ART andART andAdverse Pregnancy OutcomeAdverse Pregnancy Outcome
Catherine Racowsky, PhD, HCLDCatherine Racowsky, PhD, [email protected]
Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBrigham and Women’s Hospital
Harvard Medical School, Boston MAHarvard Medical School, Boston MA
2nd Congress of Current Opinion in Reproductive Medicine and Assisted Reproductive Technologies
Cesme, Turkey: April 19, 2008
Lecture OutlineLecture Outline
What we are doing when we perform ARTWhat we are doing when we perform ART
Consider challenges relevant to the topic of adverse Consider challenges relevant to the topic of adverse
outcomes and ARToutcomes and ART
Review possible causes of adverse outcomesReview possible causes of adverse outcomes
Discuss current knowledge regarding risks of adverse Discuss current knowledge regarding risks of adverse
outcomesoutcomes
Summarize risks and causes of adverse outcomesSummarize risks and causes of adverse outcomes
Address gaps in our knowledgeAddress gaps in our knowledge
The Goals of ARTThe Goals of ART
To minimize the risk of multiple gestations
To optimize pregnancy rates
To produce healthy, genetically normal,singleton full-term deliveries
ICSI IVF
AssistedHatching
PGD
Gamete Handling & Evaluation
Insemination
Zygote Identification
Micro-Manipulations
Embryo Growth
The ART of ARTThe ART of ARTOvarian Stimulation
Oocyte Collection Sperm Collection
The Critical Questions are …The Critical Questions are …
Are we doing harm when treating Are we doing harm when treating infertility patients with ART?infertility patients with ART?
Do the ART treatments Do the ART treatments per seper se cause cause adverse outcomes?adverse outcomes?
ChallengesChallenges
Accurate assessment of risksAccurate assessment of risks Study design issues:Study design issues:
Methodologies (retrospective, prospective, multicenter, Methodologies (retrospective, prospective, multicenter, meta-analyses)meta-analyses)
Size of datasets (power analyses & validity)Size of datasets (power analyses & validity) Comparative group issues (1yr versus 5yrs of infertility)Comparative group issues (1yr versus 5yrs of infertility) Typically, a lack of appropriate controlsTypically, a lack of appropriate controls
Distinguishing among the possible causesDistinguishing among the possible causes Genetic causes associated with sub-fertilityGenetic causes associated with sub-fertility Ovarian stimulationOvarian stimulation In vitro technologies per seIn vitro technologies per se
Study Design Issues Study Design Issues
Unit of Analysis?Unit of Analysis? Couple?Couple? Woman? Man?Woman? Man? Which cycle?Which cycle? Which pregnancy?Which pregnancy?
Analysis (assessment of correlations)Analysis (assessment of correlations) What groups (Singletons? Twins? Triplets?)What groups (Singletons? Twins? Triplets?) What correlative outcomes?What correlative outcomes? Which statistical tests?Which statistical tests?
Possible Causes of Adverse Possible Causes of Adverse OutcomesOutcomes
Oocyte
Sperm Zygote Embryos Transfer
OA or NOA GENETICS
Age Environment
EnvironmentAge
GENETICS Ovarian Stimulation
Culture ConditionsSystemMedia
Gas PhaseDuration
Manipulations
Assisted HatchingBlastomere Bx
IVF
ICSI
Number & Qualityof Embryos
Endometrial ReceptivityPlacentationMaternal HealthUterine EnvironmentGestational Order
Moore and Persaud. The developing human, clinically oriented embryology. 1998
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes
Causes of Adverse OutcomesCauses of Adverse Outcomes Possible causes:Possible causes:
Ovarian stimulation-related affectsOvarian stimulation-related affects Culture-induced phenomena Culture-induced phenomena Unidentified contributions from parents of originUnidentified contributions from parents of origin
Known causes:Known causes: Identifiable contributions from parents of originIdentifiable contributions from parents of origin Multiple gestationsMultiple gestations
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes“Ovarian Stimulation”“Ovarian Stimulation”
LL Day of Menstrual Cycle1 3 5 7 9 11 13 15
Cohort ofCohort ofGrowingGrowingFolliclesFollicles
Egg RetrievalEgg Retrieval36 h post hCG36 h post hCG
AtresiaAtresia
Est
roge
n
ExogenousExogenousFSHFSH
RecruitmentRecruitmentSelectionSelection
DominanceDominance
DFDF
DFDF
DFDF
NN N-1 N-1N-1 N-1N-1
Possible Causes of Adverse OutcomesPossible Causes of Adverse OutcomesIs Ovarian Stimulation a Stressor?Is Ovarian Stimulation a Stressor?
Urinary gonadotropins to adult CD1 miceUrinary gonadotropins to adult CD1 mice Lower levels of:Lower levels of:
VEGF120VEGF120 VEGF receptors (flt-1 and flk-1 mRNA)VEGF receptors (flt-1 and flk-1 mRNA)
Reduced size of:Reduced size of: EmbryoEmbryo Implantation siteImplantation site
Delayed implantationDelayed implantation Prolonged gestational periodProlonged gestational period
Both urinary hFSH and hCG contributed to the adverse effects
Sibug et al., 2005Sibug et al., 2005
Possible Causes of Adverse OutcomesPossible Causes of Adverse OutcomesIs Ovarian Stimulation a Stressor?Is Ovarian Stimulation a Stressor?
Cryopreserved versus Fresh OutcomesCryopreserved versus Fresh Outcomes Lower incidence of pre-term deliveries following Lower incidence of pre-term deliveries following
transfer of frozen-thawed embryos transfer of frozen-thawed embryos versusversus fresh fresh embryos embryos (Wennerholm, ‘97; Bergh ’99)(Wennerholm, ‘97; Bergh ’99)
Possible Impact on Placentation DevelopmentPossible Impact on Placentation Development
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes“Culture-Induced Effects”“Culture-Induced Effects”
Does in vitro culture modulate genetic expressionDoes in vitro culture modulate genetic expressionand/or effect post-natal development?and/or effect post-natal development?
OvarianStimulationRegimen
OocyteQuality
Culture System
EmbryoTransfer
LutealSupport
Impact of Uterine Receptivity“Quality” of Maternal System
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes“Culture-Induced Effects”: The Dishes“Culture-Induced Effects”: The Dishes
Organ dishes
Microdrop system
Oil overlay
Medium drops
Embryonic density? Co-culture with granulosa cells? Endometrial co-culture?
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes“Culture-Induced Effects”: Other Variables“Culture-Induced Effects”: Other Variables
Other “contact” materials
Gas phase O2 tension: kinetics of development & birth weight
(Thompson et al ’90)
Commercial culture media vary widely in complexity Simple: HTF Complex: G series P1 Global
Several studies have shown media effects on development: Differential allocation to ICM and TE (Van Soom et al ’97) Large calf syndrome (Walker et al ’96)
Imprinting defects (e.g. H19 gene in mouse; Doherty et al ‘00)
Possible Causes of Adverse OutcomesPossible Causes of Adverse OutcomesCulture Media FormulationsCulture Media Formulations
0
200
400
600
800
Viable singleton pregnancies at 12 weeks gestation (day 3 ET)
Orasanu et al ’06 RBMOnline 12:590-598
hC
G o
n d
ay
15
po s
t-E
T
(mI U
/ ml)
P1 IVF-500 G1.2 G1.3N = 281 81 171 153
a
b
a,cdP<0.05
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes“Culture-Induced Effects: Day of Transfer”“Culture-Induced Effects: Day of Transfer”
After Day 5 transfer:After Day 5 transfer: Increased incidence of monozygotic twins Increased incidence of monozygotic twins (Behr et al ’00; Menezo et al ’02)(Behr et al ’00; Menezo et al ’02) Increased incidence of monochorionic twins (Skiadas et al ’08)(Skiadas et al ’08) Increased incidence of male neonates? Increased incidence of male neonates? (Menezo et al ’99; Kausche et al ‘01)(Menezo et al ’99; Kausche et al ‘01)
Egg
Ret
rieva
l
Days Post-Fertilization 1 2 3 4 50
Day of Embryo Transfer
Possible Causes of Adverse OutcomesPossible Causes of Adverse Outcomes “Imprinting Defects in ART Babies”
Angelman’s Syndrome (ch 15)Angelman’s Syndrome (ch 15)Incidence of this rare subtype estimated at 1/300,0003 isolated cases reported among ICSI births1 case had a fertile fatherAll had epigenetic defect with loss of methylation of maternal allele
Beckwith-Weidemann’s Syndrome (ch 11)Beckwith-Weidemann’s Syndrome (ch 11)Baseline risk of 1/15,0003 BWS Registry studies found incidences of 3/65, 6/143 and 6/149 RR estimate of BWS children being ART-conceived from 4 to 6-foldAll cases due to imprinting defect
Clinical evidence is suggestive but not sufficient to conclude Clinical evidence is suggestive but not sufficient to conclude that ART techniques may increase frequenciesthat ART techniques may increase frequencies
http://www.laeknabladid.is/media/tolublod/1313
Possible Causes of Adverse OutcomesPossible Causes of Adverse OutcomesUnidentified Causes from OocyteUnidentified Causes from Oocyte
OI/IUI Treated WomenOI/IUI Treated Women Infertile Group: Donor spermInfertile Group: Donor sperm Fertile Group: Donor spermFertile Group: Donor sperm
Infertile women had LBW neonates than the Infertile women had LBW neonates than the fertile groupfertile group (Gaudoin ’03)(Gaudoin ’03)
Possible Causes of Adverse OutcomesPossible Causes of Adverse OutcomesUnidentified Causes from SpermUnidentified Causes from Sperm
Birth defects in ICSI versus spontaneously conceived infantsBirth defects in ICSI versus spontaneously conceived infants
Stu
dy
Re f
er e
n ce
Odds Ratio
Morin et al ’89
Hansen et al ’02
Isaksson et al ’02
Koivurova et al ’02
Ericson et al ’01
Dhont et al ’99
Westergaard et al ’99
Pooled Estimate
.1 .5 1 10 50
Known Causes of Adverse OutcomesKnown Causes of Adverse Outcomes“Parents of Origin”“Parents of Origin”
CF mutations (CBAVD), Yq11 micro deletionsCF mutations (CBAVD), Yq11 micro deletions DOR: poor embryo quality DOR: poor embryo quality Aneuploidy-related variablesAneuploidy-related variables
010203040506070
20-34 35-39 40-45
Aneuploidy
Implantation
Munne et al ’01,’04,‘06Munne et al ’01,’04,‘06
Maternal Age (y)
FemaleFemale
%
0
5
10
15
20
“0” 0-4 5-10 11-20 >20
Aneuploidy
Yoshida et al ’95Yoshida et al ’95
Sperm Concentration (x106/ml)
MaleMale
%
Known Cause of Adverse OutcomesKnown Cause of Adverse OutcomesMultiple GestationsMultiple Gestations
28.4%Twins 67.2%
Singletons
4.4%Triplets Plus
2005 US Pregnancies by 2005 US Pregnancies by MultiplicityMultiplicity
Increased risk of pre-term Increased risk of pre-term deliverydeliveryAssociated risks of prematurityAssociated risks of prematurityObstetrical complicationsObstetrical complications
SARTCORS Data Reporting System, 2005
ASRM/SART GuidelinesASRM/SART Guidelinesfor Number of Embryos to Transferfor Number of Embryos to Transfer
September, 2006September, 2006
ART programs should be aggressively moving towards SET in select patient groups who have good prognosis
< 35y 1 or 2 embryos
35-37y: 2 or 3 embryos
38-40y: 3 or 4 embryos
>40y: < 5 embryos
Most FavorableMost Favorable
Least FavorableLeast Favorable
SART Practice Committee Report
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
AntenatalAntenatal
# IVF SpontOutcome Studies % % OR (95% CI)
Gestational diabetes 4 6.8 4.7 2.0 (1.4, 3.0)
Placenta previa 6 2.4 0.9 2.9 (1.5, 5.4)
Preeclampsia 8 10.3 3.8 1.6 (1.2, 2.0)
Preterm delivery after 5 10.3 5.6 2.1 (1.7, 2.7)spontaneous labor
Vaginal bleeding 7 16.6 2.9 2.5 (1.9, 3.3)
Jackson et al ’04 BMJ 103:551-63
Studies included cohort, matched cohort or external comparisons
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
PerinatalPerinatal
# IVF SpontOutcome Studies % % OR (95% CI)
Perinatal mortality 8 2.0 0.66 2.19 (1.61, 2.98)
Preterm delivery 14 11.5 5.3 1.95 (1.73, 2.20)
Low birth weight 10 9.5 3.8 1.77 (1.40, 2.22)
Very low birth weight 8 2.5 0.99 2.70 (2.31, 3.14)
Jackson et al ’04 BMJ 103:551-63
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
L & D/NeonatalL & D/Neonatal
# IVF SpontOutcome Studies % % OR (95% CI)
Labor induction 7 21.9 19.6 1.2 (1.0, 1.3)
Spontaneous labor 7 49.0 61.3 0.6 (0.5, 0.7)
Caesarian delivery 14 26.7 19.4 2.1 (1.7, 2.6)
Elective 7 11.4 6.7 1.9 (1.5, 2.5)
Emergent 7 8.0 5.9 1.5 (1.1, 2.0)
NICU admits 5 17.8 7.8 1.6 (1.3, 2.0)
Neonatal deaths 7 0.6 0.3 2.0 (1.2, 3.4)
Jackson et al ’04 BMJ 103:551-63
Risk of Adverse OutcomesRisk of Adverse Outcomes
TwinsTwins
# IVF SpontOutcome Studies % % OR (95% CI)
Perinatal mortality 6 2.3 4.3 0.58 (0.4, 0.8)
Preterm delivery <37 wk 9 50.0 46.0 1.10 (1.0, 1.1)
Preterm delivery <32 wk 3 6.8 7.1 0.95 (0.8, 1.2)
Low birth weight 5 55.0 53.0 1.0 (1.0, 1.1)
Very low birth weight 5 6.7 7.6 0.89 (0.7, 1.1)
Small for gestational age 4 24.0 20.0 1.3 (0.97, 1.7)
Studies included cohort, matched cohort or external comparisons
Jackson et al ’04 BMJ 103:551-63
Risk of Adverse OutcomesRisk of Adverse Outcomes
Compared with non-assisted singleton pregnancies, Compared with non-assisted singleton pregnancies, ART singleton pregnancies have significantly worse ART singleton pregnancies have significantly worse outcomes for: outcomes for:
AntenatalAntenatal PerinatalPerinatal Neonatal and most L&D variablesNeonatal and most L&D variables
Most odds ratios are >2Most odds ratios are >2 Only one of these ART-related adverse outcomes for Only one of these ART-related adverse outcomes for
singletons is also evident for twinssingletons is also evident for twins
ConclusionsConclusions
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
Parents of origin: sub-fertility?Parents of origin: sub-fertility? Ovarian stimulation?Ovarian stimulation? Technology?Technology?
The Etiology?The Etiology?
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
Danish Study Danish Study (Westergaard et al ’99)(Westergaard et al ’99)
1298 ART patients1298 ART patients 1298 non-treated controls1298 non-treated controls
The Etiology: Sub-fertility?The Etiology: Sub-fertility?
Outcome OR (95% CI)
< 37 weeks 1.41 (1.02, 1.94)
< 1500g 3.84 (1.43, 10.3)
< 2500g 1.50 (1.08, 2.10)
Sub-fertility may be involved
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
Belgian Cohort StudyBelgian Cohort Study 12,021 ovarian stimulation, no ART12,021 ovarian stimulation, no ART 12,021 controls12,021 controls
The Etiology: Ovarian StimulationThe Etiology: Ovarian Stimulation
Outcome OR (95% CI)
< 1500g 3.21 (2.31, 4.47)
1500-2500g 1.86 (1.65, 2.10)
< 32 weeks 1.89 (1.69, 2.12)
Ovarian stimulation may be involved although …..
Risk of Adverse Outcomes in SingletonsRisk of Adverse Outcomes in Singletons
Comparison of :Comparison of :Infertile Infertile versusversus fertile women, both fertile women, both without without
treatment, showed the infertile treatment, showed the infertile group had:group had: Increased risk of VLBW, OR = 1.5 Increased risk of VLBW, OR = 1.5 (McElrath ’97)(McElrath ’97)
Number of smaller studies with conflicting findingsNumber of smaller studies with conflicting findings
The Etiology??The Etiology??
Throws the etiology back onto “sub-fertility” issues …..
Risks Associated with ICSIRisks Associated with ICSI
Outcome # Studies OR (95% CI)
Major birth defects 15 1.32 (1.20, 1.45)
All infants (singletons and multiples) 17 1.36 (1.28, 1.45)
Singletons only 15 1.31 (1.17, 1.46)
Hansen et al ’02 NEJM 346:725-30
• Results do not appear to be related to the ICSI-procedure itself
• ICSI babies are at a small, but increased risk for chromosomal abnormalities, mostly from paternal inheritance
Lie ’05 Int J Epid 34:696-701
ICSI vs IVFICSI vs IVF
Reviewed in Van Steirteghem et al ’02 Hum Reprod Update;8:111-6
Risk of Adverse Infant Neuro-DevelopmentRisk of Adverse Infant Neuro-Development
Most studies are reassuring, but methodological problems prevailMost studies are reassuring, but methodological problems prevail
An increased RR has been observed for:An increased RR has been observed for:
Cerebral palsy overall (OR 3.7; 2.8 in singletons)Cerebral palsy overall (OR 3.7; 2.8 in singletons)
Developmental delay (OR 4.0)Developmental delay (OR 4.0)Stromberg et al ’02 Lancet 359;461-5Stromberg et al ’02 Lancet 359;461-5
BUT, this appears to be mostly due to premature birthBUT, this appears to be mostly due to premature birth (Hvidtjorn et al ’06 Pediatrics;118:475-82)(Hvidtjorn et al ’06 Pediatrics;118:475-82)
HOWEVER, in vitro-derived mice exhibit specific behavioral alterations in anxiety/locomotor activity and spatial HOWEVER, in vitro-derived mice exhibit specific behavioral alterations in anxiety/locomotor activity and spatial memory memory (Ecker et al ’06 PNAS;101:1595-1600)(Ecker et al ’06 PNAS;101:1595-1600)
Meeting schedule:Meeting schedule:
The first meeting was in October, 2006The first meeting was in October, 2006
We currently strive to meet for 1.5 hrs monthlyWe currently strive to meet for 1.5 hrs monthly
After primary mission is established, we will meet as necessary regarding new issues and new technologies and policies etc.After primary mission is established, we will meet as necessary regarding new issues and new technologies and policies etc.
SummarySummary Meta-analyses reveal worse perinatal outcomes for Meta-analyses reveal worse perinatal outcomes for
ART singletons ART singletons versusversus non-ART singletons. non-ART singletons.
Conversely, IVF twins seem to be at no higher risk Conversely, IVF twins seem to be at no higher risk than spontaneous twins.than spontaneous twins.
The etiology for these adverse outcomes in The etiology for these adverse outcomes in singletons is unknown but may be related to:singletons is unknown but may be related to: The infertility per seThe infertility per se
The ovarian stimulation The ovarian stimulation
The lab technologyThe lab technology
Summary Summary (cont.)(cont.) Slightly higher risk of malformations and chromosomal Slightly higher risk of malformations and chromosomal
abnormalities in ICSI babies, mostly related to parents abnormalities in ICSI babies, mostly related to parents of originof origin
Psycho-motor development is normal, neuro-Psycho-motor development is normal, neuro-developmental outcome may be influenced by neonatal developmental outcome may be influenced by neonatal problemsproblems
An increased incidence of very rare disorders remains An increased incidence of very rare disorders remains possible (etiology unknown, but may be lab-related)possible (etiology unknown, but may be lab-related)
Recommended that patients are counseled about Recommended that patients are counseled about potential risks, their possible etiologies and our current potential risks, their possible etiologies and our current knowledgeknowledge base base
Gaps in Our KnowledgeGaps in Our Knowledge Etiologies of many of the adverse outcomes remain to be Etiologies of many of the adverse outcomes remain to be
resolvedresolved
Challenges remain regarding teasing out infertility factors Challenges remain regarding teasing out infertility factors versusversus treatment-related issues treatment-related issues
(e.g. ART for tubal ligation (e.g. ART for tubal ligation versusversus disease-related reasons disease-related reasons))
Absence of linkage of lab technologies with gestational Absence of linkage of lab technologies with gestational complications, birth, infant & child health outcomescomplications, birth, infant & child health outcomes: : Culture mediaCulture media ICSI, AH, PGDICSI, AH, PGD Prolonged embryo cultureProlonged embryo culture Frozen Frozen versusversus fresh transfers fresh transfers
Barker DJ. The developmental origins of adult disease. Eur J Epid ’03;8(8):733-6
Barker HypothesisBarker HypothesisA baby's nourishment before birth and during infancy, as manifest in patterns of fetal and infant growth, "programmes" the development of risk factors such as raised blood pressure and glucose intolerance that are key determinants of coronary heart disease.
Female Health
Ov Stim
Male Health Lab Effects
UterineReceptivity