Multiple pregnancies after assisted reproduction – international comparison

doi:10.1016/S1472-6483(10)62252-3

Reproductive BioMedicine Online

Volume 15, Supplement 3, 2007, Pages 53-60

https://doi.org/10.1016/S1472-6483(10)62252-3 Get rights and content

Abstract

The high incidence of multiple pregnancies after application of techniques for assisted reproduction is a phenomenon of major concern worldwide. High order multiples in particular have to be regarded as a serious adverse event. However, data show that in Europe, although the situation varies from country to country, multiple births, especially triplet births, as consequence of assisted reproductive technology are on the decline. New strategies such as elective single embryo transfer, emphasized especially by Finland and Sweden, open up new pathways towards safer treatments, reducing the incidence of high order multiples to almost zero while maintaining high pregnancy rates. Compared with Europe, in the US, more than half of all children delivered after assisted reproduction are multiples. While an incidence of 33% of multiple births may seem to be acceptable, an incidence of 54% of children born as multiples, moreover high order multiples, is certainly not. The enormous impact of legal and financial regulations on the attitude of physicians and patients regarding assisted reproduction can be observed at the moment in Germany, with a dramatic decline in number of treatments. However, the incidence of multiples has not increased.

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Ricardo Enrique Felberbaum was born in 1961 in Frankfurt am Main. He studied human medicine at the University of Cologne and became MD in 1986. After clinical specialization as a gynaecologist and obstetrician, he joined the group of Klaus Diedrich at the Medical University of Lübeck in 1993. Since then he has done extensive investigations in the use of GnRH antagonists for ovarian stimulation in assisted reproduction treatment, as well as in the treatment of uterine fibroids and endometriosis.

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Cited by (17)

Growth outcome at 2 years using Fenton and Intergrowth-21st charts in infants less than 1500 g
2022, Anales de Pediatria
No existe consenso sobre qué gráfica neonatal es mejor utilizar en niños con muy bajo peso al nacer (MBPN). El objetivo del estudio fue comparar las gráficas de Fenton 2013 e Intergrowth-21st (IW-21) con base en su capacidad predictora de la somatometría a los dos años, así como analizar factores relacionados con talla baja a los dos años.
Cohorte de niños con MBPN nacidos entre 2002-2017. Se analizó la asociación entre la somatometría neonatal (z-score por Fenton e IW-21) y el riesgo de talla baja (< -2 desviación estándar [DS]), perímetro craneal < -2 DS y desnutrición a los 2 años (IMC < -2 DS) (gráficas OMS).
Se incluyeron 513 niños con una edad gestacional media de 30,05 ± 2,5 semanas. El z-score del peso al nacimiento y al alta por Fenton y por IW-21 resultaron útiles para predecir riesgo de talla baja y desnutrición a los dos años (sin diferencias en el AUC de las curvas ROC), siendo el z-score al alta útil además para predecir perímetro craneal < -2D. A los dos años, la prevalencia de talla baja, perímetro craneal < -2 DS, y desnutrición fue del 17,2, 4,1 y 6,1%, respectivamente. El bajo peso para la edad gestacional y la duración del ingreso neonatal se identificaron como factores de riesgo independientes para talla baja a los dos años.
El z-score peso al alta resulta útil para predecir riesgo de talla baja, desnutrición y perímetro craneal < -2 DS a los dos años en niños con muy bajo peso al nacer, sin diferencias estadísticas entre utilizar las gráficas de Fenton o IW-21.
There is no consensus on which neonatal chart is best to use in very low birth weight (VLBW) infants. The aim of the study was to compare the Fenton 2013 and Intergrowth-21st (IW-21) charts based on their predictive ability for somatometry at 2 years, as well as to analyze factors related to short stature at 2 years.
Cohort of children with VLBW born in 2002–2017. Association between neonatal somatometry (z-score by Fenton and IW-21) and risk of short stature (< −2 DS), head circumference < −2 DS and malnutrition at 2 years (BMI < −2 DS) was analyzed (WHO charts).
513 children with a mean gestational age of 30.05 ± 2.5 weeks were included. Birth and discharge weight z-score by Fenton and IW-21 were useful for predicting risk of short stature and malnutrition at 2 years (without differences in the AUC of the ROC curves). Weight z-score at discharge was also useful for predicting head circumference < −2 DS. At 2 years, prevalence of short stature, head circumference < −2 DS, and malnutrition was 17.2, 4.1, and 6.1%, respectively. Low weight for gestational age and length of stay were identified as independent risk factors for short stature at 2 years.
Discharge weight z-score is useful for predicting risk of short stature, malnutrition and head circumference < −2 DS at 2 years in very low birth weight children, with no statistical difference between using Fenton or IW-21 charts.
A cybernetic framework for predicting preterm and enhancing care strategies: A review
2021, Biomedical Engineering Advances
Preterm is viewed as the birth of a human foetus prior to 37 complete weeks of gestation. It has effects on the health of both the foetus and the mother, has financial consequences to the clinic and society as a whole, and due to its widespread occurrence is viewed as a global pandemic. Preterm can be viewed as a heterogeneous condition which is influenced by a variety of factors, the majority of which have been discussed separately in the medical literature, thus making it challenging for a comprehensive view and understanding to be formed of the topic. Using a semisystematic review methodology, this paper is structured in two parts where the first part gives a comprehensive review to what preterm is alongside a review of the topic under a number of pivotal discussion headings. Following this, in the second part of the paper, a review is conducted on the need and relevance of Artificial Intelligence (AI) models in clinical medicine, after which a cybernetic framework is proposed which utilises a combination of AI and a clinical expert within the loop (human intelligence) to yield a ‘superintelligence’ platform aimed at producing a more reliable means of preterm prediction, and also allowing for enhanced and optimised care strategies to be delivered to the pregnant patient. The paper concludes with a number of key future areas that need to be addressed in order for the overall enhancement of the proposed cybernetic framework, which includes the need for ethical sharing of patient physiological data, the further consideration of ethnicity in preterm prediction due to disparity in gestational length amongst various ethnic groups, and also the prospect of mobile pregnancy monitoring using wearables and telemedicine.
Current evidence supporting a goal of singletons: a review of maternal and perinatal outcomes associated with twin versus singleton pregnancies after in vitro fertilization and intracytoplasmic sperm injection
2020, Fertility and Sterility
With increasing use of in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) almost 2% of all babies born in the United States each year are now conceived with these technologies, making outcomes of IVF-ICSI extremely important not only to patients and families but to public health. Twin pregnancy rates after IVF-ICSI in the United States have declined since their peak in 2013 but remain at approximately 1 in 10 to 1 in 20 pregnancies. A review of the current international literature on twin versus singleton pregnancy outcomes after IVF-ICSI treatment confirms statistically significantly higher risks to maternal and perinatal health and statistically significantly higher health care costs. The field of infertility care should continue to work to develop practices that lower twin pregnancy rates to an absolute minimum to maximize the safety of these medical treatments.
Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data
2016, Vaccine
Citation Excerpt :
Infants born from multiple pregnancies are more likely to be born preterm due to spontaneous labour or premature rupture of membranes (PROM), or as a result of maternal conditions such as pre-eclampsia or foetal disorders [8,9]. Changes to policies which limit the number of embryos implanted as part of ART have led to a decline in the number of preterm births due to assisted fertility [10,11]. Epidemiologic studies have identified preterm birth risk factors as maternal age of less than 17 years or more than 35 years, being underweight, having an overweight pre-pregnancy body mass index, and short stature.
Preterm birth is commonly defined as any birth before 37 weeks completed weeks of gestation. An estimated 15 million infants are born preterm globally, disproportionately affecting low and middle income countries (LMIC). It contributes directly to estimated one million neonatal deaths annually and is a significant contributor to childhood morbidity. However, in many clinical settings, the information available to calculate completed weeks of gestation varies widely. Accurate dating of the last menstrual period (LMP), as well as access to clinical and ultrasonographic evaluation are important components of gestational age assessment antenatally. This case definition assign levels of confidence to categorisation of births as preterm, utilising assessment modalities which may be available across different settings. These are designed to enable systematic safety evaluation of vaccine clinical trials and post-implementation programmes of immunisations in pregnancy.
Fetal and neonatal outcomes after term and preterm delivery following betamethasone administration in twin pregnancies
2016, International Journal of Gynecology and Obstetrics
Citation Excerpt :
In agreement with evidence in animal studies [2,5], studies in human beings indicate that even one course of prenatal betamethasone (the currently recommended treatment regimen is two doses of 12 mg [6]) could influence placental function, fetal growth, hypothalamic-pituitary-adrenal axis development, and endocrine stress reactivity in later life [5,7,8]. The incidence of multiple pregnancies has been increasing in the past 4 decades [9,10], and twins are at increased risk of preterm birth, making administration of prenatal glucocorticoids more likely. However, the effect of glucocorticoids on prenatal lung maturation in multiple pregnancies remains unclear because trials in twins are limited and evidence is lacking [1,11–16].
To investigate effects of betamethasone on fetal growth and neonatal outcomes in twins.
A retrospective cohort study was conducted of twins delivered at one center in Berlin, Germany, between 1993 and 2011. The betamethasone group included twin pregnancies with preterm labor, cervical shortening, preterm premature rupture of membranes, or vaginal bleeding, and exposure to betamethasone between 23^+ 5 and 33^+ 6 weeks. The control group included twin pregnancies with no betamethasone exposure matched for length at delivery. Fetal growth and neonatal anthropometric data were analyzed by twin-pair structure, dose, and gestational age (linear mixed model).
Overall, 1922 live-born twin pairs (653 betamethasone group, 1269 controls) were included. Compared with controls, late-preterm twins exposed to betamethasone were lighter (mean difference –126 g), had a smaller head circumference (–0.4 cm), and a shorter body length (–0.8 cm) after adjustment for confounders (P < 0.05). Female neonates from mixed or same-sex twin pairs had a lower birth weight than controls (betamethasone ≤ 16 mg: –114 g; betamethasone 24 mg: –124 g; betamethasone > 24 mg: –187 g), with no detectable improvement in neonatal morbidity (hyperbilirubinemia, respiratory distress, asphyxia) or mortality.
Betamethasone reduced birth weight, head circumference, and length of female preterm neonates in twin pairs in a dose-dependent manner. The neonatal mortality and morbidity were not improved by betamethasone.
Assisted Reproductive Technology-Related Multiple Births: Canada in an International Context
2011, Journal of Obstetrics and Gynaecology Canada
It has been well-documented that the use of assisted reproductive technology (ART) increases the risk for multiple births, which are associated with sub-optimal outcomes for pregnant women and their offspring. The occurrence of multiple births due to infertility treatments has been recognized as a significant problem globally, and a number of countries have developed approaches, policies, statutes, and regulations geared to decreasing the rates of multiple births as a result of ART This review was designed to explore Canada’s position in the international context of ART-related multiple births and to examine the strategies of other countries intended to decrease rates of multiple pregnancy.
Data were obtained from publicly available data sources from 21 countries, including Canada, and comparisons were made between pregnancy rates, percentages of live births, percentages of multiple births, numbers of embryos transferred, and governing guidelines and policies.
Canada has one of the highest ART-related multiple-birth rates, and the number of embryos transferred per cycle plays an important role in this Cooperation among stakeholders in the development of approaches and guidelines is essential for preventing multiple births due to infertility treatments.
In order effectively to reduce the multiple-birth rate in Canada, it is important to learn from the experiences of other countries, taking the Canadian context into consideration.
Le fait que le recours aux technologies de procréation assistée (TPA) entraîne une hausse du risque de grossesse multiple, laquelle est associée à des issues sous-optimales pour la femme enceinte et sa progéniture, a été bien documenté. La survenue d’une grossesse multiple attribuable à des traitements contre l’infertilité a été reconnue comme un problème important à l’échelle mondiale et un certain nombre de pays ont formulé des approches, des politiques, des statuts et des règlements visant à atténuer les taux de grossesse multiple attribuable aux TPA. Cette analyse a été conçue pour explorer la position du Canada dans le contexte international des grossesses multiples attribuables aux TPA, ainsi que pour examiner les stratégies adoptées par d’autres pays en vue d’atténuer les taux de grossesse multiple.
Nous avons tiré nos données de sources publiques issues de 21 pays, dont le Canada, et avons procédé à des comparaisons entre les taux de grossesse, les pourcentages de naissances vivantes, les pourcentages de grossesses multiples, les nombres d’embryons transférés et les lignes directrices et politiques en vigueur.
Le Canada compte l’un des taux de grossesse multiple attribuable aux TPA les plus élevés; le nombre d’embryons transférés par cycle y est pour beaucoup. La coopération entre les intervenants dans l’élaboration d’approches et de lignes directrices est essentielle pour la prévention des grossesses multiples attribuables aux traitements contre l’infertilité.
Afin d’atténuer efficacement le taux de grossesse multiple au Canada, il est important de tirer des leçons de l’expérience d’autres pays, tout en prenant le contexte canadien en considération.

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ArticleMultiple pregnancies after assisted reproduction – international comparison

Abstract

Section snippets

Reproductive BioMedicine Online

Reproductive BioMedicine Online

Reproductive BioMedicine Online

Assisted reproductive technology in Europe, 2002. Results generated from European registers by ESHRE. The European IVF-monitoring programme (EIM) for the European Society of Human Reproduction and Embryology (ESHRE)

Human Reproduction

Article
Multiple pregnancies after assisted reproduction – international comparison