Non-medical Indications Research Articles

Characteristics and circumstances of women in Australia who cryopreserved their oocytes for non-medical indications

Objective: This study aimed to explore the characteristics and circumstances of women who cryopreserved their oocytes for non-medical indications and their reasons for cryopreservation.Background: Oocyte cryopreservation for non-medical reasons is becoming increasingly common. Little is known about women who freeze their oocytes in this context.Methods: All women who had cryopreserved oocytes for non-medical indications at a large Australian fertility treatment centre from 1999 to 2014 were invited to complete an anonymous postal survey.Results: Of the 193 questionnaires mailed, 10 were returned to sender; 96/183 (53%) were completed and returned. Most respondents had completed tertiary education (90%) and were employed in professional occupations (89%). At the time of oocyte cryopreservation, 48% of women were aged at least 38 years (range 28–44 years). Most (90%) women were single when their oocytes were frozen. The lack of a partner or having a partner unwilling to commit to fatherhood were the most common reasons for oocyte freezing, which was viewed as an investment in hope against the possibility of remaining in these predicaments. Some women reported that discussions in the media and interactions with peers influenced their decisions. A few women were influenced by tests indicating a low ovarian reserve.Conclusion: These data provide new evidence about women’s characteristics, circumstances, and reasons for oocyte cryopreservation for non-medical indications that do not support pejorative conceptualisations of these women as selfish and hedonistic.

Anxiety and quality of life after first-trimester termination of pregnancy: a prospective study.

Possible effects of termination of pregnancy (TOP) on mental health are a matter of debate. We assessed anxiety and quality of life during a one-year follow up after first-trimester TOP using the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL Quality of Life Questionnaire (EQ-5D, EQ-VAS) in 742 women participating in a randomized controlled trial on early provision of intrauterine contraception. The measurements were performed before TOP, at 3months and 1year after TOP. Inclusion criteria were age ≥18years, residence in Helsinki, duration of gestation <12weeks, non-medical indication for TOP, and approval of intrauterine contraception. The trial was registered with Clinical Trials [NCT01223521]. When compared with baseline, the overall anxiety level was significantly lower and quality of life higher at 3months and at 1year. Reduction of anxiety and improvement of quality of life was especially evident (p<0.001) in the 58% of women reporting clinically relevant anxiety at baseline. High levels of anxiety at baseline, history of psychiatric morbidity and smoking predicted significantly greater risk of poorer quality of life and elevated level of anxiety during the follow up. TOP is associated with a significant overall reduction of anxiety and an improvement of quality of life among women undergoing it for non-medical indications. High baseline anxiety, history of psychiatric morbidity and smoking are risk factors of persistently high levels of anxiety and poor quality of life after an induced abortion. These data are important when designing and providing post-abortion care.

Pregnant women’s preference for cesarean section and subsequent mode of birth – a six-country cohort study

Introduction: The rate of cesarean section (CS) for non-medical reasons has risen and it is a concern for health care. Women’s preferences may vary across countries for psychosocial or obstetric reasons.Methods: A prospective cohort study of 6549 women in routine antenatal care giving birth in Belgium, Iceland, Denmark, Estonia, Norway or Sweden. Preference for mode of birth was self-reported in mid-pregnancy. Birth outcome data were collected from hospital records.Results: A CS was preferred by 3.5% of primiparous women and 8.7% of the multiparous women. Preference for CS was associated with severe fear of childbirth (FOC), with a negative birth experience in multiparous women and with depressive symptoms in the primiparous. Women were somewhat more prone to prefer a cesarean in Iceland, odd ratio (OR) 1.70 (1.02–2.83), adjusted for age, education, depression, FOC, history of abuse, previous cesarean and negative birth experience. Out of the 404 women who preferred CS during pregnancy, 286 (70.8%) delivered by CS, mostly for a medical indication. A total of 9% of the cesareans in the cohort had a non-medical indication only.Conclusions: Women’s preference for CS often seems to be due to health concerns. Both medical and psychological factors need to be addressed in antenatal counseling. Obstetricians need to convey accurately to women the risks and benefits of CS in her specific case. Maternity professionals should identify and explore psychosocial reasons for women’s preferences.

Induction of labor in women with a history of fast labor

Objective: History of fast labor is currently subjectively defined and inductions for non-medical indications are becoming restricted. We hypothesized that women induced for a history of fast labor do not have faster previous labors and do not deliver more quickly.Methods: A retrospective case-control cohort design studied multiparas undergoing elective induction at one high risk center. Outcomes of dyads electively induced for a history of previous fast labor indication (PFast) were compared to controls with a psychosocial indication.Results: A total of 612 elective inductions with 1074 previous deliveries were evaluated: 81 (13%) PFast and 531 (87%) control. PFast had faster previous labors (median 5.5 h, IQR: 4.5–6) versus. control (10 h, IQR: 9–10.5; p < 0.001). Subsequent delivery time from start to expulsion was shorter for PFast (median 7 h, IQR: 5–9, p < 0.001) than controls with and without a previous labor <5.5 h (8.6 h, IQR: 6–14 and 9.5 h, IQR: 7–15, respectively). PFast were less likely to have a serious maternal complication. Neonatal complications were similar.Conclusions: Patients induced for a history of fast labor do have faster previous labors, suggesting a significant history of fast labor can be defined as <5.5 h. These women deliver more quickly and with lower morbidity than controls when subsequently induced, therefore the benefit may warrant the risk for a select number of women with a history of a prior labor length <5.5 h.

Circumcision of privately insured males aged 0 to 18 years in the United States.

Male circumcision confers protection against HIV, sexually transmitted infections, and urinary tract infections. Compared with circumcision of postneonates (>28 days), circumcision of neonates is associated with fewer complications and usually performed with local rather than general anesthesia. We assessed circumcision of commercially insured males during the neonatal or postneonatal period. We analyzed 2010 MarketScan claims data from commercial health plans, using procedural codes to identify circumcisions performed on males aged 0 to 18 years, and diagnostic codes to assess clinical indications for the procedure. Among circumcisions performed in the first year of life, we estimated rates for neonates and postneonates. We estimated the percentage of circumcisions by age among males who had circumcisions in 2010, and the mean payment for neonatal and postneonatal procedures. We found that 156,247 circumcisions were performed, with 146,213 (93.6%) in neonates and 10,034 (6.4%) in postneonates. The neonatal circumcision rate was 65.7%, and 6.1% of uncircumcised neonates were circumcised by their first birthday. Among postneonatal circumcisions, 46.6% were performed in males younger than 1 year and 25.1% were for nonmedical indications. The mean payment was $285 for a neonatal and $1885 for a postneonatal circumcision. The large number of nonmedical postneonatal circumcisions suggests that neonatal circumcision might be a missed opportunity for these boys. Delay of nonmedical circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child.

Preventing the First Cesarean Delivery

With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for and arrest of labor progress. The diagnosis of failed induction should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.

569: Induction for nonmedical indications compared with expectant management

569: Induction for nonmedical indications compared with expectant management

Prenatal anxiety and cesarean section with non-medical indication

To explore the relationship between prenatal anxiety and cesarean section (c-section) with non-medical indication. Nested case-control study was used to analyze the risk factors for c-section with no medical needs: 433 pregnant women with gestational age longer than 24 weeks were enrolled in this study. According to the mode of delivery, we divided them into a vaginal delivery group, a c-section group without medical need and a c-section group with medical need. The c-section rate was 62.1%, 55.8% of which was c-section without medical need at family request. The score of state anxiety (S-AI) and trait anxiety (T-AI) was 42.53±11.04 and 44.40±10.23 respectively, much higher than that of normal population. After the adjustment of maternal social economic status and other prenatal statuses for this pregnancy, the prenatal anxiety was still associated with c-section with non-medical indication. The adjusted odd ratio for prenatal anxiety state, prenatal trait anxiety state and c-section with non-medical indication was 1.41 (95% CI: 1.06-1.87) and 1.23 (95% CI: 1.08-1.40), respectively. Prenatal anxiety state is a risk factor for c-section with non-medical indication.

Session 30: Fertility preservation for medical and non-medical indications

Session 30: Fertility preservation for medical and non-medical indications

Five years' experience using oocyte vitrification to preserve fertility for medical and nonmedical indications

To evaluate the results of controlled ovarian hyperstimulation (COH) for oocyte vitrification to preserve fertility for medical and nonmedical indications. A retrospective, multicenter, observational study performed between March 2007 and June 2012. University-affiliated infertility clinics. Of 560 nononcological patients and 475 oncological patients, we performed 1,080 oocyte vitrification cycles, 725 for nonmedical reasons and 355 in patients affected with cancer. Cycle outcome is presented, including 30 women who returned to use their frozen eggs with, 20 pregnancies obtained, 6 newborns, and 8 ongoing pregnancies. Controlled ovarian hyperstimulation, oocyte retrieval, warming of oocytes, and ET in those who already came back. Days of stimulation, total dose of gonadotropins, estrogen (E) and P levels, number of oocytes retrieved and vitrified, pregnancy rate (PR). Comparable results were obtained in both groups of patients, with lower total dose of gonadotropins used and lower serum E(2) levels in patients affected with cancer. Frozen/thawed oocytes performed similarly in both groups. Patients who vitrify eggs for medical or nonmedical reasons perform similarly, as observed in this large series. This technique offers realistic expectations to both groups of patients to have a child with their own eggs. These data could be used to adequately counsel our patients.

In Reply

Spong, Catherine Y. MD; Berghella, Vincenzo MD; Wenstrom, Katharine D. MD; Mercer, Brian M. MD; Saade, George R. MD Author Information

Cesarean section: to be or not to be, is this the question?

Dear Editor,In the third millennium, there is a new ‘‘trend’’ of delivery:cesarean section (CS).Why the increasing rate? First of all, the delayedchildbearing, the second, safer anesthesia, and third, themedical litigation.The women, today, choose to get pregnant at an olderage in comparison to the XX century. What women want?Obviously, the women want one healthy newborn; thus,they do not accept to have a malformed fetus, an abortionor a complication through the vaginal delivery. However,medicine and obstetrics, in particular, are not exact sci-ences; in fact, complications (which may even be lethal)for the fetus and pregnant woman may occur, even in asmall percentage of cases, in spite of scrupulous manage-ment of pregnancy and labor.In Italy, about 38 % of women deliver by CS withhighest rate in the south of Italy (about 60 % in Campania).WHO in 1980 stated that 10 % of CS was the gold stan-dard, but now this rate is too low and is not achievable inthe third millennium.Recently, a Swedish study [1] demonstrated that twodecades after one birth, vaginal delivery was associatedwith a 67 % increased risk of urinary incontinence (UI),and UI[10 years increased by 275 % compared withcesarean section. Nowadays, an increasing number ofwomen request CS for non-medical indications, and forsome this demand appears to be motivated by a desire toprevent pelvic floor damage, including UI.A CS: is it always safe? Complications that are relatedto CS are increased risk of infections, transfusion, andprolonged hospitalization. CS gets maternal and fetalrisks. Maternal risk may be dangerous such as pulmonaryemboly. The fetal risks regard the procedure itself such as3.12 % accidental fetal lacerations per CS [2]. Recently,Arikan et al. [3] compared maternal and perinatal mor-tality and short-term outcomes of maternal and perinatalhealth between a CS group with relative indications and avaginal delivery group. Maternal morbidity was signifi-cantly lower in the vaginal birth group than the CS group(7 vs 30, p\0.05). Perinatal mortality and perinatalmorbidity were not significantly different between the twogroups. Newborns with the first minute Apgar scorebelow 7 were higher in the CS group (p\0.05). The fifthminute Apgar scores and umbilical cord pH values weresimilar. The authors concluded that short-term maternalcomplications were more frequently seen in cesareandeliveries with relative indications than spontaneousvaginal deliveries. Furthermore, a recent cochrane data-base systematic review [4] assessed the effects of a policyof planned immediate cesarean delivery versus plannedvaginal birth for women in preterm labour and concludedthat there is not enough evidence to evaluate the use of apolicy of planned immediate cesarean delivery for pre-term babies.The last but not the least: medical litigation is increasingin all the world. In some countries, no medical doctor wantto be obstetrician for the fear of medical litigation andbecause the medical insurance do not cover the obstetri-cian, especially if the obstetrician had a previous compli-cation during delivery and relative compliant.

Prenatal Diagnosis of Chromosome Abnormalities: A 13-Year Institution Experience.

Objective: To analyze trends in screening and invasive prenatal diagnosis of chromosome abnormalities (CA) over a 13-year period and correlate them to changes in the national prenatal screening policy. Methods: We retrospectively reviewed Down syndrome (DS) screening tests and fetal karyotypes obtained by prenatal invasive testing (IT) in our fetal medicine unit between January 1999 and December 2011. Results: A total of 24,226 prenatal screening tests for DS and 11,045 invasive procedures have been analyzed. Over a 13-year period, utilization of non-invasive screening methods has significantly increased from 57% to 89%. The percentage of invasive procedures has declined from 49% to 12%, although the percentage of IT performed for maternal anxiety has increased from 22% to 55%. The percentage of detected CA increased from 2.5% to 5.9%. Overall, 31 invasive procedures are needed to diagnose 1 abnormal case, being 23 procedures in medical indications and 241 procedures in non-medical indications. Conclusions: Our experience on screening and invasive prenatal diagnostic practice shows a decrease of the number of IT, with a parallel decline in medical indications. There is an increasing efficiency of prenatal screening program to detect CA. Despite the increasing screening policies, our population shows a growing request for prenatal IT. The a priori low risk population shows a not negligible residual risk for relevant CA. This observation challenges the current prenatal screening strategy focused on DS; showing that the residual risk is higher than the current cut-off used to indicate an invasive technique.

Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop.

With more than one third of pregnancies in the United States being delivered by cesarean and the growing knowledge of morbidities associated with repeat cesarean deliveries, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. The available information on maternal and fetal factors, labor management and induction, and nonmedical factors leading to the first cesarean delivery was reviewed as well as the implications of the first cesarean delivery on future reproductive health. Key points were identified to assist with reduction in cesarean delivery rates including that labor induction should be performed primarily for medical indication; if done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous patient. Review of the current literature demonstrates the importance of adhering to appropriate definitions for failed induction and arrest of labor progress. The diagnosis of "failed induction" should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated. Operative vaginal delivery is an acceptable birth method when indicated and can safely prevent cesarean delivery. Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged. When discussing the first cesarean delivery with a patient, counseling should include its effect on future reproductive health.

Changes in the Indications for Scheduled Births to Reduce Nonmedically Indicated Deliveries Occurring Before 39 Weeks of Gestation

To estimate the change in indications for scheduled deliveries during the Ohio Perinatal Quality Collaborative's initiative to decrease scheduled deliveries for nonmedical indications before 39 weeks of gestation. Documented indications for scheduled deliveries between 36 0/7 and 38 6/7 weeks were categorized as: strong medically accepted reasons for delivery; intermediate acceptability; and unnecessary before 39 weeks. We describe each of these indication categories as a proportion of all deliveries in the participating hospitals between October 2008 and December 2009. The percentage of scheduled deliveries that were unnecessary before 39 weeks or had intermediate indications decreased over time (P=.03). There were 145 fewer with intermediate reasons and 265 fewer that were unnecessary when the first 4 months of the project were compared with the last 4 months. Strong medical indications as a percentage of all deliveries did not change significantly over time (P=.99). Our quality collaborative reduced scheduled deliveries of medically unnecessary and intermediate indications for delivery at 36 0/7 and 38 6/7 weeks. However, scheduled deliveries with strong medical indication did not change significantly over time. III.

Transfer of newborns to neonatal care unit: a registry based study in Northern Tanzania

BackgroundReduction in neonatal mortality has been slower than anticipated in many low income countries including Tanzania. Adequate neonatal care may contribute to reduced mortality. We studied factors associated with transfer of babies to a neonatal care unit (NCU) in data from a birth registry at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania.MethodsA total of 21 206 singleton live births registered from 2000 to 2008 were included. Multivariable analysis was carried out to study neonatal transfer to NCU by socio-demographic factors, pregnancy complications and measures of the condition of the newborn.ResultsA total of 3190 (15%) newborn singletons were transferred to the NCU. As expected, neonatal transfer was strongly associated with specific conditions of the baby including birth weight above 4000 g (relative risk (RR) = 7.2; 95% confidence interval (CI) 6.5-8.0) or below 1500 g (RR = 3.0; 95% CI: 2.3-4.0), five minutes Apgar score less than 7 (RR = 4.0; 95% CI: 3.4-4.6), and preterm birth before 34 weeks of gestation (RR = 1.8; 95% CI: 1.5-2.1). However, pregnancy- and delivery-related conditions like premature rupture of membrane (RR = 2.3; 95% CI: 1.9-2.7), preeclampsia (RR = 1.3; 95% CI: 1.1-1.5), other vaginal delivery (RR = 2.2; 95% CI: 1.7-2.9) and caesarean section (RR = 1.9; 95% CI: 1.8-2.1) were also significantly associated with transfer. Birth to a first born child was associated with increased likelihood of transfer (relative risk (RR) 1.4; 95% CI: 1.2-1.5), while the likelihood was reduced (RR = 0.5; 95% CI: 0.3-0.9) when the father had no education.ConclusionsIn addition to strong associations between neonatal transfer and classical neonatal risk factors for morbidity and mortality, some pregnancy-related and demographic factors were predictors of neonatal transfer. Overall, transfer was more likely for babies with signs of poor health status or a complicated pregnancy. Except for a possibly reduced use of transfer for babies of non-educated fathers and a high transfer rate for first born babies, there were no signs that transfer was based on non-medical indications.

Prenatal diagnosis and preimplantation genetic diagnosis: novel technologies and state of the art of PGD in different regions of the world

Prenatal diagnosis (PND) aims to provide accurate, rapid results as early in pregnancy as possible. Conventional PND involves sampling cells of foetal origin by chorionic villus sampling at 11-14th weeks of pregnancy or amniocentesis after 15th week. These are invasive procedures and have a small but significant rate of 0.5% to 1% for loss of pregnancy. An alternative to existing methods for conventional PND for couples at risk of transmitting a genetic disease to their child is preimplantation genetic diagnosis (PGD). PGD is a newly emerging form of a very early prenatal diagnosis. The technique combines assisted reproductive technology with molecular genetics and cytogenetics to allow the identification of abnormality in embryos prior to implantation. The diagnosis of genetic disease in human preimplantation embryos was pioneered in the late 1980s for testing of aneuploidy, single gene and X-linked disease, such as cystic fibrosis, haemophilia and chromosomal abnormalities. The PGD-related legal and ethical issues have been debated at many levels both nationally and internationally. The attitude towards PGD varies substantially not only in different parts of the world but also within the Europe, owing to scientific, cultural and religious differences. PGD has become widely practised throughout the world for various indications and can substantially decrease the eventual risks of passing a genetic undesired condition of the offspring. Nevertheless, its extension to some new and non-medical indications has raised ethical concerns, in particular its potential eugenic dimension.

Is the growing trend for cesarean sections a cause for concern?

Cesarean section is one of the most common surgical operations performed on women worldwide, and rates are increasing in all developed countries. There are many proposed causes of the increased rates. Although much safer than in the 1500s when it was first performed, cesarean section is still associated with significant short- and long-term morbidity for a woman and her infant. The issues of maternal obesity, induction of labor, continuous fetal heart rate monitoring in labor, vaginal birth after cesarean section, decision-making for the primary cesarean section and cesarean section for nonmedical indications must be addressed if we are to curb the concerning increase in this procedure.

Indications for Induction of Labour : (as in Common Practice)

Background: Rates of labour induction are increasing. Objective: To make a list of common indications of induction. Design: Prospective observational study. Setting: Gynecology unit of D.H.Q teaching hospital, Sargodha for a period of 1 year from March 2008 - March 2009. Patients and Methods: Patients admitted in the labour room through emergency or through OPD who were planned to have induction of labour, were included in the observation. Their age, parity, duration of pregnancy and the particular condition for which she was induced labour, was recorded. All essential points of examination and required investigations for the mother and the foetus were recorded. Outcome: At the end of induction in the form of mode of delivery was recorded whether spontaneous, instrumental or operative delivery. Results: Out of 400 patients 158 were primi gravidas and rest of 242 were G 2 to G 9 . 342 had alive foetuses and 58 had I.U.F.D. (Intra uterine foetal death). Duration of pregnancy ranged from 28 to 41 wks. Indications for induction of labour were prolonged pregnancy, (36). Pre-eclampsia, (46) I.U.G.R. (16). Placental abruption (32) PROM (20) foetal anomalies (20), I.U.F.D (58), gestational diabetes (10) and non-medical indications (108). Spontaneous vaginal deliveries (242) Instru-mental deliveries (60) and C - sections - (98). Conclusion: The most common was non-medical indications for induction of labour. Key Words: Indications. Induction of labour.

Knowledge and attitudes towards preimplantation genetic diagnosis in Germany.

Preimplantation genetic diagnosis (PGD) is a technique which is often related to emotional debates because of its ethical and social implications. Worldwide there are different forms of legislation; Germany constitutes an interesting case because of the historical background concerning eugenics and dealing with handicapped persons at the time of national socialism. PGD is currently not legal but there are still polarized positions and legalization remains an issue. Studies about the attitudes of the general population towards PGD are rare. Data were collected in a representative survey carried out in November 2003. Subjects were 2110 persons in Germany aged 18-50 years. Respondents had little knowledge about PGD. There were incorrect assumptions about the diagnostic possibilities and a lack of basic genetic knowledge. A tendency towards a general acceptance of PGD for medical indications was found. Non-medical indications such as sex selection were generally not accepted. It could be observed that respondents who already had a notion about PGD overestimated the diagnostic possibilities and would eventually use PGD in the future more than respondents who had never heard about PGD before.