Growth of singletons born after frozen embryo transfer until early adulthood: a Finnish register study

STUDY QUESTION

Are there growth differences between singleton children born after frozen embryo transfer (FET), fresh embryo transfer (ET), and natural conception (NC)?

SUMMARY ANSWER

Adolescent boys born after FET have a higher mean proportion and increased odds of overweight compared to those born after fresh ET.

WHAT IS KNOWN ALREADY

Children born after FET have higher mean birthweights and an increased risk of large-for-gestational-age compared to those born after fresh ET and even NC. This raises questions about possible growth differences later in childhood. Previous studies on child growth after FET report partly conflicting results and lack long-term data until adolescence.

STUDY DESIGN, SIZE, DURATION

This was a cohort study based on national population-based registers, the Finnish Medical Birth Register and the Register of Primary Health Care visits, including singletons born after FET (n = 1825), fresh ET (n = 2933), and NC (n = 31 136) in Finland between the years 1995 and 2006.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The proportions of overweight (i.e. age- and sex-adjusted ISO-BMI for children ≥ 25) were compared between the groups. Odds ratios (ORs) and adjusted odds ratios (aORs) of overweight were calculated. Adjustments were made for birth year, preterm birth, maternal age, parity, and socioeconomic status. Mean heights, weights, and BMIs were compared between the groups each year between the ages of 7 and 18.

MAIN RESULTS AND THE ROLE OF CHANCE

FET boys had a higher mean proportion of overweight (28%) compared to fresh ET (22%, P < 0.001) and NC (26%, P = 0.014) boys. For all ages combined, the aOR of overweight was increased (1.14, 95% CI 1.02-1.27) for FET boys compared to fresh ET boys. For girls, the mean proportions of overweight were 18%, 19%, and 22% for those born after FET, fresh ET, and NC, respectively (P = 0.169 for FET vs fresh ET, P < 0.001 for FET vs NC). For all ages combined, FET girls had a decreased aOR of overweight (0.89, 95% CI 0.80-0.99) compared to NC girls. Growth measurements were available for 6.9% to 30.6% of FET boys and for 4.7% to 29.4% of FET girls at different ages.

LIMITATIONS, REASONS FOR CAUTION

Unfortunately, we were not able to adjust for parental anthropometric characteristics. The growth data were not available for the whole cohort, and the proportion of children with available measurements was limited at the start and end of the follow-up. During the study period, mainly cleavage stage embryos were transferred, and slow freezing was used for ART.

WIDER IMPLICATIONS OF THE FINDINGS

The risk of overweight among FET boys warrants further research. Future studies should aim to investigate the mechanisms that explain this sex-specific finding and combine growth data with long-term health data to explore the possible risks of overweight and cardiometabolic disease in adulthood.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was obtained from the Päivikki and Sakari Sohlberg Foundation, the Alma and K.A. Snellman Foundation (personal grants to A.M.T.), and the Finnish Government Research Funding. The funding sources were not involved in the planning or execution of the study. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Health of singletons born after frozen embryo transfer until early adulthood: a Finnish register study

STUDY QUESTION

Is the health of singletons born after frozen embryo transfer (FET) comparable to that of singletons born after fresh embryo transfer (ET) until early adulthood?

SUMMARY ANSWER

The health of singletons born after FET does not differ from that of singletons born after fresh ET.

WHAT IS KNOWN ALREADY

The differences in perinatal outcomes of children born after FET and fresh ET are well known. FET is associated with an increased risk of large-for-gestational-age but diminished risks of preterm birth (PTB), small-for-gestational-age and decreased perinatal mortality compared to fresh ET. However, knowledge on the long-term health after FET is scarce.

STUDY DESIGN, SIZE, DURATION

This retrospective register-based cohort study compares singletons born after FET (n = 1825) between the years 1995 and 2006 to those born after fresh ET (n = 2933) and natural conception (NC, n = 31 136) with a mean follow-up time of 18-20 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Singletons born after FET were compared to those born after fresh ET and NC regarding the frequencies of diagnoses in the main ICD-10 chapters (International Statistical Classification of Diseases and Related Health Problems, 10th revision), the number of outpatient visits and hospital admissions, and mortality. Adjustments were made for PTB, maternal age, parity, socioeconomic status based on mother's occupation and offspring sex. The study combines data from the Finnish Medical Birth Register, the Finnish Care Register for Health Care (CRHC) and the Cause-of-Death Register at Statistics Finland. The Student's T-test was used for continuous variables, and the Chi-square test was used for categorical variables. Cox regression was used to estimate crude and adjusted hazard ratios (HRs and aHRs, respectively). A general linear model was used to compare the means of outpatient visits, hospital admissions and lengths of hospital stays per person.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant differences between the FET and fresh ET groups were found in the frequency of diagnoses in any of the ICD-10 chapters or in the parameters describing the need for hospital care. However, compared to the NC group, higher proportions in the FET group had outpatient visits in the hospital (93.5% vs 92.2%, aHR 1.23, 95% CI 1.17, 1.30) or hospital admissions (48% vs 46.5%, aHR 1.28, 95% CI 1.19, 1.37). Compared to the NC group, the FET group had elevated adjusted risks of diagnoses of infectious and parasitic diseases (aHR 1.24; 95% CI 1.11, 1.38), neoplasms (aHR 1.68; 95% CI 1.48, 1.91), diseases of the eye and adnexa, the ear or mastoid process (aHR 1.11; 95% CI 1.01, 1.21), the respiratory system (aHR 1.15; 95% CI 1.06, 1.23), the digestive system (aHR 1.17; 95% CI 1.05, 1.32), the skin or subcutaneous tissue (aHR 1.28; 95% CI 1.14, 1.43) and the genitourinary system (aHR 1.27; 95% CI 1.11, 1.45), as well as congenital malformations or chromosomal abnormalities (aHR 1.31; 95% CI 1.14, 1.50) and symptoms, signs or abnormal clinical or laboratory findings (aHR 1.25, 95% CI 1.16, 1.34).

LIMITATIONS, REASONS FOR CAUTION

Only hospital-based inpatient and outpatient care is covered by the CRHC register, excluding milder cases diagnosed elsewhere. We were not able to study the effect of ART treatments and subfertility separately in our setting. In addition, although our cohort is reasonably sized, even larger cohorts would be needed to reliably study rare outcomes, such as cancer.

WIDER IMPLICATIONS OF THE FINDINGS

For many ICD-10 chapters, we present the first published data on the long-term outcome of singletons born after FET. The results on FET versus fresh ET are reassuring, whereas the results on FET versus NC warrant further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

Finnish government research funding was obtained for this study. Funding was also obtained from the Finnish Medical Society Duodecim, the Päivikki and Sakari Sohlberg Foundation, Orion Research Foundation, Finnish Society of Obstetrics and Gynaecology (research grants to A.M.T.) and Finnish government research funding. The funding sources were not involved in the planning or execution of the study. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Puberty disorders among ART-conceived singletons: a Nordic register study from the CoNARTaS group

STUDY QUESTION

Do ART-conceived children have an increased risk for puberty disorders?

SUMMARY ANSWER

Both ART-conceived boys and girls had a higher risk of puberty disorders; early puberty was more common among girls and late puberty among boys.

WHAT IS KNOWN ALREADY

Some physiological differences in growth and metabolism have been reported for ART-conceived children compared to non-ART-conceived children. Knowledge on pubertal development and disorders in ART-conceived children is limited.

STUDY DESIGN, SIZE, DURATION

A register-based cohort study was carried out including data from 1985 to 2015. The Committee of Nordic Assisted Reproductive Technology and Safety (CoNARTaS) study population consists of all live and stillborn children, as well as their mothers, registered in the Medical Birth Registers during the study period in Denmark, Sweden, Finland and Norway.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 122 321 ART-conceived singletons and 6 576 410 non-ART singletons born in Denmark (1994–2014), Finland (1990–2014), Norway (2002–2015) and Sweden (1985–2015) were included. Puberty disorders were defined using International Classification of Diseases and Related Health Problems (ICD)-9/ICD-10 codes and classified in the following groups: late puberty (6268/E30.0), early puberty (2591 and 2958/E30.1 and E30.8) and unspecified disorders (V212 and V579/E30.9 and Z00.3 as well as Z51.80 for Finland). The results in Cox regression were adjusted for maternal age, parity, smoking, gestational diabetes, chronic hypertension, hypertensive disorders during pregnancy and country, and further for either gestational age, birthweight, small for gestational age or large for gestational age.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 37 869 children with diagnoses related to puberty disorders, and 603 of them were born after ART. ART-conceived children had higher risks for early (adjusted hazard ratio (aHR) 1.45, 95% CI: 1.29–1.64) and late puberty (aHR 1.47, 95% CI: 1.21–1.77). Girls had more diagnoses related to early puberty (aHR 1.46, 95% CI: 1.29–1.66) and boys with late puberty (aHR 1.55, 95% CI: 1.24–1.95).

LIMITATIONS, REASONS FOR CAUTION

Using reported puberty disorders with ICD codes in health care registers might vary, which may affect the numbers of cases found in the registers. Register data may give an underestimation both among ART and non-ART-conceived children, especially among non-ART children, who may not be as carefully followed as ART-conceived children. Adjustment for causes and duration of infertility, mothers’ own puberty characteristics and BMI, as well as children’s BMI, was not possible because data were not available or data were missing for the early years. It was also not possible to compare ART to non-ART siblings or to study the pubertal disorders by cause of subfertility owing to a small number of discordant sibling pairs and a large proportion of missing data on cause of subfertility.

WIDER IMPLICATIONS OF THE FINDINGS

This large, register-based study suggests that ART-conceived children have a higher risk for puberty disorders. However, the mechanisms of infertility and pubertal onset are complex, and ART is a rapidly advancing field with various treatment options. Studying the pubertal disorders of ART-conceived offspring is a continuing challenge.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Nordic Trial Alliance: a pilot project jointly funded by the Nordic Council of Ministers and NordForsk (71450), the Central Norway Regional Health Authorities (46045000), the Nordic Federation of Obstetrics and Gynaecology (NF13041, NF15058, NF16026 and NF17043), the Interreg Öresund-Kattegat-Skagerrak European Regional Development Fund (ReproUnion project), the Research Council of Norway’s Centre of Excellence funding scheme (262700), the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (ALFGBG-70940) and FLUX Consortium ‘Family Formation in Flux—Causes, Consequences and Possible Futures’, funded by the Strategic Research Council, Academy of Finland (DEMOGRAPHY 345130). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors have no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

O-274 Cancer in Children Born after Frozen-Thawed Embryo Transfer: A Cohort Study

Study question

Do children conceived after assisted reproductive technology (ART), particularly after frozen/thawed embryo transfer (FET), have a higher risk of cancer?

Summary answer

Children born after FET have a higher risk of childhood cancer than children born after fresh embryo transfer and spontaneous conception.

What is known already

Previous studies on the association of ART conception and risk of childhood cancer show conflicting results. Worldwide, the number of children born after FET increases and in many countries the number of children born after FET now exceeds the number of children born after fresh embryo transfer. Children born after FET are at increased risk of macrosomia which has been associated with a higher risk of childhood cancer.

Study design, size, duration

This large Nordic registry-based cohort study included 171 774 children born after use of ART and 7 772 474 children born after spontaneous conception during a study period of up to three decades (Denmark 1994-2014, Finland 1990-2014, Norway 1984-2015 and Sweden 1985-2015).

Participants/materials, setting, methods

Cancer rates in children born after each conception method were determined by cross-linking data from national ART and birth registries, national cancer and population registries. The primary outcome was any cancer, and secondary outcomes were 12 cancer subgroups according to the International Classification of Childhood Cancer (ICCC-3). Children were followed from birth to cancer diagnosis, death, emigration, age 18 years or the end of the study period, whichever came first.

Main results and the role of chance

Mean follow up was 9.9 years for children born after ART and 12.5 years for children born after spontaneous conception. Incidence rate (IR) of any cancer before 18 years of age was 19.3/100 000 person-years for children born after ART (329 cases) and 16.7/100 000 person-years for children born after spontaneous conception. Adjusted hazard ratio (aHR) was 1.08, 95% confidence interval (CI) 0.96-1.21. Adjustment was performed for sex, plurality, country of birth, year of birth, maternal age at birth, and parity. Children born after FET had a higher risk of any cancer (48 cases, IR 30.1/100 000 person-years), compared to both children born after fresh embryo transfer (227 cases, IR 18.8/100 000 person-years) (aHR 1.59, 95% CI, 1.15 to 2.20) and children born after spontaneous conception (aHR 1.64, 95% CI, 1.24 to 2.19). Adjustment for macrosomia (birthweight &lt;/≥4000 g), birthweight (continuous variable) or major birth defects only slightly attenuated the association. For cancer subgroups, higher risks of epithelial tumours and melanoma after any ART and of leukaemia after FET were observed.

Limitations, reasons for caution

The main limitation is the number of children with cancer in the FET group. Although including a large cohort, the number of children with cancer is of moderate size. Furthermore, all data are observational, and residual confounding by factors as genetics, parental preconception health and lifestyle cannot be excluded.

Wider implications of the findings

While risk of any cancer was not higher in children born after any ART, we found that children born after FET had a higher risk of cancer than children born after fresh transfer and spontaneously conceived children. These findings are important considering the increasing use of the freeze-all strategy.

Trial registration number

ISRCTN11789826

O-084 Risk of breast cancer for women who give birth after conception by assisted reproductive technology versus natural conception - a Nordic cohort study

Study question

Are women who give birth after assisted reproductive technology (ART) at higher risk of breast cancer than women who give birth after natural conception?

Summary answer

Risk of breast cancer was similar or lower for women who gave birth after ART-conception compared to women who gave birth after natural conception.

What is known already

Most studies indicate no increase in breast cancer risk after use of ART, but results have been conflicting and with limited confounder control. Interpretation of existing knowledge is further complicated by the well-established dual effect of pregnancy on breast cancer risk, with short-term increase in risk and long-term protection. The population of ART-treated women is still relatively young and further studies are needed to understand how fertility treatment, pregnancy and causes of infertility collectively influence breast cancer risk in women treated with ART.

Study design, size, duration

Cohort study based on data linkage between the Medical Birth Registries, ART Registries, Population and Cause of Death Registries in Denmark (1994-2014), Finland (1990-2014), Norway (1984-2015) and Sweden (1985-2015) and the Cancer Registries in each country (1958-2014, 1954-2014, 1953-2015, 1958-2015, respectively). We included 2,283,592 women who gave their first birth during the study period, at age ≥25 years. Among these, 111,781 women had at least one birth after ART conception.

Participants/materials, setting, methods

Women without prior cancer were followed from first birth to date of first cancer, death, emigration, or end of follow-up. We compared risk of breast cancer in Cox regression for women who ever gave birth after ART (time-dependent) vs women with birth(s) after natural conception only, using age as the time scale. We included age at first birth, parity (time-dependent), country and year of delivery as covariates. Sub-analyses included height, body mass index and smoking.

Main results and the role of chance

Women who gave birth after ART were on average 3 years older than women who gave birth after natural conception. Among women who gave birth after ART, 1,101 were diagnosed with breast cancer during a median follow-up of 8.8 years (incidence rate 101/100,000 person-years), compared to 26,984 cases during a median follow-up of 12.7 years (incidence rate 91/100,000 person-years) among women with naturally conceived pregnancies. Age-specific rates were similar. After covariate adjustment, risk was slightly lower for women with ART vs natural conception (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.87 - 0.99). Further adjustment for height, body mass index and smoking gave similar results. Age at first birth was not clearly associated with breast cancer risk for women with either conception method. Women with ART-conception in their first two pregnancies had lower risk (HR 0.83, 95% CI 0.70 - 0.98), whereas no clear differences were found for women with both conception methods, compared to women with two naturally conceived pregnancies. Associations according to ART indication (male, ovarian, other female and unexplained infertility) were consistent with the main findings, as were results for treatment type (IVF, ICSI, fresh and frozen transfer, and single or double embryo transfer).

Limitations, reasons for caution

We had no data on unsuccessful ART treatments, number or type of stimulation cycles. Because only women who gave birth were included, and because a large proportion of ART-treated women had unknown cause of infertility, we cannot exclude residual confounding from causes or severity of infertility.

Wider implications of the findings

Women with successful ART treatment had similar or slightly lower risk of breast cancer compared to women who gave birth after natural conception. Although this study could not completely rule out adverse effects of ART on breast cancer risk, we found no evidence to support strong adverse effects.

Trial registration number

Not applicable

O-273 Risk of hypertensive disorders in pregnancy after fresh and frozen embryo transfer in assisted reproduction: A population-based cohort study with within sibship analysis

Study question

Is the risk of hypertensive disorders in pregnancy (HDP) increased following assisted reproductive technology (ART) with fresh or frozen cycles compared to conception without ART?

Summary answer

Pregnancies after frozen embryo transfer (FET) had a substantially higher risk of HDP, also after accounting for constant parental factors in within sibship comparisons.

What is known already

FET in assisted reproductive technology (ART) is increasingly common because of improved cryopreservation methods, blastocyst culture, and freeze-all practice. Conventional observational studies have raised concerns about treatment safety due to higher risk of HDP after FET compared to both non-ART and fresh embryo transfer (fresh-ET). Whether this is attributable to parental factors or treatment is unknown. Within sibship comparisons can provide unique insight by controlling for confounding from unmeasured, constant parental factors, like genetics, preconception lifestyle and health, as well as socioeconomic status.

Study design, size, duration

Population-based cohort study with within sibship comparison using health registry data from three Nordic countries. In total, 4,523,028 singleton pregnancies resulting in delivery between 1988 and 2015 were included, of which 78,300 were after fresh-ET, and 18,037 were after FET. We identified 33,209 sibships that were conceived using two or three different conception methods (fresh-ET, FET, and non-ART).

Participants/materials, setting, methods

Data were collected from several national health registries in Denmark, Norway, and Sweden, including ART, medical birth, and patient registries, and linked using the residents’ unique identification numbers. Adjusted odds ratios (aOR) of HDP with 95% confidence intervals (CI) were estimated using multilevel logistic regression, where random effects provided conventional population estimates, and fixed effects gave within sibship estimates. Main models included adjustment for maternal age, parity, birth year and country.

Main results and the role of chance

Risk of HDP was higher after FET compared to non-ART conception, both at the population level (7.4% vs 4.3%, aOR 1.74, 95% CI 1.61 to 1.89) and within sibships (aOR 2.02, 95% CI 1.72 to 2.39). For fresh-ET, the risk was similar to non-ART, both at the population level (5.9% vs 4.3%, aOR 1.02, 95% CI 0.98 to 1.07) and within sibships (aOR 0.99, 95% CI 0.89 to 1.09). Sensitivity analyses with adjustment for body mass index (BMI) and smoking, restriction to full siblings (same mother and father) and siblings born within a three-year interval, were all consistent with our main findings. Furthermore, the results were not driven by order of conception method or other ART procedures (intracytoplasmic sperm injection, culture duration or number of embryos transferred).

Limitations, reasons for caution

Despite the extra control for shared confounders provided by the within sibship analyses, we cannot exclude residual confounding from non-shared confounders, such as smoking and BMI, where confounder control was limited by a large proportion of missingness, and causes of infertility, which were largely unknown.

Wider implications of the findings

Our findings are important for the ongoing discussion about the freeze-all policy, and further investigation of which treatment factors might be involved is warranted.

Trial registration number

Not applicable

O-303 Recurrent pregnancy loss is associated with unfavorable composition of endometrial and vaginal microbiota

Study question

Does endometrial or vaginal microbiota composition associate with recurrent pregnancy loss (RPL)?

Summary answer

Reduced relative abundance of Lactobacillus crispatus in endometrium and increased relative abundance of Gardnerella vaginalis in endometrium and vagina were associated with RPL.

What is known already

Dysbiotic vaginal microbiota associates with sporadic miscarriage and the depletion of lactobacilli in the endometrium has been associated with poor IVF outcomes, but their association with RPL has not been studied.

Study design, size, duration

A nested case-control study of 47 women investigated for RPL and 39 healthy control women without a history of pregnancy loss were recruited between March 2018 and December 2020 at a university hospital. Endometrial biopsies and vaginal samples were collected from the women 6-8 days after positive ovulation test result.

Participants/materials, setting, methods

The endometrial and vaginal microbiota compositions, analysed using 16S rRNA gene amplicon sequencing, were compared between RPL women and controls, and between individual vaginal and endometrial samples. The mycobiota composition was analysed using internal transcribed spacer 1 amplicon sequencing for a descriptive summary. The models were adjusted for BMI, age, and parity. False discovery rate -corrected P-values (q-values) were used to define nominal statistical significance at q&lt; 0.05.

Main results and the role of chance

Lactobacillus crispatus was less abundant in the RPL women’s endometrial samples compared to controls (mean relative abundance 17.2% vs. 45.6%, q= 0.04). Gardnerella vaginalis was more abundant in RPL women than in controls in both endometrial (12.4% vs. 5.8%, q&lt; 0.001) and vaginal samples (8.7% vs. 5.7%, q&lt; 0.01). The individual vaginal and endometrial microbial compositions correlated strongly (R = 0.85, P&lt; 0.001). Fungi, mostly Candida albicans, were detected in 22% of the endometrial and 36% of the vaginal samples.

Limitations, reasons for caution

Limitations include the transcervical sampling technique with a potential risk of cervicovaginal contamination of endometrial samples, the loss of a proportion of the samples from statistical analyses due to their low read count, and the presentation of the 16S rRNA sequencing results in relative rather than absolute abundances

Wider implications of the findings

Our findings suggest that an unfavorable endometrial microbiota may be a novel risk factor for RPL. Further studies should elucidate the mechanisms, how microbiota may predispose to RPL, possibilities to modify microbiota by treatments, and the effects of such treatments on the success of future pregnancies in couples having RPL.

Trial registration number

not applicable

Adolescent attachment to parents and peers in singletons and twins born with assisted and natural conception

STUDY QUESTION

Does adolescent attachment to parents and peers differ between singletons and twins born with ART or natural conception (NC)?

SUMMARY ANSWER

Adolescent attachment anxiety with the father was higher among NC singletons than among ART and NC twins, whereas attachment avoidance with the father was higher in ART singletons than in NC singletons and NC twins. No differences were found in attachment to the mother, best friend or romantic partner.

WHAT IS KNOWN ALREADY

Most studies have not found differences between ART and NC singletons in parent–adolescent relationships, but twin relationships may be more at risk. No previous study has examined all four groups in the same study, or specifically looked at attachment relationships.

STUDY DESIGN, SIZE, DURATION

This was an 18-year, prospective and controlled longitudinal study with families of 496 ART singletons, 101 ART twin pairs, 476 NC singletons and 22 NC twin pairs. Families were recruited during the second trimester of pregnancy; the ART group was recruited from five infertility clinics in Finland and the control group was recruited from a hospital outpatient clinic during a routine visit.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers and fathers gave background information for this study during pregnancy, and during the child’s first year and early school age (7–8 years). For the ART group, infertility characteristics and prenatal medical information was also obtained from the patient registry of the infertility clinics. Children (originally 50% girls) filled in electronic questionnaires related to their attachment to mother, father, best friend and romantic partner (Experiences in Close Relationships—Relationship Structures) at 17–19 years of age.

MAIN RESULTS AND THE ROLE OF CHANCE

Adolescent attachment anxiety to father was higher in NC singletons than in ART twins, P = 0.004 and marginally higher than in NC twins, P = 0.06. Adolescent attachment avoidance to father was higher in ART singletons than in NC singletons, P = 0.006 and marginally higher than in NC twins, P = 0.055.

LIMITATIONS, REASONS FOR CAUTION

The sample size was small especially in the NC twin group and there was drop-out over the 18-year time period, especially among boys and families with lower parental education level. The study only included native Finnish-speaking families. The results could differ in a more diverse population. ART singletons were younger and had fewer siblings than ART twins and NC children, and ART and NC twins had more newborn health risks than ART and NC singletons.

WIDER IMPLICATIONS OF THE FINDINGS

The study adds to a growing body of evidence that neither ART treatments nor being a twin places mother–child relationships or peer relationships at long-term risk. However, in our study, which was the first to examine both ART and twinhood simultaneously, we found that there may be more problems in father–adolescent relationships, but only in ART singletons and only related to attachment avoidance. Our findings suggest that men, as well as women, should receive enough support in pre- and peri-natal health care during and after infertility treatments.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Academy of Finland (grant number 2501308988), the Juho Vainio Foundation and the Finnish Cultural Foundation. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Probability of live birth after IVF/ICSI treatments in female early onset cancer survivors: a Finnish population-based registry study

STUDY QUESTION

Does the probability of a live birth after fresh IVF/ICSI cycles with autologous oocytes differ in early onset female cancer survivors compared to their siblings?

SUMMARY ANSWER

The probability of a live birth was similar in female cancer survivors and siblings after four fresh IVF/ICSI cycles.

WHAT IS KNOWN ALREADY

Fertility preservation strategies are rapidly being developed to help female cancer patients who wish to have children later. However, there are only a few studies available on fertility treatments and following live births in female cancer survivors before fertility preservation strategies became available. In one of them, the probability of a live birth was reduced after assisted reproductive technology with autologous oocytes in cancer survivors compared to siblings.

STUDY DESIGN, SIZE, DURATION

In this retrospective, register-based study, data from Finnish registers on cancer, birth and prescribed medications were merged to identify 8944 female cancer survivors (diagnosed with cancer between 1953 and 2012 at the age of 0-40 years) and 9848 female siblings of survivors eligible for IVF/ICSI treatments between January 1993 and December 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fresh IVF/ICSI cycles and following live birth rates (LBRs) within 22-48 weeks in cancer survivors and siblings at the age of 20-41 years were identified. A binomial regression model with log-link function was used to calculate risk ratio (RR) for live births after fresh IVF/ICSI cycles in survivors compared to siblings, adjusting for attained age and calendar time. A Poisson regression model was used to estimate incidence rate ratios (IRRs) for an IVF/ICSI treatment, as well as overall live births, including both pregnancies after fertility treatments and spontaneous pregnancies, in survivors compared to siblings.

MAIN RESULTS AND THE ROLE OF CHANCE

We observed an overall decreased LBR, irrespective of IVF/ICSI treatments, in cancer survivors compared to siblings (IRR 0.68, 95% CI 0.64-0.71). All in all, 179 (2.0%) survivors and 230 (2.3%) siblings were prescribed fertility drugs for IVF/ICSI treatments (IRR 0.72, 95% CI 0.62-0.84). For the first fresh IVF/ICSI cycle, the LBR was 17.2% among survivors and 15.7% among siblings (RR 1.13, 95% CI 0.72-1.87). The mean LBR after four fresh IVF/ICSI cycles was not statistically different in survivors compared to siblings.

LIMITATIONS, REASONS FOR CAUTION

In this study, only IVF/ICSI treatments with autologous oocytes were included. The probability of a live birth after a frozen embryo transfer or oocyte donation could not be evaluated in this study. Information on miscarriages, extrauterine pregnancies or termination of pregnancies was not available.

WIDER IMPLICATIONS OF THE FINDINGS

For those early onset cancer survivors, who received IVF/ICSI treatments, the probability of live birth was not different from siblings who received IVF/ICSI treatments. However, an overall decreased LBR, irrespective of IVF/ICSI treatments, was observed in cancer survivors compared to siblings, indicating that cancer survivors receiving IVF/ICSI treatments in our study consisted of a selected group with at least a moderate ovarian reserve.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a grant from the Cancer Foundation (Finland) (grant number 130079) and by a grant from LähiTapiola. The authors have no potential conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

O-076 Neurodevelopmental morbidity in children born after ART: a Nordic register study from the Committee of Nordic ART and Safety (CoNARTaS) group

Study question

Does the risk of neurodevelopmental disorders differ between singletons born after various assisted reproductive techniques (ART) and spontaneous conception (SC) until young adulthood?

Summary answer

ART children had a slightly increased rate of learning and motor functioning disorders, autism spectrum disorders (ASD), and ADHD and conduct disorders.

What is known already

Studies on the impact of ART on offspring have reported both increased risk and comparable incidences of neurodevelopmental disorders between ART and SC offspring. The most studied neurodevelopmental disorders with ART are autism spectrum disorders (ASD.) There is, however, no consensus on the risk of ASD for ART children. The risk for other neurodevelopmental disorders, like attention-deficit hyperactivity disorders (ADHD) or tic disorder among ART children, is also a debated issue, as studies are scarce.

Study design, size, duration

A Nordic register-based cohort study including all singleton live births (N = 5 076 444) after ART (n = 116 909) or SC (n = 4 959 535) between 1995 and 2014 in Denmark and Finland, 1995 and 2015 in Sweden; and 2005 and 2015 in Norway. Children with intellectual disability (ICD-10: F70-F79) are excluded. The children are followed up to young adulthood (the year 2014 in Denmark and Finland, and 2015 in Norway and Sweden).

Participants/materials, setting, methods

Offspring outcomes were defined as following ICD-10 diagnoses: learning and motor functioning disorders (F80-83), ASD (F84), ADHD and conduct disorders (F90-F92), and tic disorders/Tourette (F95). We calculated crude and adjusted hazard ratios (HR) for neurodevelopmental diagnoses using Cox regression. Adjustments were made for the country, maternal age at the delivery, parity, smoking, and maternal psychiatric morbidity.

Main results and the role of chance

The cumulative incidences of neurodevelopmental disorders in the cohort were 1.74% for F90-F92, 1.40% for F80-83, 0.66% for F84, and 0.22% for F95. In crude Cox-regression ART children had an increased likelihood during the follow-up of being diagnosed with F84 (HR 1.12 [95% CI 1.04-1.21]) and F95 (HR 1.21 [95% CI 1.06-1.38]), but not with F80-83 (HR 1.01 [95% CI 0.96-1.07]) or F90-92 (HR 0.82 [95% CI 0.77-0.86]). After adjustments the likelihood was increased for F80-83 (HR 1.20 [95% CI 1.13-1.27]), F84 (HR 1.12 [95% CI 1.03-1.24]), and F90-92 (HR 1.09 [95% CI 1.04-1.19]), but nor for F95 (HR 1.13 [95% CI 0.99-1.30]).

After adjustments, intracytoplasmic sperm injection children compared with in vitro fertilization children had similar likelihood during follow-up for F80-83 (1.06 [95% CI 0.89–1.25]), for F84 (HR 0.92 [95% CI 0.76–1.11]), for F90-92 (HR 0.96 [95% CI 0.83–1.12]), and for F95 (HR 1.16 [95% CI 0.83–1.63]).

After adjustments, frozen embryo transfer children compared with fresh embryo transfer children had similar likelihood during follow-up for F80-83 (HR 1.11 [95% CI 0.90–1.37]), F84 (HR 0.98 [95% CI 0.76–1.27]), F90-92 (HR 0.96 [95% CI 0.78–1.19]), and F95 (HR 0.83 [95% CI 0.51–1.35]).

Limitations, reasons for caution

There may be residual confounding by unknown or unmeasured confounders. We lack information on possible confounders like the reason and length of infertility, maternal substance use other than self-reported smoking status, paternal age, and parental somatic morbidity. Additional limitations are differences in registration practice and data availability between study countries.

Wider implications of the findings

This is the largest singleton cohort and the first multinational study on the risk for neurodevelopmental disorders among ART children. While the rate of some neurodevelopmental disorders was increased among ART children, the absolute risk was moderate. The type of ART did not associate with the incidence of neurodevelopmental disorders.

Trial registration number

ISRCTN11780826

High birth weight and large-for-gestational-age in singletons born after frozen compared to fresh embryo transfer, by gestational week: a Nordic register study from the CoNARTaS group

STUDY QUESTION

When do the differences in birth weights become apparent between singletons born after frozen embryo transfer (FET) and fresh embryo transfer (fresh ET)?

SUMMARY ANSWER

Mean birth weights after FET become significantly higher starting from gestational week (GW) 33 among boys and from GW 34 among girls.

WHAT IS KNOWN ALREADY

In recent years, there has been a steep rise in recorded FET treatments, enabling widespread use of elective single embryo transfer, thus reducing the risks associated with multiple gestations. However, singletons born after FET are heavier and there is a higher risk of large-for-gestational-age (LGA) (birth weight > 90 percentiles) compared to fresh ET. In contrast, risk of small-for-gestational-age (SGA, birth weight < 10 percentiles) is lower in singletons born after FET compared to fresh ET. The reasons, timing and consequences of these differences remain largely unclear. There is limited evidence about whether this difference in growth develops before the last trimester of pregnancy.

STUDY DESIGN, SIZE, DURATION

This retrospective Nordic register-based cohort study compared singletons born after FET (n = 17 500) to singletons born after fresh ET (n = 69 510) and natural conception (NC, n = 3 311 588). All live born singletons born between the years 2000 and 2015 in Denmark, Norway and Sweden at gestational age ≥22 weeks were included from the population-based Committee of Nordic ART and Safety (CoNARTaS) study population.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Children born after FET were compared to those born after fresh ET and NC for mean birth weight and proportion of LGA and SGA for each GW at birth. Chi-square test and tests for relative proportions were used to compare categorical variables and Student's t-test was used to compare continuous variables. Adjusted odds ratios (aORs) for LGA and SGA were calculated using logistic regressions, adjusting for year of birth, maternal age, parity, BMI, chronic hypertension, diabetes, smoking and offspring sex.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean birth weights were significantly higher after FET compared to fresh ET starting from GW 33 (range from 75 g to 228 g by week) for boys and starting from GW 34 (range from 90 g to 236 g by week) for girls. Boys born after FET had a significantly higher proportion of LGA (11.0-15.1%) at birth between GW 36 and 42, compared to those born after fresh ET (7.1-9.4%) (range from P < 0.001 to P = 0.048 by week). For girls born after FET, the difference was seen between GW 37 and 42 (10.6-13.4%) compared to those born after fresh ET (6.6-8.0%) (range from P < 0.001 to P = 0.009 by week).The proportion of SGA was significantly lower among boys born after FET (7.6-8.7%) compared to fresh ET (11.9-13.6%) between GW 36 and 42 (range from P < 0.001 to P = 0.016 by week). For girls born after FET, the difference was seen between GW 38 and 42 (7.0-9.3%) compared to those born after fresh ET (13.0-14.6%) (P < 0.001). The proportion of LGA (12.3-15.1%) was significantly higher for boys born after FET between GW 38 and 41 (P < 0.001) and for girls born after FET (12.6-13.4%) between GW 37 and 40 (range from P < 0.001 to P = 0.018 by week), compared to naturally conceived boys (9.7-9.9%) and girls (9.0-10.0%). All singletons born after FET had a higher risk of LGA compared to singletons born after fresh ET (aOR 1.87, 95% CI 1.76-1.98) and singletons born after NC (aOR 1.28, 95% CI 1.22-1.35).

LIMITATIONS, REASONS FOR CAUTION

There may be residual confounding factors that we were not able to control for, most importantly the causes of preterm birth, which may also influence foetal growth. A further limitation is that we have no knowledge on growth patterns between implantation and GW 22. Finally, the number of children born extremely preterm or post-term was limited even in this large study population.

WIDER IMPLICATIONS OF THE FINDINGS

This is, to date, the largest study on birth weights among preterm and term ART singletons with a population-based design and NC control group. The results suggest that the freeze-thaw process is associated with higher birthweights and greater risk of LGA at least in the last trimester of pregnancy. This is an important aspect of the safety profile of ART. More research is needed on the long-term outcome of these children.

STUDY FUNDING/COMPETING INTEREST(S)

The CoNARTaS collaboration has received the following funding: the Nordic Trial Alliance: a pilot project jointly funded by the Nordic Council of Ministers and NordForsk [71450], the Central Norway Regional Health Authorities [46045000], the Norwegian Cancer Society [182356-2016], the Nordic Federation of Obstetrics and Gynaecology [NF13041, NF15058, NF16026 and NF17043], the Interreg Öresund-Kattegat-Skagerrak European Regional Development Fund (ReproUnion project) and the Research Council of Norway's Centre of Excellence funding scheme [262700]. None of the authors have any competing interests to declare.

TRIAL REGISTRATION NUMBER

ISRCTN11780826.

Obstetric and perinatal risks in 4601 singletons and 884 twins conceived after fresh blastocyst transfers: a Nordic study from the CoNARTaS group

STUDY QUESTION

Are obstetric and perinatal outcomes in pregnancies after fresh blastocyst transfer (BT) comparable with those born after fresh cleavage stage transfer (CT) and spontaneous conception (SC)?

SUMMARY ANSWER

Fresh BT is associated with a higher risk of placental and perinatal complications.

WHAT IS KNOWN ALREADY

BT optimizes the selection of top-quality embryos and increases pregnancy and live birth rates per transfer compared to CT. However, concerns have been raised as extended culture duration may increase obstetric complications and impair perinatal outcomes. Previous studies have shown a higher risk of preterm birth (PTB) among infants born after BT compared with CT. Pregnancies after BT are also prone to a higher risk of same-sex twins after single embryo transfer (SET).

STUDY DESIGN, SIZE, DURATION

A retrospective register-based cohort study used data from Denmark, Norway and Sweden including three cohorts: 56 557 singletons and 16 315 twins born after fresh IVF/ICSI cycles and 2 808 323 SC singletons in Denmark (birth years 1997-2014), Norway (2010-2015) and Sweden (2002-2015). Of the fresh IVF/ICSI singletons, 4601 were born after BT and 51 956 after CT. The twin cohort consisted of 884 fresh IVF/ICSI children born after BT and 15 431 fresh IVF/ICSI children born after CT.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were obtained from a large Nordic cohort of children born after ART and SC initiated by the Committee of Nordic ART and Safety (CoNARTaS). The CoNARTaS cohort was established by cross-linking National ART-, Medical Birth-, and National Patients Registers using the unique personal identification number, allocated to every citizen in the Nordic countries. Obstetric and perinatal outcomes after BT, CT and SC were compared using logistic regression analysis. For perinatal outcomes, we calculated gestational age based on the date of oocyte pick-up (OPU) and in sensitivity analyses on data from Denmark and Norway, we also calculated gestational age based on the second-trimester ultrasonography (US) scan. Risk of pregnancies with same-sex twins after SET was used as a proxy for risk of monozygotic twins. Adjustments were made for child's sex, birth year, parity (0 or >1), maternal age, body mass index, smoking, educational level, fertilization method (IVF/ICSI), the number of aspirated oocytes, SET and country. Information on educational level and the number of aspirated oocytes was not available for Norway. Children born after frozen embryo transfer were not included. The birth cohorts were restricted according to the year in which BT was introduced in the different countries.

MAIN RESULTS AND THE ROLE OF CHANCE

A higher risk of placenta previa was found in singleton pregnancies after BT compared with CT (adjusted odds ratio [aOR] 2.11 [95% CI 1.76; 2.52]). Singletons born after BT had a higher risk of PTB (aOR 1.14 [95% CI 1.01; 1.29]) compared with CT singletons, when estimated based on OPU. Furthermore, an altered male/female ratio (aOR 1.13 [95% CI 1.06; 1.21]) with more males following BT compared with CT was seen. Risk of same-sex twins after SET was higher after single BT compared with single CT (aOR 1.94 [95% CI 1.42; 2.60]).

LIMITATIONS, REASONS FOR CAUTION

Residual confounding cannot be excluded, in particular related to duration and cause of infertility that we could not adjust for due to lack of reliable data.

WIDER IMPLICATIONS OF THE FINDINGS

Extended embryo culture to the blastocyst stage has the potential to compromise obstetric and perinatal outcomes in fresh cycles. These results are important since an increasing number of IVF/ICSI treatments are performed as BT.

STUDY FUNDING/COMPETING INTEREST(S)

NORDFORSK (project no: 71450). The Research Fund of Rigshospitalet, Copenhagen University Hospital. ReproUnion Collaborative study, co-financed by the European Union, Interreg V ÖKS. Grants from Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (LUA/ALF 70940), Hjalmar Svensson Research Foundation. The Research Council of Norway through its Centres of Excellence funding scheme, project number 262700. None of the authors has any conflicts of interests to declare regarding this study.

TRIAL REGISTRATION NUMBER

ISRCTN11780826.

Puberty problems among ART children born 1985-2015 in the Nordic countries – CoNARTaS cohort data

Background

Children born after ART (Assisted reproductive technology) are known to be at increased risk for adverse outcomes, but there are little data on health of older children. The aim of this study is to examine puberty related outcomes of ART children as available in existing health care registers, using Nordic data.

Methods

The CoNARTaS cohort contains data on 121 746 ART children and 6 538 411 naturally conceived children born in Denmark (1994-2014), Finland (1990-2014), Norway (2002-2015) and Sweden (1985-2015). All data were obtained from national health registries, disease-specific quality registries and other nationwide databases. Puberty problems were defined by using ICD-10 codes and classified as any problems, late and early puberty and unspecified problems. Cox regression adjusted for maternal age, parity, plurality, maternal diabetes and maternal smoking were made, separately for girls and boys.

Results

36 508 children had diagnoses related to puberty problems, of which 591 were ART-children including IVF (in vitro fertilization) and ICSI (intra cytoplasmic sperm injection). In total, ART children had increased risks for any pubertal problems (adjusted HR 1.60, 95% CI: 1.47-1.74), late puberty (1.57, 95% CI: 1.31-1.89) and early puberty (1.63, 95% CI: 1.46-1.82). The effect was similar for girls (1.61, 95% CI: 1.46-1.78) and boys (1.55, 95% CI: 1.33-1.81), but girls had more diagnoses related to early puberty (66.2%) and boys with late puberty (48.8%). ICSI was associated with higher risk (2.01, 95% CI 1.74-2.31) than IVF (1.46, 95% CI: 1.30-1.65), but the difference between fresh and frozen embryo transfer remained statistically insignificant.

Conclusions

Both girls and boys born after ART had the increased risk for pubertal problems. However, we could not adjust for all possible confounders such as infertility diagnoses or drugs used in ART. More studies are needed to confirm the findings and to find out reasons for the increased risks.

Key messages

Both girls and boys born after ART had the increased risk for pubertal problems. More studies are needed to confirm the findings and to find out reasons for the increased risks.

Imprinting disorders in children born after ART: a Nordic study from the CoNARTaS group

STUDY QUESTION:

Is the risk of imprinting disorders increased in children conceived after

SUMMARY ANSWER:

We found an adjusted odds ratio (AOR) of 2.84 [95% CI: 1.34–6.01] for Beckwith–Wiedemann syndrome in ART children, while the risk of Prader–Willi syndrome, Silver–Russell syndrome or Angelman syndrome was not increased in children conceived after ART.

WHAT IS KNOWN ALREADY:

Earlier studies, most of them small, have suggested an association between ART and imprinting disorders.

STUDY DESIGN, SIZE, DURATION:

This was a binational register-based cohort study. All children conceived by ART in Denmark (n = 45 393, born between 1994 and 2014) and in Finland (n = 29 244, born between 1990 and 2014) were identified. The full background populations born during the same time periods in the two countries were included as controls. Odds ratios of imprinting disorders in ART children compared with naturally conceived (NC) children were calculated. The median follow-up time was 8 years and 9 months for ART children and 11 years and 9 months for NC children.

PARTICIPANTS/MATERIALS, SETTING, METHODS:

From the national health registries in Denmark and Finland, we identified all children diagnosed with Prader–Willi syndrome (n = 143), Silver–Russell syndrome (n = 69), Beckwith–Wiedemann syndrome (n = 105) and Angelman syndrome (n = 72) born between 1994/1990 and 2014, respectively.

MAIN RESULTS AND THE ROLE OF CHANCE:

We identified a total of 388 children diagnosed with imprinting disorders; 16 of these were conceived after ART. The overall AOR for the four imprinting disorders in ART children compared with NC children was 1.35 [95% CI: 0.80–2.29], but since eight ART children were diagnosed with Beckwith–Wiedemann syndrome, the AOR for this specific imprinting disorder was 2.84 [95% CI: 1.34–6.01]. The absolute risk of Beckwith–Wiedemann syndrome in children conceived after ART was still low: 10.7 out of 100 000 newborns. The risks of Prader–Willi syndrome, Silver–Russell syndrome and Angelman syndrome were not increased in children conceived after ART.

LIMITATIONS, REASONS FOR CAUTION:

Imprinting disorders are rare events and our results are based on few ART children with imprinting disorders. The aetiology is complex and only partly clarified, and the clinical diagnoses are challenged by a broad phenotypic spectrum.

WIDER IMPLICATIONS OF THE FINDINGS:

In the existing studies, results on the risk of imprinting disorders in children conceived after ART are ambiguous. This study adds that the risk of imprinting disorders in ART children is very small and perhaps restricted to Beckwith–Wiedemann syndrome.

STUDY FUNDING/COMPETING INTEREST(S):

This work was supported by the Nordic Trial Alliance: a pilot project jointly funded by the Nordic Council of Ministers and NordForsk (grant number: 71450), the Nordic Federation of Obstetrics and Gynecology (grant numbers: NF13041, NF15058, NF16026 and NF17043) and the Interreg Öresund-Kattegat-Skagerak European Regional Development Fund (ReproUnion project). The authors have no conflicts of interest related to this work.

TRIAL REGISTRATION NUMBER:

N/A

Low anti-Müllerian hormone level is not a risk factor for early pregnancy loss in IVF/ICSI treatment

STUDY QUESTION

Is a low (&lt;1.0 μg/L) or moderately low (1.0–1.9 μg/L) serum anti-Müllerian hormone (AMH) level a risk factor for early pregnancy loss in IVF/ICSI with a fresh or frozen-thawed embryo transfer (ET)?

SUMMARY ANSWER

A low or moderately low serum AMH level does not associate with miscarriage, non-visualized pregnancy loss or overall early pregnancy loss rate in the IVF/ICSI treatment.

WHAT IS KNOWN ALREADY

Low AMH predicts poor ovarian response and small oocyte yield in IVF/ICSI treatment, but its value in the evaluation of live birth rate (LBR) is modest. Little is known about the risk of early pregnancy loss in ART among women with low AMH.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study on 1383 women undergoing their first oocyte retrieval for IVF/ICSI in Helsinki University Hospital in Helsinki, Finland, between 2012 and 2016, with all associated fresh (n = 1315) and frozen-thawed (n = 1418) ET cycles finished by August 2018. AMH was measured within 12 months before the IVF/ICSI stimulation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of all the women, 235 (17.0%) had low (&lt;1.0 μg/L), 278 (20.1%) had moderately low (1.0–1.9 μg/L) and 870 (62.9%) had normal (≥2.0 μg/L) AMH. The primary outcomes were miscarriage, non-visualized pregnancy loss and early pregnancy loss (miscarriage and non-visualized pregnancy loss combined) after fresh or frozen-thawed ET. The impact of AMH on these outcomes was calculated in three populations: among all women who became pregnant, among women with AMH ≤6.0 μg/L and in a population weighted by the inverse probability of becoming pregnant (inverse probability weighting, IPW). The impact of AMH was also assessed on the secondary outcomes, cumulative pregnancy rate (cPR) and cumulative live birth rate (cLBR) across all ET cycles in the woman’s first IVF/ICSI. Potential confounders (the woman’s age, overweight, smoking, history of endometriosis and underlying medical conditions) adjusted the final results.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 1123 pregnancies, 285 (25.4%) ended in non-visualized pregnancy loss and 143 (12.7%) in miscarriage. The LBR was 24.6% per ET (673/2733). Low or moderately low AMH, compared with normal AMH, did not associate with miscarriage or non-visualized pregnancy loss in analyses among all women who became pregnant (adjusted relative risk (RR) for miscarriage vs live birth, 0.70 and 95% CI 0.42–1.17 in low AMH and adjusted RR, 1.00 and 95% CI, 0.68–1.49 in moderately low AMH; adjusted RR for non-visualized pregnancy loss vs live birth, 0.90 and 95% CI, 0.65–1.23 in low AMH and adjusted RR, 1.09 and 95% CI 0.85–1.41 in moderately low AMH), nor did low or moderately low AMH associate with the overall early pregnancy loss rate (adjusted RR for early pregnancy loss vs live birth, 0.86 and 95% CI, 0.68–1.10 in low AMH and adjusted RR, 1.01 and 95% CI, 0.86–1.27 in moderately low AMH). Results remained similar after restricting the analysis to women with AMH ≤6.0 μg/L. Women with low or moderately low AMH had fewer pregnancies and live births than women with normal AMH in their first IVF/ICSI (cPR/cLBR in women with low AMH 50.6/34.0%, moderately low AMH 59.0/36.3% and normal AMH 68.3/49.2%). When the lower probability for pregnancy was considered by using IPW, women with low or moderately low AMH did not have a higher risk for miscarriage, non-visualized pregnancy loss or overall early pregnancy loss compared with women with normal AMH.

LIMITATIONS, REASONS FOR CAUTION

The number of miscarriages in women with low AMH was moderately small, limiting the power of the study. The real-world clinical setting of the study restricted the ability to control for all factors causing selection bias.

WIDER IMPLICATIONS OF THE FINDINGS

The cLBR was higher among women with normal AMH than among women with low or moderately low AMH in their first IVF/ICSI treatment because these women had more oocytes and embryos. Women with low or moderately low AMH did not have an increased risk for early pregnancy loss. This information is reassuring for couples and useful in counseling. These results are also valuable when assessing the overall effectiveness of IVF/ICSI treatment.

STUDY FUNDING/COMPETING INTEREST(S)

Research funds from Helsinki University Hospital (no. TYH2018232), Hyvinkää Hospital (no. M3080TUT18) and the Emil Aaltonen Foundation for P.P. Grants from the Paulo Foundation and the Finnish Medical Foundation for H.H. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

HUS/138/2017.

Mortality of midlife women with surgically verified endometriosis—a cohort study including 2.5 million person-years of observation

STUDY QUESTION

Is all-cause and cause-specific mortality increased among women with surgically verified endometriosis?

SUMMARY ANSWER

The all-cause and cause-specific mortality in midlife was lower throughout the follow-up among women with surgically verified endometriosis compared to the reference cohort.

WHAT IS KNOWN ALREADY

Endometriosis has been associated with an increased risk of comorbidities such as certain cancers and cardiovascular diseases. These diseases are also common causes of death; however, little is known about the mortality of women with endometriosis.

STUDY DESIGN, SIZE, DURATION

A nationwide retrospective cohort study of women with surgically verified diagnosis of endometriosis was compared to the reference cohort in Finland (1987–2012). Follow-up ended at death or 31 December 2014. During the median follow-up of 17 years, 2.5 million person-years accumulated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Forty-nine thousand nine hundred and fifty-six women with at least one record of surgically verified diagnosis of endometriosis in the Finnish Hospital Discharge Register between 1987 and 2012 were compared to a reference cohort of 98 824 age- and municipality-matched women. The age (mean ± standard deviation) of the endometriosis cohort was 36.4 ± 9.0 and 53.6 ± 12.1 years at the beginning and at the end of the follow-up, respectively. By using the Poisson regression models the crude and adjusted all-cause and cause-specific mortality rate ratios (MRR) and 95% confidence intervals (CI) were assessed. Calendar time, age, time since the start of follow-up, educational level, and parity adjusted were considered in the multivariate analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1656 and 4291 deaths occurred in the endometriosis and reference cohorts, respectively. A lower all-cause mortality was observed for the endometriosis cohort (adjusted MRR, 0.73 [95% CI 0.69 to 0.77])—there were four deaths less per 1000 women over 10 years. A lower cause-specific mortality contributed to this: the adjusted MRR was 0.88 (95% CI 0.81 to 0.96) for any cancer and 0.55 (95% CI 0.47 to 0.65) for cardiovascular diseases, including 0.52 (95% CI 0.42 to 0.64) for ischemic heart disease and 0.60 (95% CI 0.47 to 0.76) for cerebrovascular disease. Mortality due to alcohol, accidents and violence, respiratory, and digestive disease-related causes was also decreased.

LIMITATIONS, REASONS FOR CAUSATION

These results are limited to women with endometriosis diagnosed by surgery. In addition, the study does not extend into the oldest age groups. The results might be explained by the characteristics and factors related to women’s lifestyle, and/or increased medical attention and care received, rather than the disease itself.

WIDER IMPLICATIONS OF THE FINDINGS

These reassuring data are valuable to women with endometriosis and to their health care providers. Nonetheless, more studies are needed to address the causality.

STUDY FUNDING/COMPETING INTEREST

This research was funded by the Hospital District of Helsinki and Uusimaa and The Finnish Medical Foundation. None of the authors report any competing interest in relation to the present work; all the authors have completed the disclosure form.

Cardiorespiratory fitness and health-related quality of life in women at risk for gestational diabetes

This study examined the associations of cardiorespiratory fitness (CRF) and leisure-time physical activity (LTPA) with health-related quality of life (HRQoL) in women at risk for gestational diabetes mellitus (GDM). The participants were 39 women planning pregnancy with a history of GDM and/or BMI >29 kg/m² . We assessed CRF by measuring maximal oxygen consumption (VO_2max ) during incremental cycle ergometer exercise until voluntary fatigue. LTPA was self-reported, and HRQoL assessed with the SF-36 Health Survey (SF-36). The mean (SD) VO_2max was 27 (6) mL·kg^-1 ·min^-1 , and the mean LTPA was 2.6 (1.7) h/wk. After controlling for BMI, VO_2max was positively associated with the SF-36 General Health scale (β 1.27, 95% CI: 0.09, 2.44, P=.035) and the Physical Component Summary (β 0.48, 95% CI: 0.14, 0.82, P=.007). The General Health scale (P=.023) and the Physical Component Summary (P=.011) differed even between those with very poor and poor CRF. After controlling for BMI, LTPA was positively associated with the SF-36 Physical Functioning scale (r_s =.34, P=.039), the General Health scale (β 3.74, 95% CI: 0.64, 6.84, P=.020), and the Physical Component Summary (β 1.13 95% CI: 0.19, 2.06, P=.020). To conclude, CRF and LTPA were positively associated with perceived general health and physical well-being in women planning pregnancy and at risk for GDM. Even a slightly better CRF would be beneficial for well-being among women with low levels of CRF.

Physical health of singleton children born after frozen embryo transfer using slow freezing: a 3-year follow-up study

STUDY QUESTION

Are there differences in the physical health of singleton children born after frozen embryo transfer (FET) compared with children born after fresh embryo transfer (fresh ET)?

SUMMARY ANSWER

Register-based health indicators were similar among FET and fresh ET singletons during a 3-year follow-up.

WHAT IS KNOWN ALREADY

Large cohort studies have shown that perinatal outcomes are similar or even better in FET than fresh ET children. The early childhood morbidity among FET and fresh ET children has been shown to be quite similar, but so far these studies have been small. The short-term health outcomes of assisted reproductive technology (ART) children have been shown to be slightly worse compared with spontaneously conceived children.

STUDY DESIGN, SIZE, DURATION

This register-based study includes women who had undergone ART treatments leading to singleton live births (n = 4758 children) in 1995-2006. A 10% random sample of women with spontaneous pregnancies from the Finnish Medical Birth Register (FMBR) served as the reference group (n = 31 137 children). The children were identified through the FMBR by using the mother's personal identification (ID) number. Children's ID numbers were linked with two nationwide registries; the Finnish Hospital Discharge Register and the Cause-of-Death Register at Statistics Finland. Information on all visits was received until 2009 using ICD-10 codes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study includes 1825 children born after FET, 2933 children born after fresh ET and 31 137 children born after spontaneous pregnancies. The risk estimates for diseases were adjusted for the child's year of birth and maternal age, parity, socio-economic status and prematurity. The study focused on the differences between FET and fresh ET children.

MAIN RESULTS AND THE ROLE OF CHANCE

Most health indicators were similar among FET and fresh ET children during the 3-year follow-up. The most common discharge diagnoses, including gastroenteritis and colitis, otitis, upper and lower respiratory diseases, asthma and allergies were similar between the ART groups. A large proportion of FET children (70.1%) and fresh ET children (69.9%) had visited a hospital at least once (P = 0.877). The risk of hospital admission did not differ between the two groups after adjusting for premature births [adjusted odds ratio (aOR) 1.01; 0.88-1.17]. Comparing with children born after spontaneously conceived pregnancies, the risk of hospital admission was slightly increased in the ART group, even after adjusting for premature births (aOR 1.10; 1.02-1.19).

LIMITATIONS, REASONS FOR CAUTION

Due to the study design, we were not able to control for some parental background factors, such as the cause and length of infertility. Furthermore, the health registries do not include data on the growth of the children. Our findings are generalizable only to the slow-freezing method.

WIDER IMPLICATIONS OF THE FINDINGS

Our study provides further evidence of the safety of embryo cryopreservation. The early physical health of FET children is similar to that of children born after fresh ET.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by the University Hospital of Oulu and Helsinki, Finland. The National Institute for Health and Welfare (THL) covered the data linkages and the work of Mika Gissler. There are no competing interests to be reported.

Contribution of IL-12A and IL-12B polymorphisms to Chlamydia trachomatis-specific cell-mediated immune responses

Inherited variance in the IL-12B gene is associated with susceptibility to Chlamydia trachomatis-induced tubal factor infertility and disease severity. In this study, our aim was to discover how polymorphisms in IL-12-coding genes influence C. trachomatis-induced immune responses and IL-12 production. The study population consisted of 240 women. IL-12A and IL-12B single nucleotide polymorphisms (SNPs) were determined from isolated DNA using the Sequenom system with matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry. We studied lymphocyte proliferative (LP) responses to C. trachomatis strains E and F elementary bodies (EBs) and recombinant chlamydial heat-shock protein 60 (CHSP60) antigen. IL-12p40 and IL-12p70 levels were measured using the BD Flex Set method. We found a statistically significant association between the C. trachomatis EB antigen-specific LP response and the rs2853694 SNP (P = 0.02). Our study demonstrates that the IL-12 cytokine family is involved in C. trachomatis-specific immune responses. Moreover, C. trachomatis-induced IL-12 production and the IL-12B rs2853694 SNP partially explain individual variation in the C. trachomatis LP response.

Risk of hypertensive disorders in pregnancies following assisted reproductive technology: a cohort study from the CoNARTaS group

STUDY QUESTION

Is the risk of hypertensive disorders in pregnancies conceived following specific assisted reproductive technology (ART) procedures different from the risk in spontaneously conceived (SC) pregnancies?

SUMMARY ANSWER

ART pregnancies had a higher risk of hypertensive disorders, in particular following cryopreservation, with the highest risk seen in twin pregnancies following frozen-thawed cycles.

WHAT IS KNOWN ALREADY

The risk of hypertensive disorders is higher in ART pregnancies than in SC pregnancies. The increased risk may be partly explained by multiple pregnancies and underlying infertility, but a contribution from specific ART procedures has not been excluded.

STUDY DESIGN, SIZE, DURATION

Population-based cohort study, including sibling design with nationwide data from health registers in Sweden, Denmark and Norway.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All registered ART pregnancies and a sample of SC pregnancies with gestational age ≥22 weeks from 1988 to 2007 were included. ART singleton pregnancies (n = 47 088) were compared with SC singleton pregnancies (n = 268 599), matched on parity and birth year. ART twin pregnancies (n = 10 918) were compared with SC twin pregnancies (46 674). We used logistic regression to estimate adjusted odds ratios and risk differences for hypertensive disorders in pregnancies following IVF, ICSI and fresh or frozen-thawed cycles. We also compared fresh and frozen-thawed cycles within mothers who had conceived following both procedures using conditional logistic regression (sibling analysis).

MAIN RESULTS AND THE ROLE OF CHANCE

Hypertensive disorders were reported in 5.9% of ART singleton and 12.6% of ART twin pregnancies. Comparing singleton pregnancies, the risk of hypertensive disorders was higher after all ART procedures. The highest risk in singleton pregnancies was seen after frozen-thawed cycles [risk 7.0%, risk difference 1.8%, 95% confidence interval (CI) 1.2-2.8]. Comparing twin pregnancies, the risk was higher after frozen-thawed cycles (risk 19.6%, risk difference 5.1%, 95% CI 3.0-7.1), but not after fresh cycles. In siblings, the risk was higher after frozen-thawed cycles compared with fresh cycles within the same mother (odds ratio 2.63, 95% CI 1.73-3.99). There were no clear differences in risk for IVF and ICSI.

LIMITATIONS, REASONS FOR CAUTION

The number of ART siblings in the study was limited. Residual confounding cannot be excluded. In addition, we did not have information on all SC pregnancies in each woman's history, and could therefore not compare risk in ART versus SC pregnancies in the same mother.

WIDER IMPLICATIONS OF THE FINDINGS

Pregnancies following frozen-thawed cycles have a higher risk of hypertensive disorders, also when compared with fresh cycle pregnancies by the same mother. The safety aspects in frozen-thawed cycles merit further attention.

STUDY FUNDING/COMPETING INTERESTS

Funding was received from the European Society for Human Reproduction and Embryology, the University of Copenhagen, the Danish Agency for Science, Technology and Innovation, the Nordic Federation of Societies of Obstetrics and Gynecology and the Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology. None of the authors has any competing interests to declare.

Trends in perinatal health after assisted reproduction: a Nordic study from the CoNARTaS group

STUDY QUESTIONS

Has the perinatal outcome of children conceived after assisted reproductive technology (ART) improved over time?

SUMMARY ANSWER

The perinatal outcomes in children born after ART have improved over the last 20 years, mainly due to the reduction of multiple births.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

A Swedish study has shown a reduction in unwanted outcomes over time in children conceived after ART. Our analyses based on data from more than 92 000 ART children born in four Nordic countries confirm these findings.

STUDY DESIGN

Nordic population-based matched cohort study with ART outcome and health data from Denmark, Finland, Norway and Sweden.

PARTICIPANTS, SETTING AND METHODS

We analysed the perinatal outcome of 62 379 ART singletons and 29 758 ART twins, born from 1988 to 2007 in four Nordic countries. The ART singletons were compared with a control group of 362 215 spontaneously conceived singletons. Twins conceived after ART were compared with all spontaneously conceived twins (n = 122 763) born in the Nordic countries during the study period. The rates of several adverse perinatal outcomes were stratified into the time periods: 1988-1992; 1993-1997; 1998-2002 and 2003-2007 and presented according to multiplicity.

MAIN RESULTS AND ROLE OF CHANCE

For singletons conceived after ART, a remarkable decline in the risk of being born preterm and very preterm was observed. The proportion of ART singletons born with a low and very low birthweight also decreased. Finally, the stillbirth and infant death rates have declined among both ART singletons and twins. Throughout the 20 year period, fewer ART twins were stillborn or died during the first year of life compared with spontaneously conceived twins, presumably due to the lower proportion of monozygotic twins among the ART twins.

LIMITATIONS, REASONS FOR CAUTION

We were not able to adjust for some potential confounders such as BMI, smoking, length or cause of infertility. The Nordic ART populations have changed over time, and in recent years, both less as well as severely reproductive ill couples are being treated. This may have affected the observed trends.

WIDER IMPLICATIONS OF THE FINDINGS

It is assuring that data from four countries confirm an overall improvement over time in the perinatal outcomes of children conceived after ART. Furthermore, data show the beneficial effect of single embryo transfer, not only in regard to lowering the rate of multiples but also concerning the health of singletons.

STUDY FUNDING/COMPETING INTERESTS

The European Society for Human Reproduction and Embryology (ESHRE), the University of Copenhagen and the Danish Agency for Science, Technology and Innovation has supported the project. The CoNARTaS group has received travel and meeting funding from the Nordic Federation of Obstetrics and Gynecology (NFOG). None of the authors has any competing interests to declare.

Effect of IL12A and IL12B polymorphisms on the risk of Chlamydia trachomatis-induced tubal factor infertility and disease severity

BACKGROUND

Interleukin-12 (IL-12) and related cytokines induce activation and differentiation of T cells. Our aim was to investigate the associations between genetic differences in IL-12-family cytokines and the pathogenesis of chlamydial disease.

METHODS

The final study population consisted of 100 women with Chlamydia trachomatis-induced tubal factor infertility (TFI) and 125 pregnant women as controls. Three single nucleotide polymorphisms (SNPs) of IL12A and seven SNPs of IL12B genes were determined from isolated DNA using the Sequenom system with matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry.

RESULTS

We found that the IL12B SNP rs3212227 was associated with both susceptibility and severity of TFI. The minor allele C was rare and only one CC homozygote was found among the controls. AC heterozygotes were more common among TFI cases than among controls (P = 0.009) and were associated with increased risk of TFI [odds ratios (OR) = 2.44, 95% confidence intervals (CI) = 1.23-4.87]. Carrying the minor allele C was also associated with disease severity (P for trend = 0.008) and moderate (OR = 2.51, 95% CI = 1.06-5.95) and severe tubal damage (OR = 2.73, 95% CI = 1.15-6.52).

CONCLUSIONS

The results suggest that variation in the IL12B gene partly explains inter-individual differences in disease susceptibility and severity.

Clinical effectiveness of elective single versus double embryo transfer: meta-analysis of individual patient data from randomised trials

OBJECTIVE

To compare the effectiveness of elective single embryo transfer versus double embryo transfer on the outcomes of live birth, multiple live birth, miscarriage, preterm birth, term singleton birth, and low birth weight after fresh embryo transfer, and on the outcomes of cumulative live birth and multiple live birth after fresh and frozen embryo transfers.

DESIGN

One stage meta-analysis of individual patient data.

DATA SOURCES

A systematic review of English and non-English articles from Medline, Embase, and the Cochrane Central Register of Controlled Trials (up to 2008). Additional studies were identified by contact with clinical experts and searches of bibliographies of all relevant primary articles. Search terms included embryo transfer, randomised controlled trial, controlled clinical trial, single embryo transfer, and double embryo transfer. Review methods Comparisons of the clinical effectiveness of cleavage stage (day 2 or 3) elective single versus double embryo transfer after fresh or frozen in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatments were included. Trials were included if the intervention differed only in terms of the intended number of embryos to be transferred. Trials that involved only blastocyst (day five) transfers were excluded.

RESULTS

Individual patient data were received for every patient recruited to all eight eligible trials (n=1367). A total of 683 and 684 women randomised to the single and double embryo transfer arms, respectively, were included in the analysis. Baseline characteristics in the two groups were comparable. The overall live birth rate in a fresh IVF cycle was lower after single (181/683, 27%) than double embryo transfer (285/683, 42%) (adjusted odds ratio 0.50, 95% confidence interval 0.39 to 0.63), as was the multiple birth rate (3/181 (2%) v 84/285 (29%)) (0.04, 0.01 to 0.12). An additional frozen single embryo transfer, however, resulted in a cumulative live birth rate not significantly lower than the rate after one fresh double embryo transfer (132/350 (38%) v 149/353 (42%) (0.85, 0.62 to 1.15), with a minimal cumulative risk of multiple birth (1/132 (1%) v 47/149 (32%)). The odds of a term singleton birth (that is, over 37 weeks) after elective single embryo transfer was almost five times higher than the odds after double embryo transfer (4.93, 2.98 to 8.18).

CONCLUSIONS

Elective single embryo transfer results in a higher chance of delivering a term singleton live birth compared with double embryo transfer. Although this strategy yields a lower pregnancy rate than a double embryo transfer in a fresh IVF cycle, this difference is almost completely overcome by an additional frozen single embryo transfer cycle. The multiple pregnancy rate after elective single embryo transfer is comparable with that observed in spontaneous pregnancies.

Analyses of polymorphisms in the inflammasome-associated NLRP3 and miRNA-146A genes in the susceptibility to and tubal pathology of Chlamydia trachomatis infection

Susceptibility to Chlamydia trachomatis infections is 40% host based. microRNA-146a is a negative regulator of Tolllike receptor (TLR) signaling and possesses functional polymorphisms which decrease the production of premiR-146a and mature miR-146a. Single nucleotide polymorphisms (SNPs) in NLRP3 are associated with decreased NLRP3 expression and hypoproduction of interleukin (IL)-1beta. We investigated whether the SNPs miR-146a G>C (rs2910164), NLRP3 C>T (rs4925663) and G>A (rs12065526) are associated with the susceptibility to and severity of C. trachomatis infection. The genotypes of three SNPs were tested in two cohorts: cohort 1 consists of Dutch women (n = 318) attending a sexually transmitted disease (STD) clinic and cohort 2 (n = 277) consists of subfertile (n = 184) and healthy Finnish women (n=93). While in cohort 1 the analyzed SNPs were not associated with the susceptibility to C. trachomatis infections (C. trachomatis-positive vs. C. trachomatis-negative), we showed in C. trachomatis-positive women that the NLRP3 mutant AG and AA genotypes were a risk factor for the development of symptoms (P = 0.047, OR = 2.9) and more specifically for having lower abdominal pain (genotype AA: P = 0.022, OR = 31.3). In the Finnish tubal pathology group versus the control group no statistical significant differences in the incidences of the SNPs studied were found, nor for the degree of tubal pathology. In conclusion, the mutant NLRP3 A allele is a risk factor for the development of symptoms, specifically lower abdominal pain, after a C. trachomatis infection in women attending an STD clinic.

Cytokine polymorphisms and severity of tubal damage in women with Chlamydia-associated infertility

Chronic inflammation induced by Chlamydia trachomatis can lead to tubal factor infertility (TFI). To investigate the genetic basis of chlamydial TFI and various manifestations of tubal damage, we studied functional polymorphisms in selected cytokine genes (IL-10 -1082 A/G, -819 T/C, and -592 A/C; IFN-gamma +874 T/A; TNF-alpha -308 G/A; TGF-beta1 codons 10 T/C and 25 G/C; and IL-6 -174 G/C) in 114 women with laparoscopically verified TFI (hereafter known as "cases") and in 176 controls. Evidence of past infection with C. trachomatis was demonstrated in 96 cases by use of a combined test for humoral and cell-mediated immune responses to chlamydial elementary bodies (EBs) and chlamydial heat-shock protein 60 antigens. We found that the IL-10 -1082 AA genotype and the TNF-alpha -308 A allele increased the risk of severe tubal damage in women with infertility associated with C. trachomatis (odds ratio [OR], 7.3 [95% confidence interval {CI}, 1.3-42] and 4.0 [95% CI, 1.0-16], respectively), suggesting that differences in these genes contribute to the wide spectrum of disease manifestations.

Oral health in perimenopausal and early postmenopausal women from baseline to 2 years of follow-up with reference to hormone replacement therapy

Female sex hormones also affect the mouth but there are little data on oral health of menopause age women. This 2-year follow-up study investigated oral health of perimenopausal and early postmenopausal women. Because hormone replacement therapy (HRT) users have been reported to be more health conscious than nonusers, we expected differences between women using and women not using HRT. Of 3,173 women, a random sample of 400 (200 using and 200 not using HRT) was examined. Of them, 161 case-control pairs of women using/not using HRT were reexamined 2 years later. Dental and periodontal status was recorded according to the WHO criteria and resting and stimulated saliva flow was measured. Panoramic tomography of the jaws was taken at baseline and at follow-up. The patients also filled in a structured questionnaire on their systemic health, medication, and health habits. The results were analyzed statistically between and within the groups. No difference was observed in any dental parameters or salivary flow rates between the groups. However, during the follow-up, women in HRT group had received more dental restorations (p<0.05) and they also reported more often recent dental appointments (p<0.05). Although no difference in oral health status or salivary flow rates between women using or not using HRT was found, the observation on dental restorations may indicate a more health conscious attitude in the HRT group.

Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

The aim of this study was to calculate the probability of becoming pregnant after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, and to evaluate complications during pregnancy and childbirth.

METHODS

A questionnaire was posted to 160 women with an IPAA and to 160 controls. The probability of becoming pregnant after IPAA was calculated by the Kaplan-Meier method.

RESULTS

Of 54 women who had undergone IPAA surgery, 36 (67 per cent) succeeded in becoming pregnant naturally, compared with 49 (82 per cent) of 60 controls. The probability of pregnancy after 2 years of trying was 56 per cent in the IPAA group and 91 per cent in the control group (P < 0.001). Women in the IPAA group needed infertility investigations more often (24 versus 10 per cent; P = 0.044). In all, 39 (72 per cent) women in the IPAA group and 53 (88 per cent) in the control group bore a child. Twenty-one of 39 women in the IPAA group and 13 of 53 in the control group had a caesarean section (P = 0.005). Anal incontinence after delivery occurred more often in the control group.

CONCLUSION

Women with an IPAA mostly suffer a reduction in the probability of conception rather than complete infertility. Because complications during pregnancy and delivery were rare, caesarean section should be based mainly on obstetric indications.

Infertility treatment and marital relationships: a 1-year prospective study among successfully treated ART couples and their controls

BACKGROUND

Evidence about the effects of infertility and assisted reproduction technique (ART) on marital relationships is discrepant. Here, we examined the impact of ART on marital relationships. The roles of life stressors, infertility and treatment characteristics in predicting marital relations were also evaluated.

METHODS

SUBJECTS

367 couples with singleton IVF/ICSI pregnancies.

CONTROLS

379 couples with spontaneous singleton pregnancies. Women and men were assessed when the child was 2 months (T2) and 12 months old (T3). They further reported stressful life events at T2 and depression in pregnancy.

RESULTS

No between-group differences were found in marital satisfaction and dyadic cohesion. Dyadic consensus deteriorated from T2 to T3 only among control women. Sexual affection was low among control men at T2 and stressful life events decreased it further. Depression during pregnancy predicted deteriorated marital relations only in control couples. Several unsuccessful treatment attempts were associated with good dyadic consensus and cohesion among ART women. Spontaneous abortions and multiple parity predicted poor marital satisfaction in ART women, whereas long duration of infertility and multiple parity predicted poor marital relations in ART men.

CONCLUSIONS

Successful ART does not constitute a risk for marital adjustment. The shared stress of infertility may even stabilize marital relationships.

Obstetric and neonatal outcome after single embryo transfer

BACKGROUND

Single embryo transfer (SET) pregnancies practically lack vanishing twins and may be associated with improved neonatal outcome. Our objective was to compare the obstetric and neonatal outcome of SET singletons with the outcome of singletons following double embryo transfer (DET) and spontaneous conception.

METHODS

A 7-year (1997-2003) cohort of fresh SET (n = 269) and DET (n = 230, including 25 vanishing twins) cycles resulting in singleton birth at Helsinki University Central Hospital, Finland, was linked to the Finnish Medical Birth Register and the obstetric and neonatal outcome data compared with that from 15 037 spontaneously conceived singleton pregnancies.

RESULTS

The obstetric and neonatal outcome of the SET group was comparable to that in the DET group. Compared with the comparison cohort, gestational hypertension (P = 0.005), placenta praevia (P < 0.001), preterm contractions (P = 0.01) and maternal hospitalization (P < 0.001) was more typical of women in the SET group. After adjusting for age, parity and socio-economic status the SET pregnancies showed increased risks of Caesarean section [odds ratio (OR) 1.54 with 95% confidence interval (CI) 1.18-2.00], preterm birth (OR 2.85; 95% CI 1.96-4.16) and low birthweight (OR 2.01; 95% CI 1.19-3.99) compared with the comparison cohort.

CONCLUSIONS

Our results indicate that subject- and infertility-related mechanisms other than the number of transferred embryos influence the neonatal outcome of singleton IVF pregnancies.

Fear of Childbirth and Pregnancy-Related Anxiety in Women Conceiving With Assisted Reproduction

OBJECTIVE

To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies.

METHODS

The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 +/- 3.2 (mean+/-standard deviation).

RESULTS

The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2-0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2-16.9).

CONCLUSION

Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth.

LEVEL OF EVIDENCE

II-2.