Adverse Perinatal Events Associated With ART
Adverse Perinatal Events Associated With ART
There appears to be an association between assisted reproduction and adverse obstetric outcomes. However, there is significant evidence that these adverse outcomes may stem from the overall diminished reproductive function in infertile women and not from the fertility treatment itself. When compared with pregnancies conceived in infertile women, pregnancies following delayed conception or after an evaluation for conception delay appear to be at an increased risk of poor neonatal outcomes. Draper et al published a case control study on IVF outcomes in 1999. They described a higher incidence of perinatal death in pregnancies conceived by infertile women irrespective of whether they were treated or conceived spontaneously. Infertile women that conceived spontaneously, following IVF or gamete intrafallopian tube transfer had nearly a threefold increased risk for perinatal death compared with fertile controls.
With regard to fertility treatment, there appear to be similar outcomes irrespective of the treatment undertaken. A Belgian matched cohort study conducted in 2005 compared 126 pregnancies after IVF and 126 after intrauterine insemination, and it revealed no difference in low birthweight. These authors suggested that adverse pregnancy outcomes observed following IVF were the result of the underlying pathology and not the IVF procedure itself. Bonduelle et al evaluated 2889 infants born after ICSI and 2995 infants born after IVF. They noted comparable medications used, comparable pregnancy duration, and similar rates of multiple birth. They found that ICSI mothers were older, and there were more first pregnancies among ICSI conceptions. Prematurity was slightly more common in the ICSI versus IVF pregnancies (31.8% versus 29.3%), and very low birthweight was marginally higher in the IVF than the ICSI pregnancies (5.7% versus 4.4%). No difference was seen with regard to the risk of stillbirth between ICSI and IVF pregnancies.
At least two meta-analyses have examined the relationship between IVF, prematurity, low birthweight, and perinatal mortality. Jackson et al compared 12,283 IVF to nearly 2 million spontaneously conceived singletons and noted a 2.2-fold increased risk of perinatal mortality, a 2.0-fold increased risk in preterm delivery, and a 2.7-fold increased risk in very low birthweight among the IVF singletons. These were similar to findings reported by Helmerhorst et al, who noted relative risks of 1.7 (95% CI 1.11 to 2.55) and 3.0 (95% CI 2.07 to 4.36) for perinatal mortality and very low birthweight, respectively, when comparing IVF with naturally conceived singletons. Although evidence of an effect is persuasive, it remains to be seen if this finding results from infertility treatment or from the underlying fertility problem.
Much attention has been devoted to the study of child development in IVF children. Numerous reports examining frozen and fresh ART with and without ICSI consistently demonstrate no difference in neurodevelopment when compared with spontaneously conceived children. However, findings are not entirely favorable. In 2002, Strömberg et al studied the neurological sequelae of 5680 children born post ART with 11,316 non-ART controls born in Sweden. Their findings included an increased need for rehabilitation services and an increased risk of cerebral palsy (CP) in the IVF children. The relative risk of CP in singleton IVF children was 2.8. (95% CI was 1.3–5.8) However, there was no difference in CP prevalence in IVF relative to non-IVF twins, and the findings in singletons largely correlated with prematurity and low birthweight. Several other reports suggest that IVF increases the risk for CP. These include two population studies from Sweden and Denmark that, combined, involve >15,000 IVF children and 600,000 controls. Both reports described similar risks for CP in IVF children (odds ratio: 1.7 (95% CI 1.6–1.82) to 1.8 (95% CI 1.2–2.8)). It has been suggested that the increased risk of CP following IVF may be due to a high rate of vanishing twin following multiple embryo transfer. Early intrauterine twin demise has been suggested to increase the risk of CP in the surviving twin. Reports suggesting an increased use of medical services among IVF children can be explained by the increased risk of CP derived from the related risk of multiple birth, low birthweight, and prematurity. Despite all of this, if an IVF child is of normal birthweight and delivered at term, there are no convincing data of an increased risk for neurodevelopmental issues. The increased use of occupational therapists seen with IVF children may arise from increased parental concern regarding development or improved access to care as a result of socioeconomic factors associated with IVF.
IVF does not appear to affect parent–child relationships adversely, and some have observed the potential for enhanced parent to child warmth in IVF families when compared with naturally conceived families. In a study of 5-year-old children conceived naturally, by IVF or by ICSI, Barnes et al performed psychological testing and pediatric evaluation. They noted that ICSI mothers had less hostile feelings toward and a higher degree of commitment to their children than natural conception mothers. Overall, however, they reported very few differences between groups and that all groups were assessed as normal. Van Balen et al compared adoptive families, IVF families, and natural conception families with regard to parent–child relationships and the psychological well-being of children. These authors concluded that the few differences noted in parent-child relationships were largely positive and favoring IVF families. Further, they felt that the differences could be attributed to the experience of infertility and not its treatment. They concluded that, at age 12, the children in all groups were functioning well and were similar with regard to measures of adjustment.
Perinatal Morbidity and Mortality
There appears to be an association between assisted reproduction and adverse obstetric outcomes. However, there is significant evidence that these adverse outcomes may stem from the overall diminished reproductive function in infertile women and not from the fertility treatment itself. When compared with pregnancies conceived in infertile women, pregnancies following delayed conception or after an evaluation for conception delay appear to be at an increased risk of poor neonatal outcomes. Draper et al published a case control study on IVF outcomes in 1999. They described a higher incidence of perinatal death in pregnancies conceived by infertile women irrespective of whether they were treated or conceived spontaneously. Infertile women that conceived spontaneously, following IVF or gamete intrafallopian tube transfer had nearly a threefold increased risk for perinatal death compared with fertile controls.
With regard to fertility treatment, there appear to be similar outcomes irrespective of the treatment undertaken. A Belgian matched cohort study conducted in 2005 compared 126 pregnancies after IVF and 126 after intrauterine insemination, and it revealed no difference in low birthweight. These authors suggested that adverse pregnancy outcomes observed following IVF were the result of the underlying pathology and not the IVF procedure itself. Bonduelle et al evaluated 2889 infants born after ICSI and 2995 infants born after IVF. They noted comparable medications used, comparable pregnancy duration, and similar rates of multiple birth. They found that ICSI mothers were older, and there were more first pregnancies among ICSI conceptions. Prematurity was slightly more common in the ICSI versus IVF pregnancies (31.8% versus 29.3%), and very low birthweight was marginally higher in the IVF than the ICSI pregnancies (5.7% versus 4.4%). No difference was seen with regard to the risk of stillbirth between ICSI and IVF pregnancies.
At least two meta-analyses have examined the relationship between IVF, prematurity, low birthweight, and perinatal mortality. Jackson et al compared 12,283 IVF to nearly 2 million spontaneously conceived singletons and noted a 2.2-fold increased risk of perinatal mortality, a 2.0-fold increased risk in preterm delivery, and a 2.7-fold increased risk in very low birthweight among the IVF singletons. These were similar to findings reported by Helmerhorst et al, who noted relative risks of 1.7 (95% CI 1.11 to 2.55) and 3.0 (95% CI 2.07 to 4.36) for perinatal mortality and very low birthweight, respectively, when comparing IVF with naturally conceived singletons. Although evidence of an effect is persuasive, it remains to be seen if this finding results from infertility treatment or from the underlying fertility problem.
Much attention has been devoted to the study of child development in IVF children. Numerous reports examining frozen and fresh ART with and without ICSI consistently demonstrate no difference in neurodevelopment when compared with spontaneously conceived children. However, findings are not entirely favorable. In 2002, Strömberg et al studied the neurological sequelae of 5680 children born post ART with 11,316 non-ART controls born in Sweden. Their findings included an increased need for rehabilitation services and an increased risk of cerebral palsy (CP) in the IVF children. The relative risk of CP in singleton IVF children was 2.8. (95% CI was 1.3–5.8) However, there was no difference in CP prevalence in IVF relative to non-IVF twins, and the findings in singletons largely correlated with prematurity and low birthweight. Several other reports suggest that IVF increases the risk for CP. These include two population studies from Sweden and Denmark that, combined, involve >15,000 IVF children and 600,000 controls. Both reports described similar risks for CP in IVF children (odds ratio: 1.7 (95% CI 1.6–1.82) to 1.8 (95% CI 1.2–2.8)). It has been suggested that the increased risk of CP following IVF may be due to a high rate of vanishing twin following multiple embryo transfer. Early intrauterine twin demise has been suggested to increase the risk of CP in the surviving twin. Reports suggesting an increased use of medical services among IVF children can be explained by the increased risk of CP derived from the related risk of multiple birth, low birthweight, and prematurity. Despite all of this, if an IVF child is of normal birthweight and delivered at term, there are no convincing data of an increased risk for neurodevelopmental issues. The increased use of occupational therapists seen with IVF children may arise from increased parental concern regarding development or improved access to care as a result of socioeconomic factors associated with IVF.
IVF does not appear to affect parent–child relationships adversely, and some have observed the potential for enhanced parent to child warmth in IVF families when compared with naturally conceived families. In a study of 5-year-old children conceived naturally, by IVF or by ICSI, Barnes et al performed psychological testing and pediatric evaluation. They noted that ICSI mothers had less hostile feelings toward and a higher degree of commitment to their children than natural conception mothers. Overall, however, they reported very few differences between groups and that all groups were assessed as normal. Van Balen et al compared adoptive families, IVF families, and natural conception families with regard to parent–child relationships and the psychological well-being of children. These authors concluded that the few differences noted in parent-child relationships were largely positive and favoring IVF families. Further, they felt that the differences could be attributed to the experience of infertility and not its treatment. They concluded that, at age 12, the children in all groups were functioning well and were similar with regard to measures of adjustment.
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