Outcome of pregnancies resulting from assisted conception

Bayesian spatial analysis of factors influencing neonatal mortality and its geographic variation in Ethiopia

BACKGROUND

Ethiopia is a Sub-Saharan country with very high neonatal mortality rates, varying across its regions. The rate of neonatal mortality reduction in Ethiopia is slow, and Ethiopia may not meet the third United Nations sustainable development target by 2030. This study aimed to investigate the spatial variations and contributing factors for neonatal mortality rates in Ethiopia.

METHODS

We analysed data from the 2016 Ethiopian Demographic and Health Survey (EDHS), which used a two-stage cluster sampling technique with a census enumeration area as primary and households as secondary sampling units. A Bayesian spatial logistic regression model using the Stochastic Partial Differential Equation (SPDE) method was fitted accounting for socio-economic, health service-related and geographic factors.

RESULTS

Higher neonatal mortality rates were observed in eastern, northeastern and southeastern Ethiopia, and the Somali region had higher risks of neonatal mortality. Neonates from frequently drought-affected areas had a higher mortality risk than less drought-affected areas. Application of traditional substances on the cord increased the risk of neonatal mortality (Adjusted Odds Ratio (AOR) = 2.07, 95% Credible Interval (CrI): 1.12 to 4.30) and getting health facility delivery services had a lower odds of neonatal mortality (AOR = 0.60, 95% CrI: 0.37, 0.98).

CONCLUSIONS

Residing in drought-affected areas, applying traditional substances on the umbilical cord and not delivering at health facilities were associated with a higher risk of neonatal mortality. Policy-makers and resource administrators at different administrative levels could leverage the findings to prioritise and target areas identified with higher neonatal mortality rates.

OUP accepted manuscript

STUDY QUESTION

Can use of a commercially available time-lapse algorithm for Day 5 blastocyst selection improve pregnancy rates compared with morphology alone?

SUMMARY ANSWER

The use of a time-lapse selection model to choose blastocysts for fresh single embryo transfer on Day 5 did not improve ongoing pregnancy rate compared to morphology alone.

WHAT IS KNOWN ALREADY

Evidence from time-lapse monitoring suggests correlations between timing of key developmental events and embryo viability. No good quality evidence exists to support improved pregnancy rates following time-lapse selection.

STUDY DESIGN, SIZE, DURATION

A prospective multicenter randomized controlled trial including 776 randomized patients was performed between 2018 and 2021. Patients with at least two good quality blastocysts on Day 5 were allocated by a computer randomization program in a proportion of 1:1 into either the control group, whereby single blastocysts were selected for transfer by morphology alone, or the intervention group whereby final selection was decided by a commercially available time-lapse model. The embryologists at the time of blastocyst morphological scoring were blinded to which study group the patients would be randomized, and the physician and patients were blind to which group they were allocated until after the primary outcome was known. The primary outcome was number of ongoing pregnancies in the two groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From 10 Nordic IVF clinics, 776 patients with a minimum of two good quality blastocysts on Day 5 (D5) were randomized into one of the two study groups. A commercial time-lapse model decided the final selection of blastocysts for 387 patients in the intervention (time-lapse) group, and blastocysts with the highest morphological score were transferred for 389 patients in the control group. Only single embryo transfers in fresh cycles were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

In the full analysis set, the ongoing pregnancy rate for the time-lapse group was 47.4% (175/369) and 48.1% (181/376) in the control group. No statistically significant difference was found between the two groups: mean difference −0.7% (95% CI −8.2, 6.7, P = 0.90). Pregnancy rate (60.2% versus 59.0%, mean difference 1.1%, 95% CI −6.2, 8.4, P = 0.81) and early pregnancy loss (21.2% versus 18.5%, mean difference 2.7%, 95% CI −5.2, 10.6, P = 0.55) were the same for the time-lapse and the control group. Subgroup analyses showed that patient and treatment characteristics did not significantly affect the commercial time-lapse model D5 performance. In the time-lapse group, the choice of best blastocyst changed on 42% of occasions (154/369, 95% CI 36.9, 47.2) after the algorithm was applied, and this rate was similar for most treatment clinics.

LIMITATIONS, REASONS FOR CAUTION

During 2020, the patient recruitment rate slowed down at participating clinics owing to coronavirus disease-19 restrictions, so the target sample size was not achieved as planned and it was decided to stop the trial prematurely. The study only investigated embryo selection at the blastocyst stage on D5 in fresh IVF transfer cycles. In addition, only blastocysts of good morphological quality were considered for transfer, limiting the number of embryos for selection in both groups: also, it could be argued that this manual preselection of blastocysts limits the theoretical selection power of time-lapse, as well as restricting the results mainly to a good prognosis patient group. Most patients were aimed for blastocyst stage transfer when a minimum of five zygotes were available for extended culture. Finally, the primary clinical outcome evaluated was pregnancy to only 6–8 weeks.

WIDER IMPLICATIONS OF THE FINDINGS

The study suggests that time-lapse selection with a commercially available time-lapse model does not increase chance of ongoing pregnancy after single blastocyst transfer on Day 5 compared to morphology alone.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financed by a grant from the Swedish state under the ALF-agreement between the Swedish government and the county councils (ALFGBG-723141). Vitrolife supported the study with embryo culture dishes and culture media. During the study period, T.H. changed his employment from Livio AB to Vitrolife AB. All other authors have no conflicts of interests to disclose.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registration number NCT03445923.

TRIAL REGISTRATION DATE

26 February 2018.

DATE OF FIRST PATIENT’S ENROLMENT

11 June 2018.

The association between quality of supernumerary embryos in a cohort and implantation potential of the transferred blastocyst

PURPOSE

Despite studies focused on the association between embryo morphology and implantation potential, it is unknown how the collective quality of the supernumerary embryos in a cohort is associated with the implantation rate (IR) of the transferred embryo. This study tested the hypothesis that a relationship exists between the quality of the supernumerary cohort and IR.

METHODS

A retrospective cohort study of first fresh autologous IVF cycles from 05/2012 to 09/2016, with ≥ 3 blastocysts, resulting in a single blastocyst transfer (n = 819) was performed. Cohorts were grouped in two ways: by mean priority score (PS; 1 being best) of supernumerary embryos and by percent supernumerary embryos with low implantation potential. The relationship between cohort quality and IR was assessed using logistic regression.

RESULTS

As mean cohort PS increased, IR of the transferred embryo decreased (test for linear trend, p = 0.05). When ≥ 75% of the supernumerary cohort was predicted to have low implantation potential, IR of the transferred embryo was significantly lower compared to when < 75% of the cohort was predicted to have low implantation potential (OR 0.71; 95% CI (0.53-0.94)). All associations were attenuated when adjusting for PS of the transferred embryo.

CONCLUSIONS

Our findings suggest that quality of supernumerary embryos is associated with IR of the transferred embryo, among patients with ≥ 3 blastocysts available on day 5. As cohort quality declines and the proportion of low implantation potential embryos increases, the IR of the transferred embryo declines. These associations are attenuated when controlling for quality of the transferred embryo, suggesting that the relationship between embryo cohort quality and implantation is not independent of the transferred embryo quality.

Pregnancy Outcome Among Twins Conceived After Subfertility Treatment Compared With Natural Twins: A Population-Based Study

Pregnancy outcome and characteristics of women who conceive following subfertility treatment remains a subject of great interest. We analyzed these variables among 199 women who delivered a registerable twin birth compared with 1773 women who delivered a naturally conceived twin birth in a population-based obstetric cohort drawn from around Oxford, England. Treatment was restricted to conceptions involving simple ovulation induction only. Treated mothers were of significantly higher social class and older, more likely to deliver girls and to be delivered by cesarean section, and significantly less likely to be smokers at the time of antenatal booking and to have delivered previous pregnancies. Pregnancy outcome was similar between the two groups for most measures, with the exception of birthweight which was lower in treated twins, though not significantly so. Overall the results are reassuring with respect to outcome in twin pregnancies following simple ovulation induction.

The risk of neuro-orthopaedic malformations following in-vitro fertilization

The purpose of this study was to assess the risk of neuro-orthopaedic malformations after in-vitro fertilization. We compared the prevalence of neuro-orthopaedic malformations in two groups of pregnancies conceived either naturally or by in-vitro fertilization, and used multivariate analysis to study the impact of each variable. The results showed a prevalence of 0.89% neuro-orthopaedic malformations in the in-vitro fertilization cohort and 0.32% in the natural conception cohort. The three times greater risk of malformations in the in-vitro fertilization cohort was reduced after adjustment to other variables. We concluded that the increased risk of neuro-orthopaedic malformations after in-vitro fertilization is not due to the technique itself but rather to factors associated with it.

What factors affect intracytoplasmic sperm injection outcomes?

Within the last decade, intracytoplasmic sperm injection (ICSI), a new assisted reproductive technique that allows for the direct injection of spermatozoa into the oocyte, has become available to infertile couples. While most studies indicate that ICSI has success rates similar to those of traditional in vitro fertilization, there are many concerns about the safety of the procedure, including increased risks of chromosomal and developmental abnormalities in children conceived by ICSI. Factors that contribute to these increased risks have not been well elucidated. The purpose of this paper is to review the latest literature concerning 1) the adverse outcomes associated with ICSI; and 2) factors that affect the success rates of ICSI (with emphasis on paternal factors).

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain the procedure, intracytoplasmic sperm injection (ICSI), to outline the data surrounding chromosomal and developmental outcomes after ICSI, and to list and explain the potential factors that influence ICSI.

Obstetric and perinatal outcome of 1655 ICSI and 3974 IVF singleton and 1102 ICSI and 2901 IVF twin births: a comparative analysis

A total of 3974 IVF and 1655 ICSI singleton births and 2901 IVF and 1102 ICSI twin births were evaluated. Pregnancies after both fresh and frozen transfers were included. IVF and ICSI singleton pregnancies were very similar for most obstetric and perinatal variables. The only significant difference was a higher risk for prematurity (< 37 weeks of amenorrhoea) in IVF pregnancies compared with ICSI pregnancies (12.4 versus 9.2%, OR = 1.39, 95% CI = 1.15-1.70). For twin pregnancies, differences were not statistically different except for a higher incidence of stillbirths in the ICSI group (2.08 versus 1.03%, OR = 2.04, 95% CI = 1.14-3.64). Intrauterine growth retardation with or without pregnancy-induced hypertension was observed more often in the ICSI group. Regression analysis of the data with correction for parity and female age showed similar results for twins. For singletons, this analysis showed similar results with the exception of low birth weight babies (< 2500 g), which were also observed more often in IVF pregnancies (9.6 versus 7.9%, OR = 0.79, CI = 0.65-0.98, P = 0.03). This large case-comparative retrospective analysis showed that the obstetric outcome and perinatal health of IVF and ICSI pregnancies is comparable.

Perinatal outcome of ICSI pregnancies compared with a matched group of natural conception pregnancies in Flanders (Belgium): a cohort study

A retrospective cohort study was conducted with an intracytoplasmic sperm injection (ICSI) group and a naturally conceived comparison group. A total of 1655 singleton and 1102 twin ICSI births were studied with regard to perinatal outcome. Control subjects (naturally conceived pregnancies) were selected from a regional registry and were matched for maternal age, parity, place of delivery, year of birth and fetal sex. The main outcome measures were duration of pregnancy, birth weight, Apgar score <5 after 5 min, neonatal complications, perinatal death and congenital malformations. Twin births, when compared with singletons, carry a much higher risk of poor perinatal outcome. For both ICSI singletons and ICSI twins, no significant difference was found between ICSI and naturally conceived pregnancies for all investigated parameters. After excluding like-sex twin pairs, ICSI twin pregnancies were at increased risk for perinatal mortality (OR = 2.74, CI = 1.26-5.98), prematurity (OR = 1.38, CI = 1.10-1.75) and low birth weight (OR = 1.34, CI = 1.06-1.69) compared with spontaneously conceived different-sex twin pairs. In conclusion, the perinatal outcome of ICSI singleton and twin pregnancies was very similar to that of spontaneously conceived pregnancies in this large cohort study. After excluding like-sex twin pairs, ICSI twins were at increased risk for prematurity, low birth weight and higher perinatal mortality compared with the natural conception comparison group.

Couples becoming parents: something special after IVF?

The majority of catamnestic studies on successful IVF treatment deal with the development of the children and the parent-child-relationship. Far fewer studies pay attention to the changes within the relationship of couples that become parents. This particular study focused on the transition from partnership to parenthood with assessments at different measuring points (T1: the last trimester of pregnancy; T2: 3 months after birth; and T3: 12 months after birth) and compared 47 IVF couples with 45 couples that conceived naturally. The couples were observed with psychodynamic couple interviews and standardized as well as non-standardized questionnaires. The most striking result of our study was the inconspicuousness of IVF couples and their parent-child-relationship. Partnerships featured a high degree of satisfaction among the couples; the progress of pregnancy was described as very satisfying and free of complaints. Surprisingly these descriptions were given despite more frequent and longer hospital stays by the IVF women during their pregnancy. However, IVF couples acted less openly in the interviews and expressed their own feelings less often, especially the more negative ones. In the partnerships we found that IVF women displayed more avoiding tendencies in their relationships 1 year after the birth of their child/children.

Perinatal Outcomes in Singletons Following In Vitro Fertilization: A Meta-Analysis

OBJECTIVE

To estimate whether singleton pregnancies following in vitro fertilization (IVF) are at higher risk of perinatal mortality, preterm delivery, small for gestational age, and low or very low birth weight compared with spontaneous conceptions in studies that adjusted for age and parity.

DATA SOURCES

We searched MEDLINE, BIOSIS, Doctoral Dissertations On-Line, bibliographies, and conference proceedings for studies from 1978-2002 using the terms "in vitro fertilization," "female infertility therapy," and "reproductive techniques" combined with "fetal death," "mortality," "fetal growth restriction," "small for gestational age," "birth weight," "premature labor," "pre-term delivery," "infant," "obstetric," "perinatal," and "neonatal."

METHODS OF STUDY SELECTION

Inclusion criteria were singleton pregnancies following IVF compared with spontaneous conceptions, control for maternal age and parity; 1 of the above outcomes; and risk ratios or data to determine them. Study selection and data abstraction were performed in duplicate after removing identifying information.

TABULATION, INTEGRATION, AND RESULTS

Fifteen studies comprising 12,283 IVF and 1.9 million spontaneously conceived singletons were identified. Random-effects meta-analysis was performed. Compared with spontaneous conceptions, IVF singleton pregnancies were associated with significantly higher odds of each of the perinatal outcomes examined: perinatal mortality (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.6, 3.0), preterm delivery (OR 2.0; 95% CI 1.7, 2.2), low birth weight (OR 1.8; 95% CI 1.4, 2.2), very low birth weight (OR 2.7; 95% CI 2.3, 3.1), and small for gestational age (OR 1.6; 95% CI 1.3, 2.0). Statistical heterogeneity was noted only for preterm delivery and low birth weight. Sensitivity analyses revealed no significant changes in results. Early preterm delivery, spontaneous preterm delivery, placenta previa, gestational diabetes, preeclampsia, and neonatal intensive care admission were also significantly more prevalent in the IVF group.

CONCLUSION

In vitro fertilization patients should be advised of the increased risk for adverse perinatal outcomes. Obstetricians should not only manage these pregnancies as high risk but also avoid iatrogenic harm caused by elective preterm labor induction or cesarean.

Role of fertility treatments in multiple pregnancy at National Women's Hospital from 1996 to 2001

OBJECTIVE

To determine the influence of fertility treatments on multiple pregnancy rates.

STUDY DESIGN

A retrospective audit of women with multiple pregnancies from 1996 to 2001 at National Women's Hospital (NWH), Auckland, New Zealand was conducted. Information was collected regarding the demographics, fertility treatment, outcome of the pregnancy and complications experienced by women discharged with multiple births as an discharge diagnosis.

RESULTS

For the years 1996-2001 there were 1136 multiple births at NWH. Of these births, 201 (18%) were conceived following fertility treatment. Seventeen percent of twin births and 44% of triplet births were conceived following fertility treatment. There was a statistically significant increase in the number of births conceived following fertility treatment, from 9%, in 1996 to 24%, in 2001, although the proportion of births that were multiple overall did not change (20% in 1996 and 2.3%, in 2001). Sixty-three percent of all fertility conceived multiple births were following in vitro fertilization/intracytoplasmic sperm injection treatment. Sixty percent of these women had two embryos transferred and 31% had three embryos transferred. Ovulation induction with follicle-stimulating hormone accounted for 19% of all fertility conceived multiple births. Nineteen percent of fertility conceived multiple births followed clomiphene treatment alone.

CONCLUSIONS

The proportion of multiple pregnancies as a result of fertility treatments has increased over the 6 years studied.

Practitioner review: outcomes for parents and children following non-traditional conception: what do clinicians need to know?

BACKGROUND

The birth of the first 'test-tube' baby in 1978 has led to the creation of family types that would not otherwise have existed.

METHODS

This paper examines research on the psychological outcomes for parents and children in assisted reproduction families with particular attention to the issues and concerns that have been raised by creating families in this way.

RESULTS

Parents of children conceived by assisted reproduction appear to have good relationships with their children, even in families where one parent lacks a genetic link with the child. With respect to the children themselves, there is no evidence of cognitive impairment in singleton children born at full term as a result of assisted reproduction procedures, although the findings regarding the cognitive development of intracytoplasmic sperm injection (ICSI) children are currently unclear. In relation to socioemotional development, assisted reproduction children appear to be functioning well.

CONCLUSIONS

Few studies have included children at adolescence or beyond, and little is known about the consequences of conception by assisted reproduction from the perspective of the individuals concerned. In addition, there are some types of assisted reproduction family, such as families created through a surrogacy arrangement or through embryo donation, about whom little is known at all. Although existing knowledge about the impact of assisted reproduction for parenting and child development does not give undue cause for concern, there remain a number of unanswered questions in relation to children born in this way.

The European study of assisted reproduction families: the transition to adolescence

BACKGROUND

Findings are presented of the second phase of a European longitudinal study of families created by assisted reproduction. The present investigation reports on data obtained during the child's transition to adolescence.

METHODS

A total of 102 IVF families, 94 donor insemination (DI) families, 102 adoptive families, and 102 families with a naturally conceived child were compared on standardized interview and questionnaire measures of parenting and children's psychological well-being.

RESULTS

The assisted reproduction families were similar to the adoptive and natural conception families for many of the measures of the quality of parent-child relationships. To the extent that differences were found between the assisted reproduction families and the other family types, these reflected mainly more positive functioning among the assisted reproduction families, with the possible exception of the overinvolvement with their children of a small proportion of assisted reproduction mothers and fathers. The assisted reproduction children were functioning well and did not differ from the adoptive or naturally conceived children on any of the measures of psychological adjustment. However, only 8.6% had been told about their genetic origins.

CONCLUSIONS

IVF and DI families with an early adolescent child appear to be functioning well.

A historical perspective of the clinical evolution of the assisted reproductive technologies

The practice of assisted reproduction technology today is the result of the dedicated patient care, observation, research, and experimentation undertaken by previous generations of physicians. The building blocks of progress have been assembled over past decades, by scientists whose primary objective has been to push forward the frontiers of knowledge, in order to offer more effective methods of infertility treatment. And fortunately that process continues today. Amongst the many scientific developments that have led to the modern practice in assisted reproductive technology, a small number stand out as having had a unique importance. This historical review redraws the path through which in vitro fertilization went from an experimental to an accepted infertility treatment.

Medical, cognitive, emotional, and behavioral outcomes in school-age children conceived by in-vitro fertilization

Assessed long-term effects of assisted reproduction technologies of in-vitro fertilization (IVF) and related techniques of embryo transfer (ET) on children's adjustment. 51 school-age Israeli children conceived by IVF/ET were compared with 51 control-matched children conceived spontaneously. The assessment included a comprehensive medical evaluation, a psychological examination, teachers' reports, parents' reports, and children's self-reports. As compared with controls, IVF/ET children did not reveal significant differences in physical and neurological status or on cognitive measures of IQ, visual-motor coordination, visual memory, and verbal comprehension. Nevertheless, the IVF/ET children were scored lower by teachers on measures of socioemotional adjustment in school and on self-report measures of anxiety, aggression, and depression. Among IVF/ET children, the tendency to be at a greater risk for emotional disturbances was exacerbated among boys and among children whose parents were older.

The danger of overmatching in studies of the perinatal mortality and birthweight of infants born after assisted conception

OBJECTIVE

To examine the impact of gestation length and plurality on short-term outcome of in vitro fertilization (IVF)-children.

STUDY DESIGN

A register study using the Finnish Medical Birth Register for 1991-1993 (N = 194 383 newborns, of which 1335 were IVF-newborns).

RESULTS

For IVF-newborns, a high proportion of multiple births (27%, odds ratio (OR) 19.67 compared with non-IVF births), low birth weight infants (30%, OR 7.94), and perinatal deaths (2.9%, OR 4.17) was found. The mothers' background did not explain the increased risks. After adjusting for gestation length and/or plurality, the odds ratios decreased significantly.

CONCLUSION

Because of the high risk of plurality and premature births, matching the control group by gestation length and/or the number of multiples births may yield misleading results on the total health impact of IVF, and therefore it should be avoided.

Outcome of frozen embryo replacement cycles following elective cryopreservation of all embryos in women at risk of developing ovarian hyperstimulation syndrome

AIM

Our aim was to compare the outcome in subsequent frozen embryo replacement cycles in four groups of patients who had elective cryopreservation of all their embryos because they were considered to be at increased risk of developing severe ovarian hyperstimulation syndrome.

DESIGN

Sixty-two (91%) of 68 IVF cycles (68 patients) in which elective cryopreservation of all embryos was performed were analyzed. All patients continued on the GnRH agonist, buserelin, after oocyte recovery until the onset of vaginal bleeding. Frozen embryo replacement occurred in a hormone replacement cycle that started either on day 3 of the withdrawal bleed (group I; N = 15) or after serum estradiol levels had fallen to < 100 pmol/L (group II; N = 16). The other patients commenced a frozen embryo replacement cycle several months later in either a hormone replacement (group III; N = 15) or a natural (group IV; N = 16) cycle.

RESULTS

Two patients developed severe ovarian hyperstimulation syndrome. There were no significant differences among the four groups regarding demographic variables, the dose of hMG used, and the clinical outcome. There was a higher but not significantly different clinical pregnancy rate in group I (26.7%), compared to group II (12.5%), group III (13.3%), and group IV (18.8%).

CONCLUSIONS

Several options exist for the timing and protocol used for frozen embryo replacement in patients who had elective cryopreservation for the prevention of ovarian hyperstimulation syndrome, none of which was found to be clearly superior in this observational report.

Mechanism and management of treatment-related gonadal failure in recipients of high dose chemoradiotherapy

For the last two decades, the use of bone marrow transplantation for leukaemia, and most recently for lymphomas and other cancers, has increased dramatically and all of the systemic chemotherapy or radiotherapy used in these patients has a potential for causing infertility. This review describes the normal reproductive function of relevance to patients at risk of chemotherapy- or radiotherapy-induced infertility. The mechanism by which fertility may be affected by these agents is also described and therapeutic strategies for reducing or preventing these problems are outlined. The treatment of men and women who are infertile after chemotherapy or radiotherapy is addressed, as are the ethical and legal aspects of assisted fertilization.

Success rates with gamete intrafallopian transfer and in vitro fertilization in women of advanced maternal age

OBJECTIVE

To evaluate the effect of maternal age on outcomes for IVF and GIFT in women 40 to 45 years of age.

DESIGN

Retrospective.

SETTING

Boston IVF, a free-standing university-affiliated IVF and GIFT unit.

PATIENTS

A total of 2,931 cycles of IVF and 1,826 cycles of GIFT were analyzed in women undergoing assisted reproductive technologies (IVF or GIFT) using autologous eggs.

INTERVENTIONS

Medical records of patient outcomes were reviewed.

RESULTS

For patients undergoing IVF, the cancellation rate for initiated cycles showed significant differences in women aged 25 to 39 (38.3%), women aged 40 to 43 (49.5%), and women aged 44 to 45 years (69.5%). A significantly lower delivery rate per stimulation and delivery rate per retrieval was found in women aged 40 to 43 years when compared with women aged 25 to 39 years. No deliveries occurred in 59 cycles in women aged 44 to 45 years, thereby representing a significant difference when compared with both women aged 25 to 39 years and women aged 40 to 43 years. For patients undergoing GIFT, the cancellation rate for initiated cycles was significantly higher in women aged 40 to 43 (25.0%) and 44 to 45 years (31.0%) when compared with women aged 25 to 39 years (15.1%). A significantly lower delivery rate per stimulation and delivery rate per retrieval was found in women aged 40 to 43 and 44 to 45 years when compared with women aged 25 to 39 years.

CONCLUSIONS

Success rates for IVF and GIFT decline significantly in women > 40 years old. Women aged > or = 44 years are unlikely to benefit from the use of IVF and GIFT.

Follow-up of 30 pregnancies after embryo cryopreservation

OBJECTIVE

In an observational follow-up study, the pregnancy outcome of the first 30 women who conceived after transfer of cryopreserved embryos was evaluated.

STUDY DESIGN

The main outcome measures were duration and complications of pregnancy, mode of delivery, complications during and after childbirth, birthweight, Apgar score, and congenital anomalies.

RESULTS

Twenty-six pregnancies ended in birth of one (n = 22) or more (n = 4) infants with a cesarean section rate of 23%. Of the singleton pregnancies 77% were uncomplicated, but there was a high incidence of breech presentation (14%). Infant birthweight tended to be above average with 45% of singletons weighing more than the 75th centile of weight for gestation. There were no major congenital deformations.

CONCLUSION

The results of our embryo cryopreservation program are encouraging, but sustained follow-up of such pregnancies and infants is needed.

Actigraphic home-monitoring of the sleep patterns of in vitro fertilization children and their matched controls

The sleep patterns of 35 in vitro fertilization (IVF) children aged 19 to 57 months and their matched controls were evaluated by actigraphic home-monitoring for three consecutive nights. Actigraphic data were analysed by an automated scoring procedure developed in the authors' laboratory. There were no significant differences in activity levels between IVF multiple-birth subjects and their matched controls or between IVF singletons and their matched controls. In contrast, multiple-birth subjects had higher activity levels during sleep and lower sleep efficiency than singletons in both IVF and control groups. Sleep measures showed night-to-night stability in all groups.

Comparison of natural with clomiphene citrate-stimulated cycles in in vitro fertilization: a prospective, randomized trial

OBJECTIVE

To compare the outcome of natural with clomiphene citrate (CC)-stimulated cycles in IVF.

DESIGN

Prospective, randomized study.

SETTING

Tertiary referral center for assisted conception.

SUBJECTS

Thirty patients randomized to receive either no treatment (n = 14) or CC, 100 mg, from days 2 to 6 (n = 16).

INTERVENTIONS

Daily ultrasound (US) scan and measurements of serum LH and E2. Ovarian morphology was assessed on baseline US scan. Human chorionic gonadotrophin was administered when the mean diameter of the dominant follicle reached 17 mm. Transvaginal US-directed oocyte recovery was performed 35 hours later.

MAIN OUTCOME MEASURES

The number of patients reaching oocyte recovery; numbers of oocytes collected, fertilized and embryos transferred; and clinical pregnancy and multiple pregnancy rates (PRs) were recorded.

RESULTS

Ten cycles in the natural cycle group were abandoned before oocyte recovery compared with none in the CC group. There were significantly more follicles > 14 mm (2.4 +/- 0.3 [SE] compared with 0.9 +/- 0.2) and higher peak levels of E2 (375 +/- 67 pg/mL (1,378 +/- 247 pmol/L) compared with 204 +/- 17 pg/mL (748 +/- 61 pmol/L)) in those receiving CC compared with those receiving no drug. All 16 patients treated with CC had oocyte retrieval (mean, 1.8 +/- 0.3 oocytes) compared with only 4 in the natural cycle group (1 oocyte each). The oocyte recovery rate was 95%. Two patients conceived in the CC group (PR per ET, 18%) compared with none in the natural cycle group. Patients with polycystic ovaries developed more large follicles than those with normal ovaries. No patient developed ovarian hyperstimulation syndrome.

CONCLUSIONS

Patients undergoing natural cycle IVF are more likely to have abandoned cycles, produce fewer follicles and oocytes, and are less likely to reach ET than patients treated with CC alone. Clomiphene citrate should be considered for use in the context of a conventionally organised IVF-ET program if a mild degree of ovarian stimulation is desired.

Complications of assisted reproductive techniques

OBJECTIVE

To review and appreciate the relevant data on assisted reproduction techniques and their potential complications.

DATA RESOURCES

Major publications on assisted reproduction that include the information concerning complications associated with this practice.

RESULTS

Assisted reproduction is a common practice in modern reproductive medicine. Complications are associated with ovulation induction and the extracorporeal methods that are used for IVF-ET, GIFT, and zygote intrafallopian transfer (ZIFT). These complications are associated with laparoscopy, anesthesia, oocyte retrieval, and laboratory facilities. Pregnancies resulting from assisted reproduction are more complicated than spontaneous pregnancies. There are higher rates of ectopic, heterotopic, and multifetal pregnancies; abortions; and premature deliveries. Increased rates of perinatal mortality and morbidity result from prematurity, and higher rates of maternal diseases in pregnancy (preeclampsia, diabetes mellitus, bleeding, anemia) contribute to fetal intra-uterine growth restriction and maternal morbidity.

CONCLUSIONS

Assisted reproduction practice should be well controlled in view of the potential for complications before and during pregnancies.

A randomized trial of in vitro fertilization versus conventional treatment for infertility

OBJECTIVE

To evaluate the effectiveness of IVF in couples with infertility.

DESIGN

Two hundred forty-five consecutive couples with infertility were randomized to receive one cycle of IVF treatment (experimental group) or to wait for a period of 6 months before receiving IVF treatment, during which time other infertility treatments could have been undertaken (control group).

SETTING

Patients were referred to the Fertility Clinic at Chedoke-McMaster Hospitals, a university-associated institution in Hamilton, Ontario, Canada, in which IVF has been offered to couples since 1984.

PATIENTS

Couples with infertility (mean duration of 65 months) not corrected by conventional treatment. They came from all socioeconomic classes, and the costs of IVF treatment, except medication, were covered by the Ontario Health Insurance Plan.

MAIN OUTCOME MEASURE

Pregnancy was confirmed by ultrasound documentation of a gestational sac or histologic examination of tissue. Outcomes included livebirth, spontaneous abortion, and ectopic pregnancy. The overall pregnancy rate (PR) and the interval-to-pregnancy duration were compared in each group.

RESULTS

Univariate analysis demonstrated a significant beneficial effect of IVF treatment in patients with bilateral severe tubal disease. Although in other diagnostic categories the crude and cumulative PRs in the experimental group were higher than in the control group, the differences did not reach statistical significance. Among the early IVF group, those with endometriosis had significantly more pregnancies when compared with other diagnostic categories. Although IVF increases the likelihood of pregnancy by 40% with severe tubal disease, the overall 31% increase associated with IVF was not statistically significant.

CONCLUSIONS

There was a significant difference in favor of treatment in patients with severe bilateral tubal disease. For couples with other causes of infertility, the confidence limits around the treatment effect included unity. To reject the null hypothesis of no treatment effect, a larger sample size or a meta-analysis to combine the results of similar trials is required.

In-vitro fertilisation and neonatal ventilator use in a tertiary perinatal centre

OBJECTIVE

To determine the contribution of livebirths resulting from in-vitro fertilisation and related technologies (IVF) to the use of neonatal ventilator beds.

DESIGN

A retrospective review of records of all livebirths from our hospital's IVF program and all IVF infants receiving mechanical ventilation in our neonatal intensive care unit for the period 1985-1989. We also reviewed records of labour ward deliveries, neonatal intensive care unit admissions and transfer requests in order to obtain comparative data for livebirths of non-IVF infants whose mothers had been booked to deliver in our hospital.

SETTING

A tertiary perinatal centre with a large IVF program and a Level 3 neonatal intensive care unit.

RESULTS

IVF livebirths accounted for 5.1% of total ventilator bed days. Compared with non-IVF booked livebirths, IVF babies were more likely to require ventilation (odds ratio, 7.41; P less than 0.0001) and used more ventilator bed days per 100 livebirths (rate ratio, 9.63; P less than 0.0001), largely due to preterm delivery of multiple pregnancies; 42.3% of IVF babies who required ventilation were from triplet births and 38.5% from twin births. Nevertheless, even IVF singletons used more ventilator bed days per 100 livebirths than non-IVF booked livebirths (rate ratio, 2.78; P less than 0.0001). IVF livebirths accounted for 9.9% of the 78% increase in ventilator bed days used in 1989 compared with 1985.

CONCLUSIONS

IVF livebirths accounted for only a small percentage of the overall use of neonatal ventilator beds, but consumed relatively more of such resources per livebirth than did non-IVF livebirths. The degree of risk of requiring ventilation is directly related to the number of infants in a multiple pregnancy, but even IVF singletons are at a relatively high risk of requiring ventilation.

The use of transvaginal color flow imaging after in vitro fertilization to identify optimum uterine conditions before embryo transfer

OBJECTIVE

To assess whether a measure of uterine blood flow impedance (the pulsatility index, PI) as determined by transvaginal ultrasonography with color blood flow imaging, may be used to assess endometrial receptivity immediately before the time of embryo transfer (ET) after assisted conception.

DESIGN

A prospective study of infertile women who had undergone treatment to induce multiple follicular development followed by ultrasound-guided oocyte retrieval. The oocytes were fertilized in vitro.

SETTING

The Hallam Medical Centre.

PATIENTS

Eight-two women (22 to 44 years of age) who all had three or four good quality embryos available for transfer to the uterus.

INTERVENTIONS

All women were examined by transvaginal ultrasonography, with color flow imaging and blood flow analysis, immediately before ET.

MAIN OUTCOME MEASURES

The mean PI of the left and right uterine arteries, the pregnancy rate (PR) (%), the embryo implantation rate (%), and the multiple PR (%).

RESULTS

The patients were grouped according to whether the PI was low (1.00 to 1.99), medium (2.00 to 2.99), or high (3+). There were 27 women in the low PI group, 36 in the medium, and 19 in the high. The PR (%), embryo implantation rate (%), and multiple PR (%) were 41%, 15.3%, and 27.3% for the low PI group and 47%, 22.2%, and 47.1% for the medium PI group. There were no pregnancies in the high PI group. Thus 35% (19/54) of women who failed to become pregnant had a PI value greater than 3.0.

CONCLUSIONS

These data suggest that the PI value on the day of ET could be used to: (1) increase the implantation rate by showing which embryos should be cryopreserved until the uterus is more receptive and (2) reduce the multiple PR by indicating that the number of embryos transferred should be limited when the uterus is most receptive.