Incidence of congenital malformations in children born after ICSI

The use of ICSI in ART: evidence for practice

This article reviews the evidence regarding the safety and efficacy of intra-cytoplasmic sperm injection (ICSI). It provides evidence-based clinical and laboratory guidelines and recommendations for use of ICSI within an assisted reproductive technology (ART) service. The guidelines address the evidence for the use of ICSI rather than conventional IVF (cIVF); the use of ART techniques supplementary to ICSI; and risks associated with ICSI. This article is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs and medical history of the patient, available resources, and institutional or clinical practice limitations.

Hypospadias: A Comprehensive Review Including Its Embryology, Etiology and Surgical Techniques

Hypospadias is among the most prevalent urogenital malformations in male newborns. It is characterized by the displacement of the urethral meatus to the ventral side of the penis, an aberrant ventral curve of the penis referred to as "chordee," and an abnormally arranged foreskin with a "hood" found dorsally and lacking foreskin ventrally. Patients may have an extra genitourinary abnormality based on the area of the lesion. In around 70% of cases, the urethral meatus is positioned distally to the shaft, representing a milder form of the disease. The remaining 30% of cases are located proximally, are more complicated, and require further evaluation. Although the origin of hypospadias is mostly obscure, several suggestions exist about genetic susceptibility and hormonal factors. The objective of hypospadias restoration is to restore aesthetic and functional regularity, and surgery is currently advised at a young age, mostly between six and 18 months. At any age, hypospadias can be repaired with an equivalent risk of complications, functional outcomes, and aesthetic outcomes. However, the best age of treatment is still undetermined. Even though the long-term effects on appearance and sexual function are usually good, males may be less likely to make the first move after rectification. Also, people who have hypospadias treated are twice as likely to have problems with their lower urinary tract. These problems can last for years after the initial repair.

Prevalence of Congenital Heart Defects in Pregnancies Conceived by Assisted Reproductive Technology: A Cohort Study

BACKGROUND AND AIM OF THE STUDY

Pregnancies obtained by assisted reproductive technology (ART) are associated with an increased risk of complications and congenital anomalies, particularly congenital heart defects (CHDs). Therefore, our aim is to evaluate, retrospectively, the prevalence of CHD in ART pregnancies in our two centers and analyze their characteristics and outcomes.

METHODS

Observational study including fetuses conceived by ART referred between June 2011 and September 2020 and undergoing a fetal cardiac ultrasound scan. Cases with genetic, chromosomal abnormalities or extracardiac malformations were excluded. Population included 1511 pregnancies, which consisted of 269 twins and 1242 singletons, 547 IVF (in vitro fertilization), 773 ICSI (intracytoplasmic sperm injection) and 191 oocyte donations (OD).

RESULTS

CHDs were found in 29 fetuses, with an overall prevalence of 1.92% (29/1511), 1.85% (23/1242) in singletons and 2.23% in twins (6/269). Thirteen were IVF, eight ICSI and eight OD cases, with a greater risk of CHD after IVF and OD (IVF: 13/29 (44.8%)-one twin; ICSI: 8/29 (27.6%)-three twins); 22 had major and 7 minor defects. Two pregnancies with a hypoplastic left heart were terminated; the majority of live-born cases needed surgery. Three babies died (two post-surgery, one had a late death).

CONCLUSIONS

Our data show an increased prevalence of CHD after ART with a heterogeneous spectrum of diagnoses, mainly major defects.

Prevalence of Congenital Heart Defects in Pregnancies Conceived by Assisted Reproductive Technology: A Cohort Study

BACKGROUND AND AIM OF THE STUDY

Pregnancies obtained by assisted reproductive technology (ART) are associated with an increased risk of complications and congenital anomalies, particularly congenital heart defects (CHDs). Therefore, our aim is to evaluate, retrospectively, the prevalence of CHD in ART pregnancies in our two centers and analyze their characteristics and outcomes.

METHODS

Observational study including fetuses conceived by ART referred between June 2011 and September 2020 and undergoing a fetal cardiac ultrasound scan. Cases with genetic, chromosomal abnormalities or extracardiac malformations were excluded. Population included 1511 pregnancies, which consisted of 269 twins and 1242 singletons, 547 IVF (in vitro fertilization), 773 ICSI (intracytoplasmic sperm injection) and 191 oocyte donations (OD).

RESULTS

CHDs were found in 29 fetuses, with an overall prevalence of 1.92% (29/1511), 1.85% (23/1242) in singletons and 2.23% in twins (6/269). Thirteen were IVF, eight ICSI and eight OD cases, with a greater risk of CHD after IVF and OD (IVF: 13/29 (44.8%)-one twin; ICSI: 8/29 (27.6%)-three twins); 22 had major and 7 minor defects. Two pregnancies with a hypoplastic left heart were terminated; the majority of live-born cases needed surgery. Three babies died (two post-surgery, one had a late death).

CONCLUSIONS

Our data show an increased prevalence of CHD after ART with a heterogeneous spectrum of diagnoses, mainly major defects.

Biological and Clinical Significance of Mosaicism in Human Preimplantation Embryos

Applications and indications of assisted reproduction technology are expanding, but every new approach is under scrutiny and thorough consideration. Recently, groups of assisted reproduction experts have presented data that support the clinical use of mosaic preimplantation embryos at the blastocyst stage, previously excluded from transfer. In the light of published contemporary studies, with or without clinical outcomes, there is growing evidence that mosaic embryos have the capacity for further in utero development and live birth. Our in-depth discussion will enable readers to better comprehend current developments. This expansion into the spectrum of ART practices requires further evidence and further theoretical documentation, basic research, and ethical support. Therefore, if strict criteria for selecting competent mosaic preimplantation embryos for further transfer, implantation, fetal growth, and healthy birth are applied, fewer embryos will be excluded, and more live births will be achieved. Our review aims to discuss the recent literature on the transfer of mosaic preimplantation embryos. It also highlights controversies as far as the clinical utilization of preimplantation embryos concerns. Finally, it provides the appropriate background to elucidate and highlight cellular and genetic aspects of this novel direction.

Chromosomal abnormalities after ICSI in relation to semen parameters: results in 1114 fetuses and 1391 neonates from a single center

STUDY QUESTION

Is there a relationship between karyotype abnormalities in fetuses and children conceived by ICSI and their father's semen parameters?

SUMMARY ANSWER

The de novo chromosomal abnormality rate in pre- and postnatal karyotypes of ICSI offspring was higher than in the general population and related to fathers' sperm parameters.

WHAT IS KNOWN ALREADY

Several studies have reported a higher rate of de novo chromosomal anomalies in ICSI fetuses but recent data from large cohorts are limited. Overall, reported prevalences of non-inherited karyotype aberrations are increased in fetuses conceived after ICSI and vary between 1.6% and 4.2%. Only a few studies focus on the relation between karyotype anomalies in ICSI offspring and semen parameters of their fathers. Furthermore, an increased incidence of abnormal karyotypes in ICSI neonates has been described, but the rates vary widely across studies.

STUDY DESIGN, SIZE, DURATION

We report on karyotype results from prenatal testing by means of chorionic villus sampling and amniocentesis and results from postnatal blood sampling in offspring conceived by ICSI in a single center. Ongoing pregnancies resulting from an oocyte retrieval between January 2004 and December 2012 and after transfer of fresh ICSI embryos obtained using ejaculated or non-ejaculated sperm (fresh or frozen-thawed) were considered. Pregnancies following frozen embryo transfer, oocyte or sperm donation, IVF, preimplantation genetic testing and IVM were excluded. All abnormal prenatal results after sampling are reported irrespective of the outcome of the pregnancy.

PARTICIPANTS/MATERIALS, SETTING, METHODS

From the 4816 ongoing ICSI pregnancies, information on pregnancy outcome was available for 4267 pregnancies. Prenatal testing was performed in 22.3% of the pregnancies, resulting in a diagnosis in 1114 fetuses. A postnatal karyotype was obtained in 29.4% of the pregnancies in which no invasive prenatal diagnosis was performed, resulting in a total of 1391 neonates sampled. The prevalence of chromosomal anomalies according to maternal age and semen quality was analyzed with logistic regression. For definitions of normal semen quality, the World Health Organization reference values for human semen characteristics were adopted.

MAIN RESULTS AND THE ROLE OF CHANCE

An abnormal fetal karyotype was found in 29 singletons and 12 multiples (41/1114; 3.7%; 95% CI 2.7-4.9%): 36 anomalies were de novo (3.2%; 95% CI 2.3-4.4), either numerical (n = 25), sex (n = 6) or structural (n = 5), and five were inherited. Logistic regression analysis did not show a significant association between maternal age and a de novo chromosomal fetal abnormality (odds ratio (OR) 1.05; 95% CI 0.96-1.15; P = 0.24). In all but one case, fetuses with an abnormal karyotype were conceived by ICSI using ejaculated sperm.Abnormal karyotypes were found in 14 (1.0%; 95% CI 0.6-1.7) out of 1391 postnatal samples of children born after ICSI who were not tested prenatally: 12 were de novo anomalies and two were inherited balanced karyotypes. The 14 abnormal karyotypes were all found in children born after ICSI using ejaculated sperm.The odds of a de novo karyotype aberration increased with maternal age when combining pre- and postnatal data (OR 1.11; 95% CI 1.04-1.19). A higher rate of de novo chromosomal abnormalities was found in fetuses and children of couples with men having a sperm concentration <15 million/ml (adjusted OR (AOR) 2.10; 95% CI 1.14-3.78), sperm concentration <5 million/ml (AOR 1.9; 95% CI 1.05-3.45) and total sperm count <10 million (AOR 1.97; 95% CI 1.04-3.74).

LIMITATIONS, REASONS FOR CAUTION

We cannot exclude that the observation of a higher prevalence of karyotype anomalies in ICSI offspring compared to literature data in the general population is due to enhanced surveillance after ART given the lack of a control group. Although we did not find more chromosomal anomalies after ICSI with non-ejaculated sperm, the small numbers do not allow firm conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The observed increased risk of a de novo karyotype anomaly after ICSI conception in couples with poor sperm warrants continued counseling toward prenatal testing.The current and widespread use of innovative non-invasive prenatal testing will result in larger datasets, adding to a balanced estimation of the prevalence of karyotype anomalies in ICSI offspring.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Methusalem grants issued by the Vrije Universiteit Brussel. All authors declared no conflict of interest related to this study.

TRIAL REGISTRATION NUMBER

N/A.

Assisted reproductive technologies and the risk of congenital urogenital tract malformations: A systematic review and meta-analysis

A systematic review was conducted to evaluate the relationship between ART and the risk of urogenital tract malformations, especially hypospadias and cryptorchidism. Thirty-three papers were selected. Meta-analysis showed that ART was correlated with an increased risk of urogenital tract malformation in offspring (odds ratio (OR) = 1.61, 95% confidence interval (CI): 1.41-1.85), hypospadias (OR = 1.87, 95% CI: 1.47-2.40) and cryptorchidism (OR = 1.83, 95% CI: 1.54-2.18). Among offspring conceived by ART, multiple pregnancies appeared to result in a higher risk of urogenital tract malformation than singleton pregnancies (OR = 1.42, 95% CI: 0.99-2.04; P = 0.058). No significant difference in the risk of urogenital tract malformation was found between in vitro fertilization and intracytoplasmic sperm injection technologies. A sensitivity analysis showed that the above conclusions were relatively consistent. Conclusion: ART is correlated with an increased risk of urogenital tract malformations in offspring, especially hypospadias and cryptorchidism. Among ART offspring, multiple pregnancies may lead to a higher risk of urogenital tract malformations than singleton pregnancies, but more studies are needed for confirmation.

Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection

BACKGROUND

Transfer of more than one embryo during in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) increases multiple pregnancy rates resulting in an increased risk of maternal and perinatal morbidity. Elective single embryo transfer offers a means of minimising this risk, but this potential gain needs to be balanced against the possibility of jeopardising the overall live birth rate (LBR).

OBJECTIVES

To evaluate the effectiveness and safety of different policies for the number of embryos transferred in infertile couples undergoing assisted reproductive technology cycles.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialised register of controlled trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to March 2020. We handsearched reference lists of articles and relevant conference proceedings. We also communicated with experts in the field regarding any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different policies for the number of embryos transferred following IVF or ICSI in infertile women. Studies of fresh or frozen and thawed transfer of one to four embryos at cleavage or blastocyst stage were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial eligibility and risk of bias. The primary outcomes were LBR and multiple pregnancy rate. The secondary outcomes were clinical pregnancy and miscarriage rates. We analysed data using risk ratios (RR), Peto odds ratio (Peto OR) and a fixed effect model.

MAIN RESULTS

We included 17 RCTs in the review (2505 women). The main limitation was inadequate reporting of study methods and moderate to high risk of performance bias due to lack of blinding. A majority of the studies had low numbers of participants. None of the trials compared repeated single embryo transfer (SET) with multiple embryo transfer. Reported results of multiple embryo transfer below refer to double embryo transfer. Repeated single embryo transfer versus multiple embryo transfer in a single cycle Repeated SET was compared with double embryo transfer (DET) in four studies of cleavage-stage transfer. In these studies the SET group received either two cycles of fresh SET (one study) or one cycle of fresh SET followed by one frozen SET (three studies). The cumulative live birth rate after repeated SET may be little or no different from the rate after one cycle of DET (RR 0.95, 95% CI (confidence interval) 0.82 to 1.10; I² = 0%; 4 studies, 985 participants; low-quality evidence). This suggests that for a woman with a 42% chance of live birth following a single cycle of DET, the repeated SET would yield pregnancy rates between 34% and 46%. The multiple pregnancy rate associated with repeated SET is probably reduced compared to a single cycle of DET (Peto OR 0.13, 95% CI 0.08 to 0.21; I² = 0%; 4 studies, 985 participants; moderate-quality evidence). This suggests that for a woman with a 13% risk of multiple pregnancy following a single cycle of DET, the risk following repeated SET would be between 0% and 3%. The clinical pregnancy rate (RR 0.99, 95% CI 0.87 to 1.12; I² = 47%; 3 studies, 943 participants; low-quality evidence) after repeated SET may be little or no different from the rate after one cycle of DET. There may be little or no difference in the miscarriage rate between the two groups. Single versus multiple embryo transfer in a single cycle A single cycle of SET was compared with a single cycle of DET in 13 studies, 11 comparing cleavage-stage transfers and three comparing blastocyst-stage transfers.One study reported both cleavage and blastocyst stage transfers. Low-quality evidence suggests that the live birth rate per woman may be reduced in women who have SET in comparison with those who have DET (RR 0.67, 95% CI 0.59 to 0.75; I² = 0%; 12 studies, 1904 participants; low-quality evidence). Thus, for a woman with a 46% chance of live birth following a single cycle of DET, the chance following a single cycle of SET would be between 27% and 35%. The multiple pregnancy rate per woman is probably lower in those who have SET than those who have DET (Peto OR 0.16, 95% CI 0.12 to 0.22; I² = 0%; 13 studies, 1952 participants; moderate-quality evidence). This suggests that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following a single cycle of SET would be between 2% and 4%. Low-quality evidence suggests that the clinical pregnancy rate may be lower in women who have SET than in those who have DET (RR 0.70, 95% CI 0.64 to 0.77; I² = 0%; 10 studies, 1860 participants; low-quality evidence). There may be little or no difference in the miscarriage rate between the two groups.

AUTHORS' CONCLUSIONS

Although DET achieves higher live birth and clinical pregnancy rates per fresh cycle, the evidence suggests that the difference in effectiveness may be substantially offset when elective SET is followed by a further transfer of a single embryo in fresh or frozen cycle, while simultaneously reducing multiple pregnancies, at least among women with a good prognosis. The quality of evidence was low to moderate primarily due to inadequate reporting of study methods and absence of masking those delivering, as well as receiving the interventions.

Parental subfertility and hypospadias and cryptorchidism in boys: results from two Danish birth cohorts

OBJECTIVE

To study if parental subfertility is related to the occurrence of the male genital anomalies, cryptorchidism and hypospadias.

DESIGN

Population-based cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 80,220 singleton boys and their mothers from the Danish National Birth Cohort and the Aarhus Birth Cohort.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The two congenital anomalies; cryptorchidism and hypospadias, registered within the Danish National Patient Register up until December 31, 2012.

RESULT(S)

By means of Cox regression analyses, we found no associations between waiting time-to-pregnancy (TTP) and cryptorchidism or hypospadias among those who conceived spontaneously. The highest hazard ratio for cryptorchidism was seen among boys of couples with a TTP>12 months who conceived after fertility treatment (adjusted hazard ratio [aHR] 1.19, 95% confidence interval 0.92-1.55). For hypospadias, we found that boys of couples with a TTP>12 months who conceived after fertility treatment, had a 71% higher risk of hypospadias (aHR 1.71, [95% confidence interval 1.24-3.36]) as compared with boys of couples with a TTP<5 months.

CONCLUSION(S)

The findings from this study showed that boys of couples with TTP>12 months who conceived after fertility treatment, had a higher occurrence of hypospadias than boys conceived spontaneously of couples with a short TTP. Among those who conceived spontaneously, TTP was not associated with hypospadias or cryptorchidism. These findings indicate that fertility treatment or severity of subfertility is related to hypospadias.

Association of birth defects with the mode of assisted reproductive technology in a Chinese data-linkage cohort

OBJECTIVE

To evaluate the impact of assisted reproductive technology (ART) on the offspring of Chinese population.

DESIGN

Retrospective, data-linkage cohort.

SETTING

Not applicable.

PATIENT(S)

Live births resulting from ART or natural conception.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Birth defects coded according to ICD-10.

RESULT(S)

Births after ART were more likely to be female and multiple births, especially after intracytoplasmic sperm injection (ICSI). ART was associated with a significantly increased risk of birth defects, especially, among singleton births, a significantly increased risk in fresh-embryo cycles after in vitro fertilization (IVF) and frozen-embryo cycles after ICSI. Associations between ART and multiple defects, between ART and gastrointestinal malformation, genital organs malformation, and musculoskeletal malformation among singleton births, and between ART and cardiac septa malformation among multiple births were observed.

CONCLUSION(S)

This study suggests that ART increases the risk of birth defects. Subgroup analyses indicate higher risk for both fresh and frozen embryos, although nonsignificantly for frozen embryos after IVF and for fresh embryos were presented with low power. Larger sample size research is needed to clarify effects from fresh- or frozen-embryo cycles after IVF and ICSI.

Do the children born after assisted reproductive technology have an increased risk of birth defects? A systematic review and meta-analysis

Background: Assisted reproductive technologies (ARTs) have made great progress. However, whether tube baby born after ART were at an increased risk of birth defects is not clear.Objective: To assess whether the ART increases the risk of birth defects in children born after ART.Search strategy: Medline, Google Scholar, and the Cochrane Library were searched.Selection criteria: Clinical trials that evaluate the risk of birth defect in children born after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) and natural conceptions (NC) were included. The primary outcome was the prevalence of birth defects.Data collection and analysis: The relative risk was used as the summary measure with random effects model. We assessed heterogeneity between studies using the I² index.Main results: Totally 46 studies were included. The pooled relative risk (RR) estimated suggested there was an increased risk of birth defects in ART compared with the NC group (RR: 1.40; 95% CI 1.31-1.49). Twenty and fifteen studies were included to compare the risk of birth defects between NC and IVF/ICSI, respectively. The results indicated that both IVF and ICSI increase the risk of birth defects (IVF: RR 1.25; 95% CI 1.12-1.40; ICSI: RR 1.29; 95% CI 1.14-1.45). When subgroup according to plurality, 22 studies assessed the risk of birth defects after ART or NC in singletons and 15 studies evaluated the risk of birth defects in twins. The pooled RRs were 1.41 (95% CI 1.30-1.52) and 1.18 (95% CI 0.98-1.42), respectively.Conclusions: Children born after ART were at an increased risk of birth defects compared with NC. There was no difference in birth defects risk between ART twins and NC twins.

No-271-Delayed Child-Bearing

OBJECTIVE

To provide an overview of delayed child-bearing and to describe the implications for women and health care providers .

OPTIONS

Delayed child-bearing, which has increased greatly in recent decades, is associated with an increased risk of infertility, pregnancy complications, and adverse pregnancy outcome . This guideline provides information that will optimize the counselling and care of Canadian women with respect to their reproductive choices .

OUTCOMES

Maternal age is the most important determinant of fertility, and obstetric and perinatal risks increase with maternal age . Many women are unaware of the success rates or limitations of assisted reproductive technology and of the increased medical risks of delayed child-bearing, including multiple births, preterm delivery, stillbirth, and Caesarean section . This guideline provides a framework to address these issues .

EVIDENCE

Studies published between 2000 and August 2010 were retrieved through searches of PubMed and the Cochrane Library using appropriate key words (delayed child-bearing, deferred pregnancy, maternal age, assisted reproductive technology, infertility, and multiple births) and MeSH terms (maternal age, reproductive behaviour, fertility) . The Internet was also searched using similar key words, and national and international medical specialty societies were searched for clinical practice guidelines and position statements . Data were extracted based on the aims, sample, authors, year, and results .

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

RECOMMENDATIONS

Trends over time in congenital malformations in live-born children conceived after assisted reproductive technology

INTRODUCTION

Children born after assisted reproductive technology, particularly singletons, have been shown to have an increased risk of congenital malformations compared with children born after spontaneous conception. We wished to study whether there has been a change in the past 20 years in the risk of major congenital malformations in children conceived after assisted reproductive technology compared with children spontaneously conceived.

MATERIAL AND METHODS

Population-based cohort study including 90 201 assisted reproductive technology children and 482 552 children spontaneously conceived, born in Denmark, Finland, Norway and Sweden. Both singletons and twins born after in vitro fertilization, intracytoplasmatic sperm injection and frozen embryo transfer were included. Data on children were taken from when the national Nordic assisted reproductive technology registries were established until 2007. Multiple logistic regression analyses were used to estimate the risks and adjusted odds ratios for congenital malformations in four time periods: 1988-1992, 1993-1997, 1998-2002 and 2003-2007. Only major malformations were included.

RESULTS

The absolute risk for singletons of being born with a major malformation was 3.4% among assisted reproductive technology children vs. 2.9% among children spontaneously conceived during the study period. The relative risk of being born with a major congenital malformation between all assisted reproductive technology children and children spontaneously conceived remained similar through all four time periods (p = 0.39). However, we found that over time the number of children diagnosed with a major malformation increased in both groups across all four time periods.

CONCLUSION

When comparing children conceived after assisted reproductive technology and spontaneously conceived, the relative risk of being born with a major congenital malformation did not change during the study period.

Are children born from singleton pregnancies conceived by ICSI at increased risk for congenital malformations when compared to children conceived naturally? A systematic review and meta-analysis

Since 1992, the development of intra-cytoplasmic sperm injection (ICSI) has allowed infertile couples and couples affected by severe male factor infertility in particular, many of which with a history of failed traditional IVF, to become parents. This has generated considerable controversy over the safety of the procedure for the offspring. This systematic review seeks to determine whether evidence indicates that the use of ICSI increases the risk of congenital malformation in children born from singleton pregnancies versus naturally conceived children. Twenty-one of the 104 publications listed in the literature search were included in the analysis. Observational studies reported mostly an increased risk for congenital malformation; the risk of congenital malformations is 7.1% in ICSI and 4.0% in the general population (OR 1.99 (95% CI [1.87 - 2.11]). However, attributing higher risk solely to ICSI might seem far-fetched, as in vitro and simulation procedures, patient diseases, and ICSI indication may also be associated with higher risk of malformation.

Morbidity and mortality among very preterm singletons following fertility treatment in Australia and New Zealand, a population cohort study

BACKGROUND

Due to high rates of multiple birth and preterm birth following fertility treatment, the rates of mortality and morbidity among births following fertility treatment were higher than those conceived spontaneously. However, it is unclear whether the rates of adverse neonatal outcomes remain higher for very preterm (<32 weeks gestational age) singletons born after fertility treatment. This study aims to compare adverse neonatal outcomes among very preterm singletons born after fertility treatment including assisted reproductive technology (ART) hyper-ovulution (HO) and artificial insemination (AI) to those following spontaneous conception.

METHODS

The population cohort study included 24069 liveborn very preterm singletons who were admitted to Neonatal Intensive Care Unit (NICU) in Australia and New Zealand from 2000 to 2010. The in-hospital neonatal mortality and morbidity among 21753 liveborn very preterm singletons were compared by maternal mode of conceptions: spontaneous conception, HO, ART and AI. Univariate and multivariate binary logistic regression analysis was used to examine the association between mode of conception and various outcome factors. Odds ratio (OR) and adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated.

RESULTS

The rate of small for gestational age was significantly higher in HO group (AOR 1.52, 95% CI 1.02-2.67) and AI group (AOR 2.98, 95% CI 1.53-5.81) than spontaneous group. The rate of birth defect was significantly higher in ART group (AOR 1.71, 95% CI 1.36-2.16) and AI group (AOR 3.01, 95% CI 1.47-6.19) compared to spontaneous group. Singletons following ART had 43% increased odds of necrotizing enterocolitis (AOR 1.43, 95% CI 1.04-1.97) and 71% increased odds of major surgery (AOR 1.71, 95% CI 1.37-2.13) compared to singletons conceived spontaneously. Other birth and NICU outcomes were not different among the comparison groups.

CONCLUSIONS

Compared to the spontaneous conception group, risk of congenital abnormality significantly increases after ART and AI; the risk of morbidities increases after ART, HO and AI. Preconception planning should include comprehensive information about the benefits and risks of fertility treatment on the neonatal outcomes.

Male Reproductive Disorders and Fertility Trends: Influences of Environment and Genetic Susceptibility

It is predicted that Japan and European Union will soon experience appreciable decreases in their populations due to persistently low total fertility rates (TFR) below replacement level (2.1 child per woman). In the United States, where TFR has also declined, there are ethnic differences. Caucasians have rates below replacement, while TFRs among African-Americans and Hispanics are higher. We review possible links between TFR and trends in a range of male reproductive problems, including testicular cancer, disorders of sex development, cryptorchidism, hypospadias, low testosterone levels, poor semen quality, childlessness, changed sex ratio, and increasing demand for assisted reproductive techniques. We present evidence that several adult male reproductive problems arise in utero and are signs of testicular dysgenesis syndrome (TDS). Although TDS might result from genetic mutations, recent evidence suggests that it most often is related to environmental exposures of the fetal testis. However, environmental factors can also affect the adult endocrine system. Based on our review of genetic and environmental factors, we conclude that environmental exposures arising from modern lifestyle, rather than genetics, are the most important factors in the observed trends. These environmental factors might act either directly or via epigenetic mechanisms. In the latter case, the effects of exposures might have an impact for several generations post-exposure. In conclusion, there is an urgent need to prioritize research in reproductive physiology and pathophysiology, particularly in highly industrialized countries facing decreasing populations. We highlight a number of topics that need attention by researchers in human physiology, pathophysiology, environmental health sciences, and demography.

Nutritional modifications in male infertility: a systematic review covering 2 decades

CONTEXT

Studies suggest that appropriate nutritional modifications can improve the natural conception rate of infertile couples.

OBJECTIVES

The purpose of this study was to review the human trials that investigated the relation between nutrition and male infertility.

DATA SOURCES

A comprehensive systematic review of published human studies was carried out by searching scientific databases. Article selection was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The American Dietetic Association Research Design and Implementation Checklist was also used for quality assessment.

DATA EXTRACTION

A total of 502 articles were identified, of which 23 studies met the inclusion criteria.

DATA SYNTHESIS

Results indicated that a healthy diet improves at least one measure of semen quality, while diets high in lipophilic foods, soy isoflavones, and sweets lower semen quality.

CONCLUSION

The role of daily nutrient exposure and dietary quality needs to be highlighted in male infertility. Mechanistic studies addressing the responsible underlying mechanisms of action of dietary modifications are highly warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2013: CRD42013005953. Available at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013005953.

Multifetal gestations with assisted reproductive technique before the single-embryo transfer legislation: obstetric, neonatal outcomes and congenital anomalies

OBJECTIVE

To compare perinatal, neonatal outcome and congenital anomalies of multiple gestations conceived by means of assisted reproductive techniques with spontaneously conceived multiples before the limitation of number of embryo transfer.

METHODS

Cases consisted of assisted reproductive technique (ART) multifetal gestations and control group comprised of spontaneously conceived multifetal gestations delivered in the same time period. Outcomes were perinatal, neonatal outcome, long-term outcomes and congenital anomalies of multiple gestations. There were 270 multifetal pregnancies for analysis, of which 137 were achieved by ART and 133 were spontaneous in this prospective study.

RESULTS

Incidences of preeclampsia, gestational diabetes, deep vein thrombosis, thrombocytopenia, intrahepatic cholestasis and preterm premature rupture of membranes were similar in ART and spontaneous groups. There was no difference in fetal malformation rates between ART and control group, but higher rates of central nervous system malformation were observed (4 (1.5%) in control, 0 in ART group, p = 0.04) in spontaneous group. No difference was seen in the perinatal mortality.

CONCLUSIONS

Neonatal and maternal outcomes are comparable between ART and spontaneous multifetal gestations. Congenital fetal malformation rates between ART and spontaneous multifetal pregnancies were similar except central nervous system malformation that was more likely in spontaneously conceived ones.

Genetic and environmental factors in the aetiology of hypospadias

This article reviews the current evidence and knowledge of the aetiology of hypospadias. Hypospadias remains a fascinating anomaly of the male phallus. It may be an isolated occurrence or part of a syndrome or field defect. The increasing use of assisted reproductive techniques and hormonal manipulation during pregnancy may have been associated with an apparent rise in the incidence of hypospadias. Genetic studies and gene analysis have suggested some defects that could result in hypospadias. New light has also been thrown on environmental factors that could modulate candidate genes, causing altered development of the male external genitalia.

Environmental, parental and gestational factors that influence the occurrence of hypospadias in male patients

OBJECTIVE

Hypospadias is a congenital defect, which affects normal development of the male urogenital external tract. In this malformation, the urethral orifice of the penis is positioned ventrally, thus interfering with normal urination and creating, in some adults, problems during sexual intercourse. Heritability of hypospadias has been shown in some reports, and the abnormality has been associated with the presence of mutations in one of the genes involved in urogenital development. However, even for patients who were born in families with a higher incidence rate of this defect, no evident genetic alteration could be identified in known genes, indicating that the list of loci involved is still incomplete. To further complicate matters, recent reports also underline that epigenetic changes, without any identifiable gene sequence mutation, may be involved in gene function impairment. Therefore, the inheritance of most hypospadias cases is not evident, suggesting that the genetic background is not the only cause of this malformation; indeed, the majority of hypospadias cases are classified as sporadic and idiopathic.

MATERIALS AND METHODS

Evidence has accumulated highlighting the role of the environment and of its relationships with the genome in the etiology of this abnormality. In particular, the interaction between some chemicals, which are able to mimic endogenous molecules such as sexual hormones--for this reason called endocrine disrupting compounds (EDC)--and specific receptors has been extensively investigated during the pregnancy. Additionally, several articles have shown that parental and gestational factors play a significant role too. Indeed, physiological alterations, such as body weight of the mother and/or of the newborn, mother's diabetes, impaired father fertility, and exposure of one parent to job-related pollutants, show in many cases a direct correlation with hypospadias incidence. The overall prevalence of this condition has been studied in many countries, suggesting that at least in some periods and/or in specific populations there are detectable fluctuations, probably mirroring the different natural environments. However, many articles present data that do not agree with these findings and, consequently, most causes of hypospadias are still highly debated.

RESULTS

In this review, we summarize the developmental steps involved in urogenital tract formation, with a particular emphasis on the genes that most frequently are associated with this condition, or that are subject to environmental stress, or that may be the targets of hormone-like, exogenous molecules. Then, we make an overview of the identified factors able to impair the function of important genes, even in the absence of their mutations, including those for which contradictory reports have been published. Finally, we propose an explanation of sporadic cases of hypospadias that reconciles these contradictions and suggest some steps for moving forward in the research focused on this condition.

CONCLUSION

We hypothesize that most patients develop hypospadias because of gene-environment interactions acting on polymorphic genes that, in the absence of environmental stimuli, would otherwise cause no developmental anomaly during urogenital development.

Congenital anomalies in offspring of subfertile couples: a registry-based study in the northern Netherlands

OBJECTIVE

To study whether specific congenital anomalies occur more often with a history of subfertility and/or the use of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

DESIGN

Case-only analyses.

SETTING

Not applicable.

PATIENT(S)

We included live births, stillbirths, and terminated pregnancies with congenital anomalies without a known cause that had a birth year between 1997 and 2010 (n = 4,525). A total of 4,185 malformed cases were born to fertile couples and 340 to subfertile couples, of whom 139 had conceived after IVF/ICSI and 201 had conceived naturally after >12 months.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The contribution, expressed in odds ratios (ORs), of a history of subfertility and IVF/ICSI to each specific type of congenital anomaly, imprinting disorder, and syndromal disorder.

RESULT(S)

We found subfertility to be associated with an increase in abdominal wall defects (adjusted OR [aOR] 2.43, 95% CI 1.05-5.62), penoscrotal hypospadia (aOR 9.83, 95% CI 3.58-27.04), right ventricular outflow tract obstruction (aOR 1.77, 95% CI 1.06-2.97), and methylation defects causing imprinting disorders (aOR 13.49, 95% CI 2.93-62.06). In vitro fertilization/ICSI was associated with an increased risk of polydactyly (OR 4.83, 95% CI 1.39-16.77) and more specifically polydactyly of the hands (OR 5.02, 95% CI 1.43-17.65).

CONCLUSION(S)

In our registry-based study, parental subfertility was associated with an increase in abdominal wall defects, penoscrotal hypospadia, right ventricular outflow tract obstruction, and methylation defects causing imprinting disorders. In vitro fertilization/ICSI was associated with an increase in polydactyly, mainly of the hands.

Birth defects and assisted reproductive technologies

Assisted reproductive technologies (ART) using in-vitro fertilization (IVF) account for ∼1% of births in the USA and as much as 3-4% in Europe or Australia. Initially studies involved infants prospectively examined in an early cohort of US births, with salutary results. Later studies began to show the frequency of birth defects to be increased. In meta-analysis, odds ratio was >1.0, with the 95% confidence limit not extending to <1.0. Although ART are associated with a 30% increase in birth defects; subfertile couples achieving pregnancy without ART show a 20% increase. It thus appears that the increase in birth defects is due less, if at all, to ART protocols per se than to the biological perturbations that generated the infertility that necessitated ART to achieve pregnancy. There is consensus that traditional IVF and intracytoplasmic sperm injection (ICSI)/IVF show the same overall risk notwithstanding increased sex chromosome abnormalities in both procedures and increased hypospadias in ICSI. No other organ system seems disproportionately affected. There is no additive risk in ART twins compared with non-ART twins, nor in embryos having been cryopreserved. The increased risk observed had not appeared to dissuade couples from attempting to have their own children.

Assessment of Frequency of Twin Pregnancy and Neonatal Outcome in Deliveries of Mo'tazedi Hospital, Kermanshah in 2004-2007

INTRODUCTION

Twin pregnancy is a high-risk pregnancy with different prevalences in different regions of the world which is on the rise due to growing use of assisted reproductive technology. The objective of this study is to determine the frequency of twin pregnancy and the neonatal outcome of these pregnancies.

MATERIALS AND METHODS

This is a descriptive-analytic study conducted in 2004-2007 in Mo'tazedi Hospital, Kermanshah on 142 twin deliveries as well as the singleton deliveries before and after twin pregnancy as the control group. The required information, including maternal age, gestational age, newborn's gender, presentation of twins, birth weight, Apgar score, fetal anomalies, and neonatal mortality were extracted from medical files and analyzed statistically.

FINDINGS

After assessment of 29,438 deliveries performed from 2004 to 2007, the frequency of twin pregnancy was found out to be 1 in 208 cases (48 %). The mean age of mothers was higher in twin pregnancies. The mean gestational age of twin pregnancy was 34.3 weeks. Apgar score and neonatal weight were significantly lower in twin pregnancy compared to singleton pregnancy (p < 0.001). Furthermore, visible anomalies and mortality were significantly higher in neonates born to twin pregnancies compared to singleton pregnancies (p < 0.0001 and p = 0.009, respectively). The ratio of male to female neonates was 1.

CONCLUSION

This study indicated that twin pregnancy is a high-risk condition and entails greater neonatal complications compared to singleton pregnancy. Therefore, it is recommendable to have greater perinatal care and perform deliveries in well-equipped centers under supervision of an obstetrician.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

Comparison of the Outcome of Conventional in vitro Fertilization and Intracytoplasmic Sperm Injection in Moderate Male Infertility from Ejaculate

Objective: To evaluate whether couples with moderate male infertility should be treated with conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Patients and Methods: A total of 249 couples with moderate male infertility undergoing their first IVF/ICSI cycle were enrolled in the study. The couples were divided into two groups according to the results of semen analysis: moderate oligozoospermia (O group) and moderate oligoasthenozoospermia (OA group). Sibling oocytes were randomized into groups to be inseminated either by conventional IVF or ICSI. Fertilization rate, embryo quality, implantation rate, and clinical pregnancy rate were examined. Results: There was no difference in the fertilization, implantation, and pregnancy rates between conventional IVF and ICSI in either the O group or OA group (p > 0.05). Additionally, in the OA group, the good quality embryo rate was similar after IVF or ICSI (p > 0.05). However, in the O group, the good quality embryo rate was significantly higher after ICSI than after IVF (p < 0.05). Conclusions: Couples with moderate oligozoospermia or moderate oligoasthenozoospermia did not influence the major indices of IVF. Because of the uncertainties concerning the safety of ICSI, couples with moderate oligozoospermia or moderate oligoasthenozoospermia need not be subjected to this procedure.

Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection

BACKGROUND

Multiple embryo transfer during in vitro fertilisation (IVF) increases multiple pregnancy rates causing maternal and perinatal morbidity. Single embryo transfer is now being seriously considered as a means of minimising the risk of multiple pregnancy. However, this needs to be balanced against the risk of jeopardising the overall live birth rate.

OBJECTIVES

To evaluate the effectiveness and safety of different policies for the number of embryos transferred in couples who undergo assisted reproductive technology (ART).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, from inception to July 2013. We handsearched reference lists of articles, trial registers and relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different policies for the number of embryos transferred following IVF or intra-cytoplasmic sperm injection (ICSI) in subfertile women. Studies of fresh or frozen and thawed transfer of one, two, three or four embryos at cleavage or blastocyst stage were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias and extracted the data. The overall quality of the evidence was graded in a summary of findings table.

MAIN RESULTS

Fourteen RCTs were included in the review (2165 women). Thirteen compared cleavage-stage transfers (2017 women) and two compared blastocyst transfers (148 women): one study compared both. No studies compared repeated multiple versus repeated single embryo transfer (SET). DET versus repeated SETDET was compared with repeated SET in three studies of cleavage-stage transfer. In these studies the SET group received either two cycles of fresh SET (one study) or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle (two studies). When these three studies were pooled, the cumulative live birth rate after one cycle of DET was not significantly different from the rate after repeated SET (OR 1.22, 95% CI 0.92 to 1.62, three studies, n=811, I(2)=0%, low quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following repeated SET would be between 30% and 42%. The multiple pregnancy rate was significantly higher in the DET group (OR 30.54, 95% CI 7.46 to 124.95, three RCTs, n = 811, I(2) = 23%, low quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following repeated SET would be between 0% and 2%. Single-cycle DET versus single-cycle SETA single cycle of DET was compared with a single cycle of SET in 10 studies, nine comparing cleavage-stage transfers and two comparing blastocyst-stage transfers. When all studies were pooled the live birth rate was significantly higher in the DET group (OR 2.07, 95% CI 1.68 to 2.57, nine studies, n = 1564, I(2) = 0%, high quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following a single cycle of SET would be between 22% and 30%. The multiple pregnancy rate was also significantly higher in the DET group (OR 8.47, 95% CI 4.97 to 14.43, 10 studies, n = 1612, I(2) = 45%, high quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following a single cycle of SET would be between 1% and 4%. The heterogeneity for this analysis was attributable to a study with a high rate of cross-over between treatment arms. Other comparisons Other fresh cycle comparisons were evaluated in three studies which compared DET versus transfer of three or four embryos. Live birth rates did not differ significantly between the groups for any comparison, but there was a significantly lower multiple pregnancy rate in the DET group than in the three embryo transfer (TET) group (OR 0.36, 95% CI 0.13 to 0.99, two studies, n = 343, I(2) = 0%).

AUTHORS' CONCLUSIONS

In a single fresh IVF cycle, single embryo transfer is associated with a lower live birth rate than double embryo transfer. However, there is no evidence of a significant difference in the cumulative live birth rate when a single cycle of double embryo transfer is compared with repeated SET (either two cycles of fresh SET or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle). Single embryo transfer is associated with much lower rates of multiple pregnancy than other embryo transfer policies. A policy of repeated SET may minimise the risk of multiple pregnancy in couples undergoing ART without substantially reducing the likelihood of achieving a live birth. Most of the evidence currently available concerns younger women with a good prognosis.

Impact of assisted reproduction treatments on Spanish newborns: report of 14,119 pregnancies

PURPOSE

To investigate neonatal malformation, prematurity, and stillbirth in singleton and multiple pregnancies derived from different Assisted Reproductive Techniques (ART).

METHODS

In this prospective cohort study data were collected, from private and public Spanish IVF units, during the years 2008 and 2009. During this period, 8,682 pregnancies were analysed from the initial 14,119 pregnancies reported. Pregnancies included in the study derived from IUI (n = 1,065), IVF (n = 838), ICSI (n = 5,080), FET (n = 1,404) and PGD (n = 295). This first analysis focuses primarily on neonatal malformation, prematurity, and stillbirth both in singleton and multiple pregnancies derived from different ART. Malformations were classified according to the WHO ICD 10 code.

RESULTS

Malformations were found in 0.83 % of our newborns. No differences in malformations were observed between singletons or multiples independently of the ART used. There was a significant difference in prematurity rate among singletons depending on treatment but this association was not observed in multiple pregnancies. Stillbirth was significantly lower in singleton (0.72 %) than in multiple pregnancies (1.82 %).

CONCLUSIONS

The percentage of malformations observed in ART newborns was similar to the rate observed in the normally-conceived Spanish population. Multiplicity seems to be the most important factor associated with an increased incidence of newborn complications such as prematurity or stillbirth.

Does infertility treatment increase male reproductive tract disorder?

OBJECTIVE

To determine the association between assisted human reproduction and male reproductive disorders in infants conceived by this means.

MATERIALS AND METHODS

Between January 2008 and December 2011, 15,332 neonates were born in our hospital. We assessed the birth weight, gestational age, and other characteristics of the 7752 male infants and determined the association between methods of conception and male reproductive disorders in the infants. We also analyzed the influence of male factor on the occurrence of these disorders.

RESULTS

Ninety-nine newborns (1.3%) were diagnosed with cryptorchidism, 8 (0.1%) were diagnosed with hypospadias, and 4 (0.05%) were diagnosed with both. Cryptorchidism was more common in children conceived through in vitro fertilization (IVF) and IVF/intracytoplasmic sperm injection (IVF/ICSI; P <.05), and hypospadias was more common in children conceived through IVF/ICSI (P <.05). Children conceived through intrauterine insemination (IUI), IVF, and IVF/ICSI had higher rates of low birth weight and preterm birth. Logistic regression analysis showed that low birth weight and preterm birth were significantly associated with male reproductive disorders, whereas the method of conception was not. Male factor was not significantly associated with these disorders.

CONCLUSION

IVF and IVF/ICSI increase the risks of low birth weight and preterm birth, resulting in increased rates of hypospadias and cryptorchidism. Male factor was not associated with reproductive disorders in male infants.

Is ICSI Risky?

As assisted reproductive technology (ART) methods become the mainstream of infertility treatment, it has become even more critical to reassess its safety. Following the results of a study published by the Robinson Institute in the New England Journal of Medicine, the risk of ART, especially intracytoplasmic sperm injection (ICSI), has never been so closely scrutinized. This paper traces the origins and development of ICSI, assesses the risks documented in the literature, and finally interprets the implications of the study for couples contemplating therapy. We support the need for continued vigilance towards ICSI and the importance in investigating male-factor infertility as a prequel to its use.

The risk for four specific congenital heart defects associated with assisted reproductive techniques: a population-based evaluation

STUDY QUESTION

Are the risks of hypoplastic left heart syndrome, transposition of great arteries, tetralogy of Fallot (TOF) and coarctation of the aorta increased in infants conceived by different assisted reproductive techniques (ARTs)?

STUDY ANSWER

ARTs, and particularly intracytoplasmic sperm injection (ICSI), are specifically associated with a higher risk of TOF.

WHAT IS ALREADY KNOWN

ARTs are associated with an increase in the overall risk of birth defects. The risk for congenital heart defects (CHDs) associated with ARTs has been evaluated as a whole but there is limited information on the risks for specific CHDs. STUDY DESIGN, MATERIAL AND METHODS: We conducted a case-control study using population-based data from the Paris registry of congenital malformations for the period 1987-2009 and a cohort study of CHD (EPICARD) on 1583 cases of CHDs and 4104 malformed controls with no known associations with ARTs. ARTs included ovulation induction only, IVF and ICSI.

RESULTS

Exposure to ARTs was significantly higher for TOF than controls (6.6 versus 3.5%, P = 0.002); this was not the case for the other three CHDs. ARTs (all methods combined) were associated with a 2.4-fold higher odds of TOF after adjustment for maternal characteristics, paternal age and year of birth [adjusted odds ratios (OR): 2.4, 95% confidence interval (CI): 1.5-3.7] with the highest risk associated with ICSI (adjusted OR: 3.0, 95% CI: 1.0-8.9). No statistically significant associations were found for the other CHDs.

LIMITATIONS

Our study cannot disentangle to what extent the observed associations between the risk of TOF and ARTs are due to causal effects of ARTs and/or the underlying infertility problems of couples who conceive following ART.

IMPLICATIONS

The developmental basis of the specific association between the risk of TOF and ARTs need to be further investigated.

Neonatal outcome and congenital malformations in children born after ICSI with testicular or epididymal sperm: a controlled national cohort study

STUDY QUESTION

Does neonatal outcome including congenital malformations in children born after ICSI with epididymal and testicular sperm [testicular sperm extraction (TESE)/percutaneous epididymal sperm aspiration (PESA)/testicular sperm aspiration (TESA) (TPT)] differ from neonatal outcome in children born after ICSI with ejaculated sperm, IVF and natural conception (NC)?

SUMMARY ANSWER

Children born after TPT have similar neonatal outcome, including total malformation rates, as have children born after ICSI and IVF with ejaculated sperm. Testing for variance over the four groups may indicate smaller differences in specific malformation rates with TPT as the highest risk group.

WHAT IS KNOWN ALREADY

Regarding neonatal outcome as well as congenital malformations in children born after TPT, studies are few, with limited sample size, heterogeneous and often performed without relevant control groups.

STUDY DESIGN, SIZE, DURATION

Population-based cohort study including all Danish children born after TPT and fresh embryo transfer in Denmark from 1995 to 2009. Children born after transfer of frozen-thawed embryos were excluded. Control groups of children conceived by ICSI with ejaculated sperm, IVF and NC were identified by cross-linkage of the Danish IVF Register, Medical Birth Register (MBR) and National Hospital Discharge Register (HDR).

PARTICIPANTS/MATERIALS, SETTING

The study group consisted of 466 children born after TPT, while the control groups consisted of 8967 (ICSI with ejaculated sperm), 17 592 (IVF) and 63 854 (NC) children. Neonatal outcomes and congenital malformations were analysed for singletons and twins separately. Risk estimates for low birthweight (LBW, <2500 g) and preterm birth (PTB, <37 gestational weeks) were adjusted for maternal age, parity, child gender and year of childbirth. The study group was identified from the Danish national database on children born after TPT. Control groups were obtained from the IVF register and the MBR. All information included in the study was retrieved from the national registers.

MAIN RESULTS AND THE ROLE OF CHANCE

Considering singletons and twins as one group, the sex ratio (♂/♀) was significantly lower for children born after TPT (0.89) compared with conventional IVF (1.11; P = 0.017) but did not differ significantly when compared with ICSI with ejaculated sperm (0.94) and NC (1.05). The mean birthweight (BW) for singletons did not differ significantly between groups when including only first-born children. The mean gestational age (GA) in the TPT singletons (279 ± 12 days) was significantly higher compared with IVF (276 ± 18 days; P = 0.02), but similar to ICSI with ejaculated sperm and NC singletons when including only first-born children (277 ± 16 days and 279 ± 14 days, respectively). Rate of stillbirths, perinatal and neonatal mortality in the group of TPT singletons did not differ significantly from any of the control groups. Comparable results were found for the TPT twin group, except for perinatal mortality, which was significantly lower in the TPT group compared with naturally conceived twins. The adjusted risk of LBW was significantly higher for TPT versus NC singletons [adjusted odds ratio (AOR) = 0.67 (0.48-0.93)]; however AOR for PTB was similar in the two groups. Regarding twins, similar adjusted risks were observed for PTB and LBW between the TPT and all three control groups. Significantly more Caesarean sections were performed after IVF (27.3% for singletons) and ICSI (25.1% for singletons) with ejaculated sperm compared with the TPT group (16.4% for singletons). The total rate of congenital malformations in the TPT group was 7.7% and did not differ significantly from any of the control groups. However, singleton TPT boys showed an increased rate of cardiac malformations (3.6%) compared with singleton boys after IVF (1.4%; P = 0.04) and NC (1.1%; P = 0.02). Considering the level of male infertility as a continuum over the four groups, tests for variance in the rate of cardiac malformations in singleton boys, and undescended testicles for singleton as well as twin boys were each significantly increased from NC to IVF to ICSI to TPT (P < 0.001). The rate of hypospadias showed the same pattern, but the TPT group did not differ significantly compared with the control groups.

LIMITATIONS, REASONS FOR CAUTION

One of the limitations is that the TPT group could not be classified according to testicular or epididymal sperm, as these data were not available in the IVF register. Another limitation is that registry-based studies are encumbered with the risk of reporting or coding errors or missing data due to insufficient coding. However, the quality of data on congenital malformations in HDR has, in other studies, been validated and found acceptable for epidemiological research, and furthermore, recordings on study and control groups are performed similarly.

WIDER IMPLICATIONS OF THE FINDINGS

Accumulating data show that TPT treatment is equally safe as conventional ICSI and IVF treatment and as NC with regard to neonatal outcome including congenital malformation.

STUDY FUNDING/POTENTIAL COMPETING INTERESTS

This study is supported by Laboratory of Reproductive Biology, Scientific Unit, Horsens Hospital. No competing interests declared.

Congenital malformations and assisted reproductive technique: Where is assisted reproductive technique taking us?

Development of ART has great benefit for millions of couples all over the world and with falling fertility rate there are a growing numbers of children born with the help of ART, it is important to investigate potential risks to these children. IVF-ICSI pregnancies are associated with higher risk for multiple gestation, preterm labor and low birth weight. It is an area of great conflict and interest that whether ART is associated with increased congenital malformations or not. So, this article reviews the data and evidences linking ART to congenital malformations.

Outcome of conventional IVF and ICSI on sibling oocytes in the case of isolated teratozoospermia

PURPOSE

To reevaluate the effect of isolated teratozoospermia on IVF and determine if there was any therapeutic benefit to isolated teratozoospermia by ICSI, since there are no widely accepted criteria for the treatment technique about isolated teratozoospermia.

METHODS

A total of 441 couples with >20 million and progressive motility >30 % sperm undergoing their first IVF/ICSI cycle were included in the study between 2008 and 2010, for whom at least 8 oocytes were retrived. Isolated teratozoospermia was diagnosed in 183 of the included couples, and the rest couples (normal sperm morphology) were studied as control. Sibling oocytes were randomized to be inseminated either by ICSI or IVF. Fertilization rate, embryo quality, pregnancy rate, implantation rate and spontaneous abortion rate were assessed.

RESULTS

There was no difference in the percentage of eggs fertilized, implantation rate, pregnancy rate and spontaneous abortion rate between conventional IVF and ICSI regardless of the percentage of normal morphology. The day 3 embryonic morphology and rate of development were not different despite the insemination method and percentage of normal morphology.

CONCLUSION

Because isolated teratozoospermia did not influence the major indices of IVF and the unnecessary use of ICSI is time-consuming, costly and potential risks, couples with isolated teratozoospermia need not be subjected to ICSI.

Birth defects in children conceived by in vitro fertilization and intracytoplasmic sperm injection: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of studies assessing the effect of IVF and intracytoplasmic sperm injection (ICSI) on birth defects.

DESIGN

Meta-analysis.

SETTING

Centers for reproductive care.

PATIENT(S)

Patients treated by IVF and/or ICSI.

INTERVENTION(S)

We identified all studies published by September 2011 with data related to birth defects in children conceived by IVF and/or ICSI compared with spontaneously conceived children, or birth defects in the children conceived by IVF compared with those by ICSI. Risk ratios from individual studies were pooled with the fixed and random effect models.

MAIN OUTCOME MEASURE(S)

Risk of birth defects in children conceived by IVF and/or ICSI.

RESULT(S)

Of 925 studies reviewed for eligibility, 802 were excluded after screening titles and abstracts, 67 were excluded for duplicated data, data unavailable, or inappropriate control group, 56 were included in the final analysis. Among the 56 studies, 46 studies had data on birth defects in children conceived by IVF and/or ICSI (124,468) compared with spontaneously conceived children. These studies provided a pooled risk estimation of 1.37 (95% confidence interval [CI]: 1.26-1.48), which is also evident in subgroup analysis. In addition, 24 studies had data on birth defects in children conceived by IVF (46,890) compared with those by ICSI (27,754), which provided an overall no risk difference.

CONCLUSION(S)

Children conceived by IVF and/or ICSI are at significantly increased risk for birth defects, and there is no risk difference between children conceived by IVF and/or ICSI.