The advent of assisted reproductive technologies (ART) has increased the complexity of care in newborn nurseries. An increased number of premature infants and multiple births are among a variety of risks that occur with the increased frequency of ART. These risks should be shared with all perspective parents (patients).
An article by Schieve et al studied 42,463 infants who were born between 1996 and 1997, and who had been conceived utilizing ART. These infants were compared to the three million plus infants born in the United States during that period. Among singleton births conceived by ART, and born at 37 weeks or after, the risk for low birth weight was 2.6 times that in the general population. The use of ART was also associated with an increased rate of multiple births which also increases the rate of IUGR births and many other complications.
Hansen et al reported on 301 infants conceived by intracytoplasmic sperm injection and 837 infants conceived with in vitro fertilization (IVF). These were compared to naturally conceived infants from the same region. The infants conceived with ART had an increase of birth defects which was greater than double the occurrence among the naturally conceived. The abnormalities involved a broad spectrum of congenital anomalies. The etiology for the increased risk was unclear. However, advanced maternal age, the usual underlying causes of infertility, medications used to induce ovulation and maintain pregnancy, factors associated with procedures such as freezing and thawing of embryos, and delayed fertilization of the oocyte individually or collectively, contributed to this increased risk.
Strömberg et al studied the neurologic sequelae of children born after IVF. Through a population based retrospective cohort assessment, they compared the neurologic outcome of 5,680 children born after IVF against the neurological outcome of 11,360 matched controls. For each of the 2,060 twins born after IVF, a second set of twin controls was used. Children born after IVF demonstrated an odds ratio of 1.7 of needing habilitation services. Among singletons born after IVF, the risk was 1.4. The most common neurologic disorder was cerebral palsy, with a relative risk of 3.7 for all children born after IVF and 2.8 for singletons. Data concerning twins born after IVF was essentially the same as control twins in respect to neurologic sequelae. Twins with low birth rate and prematurity were more likely to require habilitation services. Maternal age did not seem to be a factor in this study.
Multiple births have an increased risk factor for neurologic sequelae and, consequently, Ozturk et al. strongly recommend that no more than two embryos be placed in the uterus while performing IVF.
Hansen et al. The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization N Engl J Med 2002;346:725-730.
Ozturk et al. In-vitro fertilisation and risk of multiple pregnancy. Lancet 2002;359:232.
Schieve et al. Low and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731-737.
Strömberg et al. Neurological sequelae in children born after in-vitro fertilisation: a population-based study. Lancet 2002;359:461-465.
First Editor’s Comment: Information regarding the increased risk of problems associated with ART must be shared with the families who are considering using them. Healthcare providers must also be aware of these risks. The increased expenditures associated with ART are not just the cost of the procedure, but also involve the long-term health care costs. Healthcare costs have become more expensive because of these complications, and these are not usually considered when assessing the expenditures of ART.
Judith G. Hall, OC, MD
Second Editor’s Comment: A dictum of physics is only rarely violated. Specifically every positive force has a negative force and vice versa. Chances are what we take daily. There are no positive assurances about anything except death. Therefore, we should expect that every technology will not be perfect – either in construction of the technology itself, or carrying out of a procedure with the technology and in the results thereof. Thus, we should not be disturbed by some imperfections of the system, although we should continue to try to make it perfect.
Human error as well as errors of nature also complicate life, including life related to IVF. The Associated Press on July 10th released in newspapers around the world a report entitled “Test Tube Baby Mix-Up Causes Alarm: Birth of Black Babies to White Couple Raises Questions About Reliability of the Program”. This occurrence was in England. Such occurrences of error undoubtedly are very rare, but inevitably occur.
Life goes on, but not always without error. The positivities of what IVF has, does, and will accomplish, far outweigh the negativity of the errors of nature and man.
Robert M. Blizzard, MD