twinning rate has increased by a third, from 9.1 to 12.0 twin deliveries per 1000 deliveries, to about 1.6 million twin pairs each year.

WHAT IS KNOWN ALREADY

It was already known that in the 1980s natural twinning rates were low in (East) Asia and South America, at an intermediate level in Europe and North America, and high in many African countries. It was also known that in recent decades, twinning rates have been increasing in the wealthier parts of our world as a result of the rise in medically assisted reproduction (MAR) and delayed childbearing.

STUDY DESIGN, SIZE, DURATION

We have brought together all information on national twinning rates available from statistical offices, demographic research institutes, individual survey data and the medical literature for the 1980-1985 and the 2010-2015 periods.

PARTICIPANTS/MATERIALS, SETTING, METHODS

For 165 countries, covering over 99% of the global population, we were able to collect or estimate twinning rates for the 2010-2015 period. For 112 countries, we were also able to obtain twinning rates for 1980-1985.

MAIN RESULTS AND THE ROLE OF CHANCE

Substantial increases in twinning rates were observed in many countries in Europe, North America and Asia. For 74 out of 112 countries the increase was more than 10%. Africa is still the continent with highest twinning rates, but Europe, North America and Oceania are catching up rapidly. Asia and Africa are currently home to 80% of all twin deliveries in the world.

LIMITATIONS, REASONS FOR CAUTION

For some countries, data were derived from reports and papers based on hospital registrations which are less representative for the country as a whole than data based on public administrations and national surveys.

WIDER IMPLICATIONS OF THE FINDINGS

The absolute and relative number of twins for the world as a whole is peaking at an unprecedented level. An important reason for this is the tremendous increase in medically assisted reproduction in recent decades. This is highly relevant, as twin deliveries are associated with higher infant and child mortality rates and increased complications for mother and child during pregnancy and during and after delivery.

STUDY FUNDING/COMPETING INTEREST(S)

The contribution of CM was partially supported by the European Research Council (ERC) under the European Union's Horizon 2020 Research and Innovation Programme (grant No 681546, FAMSIZEMATTERS), Nuffield College, and the Leverhulme Trust. The contribution of GP was partially supported by the French Agence Nationale de la Recherche (grant No ANR-18-CE36-0007-07). The authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

20 years of the European IVF-monitoring Consortium registry: what have we learned? A comparison with registries from two other regions

STUDY QUESTION

How has the performance of the European regional register of the European IVF-monitoring Consortium (EIM)/European Society of Human Reproduction and Embryology (ESHRE) evolved from 1997 to 2016, as compared to the register of the Centres for Disease Control and Prevention (CDC) of the USA and the Australia and New Zealand Assisted Reproduction Database (ANZARD)?

SUMMARY ANSWER

It was found that coherent and analogous changes are recorded in the three regional registers over time, with a different intensity and pace, that new technologies are taken up with considerable delay and that incidental complications and adverse events are only recorded sporadically.

WHAT IS KNOWN ALREADY

European data on ART have been collected since 1997 by EIM. Data collection on ART in Europe is particularly difficult due to its fragmented political and legal landscape. In 1997, approximately 78.1% of all known institutions offering ART services in 23 European countries submitted data and in 2016 this number rose to 91.8% in 40 countries.

STUDY DESIGN, SIZE, DURATION

We compared the changes in European ART data as published in the EIM reports (2001–2020) with those of the USA, as published by CDC, and with those of Australia and New Zealand, as published by ANZARD.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We performed a retrospective analysis of the published EIM data sets spanning the 20 years observance period from 1997 to 2016, together with the published data sets of the USA as well as of Australia and New Zealand. By comparing the data sets in these three large registers, we analysed differences in the completeness of the recordings together with differences in the time intervals on the occurrence of important trends in each of them. Effects of suspected over- and under-reporting were also compared between the three registers. X² log-rank analysis was used to assess differences in the data sets.

MAIN RESULTS AND THE ROLE OF CHANCE

During the period 1997–2016, the numbers of recorded ART treatments increased considerably (5.3-fold in Europe, 4.6-fold in the USA, 3.0-fold in Australia and New Zealand), while the number of registered treatment modalities rose from 3 to 7 in Europe, from 4 to 10 in the USA and from 5 to 8 in Australia and New Zealand, as published by EIM, CDC and ANZARD, respectively. The uptake of new treatment modalities over time has been very different in the three registers. There is a considerable degree of underreporting of the number of initiated treatment cycles in Europe. The relationship between IVF and ICSI and between fresh and thawing cycles evolved similarly in the three geographical areas. The freeze-all strategy is increasingly being adopted by all areas, but in Europe with much delay. Fewer cycles with the transfer of two or more embryos were reported in all three geographical areas. The delivery rate per embryo transfer in thawing cycles bypassed that in fresh cycles in the USA in 2012, in Australia and New Zealand in 2013, but not yet in Europe. As a result of these changing approaches, fewer multiple deliveries have been reported. Since 2012, the most documented adverse event of ART in all three registers has been premature birth (<37 weeks). Some adverse events, such as maternal death, ovarian hyperstimulation syndrome, haemorrhage and infections, were only recorded by EIM and ANZARD.

LIMITATIONS, REASONS FOR CAUTION

The methods of data collection and reporting were very different among European countries, but also among the three registers. The better the legal background on ART surveillance, the more complete are the data sets. Until the legal obligation to report is installed in all European countries together with an appropriate quality control of the submitted data the reported numbers and incidences should be interpreted with caution.

WIDER IMPLICATIONS OF THE FINDINGS

The growing number of reported treatments in ART, the higher variability in treatment modalities and the rising contribution to the birth rates over the last 20 years point towards the increasing impact of ART. High levels of completeness in data reporting have been reached, but inconsistencies and inaccuracies still remain and need to be identified and quantified. The current trend towards a higher diversity in treatment modalities and the rising impact of cryostorage, resulting in improved safety during and after ART treatment, require changes in the organization of surveillance in ART. The present comparison must stimulate all stakeholders in ART to optimize surveillance and data quality assurance in ART.

STUDY FUNDING/COMPETING INTEREST(S)

This study has no external funding and all costs are covered by ESHRE. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Comparison of DNA methylation patterns of parentally imprinted genes in placenta derived from IVF conceptions in two different culture media

Study question

Is there a difference in DNA methylation status of imprinted genes in placentas derived from IVF conceptions where embryo culture was performed in human tubal fluid (HTF) versus G5 culture medium?

Summary answer

We found no statistically significant differences in the mean DNA methylation status of differentially methylated regions (DMRs) associated with parentally imprinted genes in placentas derived from IVF conceptions cultured in HTF versus G5 culture medium.

What is known already

Animal studies indicate that the embryo culture environment affects the DNA methylation status of the embryo. In humans, birthweight is known to be affected by the type of embryo culture medium used. The effect of embryo culture media on pregnancy, birth and child development may thus be mediated by differential methylation of parentally imprinted genes in the placenta.

Study design, size, duration

To identify differential DNA methylation of imprinted genes in human placenta derived from IVF conceptions exposed to HTF or G5 embryo culture medium, placenta samples (n = 43 for HTF, n = 54 for G5) were collected between 2010 and 2012 s as part of a multi-center randomized controlled trial in the Netherlands comparing these embryo culture media. Placenta samples from 69 naturally conceived (NC) live births were collected during 2008–2013 in the Netherlands as reference material.

Participants/materials, setting, methods

To identify differential DNA methylation of imprinted genes, we opted for an amplicon-based sequencing strategy on an Illumina MiSeq sequencing platform. DNA was isolated and 34 DMRs associated with well-defined parentally imprinted genes were amplified in a two-step PCR before sequencing using MiSeq technology. Sequencing data were analyzed in a multivariate fashion to eliminate possible confounding effects.

Main results and the role of chance

We found no statistically significant differences in the mean DNA methylation status of any of the imprinted DMRs in placentas derived from IVF conceptions cultured in HTF or G5 culture medium. We also did not observe any differences in the mean methylation status per amplicon nor in the variance in methylation per amplicon between the two culture medium

groups. A separate surrogate variable analysis also demonstrated that the IVF culture medium was not associated with the DNA methylation status of these DMRs. The mean methylation level and variance per CpG was equal between HTF and G5 placenta. Additional comparison of DNA methylation status of NC placenta samples revealed no statistically significant differences in mean amplicon and CpG methylation between G5, HTF and NC placenta; however, the number of placenta samples exhibiting outlier methylation levels was higher in IVF placenta compared to NC (P < 0.00001). Also, we were able to identify 37 CpG sites that uniquely displayed outlier methylation in G5 placentas and 32 CpG sites that uniquely displayed outlier methylation in HTF. In 8/37 (G5) and 4/32 (HTF) unique outliers CpGs, a medium-specific unique outlier could be directly correlated to outlier methylation of the entire amplicon.

Limitations, reasons for caution

Due to practical reasons, not all placentas were collected during the trial, and we collected the placentas from natural conceptions from a different cohort, potentially creating bias. We limited ourselves to the DNA methylation status of 34 imprinted DMRs, and we studied only the placenta and no other embryo-derived tissues.

Wider implications of the findings

It has often been postulated, but has yet to be rigorously tested, that imprinting mediates the effects of embryo culture conditions on pregnancy, birth and child development in humans. Since we did not detect any statistically significant effects of embryo culture conditions on methylation status of imprinted genes in the placenta, this suggests that other unexplored mechanisms may underlie these effects. The biological and clinical relevance of detected outliers with respect to methylation levels of CpGs and DMR require additional analysis in a larger sample size as well. Given the importance and the growing number of children born through IVF, research into these molecular mechanisms is urgently needed.

Study funding/competing interest(s)

This study was funded by the March of Dimes grant number #6-FY13-153. The authors have no conflicts of interest.

Trial registration number

Placental biopsies were obtained under Netherlands Trial Registry number 1979 and 1298.

Prenatal growth trajectories and birth outcomes after frozen-thawed extended culture embryo transfer and fresh embryo transfer: the Rotterdam Periconception Cohort

RESEARCH QUESTION

Are there differences in prenatal growth trajectories and birth outcomes between singleton pregnancies conceived after IVF treatment with frozen-thawed extended culture embryo transfer at day 5, fresh embryo transfer at day 3 or naturally conceived pregnancies?

DESIGN

From a prospective hospital-based cohort, 859 singleton pregnancies were selected, including 133 conceived after IVF with frozen-thawed embryo transfer, 276 after fresh embryo transfer, and 450 naturally conceived pregnancies. Longitudinal 3D ultrasound scans were performed at 7, 9 and 11 weeks of gestation for offline crown-rump length (CRL) and embryonic volume measurements. Second trimester estimated fetal weight was based on growth parameters obtained during the routine fetal anomaly scan at 20 weeks of gestation. Birth outcome data were collected from medical records.

RESULTS

No differences regarding embryonic growth trajectories were observed between frozen-thawed and fresh embryo transfer. Birthweight percentiles after fresh embryo transfer were lower than after frozen-thawed embryo transfer (38.0 versus 48.0; P = 0.046, respectively). The prevalence of non-iatrogenic preterm birth (PTB) was significantly lower in pregnancies resulting from fresh embryo transfer compared with frozen-thawed embryo transfer (4.7% versus 10.9%; P = 0.026, respectively). Compared with naturally conceived pregnancies, birthweight percentiles and percentage of non-iatrogenic PTB were significantly lower in pregnancies after fresh embryo transfer and gestational age at birth was significantly higher.

CONCLUSIONS

This study shows that embryonic growth is comparable between singleton pregnancies conceived after fresh and frozen-thawed embryo transfer. The lower relative birthweight and PTB rate in pregnancies after fresh embryo transfer than after frozen-thawed embryo transfer and naturally conceived pregnancies warrants further investigation.

Laughs and Jokes in Assisted Reproductive Technologies: Quantitative and Qualitative Analysis of Video-Recorded Doctor-Couple Visits

Purpose: To explore the characteristics of the use of laughs and jokes during doctor-couple assisted reproductive technology (ART) visits.

Methods: 75 videotaped doctor-couple ART visits were analyzed and transcribed in order to: (1) quantify laugh and jokes, describing the contribution of doctors and couples and identifying the timing of appearance; (2) explore the topic of laughs and jokes with qualitative thematic analysis.

Results: On average, each visit contained 17.1 utterances of laughs and jokes. Patients contributed for 64.7% of utterances recorded. Doctor (40.6%) and women (40%) introduced the majority of laughs and jokes. Visits with female physicians had significantly more laughs and jokes than visits with male doctors; no differences were found considering physicians’ age and years of experience, cause of infertility, and prognosis. Laughs and jokes were mainly recorded during history taking and information giving. Four core themes were identified, regarding the topic of laughs and jokes: health status, infertility treatment, organizational aspects, and doctor-patient interaction.

Conclusion: Laughs and jokes are common in doctor-couple ART visits and are frequently used during the dialogue, covering a wide range of topics. Results seem to show that laughs and jokes are related to doctor’s personal characteristics (like gender), while are not associated with infertility aspects. Given the complexity of this communicative category, further studies are needed to explore the functions and the effects of laugh and jokes.

Ovarian stimulation for oocyte donation: a systematic review and meta-analysis

BACKGROUND

Since its introduction in the 1980s, oocyte donation (OD) has been largely integrated into ART. Lately, both demand and the indications for OD have increased greatly. Oocyte donors are healthy and potentially fertile women undergoing voluntarily ovarian stimulation (OS). Selection of the optimal type of stimulation is of paramount importance in order to achieve the most favourable outcomes for the oocyte recipients, but most importantly for the safety of the oocyte donors.

OBJECTIVE AND RATIONALE

This is the first systematic review (SR) with the objective to summarize the current evidence on OS in oocyte donors. The scope of this SR was to evaluate the OD programme by assessing four different aspects: how to assess the ovarian response prior to stimulation; how to plan the OS (gonadotrophins; LH suppression; ovulation trigger; when to start OS); how to control for the risk of ovarian hyperstimulation syndrome (OHSS) and other complications; and the differences between the use of fresh versus vitrified donated oocytes.

SEARCH METHODS

A systematic literature search was conducted in May 2020, according to PRISMA guidelines in the databases PubMed and Embase, using a string that combined synonyms for oocytes, donation, banking, freezing, complications and reproductive outcomes. Studies reporting on the safety and/or efficacy of OS in oocyte donors were identified. The quality of the included studies was assessed using ROBINS-I and ROB2. Meta-analysis was performed where appropriate. Data were combined to calculate mean differences (MD) for continuous variables and odd ratios (OR) for binary data with their corresponding 95% CIs. Heterogeneity between the included studies was assessed using I2 and tau statistics.

OUTCOMES

In total, 57 manuscripts were selected for the review, out of 191 citations identified. Antral follicle count and anti-Müllerian hormone levels correlate with ovarian response to OS in OD but have limited value to discriminate donors who are likely to show either impaired or excessive response. Five randomized controlled trials compared different type of gonadotrophins as part of OS in oocyte donors; owing to high heterogeneity, meta-analysis was precluded. When comparing different types of LH control, namely GnRH antagonist versus agonist, the studies showed no differences in ovarian response. Use of progesterone primed ovarian stimulation protocols has been evaluated in seven studies: the evidence has shown little or no difference, compared to GnRH antagonist protocols, in mean number of retrieved oocytes (MD 0.23, [95% CI 0.58-1.05], n = 2147; 6 studies; I2 = 13%, P = 0.33) and in clinical pregnancy rates among recipients (OR 0.87 [95% CI 0.60-1.26], n = 2260, I2 = 72%, P < 0.01). There is insufficient evidence on long-term safety for babies born. GnRH agonist triggering is the gold standard and should be used in all oocyte donors, given the excellent oocyte retrieval rates, the practical elimination of OHSS and no differences in pregnancy rates in recipients (four studies, OR 0.86, 95%CI 0.58-1.26; I2 = 0%). OS in OD is a safe procedure with a low rate of hospitalization after oocyte retrieval. The use of a levonorgestrel intrauterine device or a progestin contraceptive pill during OS does not impact the number of oocytes retrieved or the clinical pregnancy rate in recipients. Ultrasound monitoring seems enough for an adequate follow up of the stimulation cycle in OD. Use of fresh versus vitrified donated oocytes yielded similar pregnancy outcomes.

WIDER IMPLICATIONS

This update will be helpful in the clinical management of OS in OD based on the most recent knowledge and recommendations, and possibly in the management of women under 35 years undergoing oocyte vitrification for social freezing, owing to the population similarities. More clinical research is needed on OS protocols that are specifically designed for OD, especially in term of the long-term safety for newborns, effective contraception during OS, and treatment satisfaction.

Maternal and Paternal Representations in Assisted Reproductive Technology and Spontaneous Conceiving Parents: A Longitudinal Study

Aim of this study was to investigate whether parental mental representations during pregnancy and after delivery differed between parents who conceived after Assisted Reproductive Treatments (ART) and spontaneous conceiving (SC) parents. Effects of specific ART variables (previous ART attempts, treatment type and cause of infertility) were also taken into account. Seventeen ART couples and 25 SC couples were recruited at Santa Maria Nuova Hospital (Reggio Emilia, Italy). At both 32 weeks of gestation (T1) and 3 months postpartum (T2) participants completed the Semantic Differential of the IRMAG, a self-report tool which measures specific domains of mental representations pertaining either individual (Child, Self-as-woman/man, and Partner) or parental (Self-as-parent, Own parent) characteristics. Results showed that ART parents had significantly more positive representations of the child compared to SC parents, while the scores at Partner dimension improved from T1 to T2 for SC parents only. With regards to ART history, scores at the Self-as-woman/man dimension were significantly less positive for ICSI than IVF parents and improved substantially from T1 to T2 only in case of mothers with previous ART attempts and of fathers at the first ART cycle. The representation of own parents increased from T1 to T2 in case of infertility diagnosis due to male factors, while a decrease emerged when infertility was due to female factors. Findings suggest the need to investigate parental mental representations after ART, in order to improve the understanding on the transition to parenthood of infertile couples and to target more specific intervention for parenting support.

The cognitive development from childhood to adolescence of low birthweight children born after medically assisted reproduction-a UK longitudinal cohort study

Background

Previous research has documented that children conceived through medically assisted reproduction (MAR) are at increased risk of poor birth outcomes, such as low birthweight (LBW), which are risk factors for stunted longer-term cognitive development. However, parents who undergo MAR to conceive have, on average, advantaged socioeconomic backgrounds which could compensate for the negative effects of being born LBW. Previous studies have not analysed whether the negative effects of LBW are attenuated among MAR conceived children.

Methods

We draw on the UK Millennium Cohort Study (sweeps 1–6) which contains a sub-sample of (N = 396) MAR-conceived children. The dependent variable measures cognitive ability at around ages 3, 5, 7, 11 and 14. We examine the cognitive development of four groups of children: MAR-conceived low birthweight (MAR LBW); MAR-conceived non-low birthweight (MAR NLBW); naturally conceived low birthweight (NC LBW); naturally conceived non-low birthweight (NC NLBW). We estimate the two following linear regression models for each sweep: (i) a baseline model to examine the unadjusted association between cognitive development and low birthweight by mode of conception; and (ii) a model adjusted by socio-demographic family characteristics.

Results

In baseline models, MAR LBW children [age 3: β  =  0.021, 95% confidence interval (CI): -0.198, 0.241; age 5: β  =  0.21, 95% CI: 0.009, 0.418; age 7: β  =  0.163, 95% CI: -0.148, 0.474; age 11: β  =  0.003, 95% CI: -0.318, 0.325; age 14: β  =  0.156, 95% CI: -0.205, 0.517], on average perform similarly in cognitive ability relative to NC NLBW at all ages, and display higher cognitive scores than NC LBW children until age 7. When we account for family characteristics, differences are largely attenuated and become close to zero at age 14.

Conclusions

Despite the higher incidence of LBW among MAR compared with NC children, they do not seem to experience any disadvantage in their cognitive development compared with naturally conceived children. This finding is likely explained by the fact that, on average, MAR children are born to socioeconomically advantaged parents.

The Association between Assisted Reproduction Technology (ART) and Social Perception of Childbearing Deadline Ages: A Cross-Country Examination of Selected EU Countries

The advancement of assisted reproductive technologies (ART) has gained much attention in relation to childbearing postponement. Our study's purpose was to empirically examine how perceptions of childbearing deadline age vary in association with availability and prevalence of ART across different countries. The present study used data from the 2006 European Social Survey and the 2006 European Society of Human Reproduction and Embryology to examine selected EU countries. A total sample of 17,487 respondents was examined. Multilevel regression modeling was used. Results showed that first, younger generations were more generous with maternal childbearing ages but stricter with paternal deadline ages. Second, respondents residing in countries with higher percentage of reproductive clinics per population were more generous with maternal ages, however no significant association was observed with regard to paternal childbearing ages. Third, on the contrary, respondents residing in countries with higher utilization of ART treatments were stricter with maternal ages, which may be because they are more likely to be aware of the physiological and financial difficulties associated with ART treatments. The present study is meaningful in that it is the first study to empirically examine social perceptions of childbearing ages in relation with ART.

Obesity and Male Reproduction; Placing the Western Diet in Context

There is mounting evidence that obesity has negative repercussions for reproductive physiology in males. Much of this evidence has accumulated from rodent studies employing diets high in fat and sugar ("high fat" or "western" diets). While excessive fats and carbohydrates have long been considered major determinants of diet induced obesity, a growing body of research suggests that the relationships between diet composition and obesity are more complex than originally thought, involving interactions between dietary macronutrients. However, rodent dietary models have yet to evolve to capture this, instead relying heavily on elevated levels of a single macronutrient. While this approach has highlighted important effects of obesity on male reproduction, it does not allow for interpretation of the complex, interacting effects of dietary protein, carbohydrate and fat. Further, the single nutrient approach limits the ability to draw conclusions about which diets best support reproductive function. Nutritional Geometry offers an alternative approach, assessing outcomes of interest over an extended range of dietary macronutrient compositions. This review explores the practical application of Nutritional Geometry to study the effects of dietary macronutrient balance on male reproduction, including experimental considerations specific to studies of diet and reproductive physiology. Finally, this review discusses the promising use of Nutritional Geometry in the development of evidence-based pre-conception nutritional guidance for men.

IVF in women aged 43 years and older: a 20-year experience

RESEARCH QUESTION

What are the reproductive outcomes of women aged 43 years and older undergoing IVF and intracytoplasmic sperm injection (ICSI) treatment using their own eggs.

DESIGN

Retrospective study of 833 woman aged 43 years or older undergoing their first IVF and ICSI cycle using autologous oocytes at a tertiary referral hospital between January 1995 and December 2019. Live birth rate (LBR) after 24 weeks' gestation was the primary outcome.

RESULTS

Ninety-five out of 833 (11.4%) had a positive HCG, whereas 59 (62.1% per positive HCG) had a miscarriage before 12 weeks' gestation and 36 (4.3%) live births were achieved. Analysis by age showed that the number of cumulus-oocyte complexes retrieved was significantly different between the four age groups: 43 years (5 [3-9]); 44 years (5 [2-7]); 45 years (3 [2-8)]); ≥45 years (2.5 [2-6]); P < 0.01; the number of metaphase II oocytes, however, was similar. Positive HCG rates remained low: 43 years (78/580 [13.4%]); 44 years (14/192 [7.3%]); 45 years (1/39 [2.6%]; and ≥46 years (2/22 [9.1%]); P = 0.03, as did LBR: 43 years (28 [4.8%]); 44 (7 [3.6%]); 45 years (0 [0%]); and ≥46 years (1 [4.5%]); P = 0.5. Multivariate regression analysis revealed that only number of metaphase II was significantly associated with LBR, when age was considered as a continuous (OR 1.08, 96% CI 1.004 to 1.16) or categorical variable (OR 1.08, 95% CI 1.005 to 1.16).

CONCLUSION

The chances of achieving a live birth in patients aged 43 years and older undergoing IVF/ICSI with their own gametes are low, even in cases of patients with a relatively 'normal' ovarian reserve for their age.

Assisted reproductive technology outcome in United States of America and Australia with New Zealand: comparison of annual reports 2005-2016

In vitro fertilization can be considered as causative factor of increasing rate of multiple pregnancies. Analysis of factors contributing to reduction in the percentage of multiple pregnancies may contribute to overall improvement of ART results. We compared annual reports from The Australian and New Zealand Assisted Reproduction Database and US National Summary Reports presented by The Centers for Disease Control and Prevention. The aim of this study was to analyze results of ART outcomes in two countries presenting opposite approach to ART, particularly to number of transferred embryos and number of eSETs (elective single embryo transfers). We found significant increase in total number of initiated cycles and transfers with significant shift toward frozen cycles and transfers in both countries. Percentage of eSET increased while average number of embryos transferred per one transfer decreased significantly in both countries without significant difference between countries. We also noticed significant decrease in the rate of multiple pregnancies and percentage of pregnancies resulting in triplets in Australia with New Zealand. Decreasing number of multiple pregnancies and higher percentage of transfers and pregnancies resulting in singleton live birth are the changes in ART politics found in our analysis. United States of America have more significant changes toward eSET, although Australia and New Zealand have significantly higher percentage of eSET from the beginning of analysis.