Sirpa Vilska

Elective single-embryo transfer in women aged 40–44 years

STUDY QUESTION Is an elective single-embryo transfer (eSET) policy feasible for women aged 40 or older? SUMMARY ANSWER For older women (aged 40-44 years) with a good prognosis, an eSET policy can be applied with acceptable cumulative clinical pregnancy rates and live birth rates. WHAT IS KNOWN ALREADY Various studies have shown the effectiveness of eSET in women aged <35 years with high cumulative pregnancy rates and low rates of multiple births. STUDY DESIGN, SIZE, DURATION This retrospective cohort study included 628 women treated between 2000 and 2009. PARTICIPANTS, SETTING, METHODS Women aged 40-44 years underwent a fresh cycle of IVF or ICSI treatment with eSET (n = 264) or double-embryo transfer (DET) (n = 364). In the subsequent frozen-thawed embryo transfer cycles, SET/DET was performed in both groups according to the number of embryos available and the opinion of the couple. The study was performed at the Family Federation of Finland Helsinki Fertility Clinic. MAIN RESULTS AND THE ROLE OF CHANCE In the fresh cycles, the clinical pregnancy rates were 23.5 and 19.5% in the eSET and DET groups, respectively, and live birth rates were 13.6 and 11.0%, respectively. In the fresh cycles with eSET, there were no twin pregnancies, but in the DET group, there were three sets of twins (7.5%). The cumulative clinical pregnancy rates per oocyte retrieval were 37.1 and 24.2% in the eSET and DET groups, respectively (P < 0.001), and the cumulative live birth rates were 22.7 and 13.2%, respectively (P = 0.002). Cumulative twin rates were 6.7% (n = 4) in the eSET group and 8.3% (n = 4) in the DET group (P = 0.726). All of the twin pregnancies in the eSET group resulted from frozen and thawed DET embryo transfer cycles. LIMITATIONS The characteristics of the two patients groups are not comparable because the suitability of eSET was individually assessed by a clinician based on both clinical prognostic factors and the outcome of IVF or ICSI, i.e. the number and quality of embryos. WIDER IMPLICATIONS OF THE FINDINGS This study may be generalized to IVF units having experience in eSET and cryopreservation.

High and low BMI increase the risk of miscarriage after IVF/ICSI and FET

BACKGROUND The extremes of BMI are associated with an increased risk of miscarriage both in spontaneously conceived pregnancies and after fertility treatment. The aim of the present study was to study the effect of BMI on miscarriage rate (MR) in fresh IVF/ICSI, and in spontaneous and hormonally substituted frozen-thawed embryo (FET) cycles. METHODS Analysis was carried out on 3330 first pregnancy cycles, performed during the years 1999-2004, of which 2198 were fresh, 666 were spontaneous and 466 were hormonally substituted FET cycles. A categorical, a linear and a quadratic models of the effect of BMI on miscarriage were studied by logistic regression. Factors related to patient characteristics, protocol and embryo parameters were also examined. RESULTS MR was higher in hormonally substituted FET (23.0%), compared with the fresh cycles (13.8%) and spontaneous FET (11.4%, P < 0.0001). Multivariate logistic regression revealed that the relationship between BMI and the risk of miscarriage is not linear but quadratic (U-shaped) (P = 0.01), indicating a higher risk of miscarriage in underweight and obese women. Hormonal substitution for FET was also associated with a 1.7-fold higher MR, compared with the fresh cycles (P = 0.002, 95% confidence interval 1.2-2.3). CONCLUSIONS Obese and underweight women have an increased risk of miscarriage, and hormonally substituted FET is associated with an even higher MR.

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

Prenatal Expectations in Transition to Parenthood: Former Infertility and Family Dynamic Considerations

Prenatal expectations are important for the future parent-child relationship. The authors examined how maternal and paternal prenatal expectations of the relationship with the child predicted 1st-year parenting stress and whether these expectations were violated over the transition to parenthood. They further examined how former infertility affected these associations. The participants were 745 Finnish couples, 367 having undergone a successful assisted reproductive treatment and 378 conceiving spontaneously. Couples completed a questionnaire of family representations during pregnancy and when the child was 2 and 12 months old and Abidins Parenting Stress Index at 2 and 12 months postpartum. The hypothesis of moderately high expectations predicting the lowest level of parenting stress was substantiated only concerning paternal expectations of own autonomy with the child. Generally, however, negative expectations of own and spouses relationship with the child were linearly associated with higher parenting stress. Postnatal representations were more positive or equal to expectations, except for negative violation occurring in maternal expectation of the father-child relationship, especially among normative mothers. The results are discussed in relation to family dynamic considerations and special features of formerly infertile couples.

Experience of in vitro fertilization surrogacy in Finland

Background.  In vitro fertilization (IVF) surrogacy makes it possible for women who do not have a functional uterus to have their own genetic offspring. We describe here our experience of IVF surrogacy in Finland over a 10‐year period.

Ante- and perinatal factors and child characteristics predicting parenting experience among formerly infertile couples during the child's first year: a controlled study.

In this prospective controlled study, the authors examined (a) parenting experiences among couples with successful assisted reproduction treatment (ART; n = 367) and fertile spontaneously conceiving controls (n = 371) and (b) the impact of ante- and perinatal factors and child characteristics on parenting experiences. The results show that positive mothering experiences increased more during the 1st year of parenting and were generally higher among ART mothers than control mothers. No differences were found between ART fathers and controls in their fathering experience. Unpleasant birth experiences, low birth weight, and difficulty soothing the child were associated with high levels of parental stress in the control group, but this was not so among the ART parents. Psychosocial interventions in maternal care should take into account the various meanings that couples give to the history of infertility and conception and ante- and perinatal experiences.

Impact of infertility characteristics and treatment modalities on singleton pregnancies after assisted reproduction

Obstetric and neonatal outcomes of assisted reproduction and control singletons were evaluated after taking into account treatment characteristics and infertility background. The elective single embryo transfer (eSET) group (n = 45) was compared with the compulsory single embryo transfer (cSET; n = 52), double embryo transfer (DET; n = 227) and control (n = 304) groups. Infertility-related prognostic factors for neonatal outcomes were also analysed. Data were collected with structured questionnaires at gestational week 20 and 8 weeks after delivery. Spontaneous onset of delivery was more typical of the eSET group than of cSET and DET groups (68.9 versus 52.0%, P = 0.02). Mean (+/-SD) gestation at birth (39.3 +/- 1.6 weeks) and mean birth weight (3,470 +/- 505 g) of eSET singletons were comparable with other assisted reproduction groups, but gestational duration was lower than in the eSET group than in the control group (39.9 +/- 1.4; P < 0.05). However, numbers of preterm births and low birth weight infants were similar between groups. History of induced abortion increased risk of preterm birth (OR 4.5 and 95% CI 1.2-17.1) in assisted reproduction singletons. A small though clinically unimportant difference in gestational age at birth and birth weight between assisted reproduction and control singletons was found regardless of the number of embryos transferred.

Mental health of parents of twins conceived via assisted reproductive technology.

Purpose of review To review recent knowledge on mental health of parents of twins conceived via assisted reproductive technology (ART). Recent findings Mental health of mothers and fathers of twins conceived via ART is impaired when compared with that of ART singletons. Summary Existing studies are mainly cross-sectional and most of them focus on maternal mental health. It is evident that twin parenthood is the main factor impairing the mental health in parents with ART twins. This aspect should be taken into account when counseling the couples and deciding the number of embryos for transfer in ART. Well conducted prospective longitudinal studies are needed on both maternal and paternal mental health with twins conceived via ART from transition to parenthood to and beyond toddler age covering later life with school-aged and adolescent twins.

Birth experience of women conceiving with assisted reproduction: a prospective multicenter study

To determine how infertility and subsequent assisted reproductive treatment (ART) affect a womans childbirth experience.

Elective Transfer of One Embryo Results in an Acceptable Pregnancy Rate and Eliminates the Risk of Multiple Birth

To avoid multiple pregnancies without compromising pregnancy rates (PR) is a challenge in assisted reproduction. We have compared pregnancy results among 74 elective one-embryo transfers (group 2) and 94 transfers where only one embryo was available (group 1). All the fresh embryo cycles during 1997 in two clinics in Helsinki were analysed, and cumulative PR among these couples after frozen-thawed embryo transfers up to June 1998 were counted. In group 2, where at least two embryos were available for transfer, and only one was transferred on day 2 or 3, the PR per embryo transfer was 29.7%. In group 1, the PR per embryo transfer was 20.2%. In group 2, the cumulative PR after frozen-thawed embryo transfers was 47.3% per oocyte retrieval. Over the same time, 742 two-embryo transfers were carried out. The PR per embryo transfer was 29.4% in these subjects, but 23.9% of these pregnancies were twins. The implantation rates, as well as the PR, were highest when the embryos were at the four- to five-cell stage on day 2 (35.8 versus 9.7% compared with the two- to three-cell stage, P < 0.001) or at the six- to eight-cell stage on day 3 (45.5%). The PR per embryo transfer was higher when a grade 1 or 2 embryo was transferred compared with a grade three embryo (34. 0 and 26.7% versus 8.8% respectively, P < 0.05). In women 35 years or younger, the PR per elective one-embryo transfer was 32.8%. The corresponding figure in women older than 35 years was 18.8%. On the basis of these results, elective one-embryo transfer can be highly recommended, at least in subjects who are younger than 35 years of age, and who have grade one or grade two embryos available for transfer.