the relationship between infertility treatment and birth defects. where we are, where do we want to...
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The Relationship Between infertility Treatment and Birth Defects.
Where We Are, Where Do We Want to Go, and How Can We Get There
Michael Davies, MPH, PhD
Professor & Co-Director
Lifecourse and Intergenerational Health Research Group,Research Centre for the Early Origins of Health and Disease
Lifecourse and Intergenerational Health Research Group
Broad research areas
• Optimal conditions for development to birth and beyond
• Reproductive careers• Involuntary infertility & assisted conception• Intergenerational growth and chronic disease
risk
Current research topics related to ART
• Deferred child bearing in Australia and the impact on fertility
• Influence of lifestyle & demographic factors on fertility, age, smoking, obesity
• Safety and effectiveness of ART– Birth defects
• Long term consequences of infertility treatment for patients and offspring– Intergenerational transmission of metabolic risk
What’s safety?
• Safety is the opposite of danger.• However, the perception of danger is subjective.
• Kurchatov Institute, Russian Scientific Center. Translated from Atomnaya Énergiya, Vol. 80, No. 6, pp. 415–420, June, 1996.
Contributors to perceived ‘safety’
• It’s a value judgement
– Value and probability of desired outcome – Value and probability of unwanted outcome – Modifiability– Inevitability– Background level of risk– Future opportunities– Luck/fate
...“The feeling of wanting a child is so huge when you go through IVF, the least of your worries is having a child that might not be perfect”
There are always going to be children born with difficulties ...it is just one of those things.
“This will lead to a deformed nation. It's selfish and irresponsible. People nowadays think of nothing but their own desires.”
“I disagree with the applicants that infertility/subfertility is a public health problem.
ART is an expensive public health burden that reduces the health and well being of previously well women and increases the risk of suboptimal pregnancy outcomes in an already overpopulated world.”
• “The theoretic risks of pregnancy following IVF and ET ...cannot be drawn until a large number of babies are delivered and a long-term follow-up is completed. Initial results from the current small sample are encouraging.”
• Wood C, Trounsen A, et al. Fertil Steril 1982 Jul;38(1):22-9. Clinical features of eight pregnancies resulting from in vitro fertilization and embryo transfer.
http://aviation-safety.net/statistics/period/stats.php?cat=A1
Annual death rate per 1000 total births from maternal mortality in England and Wales (1850-1970) (Registrar General Reports)
WHO Maternal mortality /100,000 live births 2008
Australia, Sweden, Luxemburg 5
Japan, Canada 7
NZ 8
Western Europe 7
Central Europe 13
USA 17
Eastern Europe 32
Oceania 279
South Asia 323
Sub-Sahara Africa 586
www.thelancet.com Published online April 12, 2010 DOI:10.1016/S0140-6736(10)60518-1
‘Most children born after assisted reproduction techniques are healthy’ Bergh 2012
‘Although the large majority of births resulting from assisted conception were free of birth defects...’ Davies et al 2012
... but knowledge is limited to common, immediate outcomes where there is no lag and slow rates of technical innovation
Over 90% of our passengers arrive without death or major disability
National Birth Defects Prevention Study (NBDPS)5008 control infants and 13 586 case infant
Contributors to ‘risk’
• Patient characteristics– Age, obesity, underlying disease
• Treatment strategies– Multiple embryo transfer
• Treatment effects– Treatment modality, IVF vs ICSI, – Cryopreservation– Ovarian stimulation
• Do ART patients and pregnancies carry distinct risks for adverse pregnancy outcomes?
• Is ART associated with an increased risk of birth defects?
• Are the defects of significance?• Do twins carry the same risk as singletons?• Do all ART exposures carry the same risk?• Is any apparent increased risk due to patient or
ART factors?• Is a sibling comparison model feasible?• Is subfertility a risk?• Can any risk be modified?
N Engl J Med 2012. DOI:10.1056/NEJMoa1008095
Wilkinson, R. Published 1820. Based on work of Mathew Flinders published in 1814
Infertility 2 linkage data
Infertility 1 linkage data
Birth defects registry
South Australian perinatal collection
Terminations in SA Matched file in Dept of Health
De-identified master file N=302,811 +ART births 6,163 (1.5%)Birth defect registrations 17,546 (5.8%)
ART clinical data
Cerebral palsy registry
Groupings considered in the analysis • Group 1 - IVF, ICSI, GIFT, FET, OI, IUI, DI• Group 2 - Spontaneous pregnancies
among ART patients• Group 3 – History of infertility on maternity
record• Group 4 - Unexposed to ART, no infertility history
Confounding?
Potential confounders used in the analysis
• Pre-existing hypertension• Pregnancy induced
hypertension• Pre-existing diabetes • Gestational diabetes• Impaired glucose
tolerance• Anaemia • Urinary tract infection• Epilepsy• Asthma
• Maternal age group• Parity• Fetal sex• Gestation• Smoking in pregnancy• Australian Standard
Classification of Occupation (ASCO) with 282 categories
• Year of treatment
INCLUSION LIST EXAMPLESConditions for exclusion are contained in the appendix of the annual reports contained ate the following web site.
http://www.wch.sa.gov.au/services/az/other/phru/documents/2002_sabdr_annual_report.pdf
• CARDIOVASCULAR DEFECTS • (74500 - 74799)• Transposition of Great Vessels • (74510 - 74519) • Tetralogy of Fallot • (74520)• Ventricular Septal Defect • (74540 - 74549) • Atrial Septal Defect • (74551 - 74559) • Hypoplastic Left Heart Syndrome • (74670)• Patent Ductus Arteriosus • (74700) • Coarctation of Aorta • (74710 - 74719)
• URO-GENITAL DEFECTS • (75200 - 75399) • Undescended Testis (treated) • (75250 - 75254, 75257) .• Hypospadias • (75260, 75263 - 75269).• Renal Agenesis or Dysgenesis • (75300 - 75306) .• Cystic Kidney Disease• (75310 - 75319) .
• Obstructive Defects Renal Pelvis • (75320 - 75329) .• Vesico-Ureteric Reflux • (75344) .• Other Anomalies of Ureter • (75340 - 75343, 75345 - 75349) .
• MUSCULO-SKELETAL DEFECTS • (75400 - 75699) • Developmental Dysplasia of Hip • (75430 - 75434, 75439) .• Talipes • (75450, 75454-75456,75473) .• Polydactyly • (75500 - 75509).• Syndactyly • (75510 - 75519) • Reduction Deformities • Upper and/or Lower Limbs • (75520 - 75549)• Craniosynostosis • (75600, 75601)• Diaphragmatic Hernia • (75661)• Exomphalos • (75670)• Gastroschisis • (75671)
ART and syndromes
Non-significant ART effect on the following syndromes:
• Downs • Edwards • Pataus • Pierre-Robin • Turners • Klinefelters • Angelman • Beckwith-Wiedemann
• Imputing an ART birth defect rate of 8.3% from the Davies et al NEJM paper there has been approximately 415,000 major birth defects from the 5m ART births.
• This would be reduced by 123,125 (29%) to 291,875 if the birth defect rate matched that of the general population.
• This would require addressing treatment, patient, and multiple pregnancy factors – some of which are currently not under technical control.
• Are assisted reproductive technologies (ART) a useful model for the study of endocrine disruptors?
Selective estrogen receptor modulators (SERMs) are a class of compounds that act on the estrogen receptor. A characteristic that distinguishes these substances is that their action is different in various tissues.
Clomphene citrateTamoxifenBisphenol A
Assisted reproductive technologies and birth outcomes: overview of recent systematic reviews
Bower C, Hansen M. Reproduction Fertility and Development, 2005, 17, 329-33.
Risk of adverse perinatal outcomes among singletons by mode of conception, SA, 1986-2002
Donor Oocyte
GIFT ICSI Fresh
ICSI Frozen
IUI IVF Fresh
IVF Frozen
Mini-mal In-terven
Ov. In-duc.
Spon-tan-eous
Infertile Clomiphene at home
Male
-211.32
9
-203.65
4
-207.73
9
64.2908
-110.38
9
-294.80
5
-39.979
2
-21.530
3
-157.71
5
-8.8887
-311.57
1
-559
Fe-male
-170.10
8
-275.43
5
-150.02
1
28.9684
-127.34
2
-228.13
6
-33.348
8
-35.123
1
-8.6078
-52.697
5
-174.22
4
-282
-550
-450
-350
-250
-150
-50
50
Difference in birthweight by ART groups relative to sex specific populations for singletons adjus-
ted for gestation
Gm
s
n/a 10.0* 10.4* 7.8 8.6* 7.3* 6.7 6.1 7.2 7.4* 8.3* 19.4*Major birth defects %unadjusted
*significantly different to fertile population prevalence of 5.7% in fully adjusted model
Programming issues
• Timing, type, magnitude and duration of exposures
• Range of effects• Latency between exposures and outcomes • Critical periods for programming (pre- postnatal)• Interaction or effect modification (environment,
genetic factors)• Maternal health status (body composition)• Transgenerational effects
Range of longer term health and development outcomes
• Higher peripheral body fat deposits, sum of skin folds, fasting serum glucose concentrations, systolic and diastolic blood pressures (Ceelan et al,2007, 2008) (Belva eta l 2012).
• High infancy growth velocity (Ceelen at al 208)• Cancer in children (Kallen et al 2005; 2010)• Cancer in both child and mother after infertility treatment (Hargreave M,
et al 2013)• Hospital admission for asthma beyond the first year of life (Ericson et al
2002).• Prescription for asthma medication (Kallen et al, 2013)• Subclinical hypothyroidism (Sakka et al, 2009).• Increased contact with disability services (Pinborg, 2005)• Autism spectrum disorders (Baye, 2013; Hvidtjorn 2009)
Potential extension studies
• Add further years of data • Replicate in other locations & develop
metaanalyses• Long term follow-up of physical, metabolic, social
and intellectual development in ART offspring• Link to child and youth health, PBS, disability
services• Link to cancer registries for children and parents• Develop predictive models and collaborate on
mechanistic studies
He that will not apply new remedies, must expect new evils
Francis Bacon
(1561 - 1626)
Supported by grants from the National Health and MedicalResearch Council (349475, 349548, 453556, and 465455) and theAustralian Research Council (FT100101018).We thank Flinders Reproductive Medicine and Repromed inAdelaide for providing clinical data.
Prof Van Steirteghem told the annual meeting of the American Association for the Advancement of Science in San Diego, California:
"I have noticed from the beginning that several clinics use ICSI for everyone. We have to see what will come out in the future, and long term follow up is extremely important, but yes, ICSI has been overused."