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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTEREST(S)

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

TRIAL REGISTRATION NUMBER

N/A.

International Committee for Monitoring Assisted Reproductive Technologies world report: Assisted Reproductive Technology 2008, 2009 and 2010

STUDY QUESTION

What were utilization, outcomes and practices in assisted reproductive technology (ART) globally in 2008, 2009 and 2010?

SUMMARY ANSWER

Global utilization and effectiveness remained relatively constant despite marked variations among countries, while the rate of single and frozen embryo transfers (FETs) increased with a concomitant slight reduction in multiple birth rates.

WHAT IS KNOWN ALREADY

ART is widely practised in all regions of the world. Monitoring utilization, an approximation of availability and access, as well as effectiveness and safety is an important component of universal access to reproductive health.

STUDY DESIGN, SIZE, DURATION

This is a retrospective, cross-sectional survey on utilization, effectiveness and safety of ART procedures performed globally from 2008 to 2010.

PARTICIPANTS, SETTING, METHODS

Between 58 and 61 countries submitted data from a total of nearly 2500 ART clinics each year. Aggregate country data were processed and analyzed based on forms and methods developed by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART). Results are presented at country, regional and global level.

MAIN RESULTS AND THE ROLE OF CHANCE

For the years 2008, 2009 and 2010, >4 461 309 ART cycles were initiated, resulting in an estimated 1 144 858 babies born. The number of aspirations increased by 6.4% between 2008 and 2010, while FET cycles increased by 27.6%. Globally, ART utilization remained relatively constant at 436 cycles/million in 2008 and 474 cycles/million population in 2010, but with a wide country range of 8-4775 cycles/million population. ICSI remained constant at around 66% of non-donor aspiration cycles. The IVF/ICSI combined delivery rate (DR) per fresh aspiration was 19.8% in 2008; 19.7% in 2009 and 20.0% in 2010, with corresponding DRs for FET of 18.8, 19.7 and 20.7%. In fresh non-donor cycles, single embryo transfer increased from 25.7% in 2008 to 30.0% in 2010, while the average number of embryos transferred fell from 2.1 to 1.9, again with wide regional variation. The rates of twin deliveries following fresh non-donor transfers were, in 2008, 2009 and 2010, 21.8, 20.5 and 20.4%, respectively, with a corresponding triplet rate of 1.3, 1.0 and 1.1%. Fresh IVF and ICSI carried a perinatal mortality rate per 1000 births of 22.8 (2008), 19.2 (2009) and 21.0 (2010), compared with 15.1, 12.8 and 14.6/1000 births following FET in the same periods of observation. The proportion of women aged 40 years or older undergoing non-donor ART increased from 20.8 to 23.2% from 2008 to 2010.

LIMITATIONS, REASON FOR CAUTION

The data presented are reliant on the quality and completeness of data submitted by individual countries. This report covers approximately two-thirds of the world ART activity.

WIDER IMPLICATIONS OF FINDINGS

The ICMART World Reports provide the most comprehensive global statistical census and review of ART utilization, effectiveness, safety and quality. While ART treatment continues to increase globally, the wide disparities in access to treatment and embryo transfer practices warrant attention by clinicians and policy makers.

STUDY FUNDING/COMPETING INTERESTS

The authors declare no conflict of interest and no specific support from any organizations in relation to this manuscript. ICMART acknowledges financial support from the following organizations: American Society for Reproductive Medicine; European Society for Human Reproduction and Embryology; Fertility Society of Australia; Japan Society for Reproductive Medicine; Japan Society of Fertilization and Implantation; Red Latinoamericana de Reproduccion Asistida; Society for Assisted Reproductive Technology; Government of Canada (Research grant), Ferring Pharmaceuticals (Grant unrelated to World Reports).

TRIAL REGISTRATION

not applicable.

International Committee for Monitoring Assisted Reproductive Technologies (ICMART) world report: assisted reproductive technology 2004

STUDY QUESTION

Have changes in assisted reproductive technology (ART) practice and outcomes occurred globally between 2003 and 2004?

SUMMARY ANSWER

Globally, ART practice has changed with an increasing prevalence of the use of ICSI rather than conventional IVF. In 2004, a small but increasing number of countries are incorporating single embryo transfer. There remain unacceptably high rates of three or more embryo transfers in select countries resulting in multiple births and adverse perinatal outcomes.

WHAT IS KNOWN ALREADY

World data on the availability, effectiveness and safety of ART have been published since 1989. The number of embryos transferred is a major determinant of the iatrogenic increase in multiple pregnancies and is highly correlated with the likelihood of multiple birth and excess perinatal morbidity and mortality.

STUDY DESIGN, SIZE, DURATION

Cross-sectional survey of countries and regions undertaking surveillance of ART procedures started in 2004 and their corresponding outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of total, 2184 clinics from 52 reporting countries and regions. Number of ART clinics, types of cycles and procedures, pregnancy, delivery and multiple birth rates and perinatal outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 954 743 initiated cycles resulted in an estimated 237 809 babies born. This was a 2.3% increase in the number of reported cycles from 2003. The availability of ART varied by country and ranged from 14 to 3844 treatment cycles per million population. Over one-third (37.2%) of ART clinics performed <100 cycles per year with only 19.9% performing ≥ 500 cycles per year. Of all cycles, 60.6% were ICSI. Frozen embryo transfers (FETs) represented 31% of the initiated cycles. The overall delivery rate per fresh aspiration for IVF and ICSI was 20.2% compared with 16.6% per FET. The average number of embryos transferred was 2.35. Single (16.3%) and double embryo transfers accounted for 73.2% of cycles. The overall proportion of deliveries with twins and triplets from IVF and ICSI was 25.1 and 1.8%, respectively, but varied widely by country and region. The proportion of premature deliveries per fresh aspiration for IVF and ICSI was 33.7% compared with 26.3% per FET. The perinatal death rate was 25.8 per 1000 births for fresh aspiration for IVF and ICSI compared with 14.2 per 1000 births per FET.

LIMITATIONS, REASONS FOR CAUTION

Data are incomplete with seven countries not providing data to the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in 2004 that had in 2003. The validity of data reflects current data collection practice. In 2004, 79.3% of the clinics in participating countries reported to their national or regional registries and to ICMART. In addition, the number of ART cycles per million population is a measure which is affected by a country's government policy, regulation, funding and the number of service providers.

WIDER IMPLICATIONS OF THE FINDINGS

ART practice, effectiveness and outcomes vary markedly internationally. Notably, the increasing proportion of cycles that are FET, the change in practice to single embryo transfer and the cessation of the transfer of three or more embryos in some countries has resulted in improved perinatal outcomes with minimal impact on pregnancy rates.

STUDY FUNDING/COMPETING INTEREST(S)

ICMART receives financial support from ASRM, ESHRE, FSA, Japan Society for Reproductive Medicine, REDLARA, MEFS and SART.

Why do singletons conceived after assisted reproduction technology have adverse perinatal outcome? Systematic review and meta-analysis

BACKGROUND

Assisted reproduction technology (ART) is used worldwide, at increasing rates, and data show that some adverse outcomes occur more frequently than following spontaneous conception (SC). Possible explanatory factors for the well-known adverse perinatal outcome in ART singletons were evaluated.

METHODS

PubMed and Cochrane databases from 1982 to 2012 were searched. Studies using donor or frozen oocytes were excluded, as well as those with no control group or including <100 children. The main outcome measure was preterm birth (PTB defined as delivery <37 weeks of gestation), and a random effects model was used for meta-analyses of PTB. Other outcomes were very PTB, low-birthweight (LBW), very LBW, small for gestational age and perinatal mortality.

RESULTS

The search returned 1255 articles and 65 of these met the inclusion criteria. The following were identified as predictors for PTB in singletons: SC in couples with time to pregnancy (TTP) > 1 year versus SC singletons in couples with TTP ≤ 1 year [adjusted odds ratio (AOR) 1.35, 95% confidence interval (CI) 1.22, 1.50]; IVF/ICSI versus SC singletons from subfertile couples (TTP > 1 year; AOR 1.55, 95% CI 1.30, 1.85); conception after ovulation induction and/or intrauterine insemination versus SC singletons where TTP ≤ 1 year (AOR 1.45, 95% CI 1.21, 1.74); IVF/ICSI singletons versus their non-ART singleton siblings (AOR 1.27, 95% CI 1.08, 1.49). The risk of PTB in singletons with a 'vanishing co-twin' versus from a single gestation was AOR of 1.73 (95% CI 1.54, 1.94) in the narrative data. ICSI versus IVF (AOR 0.80, 95% CI 0.69-0.93), and frozen embryo transfer versus fresh embryo transfer (AOR 0.85, 95% CI 0.76, 0.94) were associated with a lower risk of PTB.

CONCLUSIONS

Subfertility is a major risk factor for adverse perinatal outcome in ART singletons, however, even in the same mother an ART singleton has a poorer outcome than the non-ART sibling; hence, factors related to the hormone stimulation and/or IVF methods per se also may play a part. Further research is required into mechanisms of epigenetic modification in human embryos and the effects of cryopreservation on this, whether milder ovarian stimulation regimens can improve embryo quality and endometrial conditions, and whether longer culture times for embryos has a negative influence on the perinatal outcome.

Assisted reproductive technology in Europe, 2008: results generated from European registers by ESHRE

BACKGROUND

This 12th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2008.

METHODS

From 36 countries (3 more compared with 2007), 1051 clinics reported 532 260 treatment cycles including: IVF (124 539), ICSI (280 552), frozen embryo replacements (FER, 97 120), egg donation (ED, 13 609), in vitro maturation (IVM, 562), preimplantation genetic diagnosis/screening (PGD/PGS, 2875) and frozen oocyte replacements (FOR, 4080). Overall, this represents a 7.9% increase in the activity since 2007, which is mainly related to an increase in cycles from almost all registers and only partially to the new countries entering EIM (Estonia, Kazakhstan, Moldova and Romania, 5480 cycles in total). European data on intrauterine insemination using husband/partner's (IUI-H) and donor (IUI-D) semen were reported from 27 and 21 countries, respectively. A total of 144 509 IUI-H (+1.5%) and 24 960 IUI-D (-4.3%) cycles were included.

RESULTS

In 19 countries where all clinics reported to the ART register, a total of 350 143 ART cycles were performed in a population of 369.8 million, corresponding to 947 cycles per million inhabitants. For IVF, the clinical pregnancy rates per aspiration and per transfer were 28.5 and 32.5%, respectively, and for ICSI the corresponding rates were 28.7 and 31.9%. In FER cycles, the pregnancy rate per thawing was 19.3%. The delivery rate after IUI was 9.1% for IUI-H and 13.8% for IUI-D. In IVF and ICSI cycles, one, two, three and four or more embryos were transferred in 22.4, 53.2, 22.3 and 2.1%, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (combined) were 78.3, 20.7 and 1.0%, respectively, resulting in a total multiple delivery rate of 21.7%, compared with 22.3% in 2007, 20.8% in 2006 and 21.8% in 2005. In FER cycles, the multiple delivery rate was 13.7% (13.4% twins and 0.3% triplets). In women undergoing IUI, twin and triplet deliveries occurred in 10.6% and 0.7% with IUI-H and in 9.4 and 0.3% with IUI-D, respectively.

CONCLUSIONS

In comparison with previous years, there was an increase in the reported number of ART cycles in Europe. For the first time in 5 years, the pregnancy rates failed to show a year-on-year increase. Compared with 2007, the number of transfers of multiple embryos (3+) and a multiple delivery rate showed a marginal decline.

Assisted reproductive technology in Europe, 2007: results generated from European registers by ESHRE

BACKGROUND

This 11th European IVF-monitoring report presents the results of assisted reproductive technology (ART) treatments initiated in Europe during 2007.

METHODS

From 33 countries, 1029 clinics reported 493 184 treatment cycles: IVF (120 761), ICSI (256 642), frozen embryo replacement (91 145), egg donation (15 731), preimplantation genetic diagnosis/preimplantation genetic screening (4638), in vitro maturation (660) and frozen oocytes replacements (3607). Overall, this represents a 7.6% increase since 2006, mostly related to an increase in all registers. IUI using husband/partner's (IUI-H) and donor (IUI-D) semen was reported from 23 countries: 142 609 IUI-H (+6.2%) and 26 088 IUI-D (+7.2%).

RESULTS

In 18 countries where all clinics reported, 376 971 ART cycles were performed in a population of 425.6 million (886 cycles per million). The clinical pregnancy rates per aspiration and per transfer were 29.1 and 32.8% for IVF, and 28.6 and 33.0% for ICSI. Delivery rate after IUI-H was 10.2% in women aged < 40 years. In IVF/ICSI cycles, 1, 2, 3 and ≥4 embryos were transferred in 21.4, 53.4, 22.7 and 2.5% of cycles, with no decline in the number of embryos per transfer since 2006. The proportion of multiple deliveries (22.3: 21.3% twin and 1.0% triplet), did not decrease compared with 2006 (20.8%) and 2005 (21.8%). In women < 40 years undergoing IUI-H, twin deliveries occurred in 11.7% and triplets in 0.5%.

CONCLUSIONS

In comparison with previous years, the reported number of ART cycles in Europe increased in 2007; pregnancy rates increased marginally, but the earlier decline in the number of embryos transferred and multiple births did not continue.

The methodological quality of clinical guidelines of the European Society of Human Reproduction and Embryology (ESHRE)

BACKGROUND

Clinical practice guidelines bridge the gap between the evidence from literature and clinical practice, and they may provide guidance in ethical, legal and societal dilemmas. To explore the potentials for future international guideline development within the field of human reproduction and embryology, we assessed the quality of existing guidelines produced by the European Society of Human Reproduction and Embryology (ESHRE).

METHODS

We systematically searched for the ESHRE guidelines produced after 1996 in electronic databases and on the Internet. Subsequently, we assessed the methodological quality of these guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument.

RESULTS

The overall methodological quality of most of the 11 selected ESHRE guidelines was poor. Most of the guidelines scored <30% in the domains of 'stakeholder involvement', 'rigour of development', 'applicability' and 'editorial independence'. Only one guideline was rated 'strongly recommended'.

CONCLUSIONS

The methodological quality of the guidelines produced under the auspices of ESHRE can be improved. We suggest a systematic, up-to-date methodology, investment in guideline development specialists, systematic quality control and the incorporation of indicator development. Furthermore, attention should be paid to the document nomenclature, and an ESHRE guidelines' summary on a special part of the ESHRE website would be a good initiative.

Assisted reproductive technology in Europe, 2004: results generated from European registers by ESHRE

BACKGROUND

European results of assisted reproductive techniques from treatments initiated during 2004 are presented in this eighth report.

METHODS

Data were mainly collected from existing national registers. From 29 countries, 785 clinics reported 367,066 treatment cycles including: IVF (114,672), ICSI (167,192), frozen embryo replacement (FER, 71,997), egg donation (ED, 10 334), preimplantation genetic diagnosis/screening (PGD/PGS, 2701) and in vitro maturation (IVM, 170). Overall, this represents only a marginal increase since 2003, due to a huge reduction in treatments in Germany. European data on intrauterine insemination using husband/partner's semen (IUI-H) and donor semen (IUI-D) were reported from 20 countries. A total of 115,980 cycles (IUI-H, 98,388; IUI-D, 17,592) were included.

RESULTS

In 14 countries where all clinics reported to the IVF register, a total of 248,937 ART cycles were performed in a population of 261.6 million, corresponding to 1095 cycles per million inhabitants. For IVF, the clinical pregnancy rates per aspiration and per transfer were 26.6% and 30.1%, respectively. For ICSI, the corresponding rates were 27.1% and 29.8%. After IUI-H, the clinical pregnancy rate was 12.6% in women below 40. After IVF and ICSI, the distribution of transfer of 1, 2, 3 and 4 or more embryos was 19.2%, 55.3%, 22.1% and 3.3%, respectively. Compared with 2003, fewer embryos were transferred, but huge differences still existed between countries. The distribution of singleton, twin and triplet deliveries after IVF and ICSI combined was 77.2%, 21.7% and 1.0%, respectively. This gives a total multiple delivery rate of 22.7% compared with 23.1% in 2003 and 24.5% in 2002. After IUI-H in women below 40 years of age, 11.9% were twin and 1.3% triplet gestations.

CONCLUSIONS

Compared with earlier years, the reported number of ART cycles in Europe increased and the pregnancy rates increased marginally, even though fewer embryos were transferred and the multiple delivery rates were reduced.

Assisted reproductive technology in Europe, 2003. Results generated from European registers by ESHRE

BACKGROUND

European results of assisted reproductive techniques (ARTs) from treatments initiated during 2003 are presented in this seventh report.

METHODS

Data were mainly collected from already existing national registers. From 28 countries, 725 clinics reported 365 103 treatment cycles with: IVF 132 932, ICSI 162 149, frozen embryo replacement (FER) 60 412, oocyte donation (OD) 7548, PGD/PGS 1956 and IVM 109. Overall, this represents a 13% increase since 2002. For the third time, results on European data on intrauterine inseminations (IUIs) were reported from 19 countries. A total of 99 577 cycles (IUI-H, 82 834; IUI-D, 16 743) were included.

RESULTS

In those 15 countries where all clinics reported to the register, a total of 284 765 cycles were performed in a population of 278.7 million, corresponding to 1022 cycles per million inhabitants. For IVF, the clinical pregnancy rates per aspiration and per transfer were 26.1 and 29.6%, respectively. For ICSI, the corresponding rates were 26.5 and 28.7%. After IUI-H, the clinical pregnancy rate was 12.2% in women below 40 years and 8.8% in women > or =40 years. After IVF and ICSI, the distribution of transfer of one, two, three and four or more embryos was 15.7, 55.9, 24.9 and 3.5%, respectively. Compared to the year 2002, fewer embryos were transferred, but huge differences still exist between countries. The distribution of singleton, twin and triplet deliveries for IVF and ICSI combined was 76.7, 22.0 and 1.1%, respectively. This gives a total multiple delivery rate of 23.1% compared with 24.5% in 2002. The range of triplet deliveries after IVF and ICSI varied from 0.0 to 4.4% between countries. After IUI-H in women below 40 years of age, 11.4% were twin and 2.2% triplet gestations.

Attitudes towards and management of single embryo transfer among Nordic IVF doctors

BACKGROUND

The objective of this study was to investigate the attitudes towards and management of single embryo transfer(SET) among Nordic in vitro fertilisation (IVF) doctors, and to present the rate of SET and multiple pregnancies in the different countries.

METHODS

A questionnaire was sent to all IVF doctors in the Nordic countries (n=198, 78.5% responded). Pregnancy rates, SET and multiple births rates were extracted from registries. Main outcome measure was attitudes and management of SET.

RESULTS

Almost all doctors thought that a twin pregnancy compared unfavourably to a singleton. A twin rate >10% was acceptable for 5% of Swedish doctors. Corresponding figures for Finnish, Danish and Norwegian doctors were 21, 35 and 35%, respectively. For a woman <36 years, performing her first cycle and with two good quality embryos, almost all doctors would recommend SET. For a woman ≥ 36 years in a similar situation, SET would be recommended only in Sweden and Finland. The pregnancy rate per embryo transfer (ET), the SET rate 2003, the multiple birth rate, and the estimated SET rate 2004 were 33.3, 21.5, 22.7 and 25% (Denmark), 31.3, 43.4, 14 and 51%(Finland), 40.5, 10.5, 26.5 and 16% (Iceland), 30.6, 18, 25.2 and 26% (Norway), and 35.3, 55.1, 11.8 and 71% (Sweden).

CONCLUSIONS

The SET and multiple birth rates reflect the attitudes of Nordic IVF doctors to SET and multiple births well.When introducing SET, the attitude of the IVF doctor seems to be important.

Assisted reproductive technology in Europe, 2002. Results generated from European registers by ESHRE

European results of assisted reproductive techniques (ART) from treatments initiated during 2002 are presented in this sixth report. Data was mainly collected from already existing national registers. From 25 countries, 631 clinics reported 324,238 treatment cycles with: IVF 122,634, ICSI 135,048, frozen embryo replacement (FER) 57 162, egg donation (ED) 7677, preimplantation genetic diagnosis/screening (PGD/PGS) 1563 and in vitro maturation (IVM) 154. Overall this represents a 12% increase since year 2001. For the second time, results on European data on intrauterine inseminations were reported from 17 countries. A total of 93,284 cycles [IUI-husband/partner (H), 78 505 and IUI-donor (D), 14,779] were included. In 13 countries where all clinics reported to the register, a total of 177,429 cycles were performed in a population of 193.7 million, corresponding to 916 cycles per million inhabitants. For IVF the clinical pregnancy rate per aspiration and per transfer was 26.0 and 29.5%, respectively. For ICSI the corresponding rates were 27.2 and 29.4%. These figures are marginally better than in 2001. After IUI-H the clinical pregnancy rate was 11.6% in women below 40 and 7.8% in women>or=40 years of age. After IVF and ICSI the distribution of transfer of 1, 2, 3 and 4 or more embryos was 13.7, 54.8, 26.9 and 4.7%, respectively. Compared with year 2001, less embryos were transferred, but huge differences existed between countries. The distribution of singleton, twin and triplet deliveries for IVF and ICSI combined was 75.5, 23.2 and 1.3%, respectively. This gives a total multiple delivery rate of 24.5%, compared with 25.5% in year 2001. The range of triplet deliveries after IVF and ICSI varied from 0.0 to 5.2% between countries. After IUI-H in women below 40 years of age, 10.2% were twin and 1.3% triplet gestations.

In vitro fertilisation in Sweden: obstetric characteristics, maternal morbidity and mortality

OBJECTIVE

To investigate obstetric characteristics, maternal morbidity and mortality among Swedish women giving birth after in vitro fertilisation (IVF) treatment.

DESIGN

Register study.

SETTING

Nationwide study in Sweden.

SAMPLE

All women known to have had IVF in Sweden 1982-2001.

METHODS

Using Swedish health registers, women who had given birth after IVF were identified from all Swedish IVF clinics and compared with all women who gave birth. Analysis was performed with the Mantel-Haenszel technique.

MAIN OUTCOME MEASURES

Diagnoses during pregnancy, at delivery and at re-admission within 60 days after delivery and risk of cancer.

RESULTS

IVF women had an increased risk of bleeding in early pregnancy [odds ratio (OR) = 4.59, 95% confidence interval (95% CI) 4.08-5.15] and of ovarian torsion during pregnancy (OR = 10.6, 5.69-10.7). They were also more likely to encounter pre-eclampsia (OR = 1.63, 1.53-1.74), placental abruption (2.17, 1.74-2.72), placenta praevia (3.65, 3.15-4.23), bleeding in association with vaginal delivery (1.40, 1.38-1.50) and premature rupture of membranes (PROM) (2.54, 2.34-2.76). Interventions including caesarean sections (1.38, 1.32-1.43) and induction of labour (1.37, 1.29-1.46) in singleton pregnancies was more frequent. The type of IVF method had little effect on these results, but there was a tendency for women who had received intra-cytoplasmatic sperm injection (ICSI) to have slightly fewer complications than women having standard IVF. There was a significant decrease in cancer risk after IVF (0.79, 0.69-0.91) but a suggested increase in the risk of ovarian cancer both before (2.70, 1.49-4.91) and after (2.08, 1.15-3.76) IVF. No change in mortality was observed.

CONCLUSIONS

Women treated with IVF had an increased obstetric morbidity. This seems to contribute little to the well-known increased risk of preterm delivery.

Assisted reproductive technology in Europe, 2001. Results generated from European registers by ESHRE

European results of assisted reproductive techniques from treatments initiated during 2001 are presented in this fifth report. Data were collected mainly from already existing national registers. From 23 countries, 579 clinics reported 289 690 cycles with: IVF 120 946, ICSI 114 378, frozen embryo transfer (FER) 47 195 and egg donation (ED) 7171. Overall this represents a 4% increase since the year 2000. For the first time, results on European data on intra-uterine inseminations (IUIs) were reported from 15 countries. A total of 67 124 cycles [IUI husband'sperm (IUI-H) 52 949 and IUI donor sperm (IUI-D) 14 185] were included. In 12 countries where all clinics reported to the register, a total of 108 910 cycles were performed in a population of 131.4 million, corresponding to 829 cycles per million inhabitants. For IVF, the clinical pregnancy rate per aspiration and per transfer was 25.1 and 29.0%, respectively. For ICSI, the corresponding rates were 26.2 and 28.3%. These figures are similar to the results from 2000. After IUI-H, the clinical pregnancy rate was 12.8% in women <40 and 9.7% in women > or =40 years of age. After IVF and ICSI, the distribution of transfer of one, two, three and > or =4 embryos was 12.0, 51.7, 30.8 and 5.5%, respectively. Compared with the year 2000, fewer embryos were transferred, but huge differences existed between countries. The distribution of singleton, twin and triplet deliveries for IVF and ICSI combined was 74.5, 24.0 and 1.5%, respectively. This gives a total multiple delivery rate of 25.5%, compared with 26.9% in the year 2000. The range of triplet deliveries after IVF and ICSI differed from 0.0 to 8.2% between countries. After IUI-H in women <40 years of age, 10.2% were twin and 1.1% were triplet gestations.

Avoidance of multiple pregnancy by use of single embryo transfer

The benefits of single embryo transfer (SET) for both mother and child are evident. Already twin pregnancies constitute a relatively serious problem exemplified by the incidence of cerebral palsy, which will increase significantly as well as a risk for premature birth. Selective embryo reduction in countries where this is allowed may be one way to acutely solve the situation. In the beginning the use of natural cycle in vitro fertilization (IVF) avoided the problem, but with the introduction of controlled ovarian hyperstimulation predominantly by use of gonadotrophins in the early 1980ies the temptation to replace more than 1 embryo at a time became too strong. SET with maintenance of acceptable pregnancy rates can only be achieved if tools (improved morphological criteria, biomarkers, preimplantation genetic screening) to select the most viable/normal embryos are at hand together with improved cryopreservation procedures. In reports from Finland and Belgium already 5 years ago, elective single embryo transfer (eSET) was shown to reach almost the same success rates as double embryo transfer (DET) in selective patient groups (age under 37, good quality embryos). The indications for eSET have increased during the last years. In Finland the initiative came from the IVF clinics while in Sweden a legislative process (in act from January 2003) resulted in the recommendation that eSET should be used in the vast majority of the IVF cycles. In both these Nordic countries around 60% of the transfers are today eSET and the multiple pregnancy rate below 10% with no triplets. From an economical point of view, it is of course evident that multiple pregnancies with the numerous potential complications should be avoided altogether. Countries where IVF is included in the government health insurance will thus most likely show the way towards an even more successful, safer and cheaper treatment of infertile couples in the future.

Assisted reproductive technology in Europe, 2000. Results generated from European registers by ESHRE

European results of assisted reproductive techniques from treatments initiated during 2000 are presented in this fourth annual report. Data were collected mainly from pre-existing national registers. From 22 countries, 569 clinics reported 279 267 cycles: IVF 126 961, ICSI 99 976, frozen embryo replacement (FER) 45 800 and oocyte donations (OD) 6530. In nine countries where all clinics reported to the register, a total of 142 174 cycles were performed in a population of 166 million, corresponding to 856 cycles per million inhabitants. After IVF and ICSI, the distribution of transfer of one, two, three and >or=4 embryos was 12.1, 46.7, 33.3 and 6.8%, respectively. Huge differences existed between countries. For IVF, the clinical pregnancy rate per aspiration and per transfer was 24.7 and 28.4%, respectively. For ICSI, the corresponding rates were 26,6% and 28,7%. These figures represent increases of 0.7 and 0.8% compared with 1999. The distribution of singleton, twin, triplet and quadruplet deliveries for IVF and ICSI combined was 73.6, 24.4, 2.0 and 0.04%. This gives a total multiple delivery rate of 26.4%. The range of triplet deliveries after IVF and ICSI ranged from 0.3 to 7.0% between countries. Compared with 1999, the number of reported cycles was increased by 8% and the clinical pregnancy rate per transfer was increased by 0.7% after IVF and by 0.8% after ICSI. The total multiple delivery rates after IVF and ICSI remain unchanged during the last 4 years.

Assisted reproductive technology in Europe, 1999. Results generated from European registers by ESHRE

European results of assisted reproductive techniques from treatments initiated during 1999, are presented in this third report. Data were collected mainly from pre-existing national registers. From 22 countries 538 clinics reported 258 460 cycles: IVF 125 370, ICSI 95 221, frozen embryo replacement (FER) 34 002 and oocyte donations (OD) 3867. In eight countries, where all clinics reported to the register, a total of 99 629 cycles was performed in a population of nearly 106 million, corresponding to 943 cycles per million inhabitants and 3.9 cycles per 1000 women aged 15-49 years. After IVF and ICSI the distribution of transfer of 1, 2, 3 and >or=4 or more embryos was 11.9, 39.2, 39.6 and 9.3% respectively. Huge differences existed between countries. For IVF the clinical pregnancy rate per aspiration and per transfer was 24.2 and 27.7% respectively. For ICSI the corresponding rates were 26.1 and 27.9%. These figures represent relative increases by 2.2 to 5.2% compared with 1998. The distribution of singleton, twin, triplet and quadruplet deliveries for IVF and ICSI combined was 73.7, 24.0, 2.2 and 0.1%. This gives a total multiple delivery rate of 26.3%. Triplet deliveries after IVF and ICSI ranged from 0.3-7.0% between countries. Compared with 1998, the number of reported cycles increased by 11% and the clinical pregnancy rate per transfer increased from 27.0 to 27.7% after IVF and from 26.8 to 27.9% after ICSI. Multiple deliveries after IVF and ICSI remained unchanged at 26.3% in 1999.

Neonatal outcome in pregnancies from ovarian stimulation

OBJECTIVE

To study the neonatal outcome in pregnancies after ovarian stimulation, not including in vitro fertilization. The outcomes studied were multiple birth, preterm birth, and low birth weight among singletons, congenital malformations, and infant death.

METHODS

We identified 4029 women who delivered between 1995-1999 after ovarian stimulation alone and compared them with 438,582 women who neither had ovarian stimulation nor in vitro fertilization. We controlled for the confounding effect of year of birth, maternal age, parity, and length of subfertility before the pregnancy.

RESULTS

The twinning rate was 5.9% in the study group and 1.2% in the control group. The triplet rate was 0.5% in the study group and 0.02% in the control group. A nearly doubling of the rate of monozygotic twinning was indicated in the study group compared with the control group. There was an excess of singleton preterm births and low birth weight infants in the study group, but this was mainly explainable by confounding of maternal age, parity, and subfertility. The rates of congenital malformations and perinatal deaths were increased, also mainly explainable by maternal characteristics. No increase in specific types of congenital malformations was seen.

CONCLUSION

As the deviations in neonatal outcome after ovarian stimulation alone were reduced or disappeared when the confounding of maternal age, parity, and subfertility was taken into consideration, there is probably little direct effect of the stimulation procedure as such.

Hospital care utilization of infants born after IVF

BACKGROUND

Infants born after IVF are often twins, and singleton IVF babies have an increased risk for preterm birth. Both conditions are likely to increase morbidity. We examined the frequency and duration of hospitalization required by babies born after IVF, and compared this information with all infants born in Sweden during the same time period.

METHODS

We used a nationwide registration of IVF pregnancies from 1984 to 1997 and a nationwide register of all in-patient care up to the end of 1998. We identified 9056 live born infants after IVF treatment and compared them with 1 417 166 non-IVF live born infants.

RESULTS

The highest odds ratio (OR approximately 3) was seen for neonatal hospitalization, but an increased OR (1.2-1.3) was noted for children up to 6 years of age. The OR for being hospitalized after IVF was 1.8, but when the analysis was restricted to term infants it was 1.3 and this excess was then explainable by maternal subfertility. Statistically significant increased ORs were seen for hospitalization for cerebral palsy (1.7), epilepsy (1.5), congenital malformation (1.8) or tumour (1.6), but also for asthma (1.4) or any infection (1.4). When information from the Swedish Cancer Registry was used, no excess risk for childhood cancer was found. The average number of days spent in hospital by IVF and non-IVF children was 9.5 and 3.6 respectively.

CONCLUSIONS

The increased hospitalization of IVF children is, to a large extent, due to the increased incidence of multiple births. Therefore, the increased costs associated with this may be reduced by the use of single embryo transfers, with the savings in health care costs being offset against the increased number of embryo transfer cycles required to maintain the pregnancy rate.

Assisted reproductive technology in Europe, 1998. Results generated from European registers by ESHRE. European Society of Human Reproduction and Embryology

European results of assisted reproductive techniques from treatments initiated during 1998 are presented in this second ESHRE report. Data was collected from 18 European countries usually from pre-existing national registers. A total of 521 clinics from these 18 countries reported 232 443 cycles: IVF 103 919 intracytoplasmic sperm injection (ICSI) 89 192 unclassified fertilization method 667 frozen embryo replacement (FER) 34 03 oocyte donations (OD) 4629. In nine countries where all clinics reported to the register a total of 128 801 cycles were performed in a population of 165 million corresponding to 781 cycles per million inhabitants 3.2 cycles per 1000 women aged 15-49 years. After IVF ICSI the distribution of transfer of 1, 2, 3 > or =4 embryos was 11.5, 37.2, 42.0 and 9.4% respectively. Huge differences existed between countries. For IVF the clinical pregnancy rate per aspiration per transfer was 23.2% 27.0% respectively. For ICSI the corresponding rates were 24.8% 26.8%. The distribution of singleton, twin, triplet, quadruplet deliveries for IVF and ICSI combined was 73.7, 23.9, 2.3 and 0.1%. This gives a total multiple delivery rate of 26.3%. The range of triplet deliveries after IVF and ICSI differed from 0.2-5.3% between countries. Compared with 1997, the number of reported cycles has increased by 14% and the number of reporting clinics by 8%. The clinical pregnancy rate per transfer increased from 26.1 to 27.0% after IVF and from 26.4 to 26.8% after ICSI. Multiple deliveries after IVF and ICSI decreased from 29.6 to 26.3%.

Assisted reproductive technology in Europe, 1997. Results generated from European registers by ESHRE. European IVF-Monitoring Programme (EIM), for the European Society of Human Reproduction and Embryology (ESHRE)

European results of assisted reproductive techniques from treatments initiated during 1997 are presented in this first ESHRE report. Data were collected from 18 European countries, usually from already-existing national registers. A total of 482 clinics from these 18 countries reported 203 893 cycles. In 10 countries with complete registration, 133215 cycles were performed in a population of 174 million, corresponding to 765 cycles per million inhabitants. After IVF and intracytoplasmic sperm injection (ICSI), the distribution of transfer of one, two, three and four or more embryos was 11.5, 35.9, 38.4 and 14.3% respectively. Huge differences existed between countries. For IVF, the clinical pregnancy rate per transfer was 26.1%, and the delivery rate per embryo transfer 20.9%. For ICSI, the corresponding rates were 26.4% and 21.5%. Singleton, twin, triplet and quadruplet delivery rates for IVF were 70.4, 25.8, 3.6 and 0.2% respectively, giving a total multiple delivery rate for IVF of 29.6%. After ICSI, the corresponding rates were 71.7, 25.2, 2.9 and 0.1%, amounting to a total multiple delivery rate of 28.2%. The range of triplet delivery rates after IVF range from 0.4% to 11.9% among countries.

Deliveries and children born after in-vitro fertilisation in Sweden 1982-95: a retrospective cohort study

BACKGROUND

In-vitro fertilisation is an effective treatment for infertility, but there is concern about the health of children. We investigated, in a retrospective registry study, malformations, cancers, and deaths in the complete Swedish in-vitro-fertilisation birth cohort compared with the general population.

METHODS

We collected data from all in-vitro-fertilisation clinics in Sweden and compared the obstetric outcomes of babies (n=5856) born between 1982 and 1995 with all babies born in the general population (n=1,505,724) during the same period, according to data from the Swedish Medical Birth Registry and the Registry of Congenital Malformations. We investigated the incidence of childhood cancer through the Swedish Cancer Registry. Data were stratified for maternal age, parity, previous subfertility, year of birth, and multiple of pregnancies.

FINDINGS

Multiple births occurred in 27% of pregnancies compared with 1% in the control group. In the in-vitro-fertilisation group, more babies were born preterm (<37 weeks) than controls (30.3 vs 6.3%) and more had low birthweights (<2500 g, 27.4 vs 4.6%). The perinatal mortality was 1.9% in the in-vitro fertilisation group and 1.1% in the controls. For in-vitro-fertilisation singletons, the risk ratios, adjusted for year of birth, for very preterm birth (<32 weeks) and very low birthweight (<1500 g) were 3.54 (95% CI 2.90-4.32) and 4.39 (3.62-5.32), respectively. Malformations occurred in 5.4% of all babies in the in-vitro-fertilisation group (1.39 [1.25-1.54]), and the rates of neural-tube defects and oesophageal atresia were higher than those in the controls. There was no increase in childhood cancer in the in-vitro-fertilisation group.

INTERPRETATION

A high frequency of multiple births and maternal characteristics were the main factors that led to adverse outcomes, and not the in-vitro-fertilisation technique itself. The clinical practice of in-vitro-fertilisation needs to be changed to lower the rate of multiple pregnancy.

The utilization rate and pregnancy outcome of multifetal pregnancy reduction in the Nordic countries

OBJECTIVE

To review the utilization rate and pregnancy outcome of multifetal pregnancy reductions (MFR) in the Nordic countries during the period January 1986-June 1992.

STUDY DESIGN

All centers offering assisted conception in Denmark, Finland, Norway and Sweden were retrospectively surveyed by means of a questionnaire with regard to the number and methods used for MFR, pregnancy loss and the outcomes of the pregnancies. The response rate was 100%.

RESULTS

During the period studied, 185 births of triplets or higher multiples occurred in Sweden, 120 in Finland and 102 in Denmark. MFR was performed in 42 women (Sweden 26, Finland 10, Denmark 6) but not in Norway at all. This gives an estimated average utilization rate of 1/7 multiple births of three or more in Sweden, 1/17 in Denmark and 1/12 in Finland. The most frequently used method was intracardiac or intrathoracic injection of a potassium chloride solution in gestational weeks 9-12. One pregnancy was reduced from seven to four fetuses, two from five to three, 10 from five to two, one from four to three, 17 from four to two, one from four to one, five from three to two, four from three to one and one from two to one. Nine (21%) pregnancies terminated in a spontaneous abortion within one week (n = 2) to several weeks (n = 7) after the procedure. Of the remaining 33 (79%) pregnancies which continued to delivery, two fetuses died in utero in the second trimester, three infants died perinatally and one child had transverse limb reduction defects. A successful pregnancy defined by the discharge home of at least one infant occurred in 79% of the cases.

CONCLUSION

This study gives national estimates on the utilization rate of MFR. Although MFR is performed more frequently in Sweden than in Denmark and Finland, the overall figures remain low in the Nordic countries. The incidence of pregnancy loss in this study is somewhat higher than in several larger reported series, probably reflecting the learning curve of the procedure. It seems reasonable that MFR should be performed in only a few centers in the Nordic countries.

Multifetal pregnancy reduction in Sweden. Utilization rate and pregnancy outcome (1986-1992)

All departments of Obstetrics and Gynecology, as well as all private clinics in Sweden offering assisted conception, were surveyed by means of a questionnaire to determine the utilization rate and outcome of multifetal pregnancy reduction (MFR) for the period 1 January 1986 to 30 June 1992. The response rae was 100%. Multifetal reduction was performed in 26 women, giving an average utilization rate of 1/7 multiple births of three or more for the entire period. Of the various techniques used, intracardiac or intrathoracic injection of a potassium chloride solution was predominant. The experience of each center with multifetal reductions varied between one and six procedures. In this series, the overall complete pregnancy loss was 27% (n = 7). In 73% (n = 19) of women the pregnancy continued to delivery. One fetus died in utero in the second trimester, one child died from a subtentorial hemorrhage perinatally, and one child had a malformation of the right foot and hand. It seems necessary to limit MFR to a few centers in Sweden in order to maintain and increase the experience of the operators involved, and to decrease the fetal loss rate associated with the procedure. However, the ultimate goal is to make these procedures unnecessary when methods of avoiding excessive ovulation are refined and by limiting the number of replaced embryos in IVF-treatment.