A. Loft

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

BACKGROUNDnAssisted 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.nnnMETHODSnPubMed 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnSubfertility 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.

Children born after cryopreservation of embryos or oocytes: a systematic review of outcome data

BACKGROUNDnAn estimated 3.5 million children have been born to date using assisted reproduction technologies. We reviewed the data in order to evaluate current knowledge of medical outcome for IVF/ICSI children born after cryopreservation, slow freezing and vitrification of early cleavage stage embryos, blastocysts and oocytes.nnnMETHODSnA systematic review was performed. We searched the PubMed, Cochrane and Embase databases from 1984 to September 2008. Inclusion criteria for slow freezing of early cleavage stage embryos were controlled studies reporting perinatal or child outcomes. For slow freezing and vitrification of blastocysts and oocytes, and vitrification of early cleavage stage embryos, case reports on perinatal or child outcomes were also included. Three reviewers independently read and evaluated all selected studies.nnnRESULTSnFor early cleavage embryos, data from controlled studies indicated a better or at least as good obstetric outcome, measured as preterm birth and low birthweight for children born after cryopreservation, as compared with children born after fresh cycles. Most studies found comparable malformation rates between frozen and fresh IVF/ICSI. For slow freezing of blastocysts and for vitrification of early cleavage stage embryos, blastocysts and oocytes, limited neonatal data was reported. We found no long-term child follow-up data for any cryopreservation technique.nnnCONCLUSIONnData concerning infant outcome after slow freezing of embryos was reassuring. Properly controlled follow-up studies of neonatal outcome are needed after slow freezing of blastocysts and after vitrification of early cleavage stage embryos, blastocysts and oocytes. In addition, child long-term follow-up studies for all cryopreservation techniques are essential.

Infant outcome of 957 singletons born after frozen embryo replacement: The Danish National Cohort Study 1995–2006

OBJECTIVEnTo examine infant outcome of singletons born after cryopreservation of embryos (Cryo).nnnDESIGNnNational population-based controlled follow-up study.nnnSETTINGnDenmark, 1995-2007.nnnPATIENT(S)nThe study population was 957 Cryo singletons (Cryo-IVF, n=660; Cryo-ICSI, n=244; Cryo-IVF/-ICSI, n=53). The first control group was all singletons born after fresh IVF or intracytoplasmic sperm injection (ICSI) during the same period (IVF, n=6904; ICSI, n=3425). The second control group comprised a random sample of non-assisted reproductive technology (ART) singletons (n=4800).nnnINTERVENTION(S)nAll observations were obtained from national registers.nnnMAIN OUTCOME MEASURE(S)nLow birth weight (LBW; <2500 g), preterm birth (PTB; <37 weeks), congenital malformations, mortality, and morbidity.nnnRESULT(S)nBirth weight was higher in Cryo (mean=3578 g, SD=625) versus fresh (mean=3373 g, SD=648) and in Cryo versus non-ART (mean=3537 g, SD=572), and this was also the case for first birth only. Lower adjusted risk of LBW (odds ratio [OR]=0.63; 95% confidence interval [CI], 0.45-0.87) and PTB (OR=0.70; 95% CI, 0.53-0.92) was observed in Cryo versus fresh. Similar LBW and PTB rates were observed when comparing Cryo with non-ART, but the perinatal mortality rate was doubled in Cryo (1.6%) compared with non-ART (0.8%) singletons, and the adjusted risks of very preterm birth (<34 weeks) and neonatal admittance were also significantly increased. No significant differences in the prevalence rates of birth defects, neurological sequelae, malignancies, and imprinting-related diseases were observed between the Cryo and the two control groups. However higher malformation and cerebral palsy rates were observed in the total Fresh vs. non-ART group.nnnCONCLUSION(S)nCryo singletons have better neonatal outcome than offspring after fresh ET but poorer compared with non-ART singletons.

The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria versus revised criteria including anti-Müllerian hormone

STUDY QUESTIONnWhat is the prevalence in a normal population of polycystic ovary syndrome (PCOS) according to the Rotterdam criteria versus revised criteria including anti-Müllerian hormone (AMH)?nnnSUMMARY ANSWERnThe prevalence of PCOS was 16.6% according to the Rotterdam criteria. When replacing the criterion for polycystic ovaries by antral follicle count (AFC) > 19 or AMH > 35 pmol/l, the prevalence of PCOS was 6.3 and 8.5%, respectively. WHAT IS KNOWN ALREADY?: The Rotterdam criteria state that two out of the following three criteria should be present in the diagnosis of PCOS: oligo-anovulation, clinical and/or biochemical hyperandrogenism and polycystic ovaries (AFC ≥ 12 and/or ovarian volume >10 ml). However, with the advances in sonography, the relevance of the AFC threshold in the definition of polycystic ovaries has been challenged, and AMH has been proposed as a marker of polycystic ovaries in PCOS.nnnSTUDY DESIGN, SIZE, DURATIONnFrom 2008 to 2010, a prospective, cross-sectional study was performed including 863 women aged 20-40 years and employed at Copenhagen University Hospital, Rigshospitalet, Denmark.nnnPARTICIPANTS/MATERIAL, SETTING, METHODSnWe studied a subgroup of 447 women with a mean (±SD) age of 33.5 (±4.0) years who were all non-users of hormonal contraception. Data on menstrual cycle disorder and the presence of hirsutism were obtained. On cycle Days 2-5, or on a random day in the case of oligo- or amenorrhoea, sonographic and endocrine parameters were measured.nnnMAIN RESULTS AND THE ROLE OF CHANCEnThe prevalence of PCOS was 16.6% according to the Rotterdam criteria. PCOS prevalence significantly decreased with age from 33.3% in women < 30 years to 14.7% in women aged 30-34 years, and 10.2% in women ≥ 35 years (P < 0.001). In total, 53.5% fulfilled the criterion for polycystic ovaries with a significant age-related decrease from 69.0% in women < 30 years to 55.8% in women aged 30-34 years, and 42.8% in women ≥ 35 years (P < 0.001). AMH or age-adjusted AMH Z-score was found to be a reliable marker of polycystic ovaries in women with PCOS according to the Rotterdam criteria [area under the curve (AUC) 0.994; 95% confidence interval (CI): 0.990-0.999] and AUC 0.992 (95% CI: 0.987-0.998), respectively], and an AMH cut-off value of 18 pmol/l and AMH Z-score of -0.2 showed the best compromise between sensitivity (91.8 and 90.4%, respectively) and specificity (98.1 and 97.9%, respectively). In total, AFC > 19 or AMH > 35 occurred in 17.7 and 23.0%, respectively. The occurrence of AFC > 19 or AMH > 35 in the age groups < 30, 30-34 and ≥ 35 years was 31.0 and 35.7%, 18.8 and 21.3%, and 9.6 and 18.7%, respectively. When replacing the Rotterdam criterion for polycystic ovaries by AFC > 19 or AMH > 35 pmol/l, the prevalence of PCOS was 6.3 or 8.5%, respectively, and in the age groups < 30, 30-34 and ≥ 35 years, the prevalences were 17.9 and 22.6%, 3.6 and 5.6%, and 3.6 and 4.8%, respectively.nnnLIMITATIONS, REASON FOR CAUTIONnThe participants of the study were all health-care workers, which may be a source of selection bias. Furthermore, the exclusion of hormonal contraceptive users from the study population may have biased the results, potentially excluding women with symptoms of PCOS.nnnWIDER IMPLICATIONS OF THE FINDINGSnAMH may be used as a marker of polycystic ovaries in PCOS. However, future studies are needed to validate AMH threshold levels, and AMH Z-score may be appropriate to adjust for the age-related decline in the AFC.nnnSTUDY FUNDING/COMPETING INTEREST(S)nNone.nnnTRIAL REGISTRATION NUMBERnNot applicable.

Ovarian function after removal of an entire ovary for cryopreservation of pieces of cortex prior to gonadotoxic treatment: a follow-up study

BACKGROUNDnOvarian function was studied in Danish patients who had ovarian tissue cryopreserved, and the patients experiences with the procedure were investigated.nnnMETHODSnThere were 92 women who had an entire ovary removed for cryopreservation 18-75 months earlier. Reasons included: breast cancer (n = 31; 34%), Hodgkins lymphoma (n = 23; 25%), bone marrow transplantation (BMT) (n = 19; 21%) and others (n = 19; 21%). Patients completed a questionnaire, and transvaginal ultrasonic antral follicle count and serum analysis for follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) were performed in 73 women.nnnRESULTSnIn total, 11% of the BMT patients had normal ovarian function. Hodgkins patients who only received ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) (n = 12) and 60% of the breast cancer patients showed little evidence of ovarian damage. Regular menstruation was shown to be a good indicator of ovarian function. The cryopreservation procedure rarely complicated cancer treatment (5%) and 84% felt comforted because they had potentially secured their fertility.nnnCONCLUSIONSnCryopreservation of ovarian tissue should be considered in young female patients with Hodgkins lymphoma receiving more aggressive treatment than ABVD and in patients scheduled for BMT. The recommendation for breast cancer patient should be individualized. The cryopreservation process did not delay cancer treatment.

Trends in the use of intracytoplasmatic sperm injection marked variability between countries

BACKGROUNDnICSI is used increasingly often compared with standard IVF. The aim of the present study was to analyse the changes in the use of ICSI, and discuss possible causes and consequences.nnnMETHODSnData from National and Regional registers were analysed for trends in the use of ICSI and indications for assisted reproductive technology (ART).nnnRESULTSnThe use of ICSI increased from 39.6% of ART cycles in 1997 to 58.9% in 2004 (USA 57.5%, Australia/New Zealand 58.6%, Europe 59.3%). The Nordic countries, the Netherlands and the UK used ICSI to a low extent (40.0-44.3%), whereas Austria, Belgium and Germany (68.5-72.9%) and the southern European countries like Greece, Italy and Spain used ICSI frequently (66.0-81.2%). The marked increase in the proportion of ICSI cycles seems primarily due to an increased use in couples classified as having mixed causes of infertility, unexplained infertility and advanced age together with a relative decline in tubal factor infertility. An absolute increase in the prevalence of couples with impairment in semen quality remains a possibility.nnnCONCLUSIONSnICSI is used increasingly, but huge differences exist between countries within Europe. It is not possible to determine specific factors that explain the differences. As ICSI does not give higher pregnancy rates than IVF in couples without male factors, and as it adds additional costs, infertile couples and society may benefit from a less frequent use of ICSI in some countries.

Autotransplantation of cryopreserved ovarian tissue in 12 women with chemotherapy-induced premature ovarian failure: the Danish experience

OBJECTIVEnTo describe a cohort of 12 Danish women who received autotransplantation of frozen-thawed cryopreserved ovarian tissue because of premature ovarian failure after cancer treatment.nnnDESIGNnRetrospective study.nnnSETTINGnUniversity hospitals.nnnPATIENT(S)nTwelve women with autotransplanted frozen-thawed ovarian tissue.nnnINTERVENTION(S)nMonitoring of hormonal parameters and results of 56 IVF cycles in 10 women.nnnMAIN OUTCOME MEASURE(S)nLevels of gonadotropins and sex steroids, functional life span of the grafts, and results of IVF.nnnRESULT(S)nAll 12 women regained ovarian function between 8 and 26 weeks (mean 19 weeks) after transplantation. Ten women underwent a total of 56 IVF cycles, 76 follicles developed, 49 oocytes were aspirated, 18 were fertilized, and 16 embryos were transferred resulting in six pregnancies: two biochemical, one clinical that miscarried in week 7, and two ongoing resulting in the delivery of two healthy infants born at term to two women. One of these women subsequently conceived spontaneously and delivered another healthy infant. The life span of the transplanted tissue has been between 6 months and still functioning after 54 months.nnnCONCLUSION(S)nAutotransplantation consistently leads to recovery of ovarian function after treatment-induced ovarian failure. Four women became pregnant, after IVF or spontaneously, resulting in the delivery of three healthy infants.

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

STUDY QUESTIONnDoes neonatal outcome including congenital malformations in children born after ICSI with epididymal and testicular sperm [testicular sperm extraction (TESE)/percutaneous epididymal sperm aspiration (PESA)/testicular sperm aspiration (TESA) (TPT)] differ from neonatal outcome in children born after ICSI with ejaculated sperm, IVF and natural conception (NC)?nnnSUMMARY ANSWERnChildren born after TPT have similar neonatal outcome, including total malformation rates, as have children born after ICSI and IVF with ejaculated sperm. Testing for variance over the four groups may indicate smaller differences in specific malformation rates with TPT as the highest risk group.nnnWHAT IS KNOWN ALREADYnRegarding neonatal outcome as well as congenital malformations in children born after TPT, studies are few, with limited sample size, heterogeneous and often performed without relevant control groups.nnnSTUDY DESIGN, SIZE, DURATIONnPopulation-based cohort study including all Danish children born after TPT and fresh embryo transfer in Denmark from 1995 to 2009. Children born after transfer of frozen-thawed embryos were excluded. Control groups of children conceived by ICSI with ejaculated sperm, IVF and NC were identified by cross-linkage of the Danish IVF Register, Medical Birth Register (MBR) and National Hospital Discharge Register (HDR).nnnPARTICIPANTS/MATERIALS, SETTINGnThe study group consisted of 466 children born after TPT, while the control groups consisted of 8967 (ICSI with ejaculated sperm), 17 592 (IVF) and 63 854 (NC) children. Neonatal outcomes and congenital malformations were analysed for singletons and twins separately. Risk estimates for low birthweight (LBW, <2500 g) and preterm birth (PTB, <37 gestational weeks) were adjusted for maternal age, parity, child gender and year of childbirth. The study group was identified from the Danish national database on children born after TPT. Control groups were obtained from the IVF register and the MBR. All information included in the study was retrieved from the national registers.nnnMAIN RESULTS AND THE ROLE OF CHANCEnConsidering singletons and twins as one group, the sex ratio (♂/♀) was significantly lower for children born after TPT (0.89) compared with conventional IVF (1.11; P = 0.017) but did not differ significantly when compared with ICSI with ejaculated sperm (0.94) and NC (1.05). The mean birthweight (BW) for singletons did not differ significantly between groups when including only first-born children. The mean gestational age (GA) in the TPT singletons (279 ± 12 days) was significantly higher compared with IVF (276 ± 18 days; P = 0.02), but similar to ICSI with ejaculated sperm and NC singletons when including only first-born children (277 ± 16 days and 279 ± 14 days, respectively). Rate of stillbirths, perinatal and neonatal mortality in the group of TPT singletons did not differ significantly from any of the control groups. Comparable results were found for the TPT twin group, except for perinatal mortality, which was significantly lower in the TPT group compared with naturally conceived twins. The adjusted risk of LBW was significantly higher for TPT versus NC singletons [adjusted odds ratio (AOR) = 0.67 (0.48-0.93)]; however AOR for PTB was similar in the two groups. Regarding twins, similar adjusted risks were observed for PTB and LBW between the TPT and all three control groups. Significantly more Caesarean sections were performed after IVF (27.3% for singletons) and ICSI (25.1% for singletons) with ejaculated sperm compared with the TPT group (16.4% for singletons). The total rate of congenital malformations in the TPT group was 7.7% and did not differ significantly from any of the control groups. However, singleton TPT boys showed an increased rate of cardiac malformations (3.6%) compared with singleton boys after IVF (1.4%; P = 0.04) and NC (1.1%; P = 0.02). Considering the level of male infertility as a continuum over the four groups, tests for variance in the rate of cardiac malformations in singleton boys, and undescended testicles for singleton as well as twin boys were each significantly increased from NC to IVF to ICSI to TPT (P < 0.001). The rate of hypospadias showed the same pattern, but the TPT group did not differ significantly compared with the control groups.nnnLIMITATIONS, REASONS FOR CAUTIONnOne of the limitations is that the TPT group could not be classified according to testicular or epididymal sperm, as these data were not available in the IVF register. Another limitation is that registry-based studies are encumbered with the risk of reporting or coding errors or missing data due to insufficient coding. However, the quality of data on congenital malformations in HDR has, in other studies, been validated and found acceptable for epidemiological research, and furthermore, recordings on study and control groups are performed similarly.nnnWIDER IMPLICATIONS OF THE FINDINGSnAccumulating data show that TPT treatment is equally safe as conventional ICSI and IVF treatment and as NC with regard to neonatal outcome including congenital malformation.nnnSTUDY FUNDING/POTENTIAL COMPETING INTERESTSnThis study is supported by Laboratory of Reproductive Biology, Scientific Unit, Horsens Hospital. No competing interests declared.

First-trimester screening markers are altered in pregnancies conceived after IVF/ICSI

To determine the levels of first‐trimester screening markers and to assess the false‐positive rate for first‐trimester combined screening for Down syndrome in a large national population of women pregnant after assisted reproductive technology (ART), in order to decide whether or not to correct risk calculation for mode of conception.

Prenatal testing among women pregnant after assisted reproductive techniques in Denmark 1995–2000: a national cohort study

BACKGROUNDnWomen pregnant after assisted reproductive techniques (ART) are generally older than women with spontaneously conceived pregnancies, and are consequently more likely to carry a child affected by a chromosomal disorder. Furthermore, a significantly increased rate of chromosomal abnormalities after intracytoplasmatic sperm injection (ICSI) has been reported. The aim of this study was to describe the use and results of prenatal invasive diagnostic testing in a national Danish cohort of in vitro fertilization (IVF)/ICSI pregnancies. Additionally, we examined to what extent second trimester serum screening was used.nnnMETHODSnWe used a register-based cohort study including all ongoing clinical pregnancies achieved by IVF/ICSI in 1995-2000 in Denmark. Data on fertility treatment, pregnancy and pregnancy outcome together with data on cytogenic testing and the use of triple test were retrieved from national statutory registers. Data on the invasive testing rate among the general Danish population were retrieved from the same national registers.nnnRESULTSnIn this 6 year period, 8531 ART pregnancies were recorded representing an unselected national ART population (6122 IVF, 2087 ICSI and 322 IVFICSI). The number of prenatal invasive procedures was relatively low, 16.3%, and the uptake of second trimester serum screening was very low, 7.4%. The invasive testing rate, corrected for advanced maternal age distribution, was lower in the study population than in the general population. The rate of karyotype aberrations detected by prenatal testing was 2.7% (43/1586), whereas the overall rate of pre- and post-natally detected aberrations was 0.6% (62/9625). Chromosome aberrations were more common in the ICSI-treated group compared with the IVF-treated group [1.3% (30/2297) versus 0.5% (32/6957), P < 0.0001]. This was also the case if only prenatally diagnosed chromosome aberrations were compared [4.3% (24/556) versus 1.9% (19/975), respectively, P < 0.01].nnnCONCLUSIONSnART pregnancies represent a group of high-risk pregnancies with regard to chromosomal aberrations, but nevertheless their uptake of prenatal testing was low. ICSI pregnancies compared with IVF pregnancies had a higher rate of chromosomal abnormalities, even though the average maternal age was lower.