[show abstract][hide abstract] ABSTRACT: To compare obstetric and perinatal outcomes of singleton births after assisted reproductive technology (ART) with blastocyst transfer (days 5 to 6) versus nonblastocyst transfer (days 2 to 4).
Retrospective cohort study.
4,202 women who conceived using in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) between 2004 and 2009.
Records analysis of fresh and frozen-thawed embryo transfers resulting in singleton births of at least 20 weeks' gestation.
Perinatal outcomes: preterm birth, low birthweight, very low birthweight, small for gestational age, large for gestational age, preeclampsia, antepartum hemorrhage, placental abruption, placenta previa, and postpartum hemorrhage; and covariates: maternal age, year of birth of the baby, private health insurance status, maternal body mass index, smoking status, parity, gender of baby, and variations in treatment procedures.
Multivariate analysis found no statistically significant difference between transfers on days 5 and 6 and days 2 and 4 for all maternal and perinatal outcomes. There were modest increases in the adjusted odds ratios for preeclampsia (adjusted odds ratio 1.72, 99% confidence interval 0.93-3.20) and placenta previa (1.65, 0.92-2.98).
Obstetric and perinatal outcomes after blastocyst transfer on days 5 to 6 are similar when compared with embryo cleavage-stage transfers on days 2 to 4.
Fertility and sterility 03/2012; 97(3):579-84. · 3.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: It is unclear whether assisted reproductive technologies (ART) or factors associated with infertility contribute to adverse perinatal outcomes in subfertile women who undergo in vitro fertilization. Some investigators have suggested that specific effects of ART due to the laboratory procedures are largely responsible for adverse perinatal outcomes. Others believe that procedures involved with in vitro fertilization are not causative, but factors related to the health of the infertile woman are responsible.
This cohort study compared the prevalence of adverse perinatal birth outcomes among subfertile women who conceived and delivered without ART and women from the general population (controls). The study subjects were 2171 subfertile women who registered at 2 fertility clinics and subsequently conceived and gave birth to singleton infants without ART. A total of 4363 controls, matched by maternal age and year of infant's birth were selected randomly from birth records. The primary study outcome measures were adverse obstetric and perinatal outcomes. Multivariable analysis was used to adjust for known confounders.
Compared with controls, there were increased odds among subfertile women of hypertension or preeclampsia (adjusted odds ratio [aOR],1.29; 95% confidence interval [CI], 1.02–1.61); antepartum hemorrhage (aOR, 1.41; 95% CI, 1.05–1.89); preterm birth < 37 weeks (aOR, 1.32; 95% CI, 1.05–1.67) or < 31 weeks (aOR; 2.37; 95% CI, 1.35–4.13); low birth weight (aOR,1.44; 95% CI, 1.11–1.85); perinatal death (aOR, 2.19; 95% CI, 1.10–4.36); and cesarean delivery (aOR, 1.56; 95% CI, 1.37–1.77; P values for all these comparisons were <0.05). Only weak evidence was found in subfertile women for increased risk of gestational diabetes (aOR, 1.25; 95% CI, 0.96–1.63; P < 0.09) or birth defects (aOR, 1.30; 95% CI, 0.98–1.72; P < 0.07). There was no increased risk for prelabor rupture of membranes, small for gestational age, or postpartum hemorrhage.
These findings show that subfertile singleton women who conceive without ART are at increased risk of several adverse perinatal outcomes. These data suggest more careful monitoring of subfertile women during antenatal care.
Obstetrical and Gynecological Survey 03/2011; 66(4):203-204. · 2.51 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine whether adverse perinatal outcomes are increased in subfertile women.
Two tertiary assisted reproductive technologies (ART) centers; Victorian births register.
Records of women who registered with the clinics (1991-2000), but did not have an infant using ART, were linked to the birth register (1991-2004) to identify singleton non-ART births within 5 years of registration (N = 2171). Controls, matched by maternal age and year of infant's birth, were selected randomly from birth records (N = 4363).
Adverse obstetric and perinatal outcomes.
After adjusting for confounders, compared with controls, subfertile women had increased odds of hypertension or preeclampsia (adjusted odds ratio [OR] 1.29, 1.02-1.61), antepartum hemorrhage (adjusted OR 1.41, 1.05-1.89), perinatal death (adjusted OR 2.19, 1.10-4.36), low birth weight (adjusted OR 1.44, 1.11-1.85), preterm birth <37 weeks (adjusted OR 1.32, 1.05-1.67) or <31 weeks (adjusted OR 2.37, 1.35-4.13), and cesarean delivery (adjusted OR 1.56, 1.37-1.77). There was weak evidence for increased birth defects (adjusted OR 1.30, 0.98-1.72) and gestational diabetes (adjusted OR 1.25, 0.96-1.63). No increased risk was found for prelabor rupture of membranes, small for gestational age, or postpartum hemorrhage.
Subfertile women with singleton births are at increased risk of several adverse outcomes. These risks should be considered during their antenatal care and when analyzing adverse effects of ART.
Fertility and sterility 04/2010; 94(7):2674-9. · 3.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: Obstetric haemorrhages have been reported to be increased after assisted reproduction technologies (ART) but the mechanisms involved are unclear.
This retrospective cohort study compared the prevalence of antepartum haemorrhage (APH), placenta praevia (PP), placental abruption (PA) and primary post-partum haemorrhage (PPH) in women with singleton births between 1991 and 2004 in Victoria Australia: 6730 after IVF/ICSI, 24 619 from the general population, 779 after gamete intrafallopian transfer (GIFT) and 2167 non-ART conceptions in infertile patients. Risk factors for haemorrhages in the IVF/ICSI group were examined by logistic regression.
The IVF/ICSI group had more APH: 6.7 versus 3.6% (adjusted OR 2.0; 95% CI 1.8-2.3), PP: 2.6 versus 1.1% (2.3; 1.9-2.9), PA: 0.9 versus 0.4% (2.1; 1.4-3.0) and PPH: 11.1 versus 7.9% (1.3; 1.2-1.4) than the general population. APH, PP and PA were as frequent in the GIFT group as in the IVF/ICSI group, but were less frequent in the non-ART group. Within the IVF/ICSI group, fresh compared with frozen thawed embryo transfers (FET) was associated with more frequent APH (1.5; 1.2-1.8) and PA (2.1; 1.2-3.7) and the odds ratio increased with number of oocytes collected (1.02; 1.00-1.04). Endometriosis patients had more PP (1.7; 1.2-2.4) and PPH (1.3; 1.1-1.6) than those without endometriosis. FET in artificial cycles was associated with increased PPH (1.8; 1.3-2.6) compared with FET in natural cycles.
Obstetric haemorrhages are more frequent with singleton births after IVF, ICSI and GIFT. The exploratory analysis of factors in the IVF/ICSI group, showing associations with fresh embryo transfers in stimulated cycles, endometriosis and hormone treatments, suggests that events around the time of implantation may be responsible and that suboptimal endometrial function is the critical mechanism.
Human Reproduction 11/2009; 25(1):265-74. · 4.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: The reasons for increased birth defect prevalence following in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are largely unknown. Classification of birth defects by pathology rather than organ system, and examination of the role of embryo freezing and thawing may provide clues to the mechanisms involved. This study aimed to investigate these two factors.
Data on 6946 IVF or ICSI singleton pregnancies were linked to perinatal outcomes obtained from population-based data sets on births and birth defects occurring between 1991 and 2004 in Victoria, Australia. These were compared with 20,838 outcomes for singleton births in the same population, conceived without IVF or ICSI. Birth defects were classified according to pathogenesis.
Overall, birth defects were increased after IVF or ICSI [adjusted odds ratio (OR) 1.36; 95% CI: 1.19-1.55] relative to controls. There was no strong evidence of risk differences between IVF and ICSI or between fresh and thawed embryo transfer. However, a specific group, blastogenesis birth defects, were markedly increased [adjusted OR 2.80, 95% CI: 1.63-4.81], with the increase relative to the controls being significant for fresh embryo transfer (adjusted OR 3.65; 95% CI: 2.02-6.59) but not for thawed embryo transfer (adjusted OR 1.60; 95% CI: 0.69-3.69).
Our findings suggest that there is a specific risk of blastogenesis birth defects arising very early in pregnancy after IVF or ICSI and that this risk may be lower with use of frozen-thawed embryo transfer.
Human Reproduction 10/2009; 25(1):59-65. · 4.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: First trimester screening (FTS) for Down syndrome combines measurement of nuchal translucency, free beta-human chorionic gonadotrophin and pregnancy-associated plasma protein-A (PAPP-A). The aim of this study was to undertake a detailed analysis of FTS results in singleton pregnancies conceived using assisted reproductive technologies (ART) and non-ART pregnancies.
A record linkage study compared outcomes in 1739 ART-conceived and 50 253 naturally conceived pregnancies.
Overall, significantly lower PAPP-A levels were detected in ART pregnancies (0.83 multiples of median, MoM) than in controls (1.00 MoM) (t-test P < 0.001). This difference remained after excluding complicated pregnancies. Analysis of factors affecting PAPP-A levels suggested fresh compared with frozen embryo transfers and use of artificial cycles compared with natural cycles for frozen transfers were associated with lower values. The adjusted odds ratio (AdjOR) for receiving a false-positive result was 1.71 (95% CI 1.44-2.04; P < 0.001) for ART pregnancies compared with non-ART pregnancies, and this leads to a higher AdjOR (1.24, 95% CI 1.03-1.49; P = 0.02) for having a chorionic villous sampling (CVS) or amniocentesis.
ART pregnancies have reduced FTS PAPP-A levels leading to an increased likelihood of receiving a false-positive result and having a CVS/amniocentesis. Lower PAPP-A may reflect impairment of early implantation with some forms of ART.
Human Reproduction 02/2009; 24(6):1330-8. · 4.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: Data show that differences exist in the birthweight of singletons after frozen embryo transfer (FET) compared with fresh transfer or gamete intra-Fallopian transfer (GIFT). Factors associated with low birthweight (LBW) after assisted reproduction technology (ART) were studied.
Birthweight, distribution of birthweight, z-score, LBW (<2500 g), gestation and percentage preterm (<37 weeks) for singleton births >19 weeks gestation, conceived by ART or non-ART treatments (ovulation induction and artificial insemination) between 1978 and 2005 were analysed for one large Australian clinic.
For first births, the mean birthweight was significantly (P < 0.005) lower, and LBW and preterm birth more frequent for GIFT (mean = 3133 g, SD = 549, n = 109, LBW = 10.9% and preterm = 10.0%), IVF (3166, 676, 1615, 11.7, 12.5) and ICSI (3206, 697, 1472, 11.5, 11.9) than for FET (3352, 615, 2383, 6.5, 9.2) and non-ART conceptions (3341, 634, 940, 7.1, 8.6). Regression modelling showed ART treatment before 1993 and fresh embryo transfer were negatively related to birthweight after including other covariates: gestation, male sex, parity, birth defects, Caesarean section, perinatal death and socio-economic status.
Birthweights were lower and LBW rates higher after GIFT or fresh embryo transfer than after FET. Results for FET were similar to those for non-ART conceptions. This suggests IVF and ICSI laboratory procedures affecting the embryos are not causal but other factors operating in the woman, perhaps associated with oocyte collection itself, which affect endometrial receptivity, implantation or early pregnancy, may be responsible for LBW with ART.
Human Reproduction 08/2008; 23(7):1644-53. · 4.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: To report preterm birth and small for gestational age (SGA) rates from assisted reproduction technologies (ART) patients with ovarian endometriomata compared with control groups.
Retrospective cohort study.
Tertiary university affiliated ART center and Perinatal Data Collection Unit (PDCU).
Every woman who had an ART singleton baby born between 1991 and 2004 had her database record assessed (N = 4382). Control groups included 1201 singleton babies from ART patients without endometriosis and 2400 randomly selected women from the PDCU database of 850,000 births.
There were 95 singleton ART babies from patients with ovarian endometriomata and 535 ART singleton babies from patients who had endometriosis but no ovarian endometriomata.
Preterm birth rates and SGA birth rates.
Preterm birth rate increased only in the ovarian endometriomata group when compared with community birth records (n = 850,000). Furthermore, ART patients with ovarian endometriomata had a statistically significantly increased likelihood of having a SGA baby when compared with other forms of endometriosis.
Rates of preterm birth and SGA babies doubled in infertility patients with ovarian endometriomata who required ART.
Fertility and sterility 04/2008; 91(2):325-30. · 3.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: Activin is a well-characterised growth and differentiation factor and an important inflammatory mediator. Activin is secreted by normal endometrial glands and stroma and is expressed by endometrial leucocytes. It is also known that the eutopic endometrium from women with endometriosis is functionally different to that from women without endometriosis. In this study, we hypothesise that the endometrial secretion of activin is altered in women with endometriosis.
To determine whether the expression of inhibin/activin subunits and the secretion of activin-A is different in eutopic endometrium from women with and without endometriosis.
Endometrial biopsies were obtained from premenopausal, regularly menstruating women with and without endometriosis. Staining intensity for the different inhibin/activin subunits was compared in endometrial and endometriotic biopsies. Activin-A secretion was studied using endometrial explants and endometrial glandular and stromal monolayer cell cultures.
The alpha- and betaA-subunits of inhibin/activin were more abundant in eutopic glandular cells from patients with minimal to mild endometriosis compared to women without endometriosis. In patients with endometriosis, the betaB-subunit was more abundant in eutopic stromal cells and endometrial leucocytes. Comparison of paired endometrial and endometriotic biopsies from the same patient did not reveal significant differences for any of the inhibin/activin subunits or activin receptors. Activin-A secretion by glandular and stromal endometrial cells was sevenfold and threefold higher, respectively, in women with endometriosis compared to women without endometriosis.
The expression of inhibin/activin subunits in eutopic endometrium is altered in women with endometriosis, leading to higher levels of activin-A secretion by both glandular cells and stromal cells.
Australian and New Zealand Journal of Obstetrics and Gynaecology 05/2006; 46(2):148-53. · 1.30 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of this study was to assess the level of skill of laparoscopic surgeons in electrosurgery.
Subjects were asked to complete a practical diathermy station and a written test of electrosurgical knowledge.
Tests were held in teaching and non-teaching hospitals.
Twenty specialists in obstetrics and gynaecology were randomly selected and tested on the Monash University gynaecological laparoscopic pelvi-trainer. Twelve candidates were consultants with 9-28 years of practice in operative laparoscopy, and 8 were registrars with up to six years of practice in operative laparoscopy. Seven consultants and one registrar were from rural Australia, and three consultants were from New Zealand.
Candidates were marked with checklist criteria resulting in a pass/fail score, as well as a weighted scoring system. We retested 11 candidates one year later with the same stations.
No improvement in electrosurgery skill in one year of obstetric and gynaecological practice.
No candidate successfully completed the written electrosurgery station in the initial test. A slight improvement in the pass rate to 18% was observed in the second test. The pass rate of the diathermy station dropped from 50% to 36% in the second test.
The study found ignorance of electrosurgery/diathermy among gynaecological surgeons. One year later, skills were no better.
BJOG An International Journal of Obstetrics & Gynaecology 01/2005; 111(12):1413-8. · 3.76 Impact Factor
[show abstract][hide abstract] ABSTRACT: Metabolic abnormalities and obesity have long been associated with the development of cardiovascular disease in the general population. These same features are also associated with polycystic ovary syndrome (PCOS). An increased prevalence of hypertension, dyslipidaemia, obesity and hyperinsulinaemia, as well as changes in coagulation and blood vessel function, provide an explanation as to why women with PCOS are at an increased risk of developing cardiovascular disease over the long term.
Bailliè re s Best Practice and Research in Clinical Obstetrics and Gynaecology 11/2004; 18(5):803-12. · 2.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Objective The purpose of this study was to assess the level of skill of laparoscopic surgeons in electrosurgery.Design Subjects were asked to complete a practical diathermy station and a written test of electrosurgical knowledge.Setting Tests were held in teaching and non-teaching hospitals.Sample Twenty specialists in obstetrics and gynaecology were randomly selected and tested on the Monash University gynaecological laparoscopic pelvi-trainer. Twelve candidates were consultants with 9–28 years of practice in operative laparoscopy, and 8 were registrars with up to six years of practice in operative laparoscopy. Seven consultants and one registrar were from rural Australia, and three consultants were from New Zealand.Methods Candidates were marked with checklist criteria resulting in a pass/fail score, as well as a weighted scoring system. We retested 11 candidates one year later with the same stations.Main outcome measures No improvement in electrosurgery skill in one year of obstetric and gynaecological practice.Results No candidate successfully completed the written electrosurgery station in the initial test. A slight improvement in the pass rate to 18% was observed in the second test. The pass rate of the diathermy station dropped from 50% to 36% in the second test.Conclusion The study found ignorance of electrosurgery/diathermy among gynaecological surgeons. One year later, skills were no better.
BJOG An International Journal of Obstetrics & Gynaecology 09/2004; 111(12):1413 - 1418. · 3.76 Impact Factor
[show abstract][hide abstract] ABSTRACT: Assisted reproduction programmes do not report success consistently. Rates vary with the definition used. Success must reflect delivery of healthy babies, and the burden of treatment to couples. We report the singleton, term gestation, live birth rate of a baby per assisted reproductive technology cycle initiated for a large IVF programme. We defined assisted reproductive technology cycles as those initiated with the intention of oocyte collection. We examined cycles conducted through Monash IVF in 2001. All women with positive pregnancy tests had first trimester ultrasonography. Obstetric outcomes were recorded. All babies had neonatal examinations conducted by paediatricians. A total of 644 positive pregnancy tests were recorded in 2600 cycles; 509 showed fetal heart motion. Of 448 deliveries, 328 were singleton and 120 were multiple. There were 290 singleton deliveries at term gestation. In 2001, a couple had an 11.1% chance of delivering a singleton, term gestation, live baby per assisted reproductive technology cycle begun. We suggest that delivery of a single, term gestation, live baby per cycle initiated is the most relevant standard of success. This statistic was 11.1% at Monash IVF. We encourage programmes to report this BESST (Birth Emphasizing a Successful Singleton at Term) outcome.
Human Reproduction 02/2004; 19(1):3-7. · 4.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: Introduction: Optimizing outcome in assisted reproduction requires definition of a successful outcome. We suggest delivery of a single term gestation, live baby, per cycle of assisted reproduction initiated is the most relevant standard of success. We have defined this outcome as the birth emphasising a successful singleton at term (BESST). Methods: We have evaluated the BESST outcome in a series of patients requiring controlled ovarian hyperstimulation–intrauterine insemination (COH–IUI) as well as series of patients requiring in vitro fertilisation (IVF). Results: We found that our BESST outcome for COH–IUI was 6%. We also found that our BESST statistic over a large IVF program was 11%. Conclusions: Clinical ART is now established worldwide in both developed and developing nations. Although the science is mature, the outcome of treatment and the reporting of endpoints require emphasis if reducing multiple pregnancy and reducing damage to babies is to occur. We propose the singleton, term gestation, live birth rate of the baby per cycle begun as the BESST measure of ART success.
[show abstract][hide abstract] ABSTRACT: So far as is known, this is the first series to report the effects of embryo transfers on endometrial integrity as assessed by direct hysteroscopic visualization. Subjects (n = 30) were patients of reproductive age undergoing diagnostic hysteroscopy. A mock embryo transfer was performed by a single clinician, immediately followed by saline hysteroscopy using a 2.7 mm hysteroscope. Hegar dilators or uterine sounds were not used. Representative video clips were recorded for independent assessment of endometrial integrity. (The movie sequence may be purchased for viewing on the internet at www.rbmonline.com/Article/1040; it is free to web subscribers.) Outcomes measured were ease of transfer (easy, moderate, difficult, very difficult) and details of the transfer technique. Endometrial damage was independently assessed and graded as follows: none, minor, moderate or severe. Of the easy transfers, 54% showed no endometrial damage. However, there 37% showed moderate to severe damage in the easy transfer group. Of the moderately difficult transfers, there was no clear association between perceived difficulty of transfer and amount of endometrial damage. Clinical perception of ease of transfer does not correlate well with the degree of endometrial disruption (P = 0.41). Use of hysteroscopy offers a unique insight into the effects of embryo transfer on endometrial integrity.
[show abstract][hide abstract] ABSTRACT: Objectives Our purpose was to review all the major complications of laparoscopy in 6500 consecutive laparoscopies from one centre. We also felt it was important to conduct this study because of the current debate on the use of the Veress needle or the Hasson cannula. Design All the major complications from laparoscopies performed from June 1 1991 to March 31 1995 were documented. This is the largest series from one centre. Each laparoscopy was registered on computer. A distinction between operative and diagnostic laparoscopies was not made by the computer. Results A major complication was defined as one that required laparotomy. In this series eight major complications were recorded. The incidence of major complications was 1.23 per 1000. No vascular injury occurred as a result of using a Veress needle or closed trocar entry. Conclusion Despite advances in operative and diagnostic laparoscopy, complications still occur. From this study there is currently no evidence to suggest that the Veress needle should be banned in favour of the open Hasson technique. The gynaecologist, anaesthetist and consumer need to be aware of the complication rates for gynaecological day surgery laparoscopy.
[show abstract][hide abstract] ABSTRACT: With the Human Genome Project complete, and microarray technology progressing rapidly, the study of whole genomes has become a reality. The emerging field of genomics is full of promise, has become a cornerstone of commercial drug development, and looks certain to make a major contribution to clinical practice in the future. There is an increasing number of genomic studies concerned with obstetric and gynaecological conditions. Despite this, clinicians in their busy practices often lack a basic understanding of genomics and the tools involved in generating genome-based information. In the present review, we aim to provide the clinician with a basic overview of genomics--what it is, what tools it uses, and how it may benefit our patients. The existing published reports on genomic studies in the reproductive field is reviewed.
Australian and New Zealand Journal of Obstetrics and Gynaecology 09/2003; 43(4):264-72. · 1.30 Impact Factor