High-order Pregnancies Research Articles

Fetal reduction in patient with internal jugular vein thrombosis following Ovarian Hyper Stimulation Syndrome (OHSS)

Thrombosis of the internal jugular vein is an uncommon entity with potential for serious consequences [1]. Majority of the reported cases of jugular venous thrombosis have occurred in the presence of an indwelling venous catheter, an established hyper-coagulable state, or in association with head and neck sepsis. We report a case in whom jugular venous thrombosis developed during the first trimester following Ovarian Hyper Stimulation Syndrome (OHSS) and quintuplet pregnancy. The presentation of severe neck pain in pregnant women, especially in those who have undergone assisted reproduction procedures and had OHSS, should prompt evaluation by duplex scan to evaluate the jugular veins for thrombosis. Fetal reduction should be considered in these high order pregnancies.

Criteria to select quality blastocyst to transfer: a SART study

OBJECTIVE: To avoid high order pregnancy, single embryo transfer (SET) is a trend. SET not only raise the concern of patients but also fertility centers about which blastocyst to transfer. Studies claimed the stage of blastocyst, quality of inner cell mass (ICM), or quality of Trophectoderm(TRO) were sensitive indicators. But the conclusion sometimes contra-indicated each other and the sample size were small. In order to obtain reliable and sensitive indicator(s), this study utilized SART CORS big data file to examine the question.

Is the Rate of Congenital Heart Defects Detected by Fetal Echocardiography Among Pregnancies Conceived by In Vitro Fertilization Really Increased?

We investigated the prenatal prevalence of congenital heart defects (CHDs) among in vitro fertilization (IVF) pregnancies at a referral program in the United States. Study patients were referred for fetal echocardiography between April 1, 2006, and May 1, 2009, due to IVF. An IVF pregnancy was defined as a patient who conceived with IVF with or without intracytoplasmic sperm injection. Congenital heart defect odds relative to historical data were calculated by standard methods. P < .05 was considered statistically significant. During the study period, we performed fetal echocardiography on 749 consecutive IVF pregnancies. Overall, the frequency of CHDs was 1.1% (95% confidence interval, 0.3%-1.8%) per pregnancy. Compared to earlier historical population data, IVF pregnancies had a significantly higher risk of CHDs (odds ratios, 7.3 [3.6-14.7] and 2.9 [1.4-5.9], respectively). However, compared to more contemporary population data, there was no difference in the CHD risk between IVF gestations and naturally conceived pregnancies. Further analysis indicated that IVF twin pregnancies were as much as 12.5 (4.6-33.5) times as likely to have CHDs compared to a general population. In this study population, the frequency of CHDs in IVF pregnancies was higher than early historical population data; however, it was similar to that of a more contemporary general population. Further analysis showed that this increase was mainly driven by IVF twin gestations. Previous reports of increased CHD risk in pregnancies conceived via IVF may have been due, in part, to an increased frequency of higher-order pregnancies seen among these patients.

Hysteroscopic Subendometrial Embryo Delivery (SEED), Mechanical Embryo Implantation

Background A major hurdle to improved in vitro fertilization (IVF) success rate is defective endometrial receptivity and implantation. Various techniques have been advocated to increase implantation while reducing side effects. Currently, embryo transfer (ET) is performed blindly without direct visualization. As such, we sought to develop a technique utilizing a flexible minihysteroscope with a flexible catheter for direct implantation of the blastocyst(s). Materials and methods This was a case study performed at West Coast IVF Clinic, Inc., Beverly Hills, California 90212. A total of 15 IVF Cycles in 13 patients (average age = 29) underwent visually directed ET and endometrial implantation. All women received luteal support. The main outcome measure in this study, both clinically and procedurally, was the relevant development and assessment of a novel surgical technology. Results In this study, eight (60%) pregnancies ensued [5 (62.5%) clinical and 3 (37.5%) biochemical]. Of note, there was no uterine scratching, uterine bleeding, or ectopic pregnancies. Significantly, high-order pregnancies were decreased; only one twin was conceived. Conclusion Preliminary data suggest mechanically assisting implantation with a hysteroscopic blastocyst ET (SEED) offers a viable option for improving pregnancy outcome.

Gestación multifetal yatrogénica

Multiple pregnancies spontaneously occur in one out of 90 pregnancies for twins and in one out of 8,100 for triplets. However, since the introduction of human reproduction units, there has been a 52% increase in twins, and a 404% increase in high-order pregnancies. Given the high perinatal and maternal morbidity and mortality in these pregnancies, selective embryo reduction was developed to increase fetal survival and reduce long-term morbidity in neonates. Although effective, this procedure represents a technical and ethical challenge for the practitioner. Consequently, we believe that the most effective approach to multifetal pregnancies is primary prevention.

Knowledge and Attitudes of Women towards Multiple Embryo Transfer, Fetal Reduction and Multiple Pregnancy

ABSTRACTBackgroundMultiple pregnancy and preterm delivery are well-known complications of IVF/ICSI treatment. Fetal reduction is also performed in the cases of high order multiple pregnancy. There is increased impetus on transferring fewer embryos, preferably only one in younger women.Materials and Methods186 women, who conceived following IVF/ICSI treatment participated in a questionnaire study regarding their knowledge and attitudes towards multiple embryo transfer, fetal reduction and multiple pregnancyResultsA majority of women said that they were aware of the complications of multiple pregnancy (90%) and preterm delivery (85%). Nevertheless, none of them opted for a single embryo transfer. A positive pregnancy test was more important to most women than the outcome of that pregnancy (74%). Fetal reduction did not pose any moral concerns to most women (67%). Anxiety about the safety of the remaining twins persisted throughout pregnancy (73%). Having twin babies did not affect the quality of life of most women (74%).ConclusionIndian women were similar with their western counterparts in desiring multiple embryo transfer in order to maximize their chance of getting a positive pregnancy result. The negative impact of twin or higher order pregnancy appears to be disregarded by the women prior to getting pregnant. The confidence of the treating physician to offer single embryo transfer also appears to affect the patients’ choices.

Diagnosing twins in early pregnancy

Multiple pregnancy has increased in frequency as a result of the ageing maternal population as well as the advent and wider availability of assisted reproductive technologies. Higher-order pregnancies are associated with increased morbidity and mortality for both the foetuses and mother. The introduction of transvaginal ultrasound has made accurate diagnosis of twin pregnancy, determination of chorionicity and subsequent planning of these high-risk pregnancies a common part of obstetric care. In this article, we critically evaluate the role of transvaginal ultrasound in the diagnosis of twin pregnancies.

Blastocyst stage transfer vs cleavage stage embryo transfer.

OBJECTIVE:To evaluate the efficacy of blastocyst transfer in comparison with cleavage stage embryo in a similar cohort of women.DESIGN:Retrospective analysis.SETTING:University teaching hospital.MATERIALS AND METHODS:Women aged 35 or less undergoing in vitro fertilization/intracytoplasmic sperm injection between January 2005 and December 2006 were included in the study. When four or more grade 1 embryos were observed on day 3, extended culture till day 5 was undertaken. This policy was compared with a cohort of women who had at least three grade 1 embryos on day 3 and who had undergone a cleavage stage embryo transfer during the time period of January 2002–December 2004. Primary outcome evaluated was implantation rate and clinical pregnancy rate.RESULTS:Group 1 consisted of 50 women who underwent extended culture and blastocyst transfer. Group 2 comprised of 85 women who had cleavage transfer. The implantation rate for embryos transferred in group 1 was significantly higher than that for embryos transferred on day 3 (40.16% vs 11.43%). The clinical pregnancy rate was also significantly better with blastocyst transfer as compared with cleavage stage transfer (62% vs 29.76%). Significantly fewer embryos were required for transfer at the blastocyst stage compared with day 3 transfer (2.54 vs 3.45).CONCLUSION:In selected cases, blastocyst transfer with fewer embryos can be performed with high implantation and clinical pregnancy rates. This policy could lead to a reduction in the incidence of higher-order pregnancies.

Arguments for elective single-embryo transfer

Over the past 25 years, artificial reproductive techniques have significantly improved and are now a well-established practice. While pregnancy, without consideration of obstetric and neonatal outcomes, was the main focus of the practice in the past, today a practice is esteemed successful if a healthy baby is delivered in a short treatment time with low risks for the patient and the baby. Human reproduction itself is quite inefficient. During the period of conception, implantation and placentation to the delivery of a baby, a number of aberrations can occur, resulting either in no pregnancy or a loss of pregnancy. In order to compensate for the low implantation rate of human embryos, it is routine to transfer more than one embryo in each treatment cycle as a routine procedure. As a result, the incidence of multiple pregnancy (MP; twins and higher order pregnancies) after IVF/intracytoplasmic sperm injection is much higher (30%) than after natural conception (1%). The obstetric, neonatal and long-term con...

Réduction embryonnaire : indications, techniques, impact psychologique

High-order multiple pregnancies (triplets and above) are associated with high pediatric mortality and morbidity, mainly due to their premature delivery. Maternal morbidity is also substantially higher than for singleton gestations. The main goal of multifetal pregnancy reduction (MFPR) is to decrease the rate of severe prematurity and its consequences, including neurodevelopmental handicaps. It may also reduce the risk of maternal complications. Transabdominal needle-guided procedures, performed at 10-12 weeks, are the most common technique for MFPR. Transvaginal needle aspiration can be used successfully earlier in gestation (7-8 weeks). Transcervical aspiration is no longer used. There is generally no medical indication for MFPR in twins. MFPR does not reduce the risk of loss of the entire pregnancy before 24 weeks and may increase the risk of a second-trimester miscarriage by 1-2%. MFPR substantially decreases premature delivery rates, cutting the risk of delivery at 29-32 menstrual weeks in triplet pregnancies in half for reductions to twins and by five for reduction to singletons. The positive effect of MFPR on perinatal outcome is incontrovertible for quadruplets and higher-order pregnancies. Advances in perinatal medicine have substantially reduced mortality in premature triplet deliveries, however, and this should be taken into account when considering the potential benefit of MFPR. MFPR is a distressing experience for parents, but seems not to have long-term adverse effects on women's psychological well-being. Maternal distress related to MFPR tends to fade with time. The negative psychological impact of MFPR should be weighed against that related to raising the children from high-order pregnancies. Prevention of high-order multifetal pregnancies is essential and requires careful monitoring of infertility therapies.

Association of sperm chromatin status with early pregnancy loss and high order pregnancies after ICSI

Sperm chromatin may play a role in fertilization process and embryo development. ICSI is a gold standard for severe male factor infertility. However it may result in multiple pregnancies as well as an increase in early pregnancy loss after embryo transfer. The aim of our study was to evaluate sperm chromatin status in infertile couples undergoing ICSI for male factor infertility with high order pregnancies and early pregnancy loss.

Triplet pregnancy after metformin in a woman with polycystic ovary syndrome

To report a case of triplet pregnancy after metformin treatment only, in a woman with polycystic ovary syndrome (PCOS) and a family history of twin pregnancies. Case report and literature review. Gynecologic endocrinology clinic, tertiary federal hospital. A white, lean, 34-year-old woman, treated for PCOS since age 28, who had tried to conceive spontaneously for 6 months, with no evidence of ovulation. Metformin, 850 mg, for 1.5 months. Pregnancy (triplet). Pregnancy developed up to premature labor at 31 weeks. The patient delivered two boys and one girl, in need of neonatal intensive care for 33 to 44 days. Despite the paucity of literature data, we believe that metformin, when associated with predisposing therapies or conditions, may facilitate high-order pregnancies.

Global epidemiology of multiple birth

Multiple births, which account for approximately 3% of births and 14% of infant deaths, are increasing in frequency. Multiple birth rates began to decline in the 1950s, reaching a minimum in the 1970s and rising since then. Both twin and triplet rates followed the same rising trend until 1998, after which triplet birth rates began to decline while twin birth rates continued to rise. Rising maternal age is associated with rising frequency of dizygotic twinning up to 37 years of age. Older maternal age, associated with the social trend to delayed child bearing, accounts for 25–30% of the rise in multiple birth rates since 1970. The resulting rise in the prevalence of infertility has given rise to unprecedented use of ovarian stimulation treatments that stimulate the development of multiple oocytes. Assisted reproduction technology and ovulation stimulation with clomiphene citrate or gonadotrophins without assisted reproduction account for similar proportions of both twin births (20–30%) and triplet births (30–40%). The fall in triplet rates since 2000 is reassuring, but fetal reduction of high order pregnancies may be a factor in rising twin rates. Continuing attention is needed to all possible means of minimizing triplet pregnancies.

Chorionicity and mode of fertilization: a long‐standing misconception

Chorionicity and mode of fertilization: a long‐standing misconception

O-180: Consequences of an eventual restrictive embryo transfer policy on ICSI outcome

The occurrence of multiple gestations in association with ART varies among different countries, and ranges from about 14% in Europe to as high as 40% in the USA. The pre- and post-natal care costs associated with the morbidity involved in these high order pregnancies have induced governments and reproductive associations to provide guidelines aimed at limiting the number of embryos replaced. Currently, Scandinavian and northern European countries are considering whether to mandate the transfer of only one embryo at a time.

P-281: Estimative of embryo implantation potential avoids the occurrence of high-order pregnancies in IVF cycles

Multiple pregnancy rates are high in assisted reproductive technology (ART) as a consequence of the stimulation of several ovarian follicles and the following transference of more than 1 embryo. Multiple pregnancies are known to have higher incidence of complications. The perinatal mortality is 4-fold higher for twins and 6-fold higher for triplets when compared to single pregnancies. Aiming to avoid the occurrence of high-order pregnancies, we transfer only 2 embryos for patients with a possibly higher potential of implantation.

Ethical considerations in embryo-reduction

Summary The incidence of multifetal pregnancy has increased dramatically with the introduction of artificial reproductive techniques (ART). These pregnancies are at high risk for maternal, perinatal and long-term complications, and embryo reduction (ER) has been used for a number of years in an attempt to improve these outcomes. In high-order multifetal pregnancies ER is associated with a decrease in the background risk of miscarriage and perinatal death, but there are some questions regarding the benefits of reduction in triplet pregnancies. The importance of preventative ethics, by restricting the number of embryos transferred or careful monitoring of ovulation induction agents is generally agreed upon. Regulation of treatment regimes coupled with refinements to ART, have reduced the rate of triplet- and higher-order multifetal pregnancies in the last few years. In this article, the moral status of a fetus is discussed and biomedical ethical principles are examined in the context of ER. In addition, religious considerations and medical guidelines are discussed.

Pregnancy-Related Mortality Among Women With Multifetal Pregnancies

To examine the relative risk of pregnancy-related mortality between multifetal pregnancies and singleton pregnancies. We used data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to examine singleton and multifetal pregnancy-related deaths among women with a live birth or fetal death from 1979-2000. The plurality-specific (singleton or multifetal) pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths per 100,000 pregnancies with a live birth. We analyzed the risk of death due to pregnancy for singleton and multifetal pregnancies by age, race, education, marital status, and cause of death. Of 4,992 pregnancy-related deaths in 1979-2000, 4.2% (209 deaths) were among women with multifetal pregnancies. The risk of pregnancy death among women with twin and higher-order pregnancies was 3.6 times that of women with singleton pregnancies (20.8 compared with 5.8). The leading causes of death were similar for women with singleton pregnancies and women with multifetal pregnancies: embolism, hypertensive complications of pregnancy, hemorrhage, and infection. Women with multifetal pregnancies have a significantly higher risk of pregnancy-related death than their counterparts with singleton pregnancies; this holds true for all women regardless of age, race, marital status, and level of education. II-2.

Prevention of multiple pregnancies in assisted reproduction

The incidence of multiple births has increased parallel with the success of assisted reproduction treatments (ART) mainly because of the multiple embryo transfer. As a response to the increased multiple birth rate, the number of embryos transferred was reduced in 1992–1994 from three or more to two in many European countries. After that, a dramatic drop in the number of triplet and higher-order pregnancies was seen, but the twin rate still remained high. According to the European registers by ESHRE, in 2001 still 34.4% of children conceived with ART originated from multiple pregnancies, of which 94% were twin pregnancies. Obstetric and perinatal complications affect twins more often than singletons, contributing to increased health risk of the mother of twins and the children born as twins. In addition to the medical complications, twin families are at a greater risk for psychosocial burden. From the health-economic point of view, cost impact for twins is threefold to that of singletons. Recently, the standards of success of infertility treatment have been widely debated in journals of reproductive medicine. The general conclusion from this debate is that both the delivery rate per treatment and the final outcome of the pregnancy should be considered when the success of ART is reported. The high iatrogenic twin rate resulting from ART still offers the infertility treatment providers a challenge to strive for minimizing the number of ART-related twins. The most efficient way to reduce twin rate in ART is single embryo transfer (SET). However, the worry about impairment of delivery rate if only one embryo is transferred has hampered the acceptance of SET. The four randomised controlled trials and some retrospective cohort studies published until now have confirmed the effectiveness of elective single embryo transfer (eSET) in reducing the twin rate below 10%. In addition, highly acceptable delivery rate is achieved with eSET. The final results of eSET are most obviously further improved by transfer of frozen-thawed embryos. The experience of eSET until now encourages mowing towards an individualised embryo transfer policy, where eSET is performed in good prognosis patients at high risk for a twin pregnancy when two embryos would be transferred. The aim of this article is to review studies about eSET as a method to prevent ART-related twin pregnancies and the ways used in nationwide implementation of eSET in Finland, Belgium and Sweden.

Semen Parameters as Determinants of Success in 1662 Cycles of Intrauterine Insemination After Controlled Ovarian Hyperstimulation

Male factor as the etiology of infertility occurs in up to 35% of infertile couples. Intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) is a powerful tool that may be utilized in infertile patients with mild semen parameter abnormalities and non-tubal infertility. The objective of this study was to define the values of semen parameters that determine success. Historical cohort study The cycle information on all patients who underwent IUI during the period of April 1990- February 2004 at our referral center was being collected prospectively. A total of 1656 cycles of IUI were included. The patients had similar ovarian stimulation protocols, GnRH agonist or antagonist with pure FSH and/or HMG. They had a single IUI performed 42 hours after human chorionic gonadotropin injection. The analysis included pre-wash and post-wash semen parameters. Statistical analysis was performed using the Student’s-test and χ2 where appropriate. Multiple logistic regression analysis was performed to control for age, type and duration of infertility and the number of follicles ≥14mm as an indication of response to ovarian stimulation. The mean age was 32.0 ±5.1 years, the mean duration of infertility was 3.1±2.6 years, and 47.1% had primary infertility. Out of the 1656 cycles there were 496 pregnancies (30.0%) out of which 22.0% were twins, 9.6% were triplets and 6.0% were higher order pregnancies. Of those that conceived, the miscarriage rate was 16.2%, the ectopic rate was 4.1%, and the multiple pregnancy rate was 37.5%. When the cycles were divided into a range of 5 million/mL pre-wash concentration, there was an increase in the pregnancy rate above 5 million/mL (Table 1). The pregnancy rate for those below 5 million/mL was 18.8% and those greater than 5 was 30.3% (P=0.109). When the data was analyzed by the post-wash absolute number of motile sperms in the pellet to be inseminated, those ≤0.5 million had a pregnancy rate of 8.0% as compared to 30.3% in those > 5million (P=0.009). The cycles with pre-wash sperm motility ≤20% had a pregnancy rate of 17.1% as compared to 30.4% in those with motility>20% (P=0.062). Those with normal sperm morphology had a pregnancy rate 30.6% as compared to 27.4% in those with abnormal morphology (P=0.123). Using multiple logistic regression, the cut off limit of 0.5 million post-wash motile sperm and pre-wash motility 20% as well as female age were found to be independent factors. When analyzed by age, the pregnancy rate for women below the age of 40 was 31.0% as compared to 11.5% in women ≥40 years (p=0.000). Tabled 1 A post wash total motile sperm count below 500,000 adversely affects the outcome of IUI+COH. The post-wash total motile sperm count, pre-wash motility and age were independent factors in the pregnancy rate of IUI+COH The pregnancy rate was adversely affected in women beyond 40 years which may raise the question of whether IUI+COH is recommended in this age group.