Safety issues in assisted reproduction technology: the children of assisted reproduction confront the responsible conduct of assisted reproductive technologies

Neurological sequelae and multiple birth defects have been observed in children conceived by IVF and ICSI. Multiple pregnancy is the most important risk factor. These health problems challenge the responsible practice of medicine. The core values of medicine and the deontology of the profession have been reviewed to define the responsible conduct of research and clinical practice. Professional associations have proposed guidelines to reduce health problems in assisted reproductive technology. Although these health problems could have been prevented, this response by the medical community is nonetheless an important step towards improving responsible medical practices that have become questionable over the years. Professional associations must find out means, not only to implement their guidelines, but also to prevent the recurrence of such episodes in the history of medicine.     

Safety issues in assisted reproduction technology. A rebuttal

As part of an ongoing debate on safety in assisted reproduction, this paper supports the notion that assisted reproductive technologies must be applied responsibly, while rebutting previously expressed opinions and interpretations of history.     

Cumulative pregnancy and live birth rates in women with antiphospholipid antibodies undergoing assisted reproduction.

The aims of this study were to investigate the influence of antiphospholipid antibodies (APA) on cumulative pregnancy and live-birth rates in patients undergoing assisted reproductive treatment. Serum samples from 173 patients were collected prior to initiation treatment cycle and tested by enzyme-linked immunosorbent assay (ELISA) for the presence of immunoglobulin (Ig)G, IgM and IgA against cardiolipin, phosphoserine, phosphoethanolamine, phosphoinositol, phosphatidic acid, and phosphoglycerol. Fifty-six samples from patients who had at least two failed cycles by assisted reproductive treatment were also tested by a bioassay for the presence of lupus anticoagulants. Both cumulative pregnancy and live birth rates were not affected by the presence of any specific or any number of seropositive APA. There was no association between multiple assisted reproductive treatment failures and APA seropositivity. Neither the serum concentration of any of the 18 APA, nor the number of positive APA was correlated with the number of assisted reproductive treatment failed cycles or affected the probability of pregnancy. No patient was found to be positive for lupus anticoagulants. Using life table analyses, which has been recognized as the most appropriate method available to analyse assisted reproductive treatment results, we conclude that there is no relationship between circulating APA and assisted reproductive treatment outcome. APA do not affect the early process of implantation or maintenance of pregnancy among assisted reproductive treatment patients.     

Antithyroid antibodies do not affect pregnancy outcome in women undergoing assisted reproduction.

The purpose of this study was to determine the association of antibodies to thyroglobulin and thyroid peroxidase and pregnancy outcome in women undergoing assisted reproductive techniques. The study included three centres and retrospectively evaluated patient sera for antithyroid antibodies, then related the results to pregnancy outcome. Enzyme-linked immunosorbant assays for thyroglobulin and thyroid peroxidase antibodies were performed using two different commercially available kits. Controls included 200 healthy women of reproductive age. Women (n = 873) who were undergoing assisted reproductive techniques for pelvic adhesions, endometriosis, ovarian dysfunction, or unexplained/other were included. All women utilized a standard regimen of gonadotrophin releasing hormone agonist down-regulation followed by ovulation induction. Embryos were cultured for 3 days, at which time embryo transfer occurred. Statistical analysis utilized the two-tailed Fisher's exact test. Antithyroid antibodies were positive in 143 of 873 (16.4%) women undergoing assisted reproductive techniques while 29 of 200 (14.5%) normal controls were positive (not significant). Deliveries were achieved in 396 of 730 (54.2%) of women who had no thyroid antibodies versus 78 of 143 (54.5%) of women who had thyroid antibodies (not significant). No difference in biochemical pregnancies (not significant) or clinical pregnancy losses (not significant) were detected. Antithyroid antibodies were found no more frequently in women undergoing assisted reproductive techniques than in normal controls. There were no differences in pregnancy outcome based on antithyroid antibody positivity in women undergoing assisted reproductive techniques. These data do not support the testing or treatment for antithyroid antibodies of women undergoing assisted reproductive techniques.     

Serological testing for celiac disease in women undergoing assisted reproduction techniques

BACKGROUND: The assertion of a causal relationship between celiac disease and infertility is suggested by several lines of research. Nevertheless, robust evidence has not yet been provided. The present study evaluated, for the first time, the prevalence of celiac disease in women undergoing assisted reproduction techniques (ART). METHODS: Serum samples from 200 Italian women undergoing ART were evaluated for celiac disease by endomisium antibody (EMA) and transglutaminase antibody (t-TGA)-two highly sensitive and specific serological markers. Two hundred women not reporting reproductive problems and having delivered at least one child served as controls. In cases of positive serology, the diagnosis was confirmed by jejunal biopsy. RESULTS: Five (2.5%) women from the study group and two (1.0%) from the control group were found to have celiac disease (P = 0.44). The main indications for ART in women found to have celiac disease were tubal factor in two cases and male infertility in three cases. None of these women reported major gastrointestinal complaints. Extra intestinal signs linked to celiac disease were noted in four out of five patients. CONCLUSION: This study raises the issue of celiac disease screening in ART programmes. Given the available evidence in the literature combined with our observations from this study, the value of serological testing for celiac disease in infertile women remains uncertain. Further studies to address this issue are required.     

Implantation is apparently unaffected by the dopamine agonist Cabergoline when administered to prevent ovarian hyperstimulation syndrome in women undergoing assisted reproduction treatment: a pilot study

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is a result of ovarian overexpression of vascular endothelial growth factor (VEGF) and its receptor 2 (VEGFR2). VEGF/VEGFR2 binding disrupts cellular junctions and increases vascular permeability (VP), a characteristic of OHSS, but enhances angiogenesis, which is a fundamental step in implantation. In animals, the dopamine agonist Cabergoline (Cb2) prevents VP without affecting angiogenesis. In humans, Cb2 averts OHSS, but a possible detrimental effect on angiogenesis and implantation has not been explored. A pilot study was designed to analyze whether or not Cb2 administration, as a procedure for preventing OHSS, affects the outcome of assisted reproduction treatment (ART). METHODS: A retrospective study with endpoints of implantation and ongoing/term pregnancy rates. Women (n = 35) at risk of OHSS (20-30 follicles developed and >20 oocytes collected) took a daily oral dose of 0.5 mg Cb2 for 8 days, beginning on the day of hCG. They were matched with controls treated during the same period and who were similar with respect to age, number and quality of the embryos replaced, embryonic stage at transfer and sperm quality. RESULTS: No difference was detected between the groups in fertilization, implantation or pregnancy rates. A total of 14 ongoing (beyond 32 weeks) or full term pregnancies were registered in each group. No major problem was detected during pregnancy or after delivery in any of these babies. CONCLUSIONS: Administration of Cb2 in order to prevent OHSS is safe and does not appear to affect ART outcome.     

A formal comparison of the practice of assisted reproductive technologies between Europe and the USA

In this study, we compared pregnancy and delivery outcomes after the utilization of assisted reproductive technologies (ART) in Europe and the United States (US). ART outcomes were compared between Europe and the US for the year 2001, based on formal reports published by the European Society for Human Reproduction and Embryology (ESHRE) and the Center for Disease Control and Prevention (CDC) in collaboration with the American Society for Reproductive Medicine (ASRM) and Society for ART (SART). Europe utilizes ART at approximately twice the rate of the US (P < 0.001). United States patients showed a significantly decreased likelihood of reaching oocyte retrieval (P < 0.001) and embryo transfer (P < 0.001). Despite this lower chance of reaching oocyte retrievals and embryo transfers, US patients experienced significantly higher clinical pregnancy rates (P < 0.001) and delivery rates per started cycle (P < 0.001) than European patients. Amongst patients reaching oocyte retrieval, the difference in clinical pregnancy rates and live birth rates was even more pronounced in favour of the US. However, US patients received significantly more embryos per embryo transfer (P < 0.001) and experienced a significantly higher multiple pregnancy rate (P < 0.001). Significant differences in favour of US patients in pregnancy rates and live birth rates were also observed for frozen embryo cycles and oocyte donation cycles, where the difference was most pronounced. The better pregnancy and live birth outcomes in the US are not explainable by the transfer of larger embryo numbers alone.     

Safety issues in assisted reproductive technology: aetiology of health problems in singleton ART babies

The frequency of health problems in singleton assisted reproductive technologies (ART) babies is higher than in singletons from spontaneous gestations. Any of the following factors may be involved: in-vitro technology, ovarian stimulatory drugs and infertility itself. A literature review on premature birth, low birth weight, perinatal mortality and major birth defects in children conceived from infertility treatments was conducted. Only publications comparing the outcome of pregnancy in an infertile group of patients to a matched control group were selected. The analysis of the outcome of singleton pregnancies resulting from IVF versus artificial insemination, obtained with or without the use of ovarian stimulatory agents and obtained with or without the use of a semen donor, suggests that female infertility is an important risk factor. Criteria for screening at-risk infertile women have not yet been identified. Prospective studies designed to identify precisely the aetiology of health problems in singletons ART babies will have to be conducted. The absence of criteria correlating at-risk infertile women to health problems in their children does not allow a gynaecologist the opportunity to offer infertility treatments to the least susceptible patients.     

Quality of infertility care in poor-resource areas and the introduction of new reproductive technologies

The quality of infertility care is dependent upon adequate material resources and the appropriate use of it. In addition, a mutual understanding between physicians and patients is necessary. These imperatives are more salient in the era of the new reproductive technologies. However, in poor-resource areas these imperatives are insufficiently met. Moreover, in developing countries the negative consequences of childlessness are much stronger than in Western societies. Until recently, the problem of infertility in Third World countries has received little public attention. A plea is made for a stronger policy interest in Third World infertility care. In this it is important to focus on prevention, appropriate diagnosis and treatment at primary and secondary health-care level and to take the existing cultural beliefs into account.     

The impact of successful assisted reproduction treatment on female and male mental health during transition to parenthood: a prospective controlled study

BACKGROUND: The dynamics of mental health during the transitionto parenthood have not been a focus of research. Our prospectivelongitudinal study was designed to reveal whether there aredifferences in mental health during the transition to parenthoodbetween parents undergoing treatment with assisted reproductiontechniques (ART) and those who conceive spontaneously. METHODS:Study group: 367 couples with a singleton ART pregnancy usingtheir own gametes. Control group: 379 couples with a spontaneoussingleton pregnancy. Men and women separately filled in questionnairesincluding the General Health Questionnaire: at the 18th–20thweek of pregnancy, 2 months postpartum and 1 year postpartum(T3). The effect of social and child-related factors on mentalhealth was examined. RESULTS: ART women had fewer depressivesymptoms during pregnancy than controls, but at T3 their depressivesymptoms were at the same level as seen in controls. Anxietysymptoms increased among control but not among ART women acrossthe transition. ART men reported generally fewer mental healthsymptoms than their controls. Social and child-related stressorshad negative impacts on mental health changes among controlcouples, whereas no impact was found among ART couples. CONCLUSIONS:Successful ART did not predict mental health problems duringthe transition to parenthood. Moreover, ART couples’ mentalhealth was remarkably resistant to social and child-relatedstress during the transition to parenthood.     

Prediction of outcomes of assisted reproduction treatment using the calcium ionophore-induced acrosome reaction

BACKGROUND: Sperm concentration and motility are poor predictors of the outcome of intrauterine insemination (IUI), hysteroscopic intratubal insemination (HIT), or complete fertilization failure (CFF) in conventional IVF. We investigated whether the calcium ionophore-induced acrosome reaction (AR) constitutes an additional indicator of CFF and pregnancy that is independent of these semen parameters. METHODS: Infertile couples with no female factor (n=388) and women with tubal obstruction (n=32) were studied: IVF (n=133), ICSI (n=72), HIT (n=245) and IUI (n=61). The percentage of acrosome-reacted sperm in relation to viable sperm was calculated. Receiver operating characteristic curve and multiple logistic regression analyses were used to determine threshold values and the best predictor for CFF and pregnancy. RESULTS: Threshold values of AR for predicting CFF in IVF and pregnancy in IVF and HIT + IUI were 21, 26 and 22% respectively. These values were independent of the conventional semen analysis parameters. CFF was lower (2 versus 20%; P<0.01) and the pregnancy rate was higher (46 versus 24% P<0.05) for those with AR >21% in IVF. CFF and pregnancy rate in ICSI did not differ according to AR. Pregnancy rate was higher for those with an AR >22% for HIT + IUI (23 versus 11% P<0.01). CONCLUSIONS: Ionophore-induced AR appears to be a useful indicator in addition to routine semen analysis for selection of patients for treatment with appropriate assisted reproduction procedure.     

A retrospective study of New Zealand case law involving assisted reproduction technology and the social recognition of 'new' family

The New Zealand Human Assisted Reproductive Technology (HART) Act became law in 2004. In this article, we provide a retrospective analysis of New Zealand case law from September 1990 to March 2004, leading up to the creation of the HART Act. We examine the new understandings of parenting (developed through the routine use of ART in New Zealand) which the case law attempted to test. We examine these concepts against the previous understandings of family enshrined in the pre-existing legislation, which formed the basis for judicial rulings in the various cases to which we refer. In conclusion, we provide a brief summary of the 2004 HART legislation and draw comparisons between the old and new legislative and bureaucratic frameworks that define and support New Zealand family structure. We suggest that a change in cultural backdrop is occurring from the traditional western ideology of the nuclear family towards the traditional Maori concept of family formation, which includes a well-accepted traditional practice of guardianship and a more open and extended family structure. This 'new' structure reflects the contemporary lived experience of family kinship in western societies as individualized and open to choice.     

Recombinant versus urinary follicle stimulating hormone for ovarian stimulation in assisted reproduction.

The recent availability of recombinant follicle stimulating hormone (rFSH), with its high level of purity and batch-to-batch consistency has made it an attractive alternative to urinary FSH (uFSH) for ovarian stimulation. Several trials have compared the two preparations, but none had sufficient power to detect a clinically meaningful difference in pregnancy rates. The purpose of this study was to determine the clinical pregnancy rates per started cycle by pooling data from randomized trials which compared the use of rFSH and uFSH in treatment cycles using in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). A thorough search of the literature identified 12 trials which met the inclusion criteria. In four trials, both IVF and ICSI were performed, in seven trials only IVF was performed and in one trial only ICSI was performed. Data were extracted and pooled using the principles of meta-analysis. There was no significant heterogeneity of treatment effect across the trials. The common odds ratio and the risk difference (and their 95% confidence intervals), obtained by pooling the data using a fixed effects model, were 1.20 (1.02-1.42) and 3.7% (0.5-6.9%) respectively, in favour of rFSH. The pregnancy rate with the alpha preparation of rFSH was statistically significantly higher than with uFSH in IVF cycles. The overall conclusion from this meta-analysis is that the use of rFSH in assisted reproduction is preferred over uFSH.     

Attitudes towards human reproductive cloning, assisted reproduction and gene selection: a survey of 4600 British twins

BACKGROUND: Surveys have shown opposition to human reproductive cloning (HRC) in many countries. Views of identical (monozygotic, MZ) twins are of particular interest, as they naturally share 100% of their genes. We investigated attitudes of British twins towards HRC in the context of assisted reproduction technologies (ART) and gene selection. METHODS: About 4651 identical and non-identical (dizygotic, DZ) twins expressed their degree of agreement or disagreement to nine statements relating to ART, gene selection and HRC in a self-completion questionnaire. RESULTS: Most subjects (70% and 78% respectively) did not regard the use of medical technologies to treat infertility as interfering with either nature or God's will, despite believing that infertility is not a disease (54%). Attitudes to gene selection and HRC were context dependent, with more favourable views towards preventing serious diseases than towards enhancing traits. About 44% supported a permanent ban of HRC. MZ twins were significantly more likely to agree that HRC should be allowed for medical purposes, such as saving a sibling's life, than were DZ twins. Increasing religiosity generally correlated with more negative attitudes. CONCLUSIONS: Many attitudes are context dependent. More positive views of MZ twins towards HRC could be linked to their experience with being genetically identical.     

Infertility, assisted reproduction technologies and imprinting disturbances: a Dutch study

BACKGROUND: Evaluation of relationships between assisted reproduction technologies (ART), fertility problems and disorders caused by disturbed genetic imprinting such as Angelman syndrome (AS) and Beckwith-Wiedemann syndrome (BWS). METHODS: A nation-wide questionnaire survey was performed regarding ART in families with a child with AS, BWS or Prader-Willi syndrome (PWS) including questions on fertility. Molecular data on the genetic disorder in affected children were gathered. RESULTS: Of the 220 affected children in this study, 14 (6.4%) were born following any form of ART compared with 83 818 (2.1%) in the Dutch population. Of AS, PWS or BWS children 15 (6.8%) were born after a fertility problem (Time To Pregnancy > 12 months, no forms of ART) compared to 141,340 (3.5%) in the Dutch population. Maternal age in the individual syndromes was higher than in the Dutch population. Families with affected children were three times more likely to experience fertility problems than the general population. All three syndromes were also individually associated with increased fertility problems in the families. CONCLUSIONS: After correction for the increased fertility problems of the parents, there is no increased incidence of ART related birth of AS, PWS or BWS children. ART does not seem to have a direct effect on the increase of imprinted diseases.     

Epigenetic risks related to assisted reproductive technologies: risk analysis and epigenetic inheritance

A broad spectrum of assisted reproductive technologies has become available for couples with fertility problems. Follow-up studies of children born as a result of assisted reproduction have shown that neonatal outcome and malformation rates are not different from those of the general population, except for a low birthweight and a slight increase in chromosomal abnormalities. The safety aspect of assisted reproduction at the epigenetic level has not been well studied. Epigenetics refers to phenomena where modifications of DNA methylation and/or chromatin structure underlie changes in gene expression and phenotype characteristics. This article intends to analyse epigenetic risks related to assisted reproduction on the basis of an overview of epigenetic reprogramming events in the gamete and early embryo. Two epigenetic modifications, methylation and imprinting, are considered in more detail. The interference of in-vitro embryo culture, immature sperm cells and nuclear transfer with epigenetic reprogramming is discussed, as well as the possibility of epigenetic inheritance.     

GnRH antagonist in assisted reproduction: a Cochrane review

BACKGROUND: In the present systematic review, we wished to compare the efficacy of gonadotrophin-releasing hormone (GnRH) antagonist and GnRH agonist administration for controlled ovarian hyperstimulation in assisted conception. METHODS: Five randomized controlled trials fulfilled the inclusion criteria. In four studies, the multiple low-dose (0.25 mg) antagonist regimen was applied and, in one study, the single high-dose (3 mg) antagonist regimen was investigated. In all trials, reference treatment included a long protocol of GnRH agonist (buserelin, leuprorelin or triptorelin) starting in the mid-luteal phase of the preceding cycle. RESULTS: In comparison with the long protocol of GnRH agonist, the overall odds ratio for the prevention of premature LH surges was 1.76 [95% confidence interval (CI) 0.75-4.16], which was not statistically significant. There were significantly fewer clinical pregnancies in those treated with GnRH antagonists (OR 0.79; 95% CI 0.63-0.99). There was no statistically significant reduction in incidence of severe ovarian hyperstimulation syndrome between the two regimens (relative risk 0.51; OR 0.79; 95% CI 0.22-1.18). CONCLUSIONS: We concluded that the fixed GnRH antagonist protocol is a short and simple protocol with good clinical outcome, but the lower pregnancy rate compared with the GnRH agonist long protocol and the non-significant difference between both protocols regarding prevention of premature LH surge and prevention of severe ovarian hyperstimulation syndrome necessitates counselling subfertile couples before recommending change from GnRH agonist to antagonist. The clinical outcome may be further improved by developing more flexible antagonist regimens, taking into account individual patient characteristics.     

Bacterial colonization of the uterine cervix and success rate in assisted reproduction: results of a prospective survey

BACKGROUND: Overgrowth of bacteria in the birth canal is associated with an increased risk of late miscarriage, preterm labour, post-partum endometritis and low birthweight. Conception rates in assisted reproduction treatments (ART) remain frustratingly low. We examined whether the nature of bacterial flora, found in the uterine cervical canal at embryo transfer, is associated with the rate of conception in ART. METHODS: We sampled for bacteriological culture the cervical canal of 204 patients who underwent embryo transfer. Of these, 139 (68%) were of fresh embryos, following recent vaginal oocyte retrieval and prophylactic antibiotic therapy, and 65 (32%) of frozen-thawed embryos, without any vaginal intervention in the preceding days. Bacteriological work-up included identification, colony count and antibiotic susceptibility profile. Conception was correlated with bacterial type and colony count. RESULTS: In 75 patients (36.8%) sterile cervical cultures or lactobacillus were recorded. Of these 75 patients, 23 (30.7%) conceived, whereas among the 129 in whom any pathogenic micro-organism was recovered only 21 (16.3%) conceived (P = 0.002). No difference in colonization was found between women who underwent frozen-thawed versus fresh embryo transfer (57 and 67% respectively). Any Gram-negative colonization was associated with no conception. All Gram-positive, and 90% of the Gram-negative bacteria, were sensitive to augmentin. CONCLUSIONS: Failure to conceive in ART is significantly associated with bacterial colonization of the uterine cervix.     

Pentoxifylline: actions and applications in assisted reproduction

Data are presented covering various studies on the use of thephosphodiesterase inhibitor pentoxifylline (PF) in the spermpreparation for procedures in assisted reproduction. Significantimprovements have been shown in the fertilization rate of oocytesalong with a reduced risk of failed fertilization cycles utilizingoligo/asthenozoospermic semen samples. Fertilization is alsoimproved for normozoospermic samples when the acrosome reactionis suboptimal. PF has proven effects on sperm motility, increasingthe proportion of hyperactivated spermatozoa. It can also enhancethe acrosome reaction and this may be the more relevant functionfor clinical prediction. There is a further action as a suppressoror scavenger of reactive oxygen species although higher concentrationsthan that in current clinical use may be required to optimizethis effect. PF should be washed out of the sample used forinsemination to avoid inhibiting the completion of oocyte maturation.     

Increased risk of early pregnancy loss by profound suppression of luteinizing hormone during ovarian stimulation in normogonadotrophic women undergoing assisted reproduction

The impact of suppressed concentrations of circulating luteinizing hormone (LH) during ovarian stimulation on the outcome of in-vitro fertilization or intracytoplasmic sperm injection treatment in 200 consecutive, normogonadotrophic women (couples) was analysed retrospectively. A standard stimulation protocol with mid-luteal gonadotrophin-releasing hormone (GnRH) agonist down-regulation and ovarian stimulation with recombinant follicle stimulating hormone (FSH) was used in all cases. Blood was sampled from each woman on stimulation days 1 and 8 for analysis of oestradiol and LH in serum. A threshold value of serum LH of 0.5 IU/l on stimulation day 8 (S8) was chosen to discriminate between women with low or 'normal' LH concentrations. Low concentrations of LH on S8 (<0.5 IU/l) were found in 49% (98/200) of the women. This group of women was comparable with the normal LH group with regard to pre-treatment clinical parameters, and to the parameters characterizing the stimulation protocol with the exception of serum oestradiol concentration, which on S8 was significantly lower than in the normal LH group (P < 0.001). The proportion of positive pregnancy tests was similar in the two groups (30% versus 34% per started cycle), but the final clinical treatment outcome was significantly different, with a five-fold higher risk of early pregnancy loss (45% versus 9%; P < 0.005) in the low LH group and consequently a significantly poorer chance of delivery than in the normal LH group. It is concluded that a substantial proportion of normogonadotrophic women treated with GnRH agonist down-regulation in combination with FSH, devoid of LH activity, experience LH suppression, which compromises the treatment outcome. Whether these women would benefit from supplementation with recombinant LH or human menopausal gonadotrophin during ovarian stimulation, remains to be proven in the future by prospective randomized trials.