Assisted reproductive techniques and the risk of anorectal malformations: a German case-control study

BACKGROUND

The use of assisted reproductive techniques (ART) for treatment of infertility is increasing rapidly worldwide. However, various health effects have been reported including a higher risk of congenital malformations. Therefore, we assessed the risk of anorectal malformations (ARM) after in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

METHODS

Data of the German Network for Congenital Uro-REctal malformations (CURE-Net) were compared to nationwide data of the German IVF register and the Federal Statistical Office (DESTATIS). Odds ratios (95% confidence intervals) were determined to quantify associations using multivariable logistic regression accounting for potential confounding or interaction by plurality of births.

RESULTS

In total, 295 ARM patients born between 1997 and 2011 in Germany, who were recruited through participating pediatric surgeries from all over Germany and the German self-help organisation SoMA, were included. Controls were all German live-births (n = 10,069,986) born between 1997 and 2010. Overall, 30 cases (10%) and 129,982 controls (1%) were born after IVF or ICSI, which translates to an odds ratio (95% confidence interval) of 8.7 (5.9-12.6) between ART and ARM in bivariate analyses. Separate analyses showed a significantly increased risk for ARM after IVF (OR, 10.9; 95% CI, 6.2-19.0; P < 0.0001) as well as after ICSI (OR, 7.5; 95% CI, 4.6-12.2; P < 0.0001). Furthermore, separate analyses of patients with isolated ARM, ARM with associated anomalies and those with a VATER/VACTERL association showed strong associations with ART (ORs 4.9, 11.9 and 7.9, respectively). After stratification for plurality of birth, the corresponding odds ratios (95% confidence intervals) were 7.7 (4.6-12.7) for singletons and 4.9 (2.4-10.1) for multiple births.

CONCLUSIONS

There is a strongly increased risk for ARM among children born after ART. Elevations of risk were seen after both IVF and ICSI. Further, separate analyses of patients with isolated ARM, ARM with associated anomalies and those with a VATER/VACTERL association showed increased risks in each group. An increased risk of ARM was also seen among both singletons and multiple births.

[LFA-1 defect: a rare granulocyte function disorders as a cause of therapy-resistant omphalitis in newborn infants]

A newborn infant suffered from severe omphalitis resistant to antibiotic therapy. The combination of the symptoms: delayed separation of the umbilical cord, omphalitis, impairment of wound-healing and extreme leukocytosis led to the diagnosis of LFA-1 (leukocyte function antigen)-deficiency, which was confirmed by monoclonal antibodies. The pathophysiology of this disorder is described shortly.

[Pathophysiology of urethral valves]

The pathophysiology of congenital urinary tract obstruction by posterior urethral valves is reviewed. Emphasis is on the effects of fetal urinary obstruction on the development of the structure and functioning of the urinary system and of the kidney, including the correlation between renal dysplasia and vesicoureteral reflux. Possibilities of surgery and drug treatment are discussed.

[Late results following partial and total colectomy in infancy]

26 children were investigated on an average 11.5 years after partial (n = 13) and total (n = 13) colonic resection. Total colectomy was followed by an increased frequency of gastrointestinal symptoms such as recurrent abdominal pain, flatulence, attacks of diarrhoea, frequent and pasty or liquid stools with strange smell. An increased salt or fluid intake was observed in one half of these patients. Their height and bone age was slightly but significantly reduced. Laboratory investigations revealed no significant deficiencies of electrolyts, vitamins or trace elements. However Renin (mean and 2s-range = 5.2; 2.7-6.8 ng/ml.h, normal values (NV) 1.3; 0.5-4.0 ng/ml.h, p less than 0.02), aldosterone (242.1; 168.4-357.8 pg/ml, NV 78.9; 39.4-168.4 pg/ml, *p less than 0.02), conjugated bile acids (11.3; 5.2-20.0 mumol/1, NV 4.2; 1.5-7.0 mumol/1, p less than 0.01) and serum urea concentration (32.5; 20.8-48.7 mg/dl, NV 14.6; 6.0-22.5 mg/dl, p less than 0.01) were significantly elevated. Three postprandial plasma levels of gastrin, VIP and neurotensin were within normal limits. In patients with partial large bowel resection all signs were less pronounced. According to our results a special diet in children years after colectomy seems not to be required.

[Sonographic detection and consequences of prenatally recognizable abnormalities]

Four cases of a fetal malformation and the antenatal diagnosis by ultrasound are reported (omphalocele, hydronephrosis, hydrocephaly, esophagus atresia). In our clinic about 50% of all fetuses with a malformation presented one of the reported anomalies. The obstetric, neonatale and surgical cooperation is essential in the management of the delivery and will improve fetal outcome. Frequently associated malformations are discussed.

[Anemic infarct of the liver following blunt abdominal trauma]

Particularly in childhood, ischaemias of the liver are very rare. This is due to numerous collateral vessels and a dual blood supply of the liver. We, therefore, report on a 2-year old boy who suffered from an anaemic infarction of the whole left lobe of the liver after a fall. The clinical course and findings, including histology, are described. After resection of the left lobe the boy was free of symptoms.

[Peculiarities of burns in childhood]

In contrast to adults the protein and energy loss leads to hypermetabolism in the burned child. This is because their glycogen and fat reserves are limited. The catabolism finds expression in the rapid loss of weight resulting from reduction of the structure proteins. Therapeutic consequences will be discussed in this paper. Furthermore cases will be demonstrated where extensive third degree burns were able to be treated by mixed allografts and autografts.

[Roentgen diagnosis of statically-induced chronic fractures]

Three patients with statically conditioned non-traumatic permanent fractures are presented. X-ray morphology classification criteria and commonly used definitions are presented, basing on an extensive list of references. Different non-traumatic fracture types are demarcated according to roentgenological and aetiological criteria. Typical characteristics of permanent fractures are highlighted and illustrated by means of pictorial representations.

[Echinococcosis in children--a case contribution]

Hydatid disease, or echinococcosis, is the most dangerous type of parasitosis in man in Europe. Two types are of clinical importance, namely, alveolar hydatid disease caused by Echinococcus multilocularis and cystic hydatid disease caused by Echinococcus granulosus. Cystic hydatid disease is characterised by an expansive growth via the formation of single or multiple cysts expanding in such a manner that they cause symptoms of space-occupying lesions, whereas the cysts of Echinococcus multilocularis undergo endogenous budding forming aggregates of innumerable small cysts honeycombing and even infiltrating the affected organ like a malignant tumour unlimited by the natural boundaries of the organ. Usually it takes about 10-15 years before the disease becomes manifest after the infection, because it is only then that compression of the surrounding organ tissue gives rise to symptoms. Hence, echinococcus disease is rare in children. The article reports on 7 children treated for Echinococcus granulosus. Complete exstirpation of the hydatid tissue is the treatment of choice. This is mostly achieved because of the benign nature of the growth. Chemotherapy remains an exception to the rule.

[Peritovenous shunt (Denver Shunt) in therapy resistant ascites in childhood]

This paper describes a 14 year old girl with massive, intractable ascites. After implantation of a peritoneovenous shunting-system (Denver-Shunt) the ascites completely disappeared and the girl's state of health improved markedly. Although the surgical procedure is simple many problems may arise postoperatively which demand intensive monitoring. As there is almost no experience in childhood a shunting-system should only be employed if medical therapy has failed over a long period and respiration, mobility or nutrition of the child is considerably affected by the ascites.

[Contribution of radiology to the postoperative after care of patients with colorectal tumors]

The prognosis of local recurrences after surgery for colorectal cancer is better than in recurrences of many other tumor sites. Since in most cases secondary tumor growth takes place as local recurrence and distant metastases are infrequent, there is a good chance of detecting the recurrence early in a curable state. This offers good conditions for a radical second operation. Following excision of tumors, double-contrast enema permits a very detailed assessment of the anastomosis, allowing detection of small local recurrences and recognition of postoperative changes or sequelae of delayed healing at the site of the anastomosis. Following amputation of the rectum, computed tomography permits better control of the presacral space than other conventional radiodiagnostic procedures. In both situations, however, integration of both methods is necessary in a consequent time schedule of clinical follow-up with suitable intervals.

[Correlation between changes of bowel metabolism and of the small bowel mucosa after extensive small bowl resection- animal experiments (author's transl)]

The estimation of the bile acids in the liver and changes in the mucosa of the small intestine after extensive resection of the small bowel are reported. It is shown that through the implantation of an isoperistaltic segment a delay of the intestinal passage was achieved, which resulted in better contact between chyme and intestinal mucosa, as well as in a faster and more prominent hypertrophy of the mucosa of the small intestine. As a consequence of the hypertrophy, the resorption of bile acids in the small intestine was much improved.

[Pulmonary blastoma in a 4 year old girl (author's transl)]

A case of a pulmonary blastoma is presented. The tumor's histological demarcation is difficult and contested. The diagnosis was delivered by two independent pathologists. Because of the malignancy of the tumor we decided on a combined surgical-cytostatic-radiological therapy, which has not yet been done in this way. The patient was symptom-free for 6 months, she then died however, from a brain metastasis.

[Congenital megacolon in adults]

Hirschsprung's disease is reported in 11 adults. About half of the patients had had previous surgery without relief of their symptoms. Diagnosis is established by a history of obstinate constipation since birth, the physical finding of abdominal distension and signs of large bowel obstruction without mechanical impediment. The definite diagnosis of Hirschsprung's disease rests on the demonstration of the absence of intramural ganglion cells in the rectum. The patients reported on underwent either the Rehbein-type operation or the Duhamel retrorectal pull-through. A three-stage procedure is recommended. Late results were satisfactory with both techniques provided there had been adequate resection of the aganglionic segment and anal dilatation to overcome the spasm of the internal anal sphincter.

[Solitary nonparasitic cysts of the liver in childhood (author's transl)]

3 patients with solitary, non-parasitic cysts of the liver are reported. 2 of these were seen in infants and one in a 7 year old child. The clinical presentation, diagnosis and treatment are discussed. Complete excision of the cyst is the treatment of choice and the various operative procedures described in the literature are discussed. The macroscopic and microscopic findings of these cysts are described.

[The postoperative course following antireflux operations for vesico ureteral reflux (author's transl)]

The authors report 779 ureters related to vesico-ureteric reflux. 602 were treated by the method of Politano-Leadbetter and 177 by the method of Grégoir. Follow-up observations in these patients showed lesions requiring further surgery in relation to bleeding, stone-formation in the urinary tract and lesions of the bladder wall. The question of postoperative urinary obstruction and recurrent reflux was stressed and the problems related to the indication for surgery for vesico-ureteric reflux in infancy are discussed.

Intramural ganglion cell degeneration in inflammatory bowel disease

Comparable histologic alterations of intramural nervous tissue were reported in various diseases of the small and large intestine. In 6 cases, an intestinal obstruction was present which led to secondary intramural inflammation. The obstruction was induced by the spastic segment in Hirschsprung's disease (3 cases), by rectal atresia (2 cases) and by postoperative ischemic damage to the intestinal wall (1 case). In 4 other patients, the inflammation was predominant. The diseases considered were necrotizing enterocolitis (1 case), membranous enteritis (1 case) and Crohn's disease (2 cases). On the one hand, inflammatory infiltration composed primarily of lymphocytes was observed histologically in various degrees proximal to the obstruction in all cases. On the other, comparable alterations were found in splittering of nerve fibers and deterioration of nerve cells (degenerative alterations) in the plexus myentericus as well as hyperplasia and hyperchromasia of ganglion cells. Schwann cell proliferation and fibrosis in nerve fibers (reactive alterations). Until now such alterations were only observed in Chagas' disease and in ulcerative colitis, especially complicated by toxic megacolon. It is suspected that the neurodegenerative alterations in these diseases are toxically induced.

[Toxic megaileum. Relapse of ulcerative colitis in the ileum following colectomy]

A 19 year old male patient suffered from ulcerative colitis and was colectomized 5 1/2 years ago. He presented now with an acute illness, characterized by massive discharges from the ileostoma, fever, leucocytosis, meteroism, melaena and a tender abdomen. A severe ulcerative inflammation of the total ileum was found. A "toxic megaileum" developed. At an operation the ileum was opened and drained. The patient recoverd under treatment with prednisolone, salazosulfypyridine, parenteral nutrition and Vivasorb. It is suggested that in this case the severe ileitis was due to the same disease which led to the total colectomy 5 1/2 years ago: ulcerative colitis.

[Histochemical studies on innervation of the distal ureter in primary vesico-ureteral reflux in children (author's transl)]

The purpose of the present investigation was to evaluate the distribution-pattern of the intramural vegetative nerve fibres in cases of vesico-ureteral reflux. Resected specimens of the vesico-ureteral junction of 14 children with primary vesico-ureteral reflux are investigated using histochemical technics for demonstrating acetylcholinesterase (El Badawi and Schenk, 1967). Additionally the catecholamines (Falck et al. 1962) were demonstrated in two of the cases. The results are compared with findings in normal ureters in literature. There was no evidence of a pathological pattern of distribution of the nerve fibres.