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PubMed2003

Assisted reproductive technology surveillance--United States, 2000.

PROBLEM/CONDITION: In 1996, CDC initiated data collection regarding assisted reproductive technology (ART) procedures performed in the United States to determine medical center-specific pregnancy success rates, as mandated by the Fertility Clinic Success Rate and Certification Act (FCSRCA) (Public Law 102-493, October 24, 1992). ART includes fertility treatments in which both eggs and sperm are handled in the laboratory (i.e., in vitro fertilization and related procedures). Patients who undergo ART treatments are more likely to deliver multiple-birth infants than women who conceive naturally. Multiple births are associated with increased risk for mothers and infants (e.g., pregnancy complications, premature delivery, low-birthweight infants, and long-term disability among infants). REPORTING PERIOD COVERED: 2000. DESCRIPTION OF SYSTEM: CDC contracts with a professional society, the Society for Assisted Reproductive Technology (SART), to obtain data from fertility medical centers located in the United States. Since 1997, CDC has compiled data related to ART procedures. The Assisted Reproductive Technology Surveillance System was initiated by CDC in collaboration with the American Society for Reproductive Medicine, the Society for Assisted Reproductive Technology, and RESOLVE: The National Infertility Association. RESULTS: In 2000, a total of 25,228 live-birth deliveries and 35,025 infants resulting from 99,629 ART procedures were reported to CDC from 383 medical centers that performed ART in the United States and U.S. territories. Nationally, 75,516 (76%) of ART treatments were freshly fertilized embryos using the patient's eggs; 13,312 (13%) were thawed embryos using the patient's eggs; 7,919 (8%) were freshly fertilized embryos from donor eggs; and 2,882 (3%) were thawed embryos from donor eggs. The national live-birth delivery per transfer rate was 30.8%. The five states that reported the highest number of ART procedures were California (13,194), New York (11,239), Massachusetts (8,041), Illinois (7,323), and New Jersey (5,506). These five states also reported the highest number of live-birth deliveries and infants born as a result of ART. Overall, 47% of women undergoing ART-transfer procedures using freshly fertilized embryos from their own eggs were aged <35 years; 23% were aged 35-37 years; 19% were aged 38-40 years; 7% were aged 41-42 years; and 4% were aged >42 years. Among ART treatments in which freshly fertilized embryos from the patient's eggs were used, substantial variation in patient age, infertility diagnoses, history of past infertility treatment, and past births was observed. Nationally, live-birth rates were highest for women aged <35 years (38%). The risk for a multiple-birth delivery was highest for women who underwent ART-transfer procedures using freshly fertilized embryos from either donor eggs (40%) or from their own eggs (35%). Among women who underwent ART-transfer procedures using freshly fertilized embryos from their own eggs, further variation by patient age and number of embryos transferred was observed. Of the 35,025 infants born, 44% were twins, and 9% were triplet and higher order multiples, for a total multiple-infant birth rate of 53%. Patient's residing in states with the highest number of live-birth deliveries also reported the highest number of infants born in multiple-birth deliveries. INTERPRETATION: Whether an ART procedure was successful (defined as resulting in a pregnancy and live-birth delivery) varied according to different patient and treatment factors. Patient factors included the age of the woman undergoing ART, whether she had previously given birth, whether she had previously undergone ART, and the infertility diagnosis of both the female and male partners. Treatment factors included whether eggs were from the patient or a woman serving as an egg donor, whether the embryos were freshly fertilized or previously frozen and thawed, how long the embryos were kept in culture, how many embryos were transferred, and whether various specialized treatment procedures were used in conjunction with ART. ART poses a major risk for multiple births. This risk varied according to the patient's age, the type of ART procedure performed, and the number of embryos transferred. In addition, the increased risk for multiple births has a notable population impact in certain states. PUBLIC HEALTH ACTIONS: As use of ART and ART success rates continue to increase, ART-related multiple births are an increasingly important public health problem nationally and in many states. The proportion of infants born through ART in 2000 that were multiple births (53%) was substantially higher than in the general U.S. population during the same period. Data in this report indicate a need to reduce multiple births associated with ART. Efforts should be made to limit the number of embryos transferred for patients undergoing ART. In addition, continued research and surveillance is key to understanding the effect of ART on maternal and child health.

Adult↗
PubMed2001

A regional approach to promoting improved care of multiples.

Live births of multiples in the U.S. rose 35% from 87,700 in 1988 to 118,295 in 1998. This increase presents public health issues due to the elevated health and psychosocial risks that accompany multiple birth. However, health and social service providers and educators are poorly prepared to address the specific needs of the multiple birth population. The Twin Service Network Project therefore developed regional networks of multiple birth training and resources in California to address this problem. Results indicate that these can substantially improve the care available to multiples. The project's integrated package of training and parenting education materials is available to other regions to assist in such efforts.

California↗
PubMed1998

Adverse outcome after multiple pregnancy.

There is increasing interest in the outcomes of multiple pregnancies as their numbers rise, mainly owing to advances in fertility-enhancing techniques. In addition, the numbers of multiple births surviving the perinatal period is increasing with the increasing survival of very tiny babies. In order to investigate these outcomes or to evaluate procedures that may improve them, it is important to consider a number of methodological issues that affect the comparability of data both between and within populations. How a birth and a multiple birth are defined, data sources, whether multiple pregnancies or individual births are being counted and the identification of multiple gestations by zygosity and chorionicity will all affect the reported outcome rates. In light of this, perinatal mortality and neurodevelopmental disabilities are examined as adverse outcomes of multiple pregnancies.

Abortion, Spontaneous↗
PubMed2003

Adverse pregnancy outcomes around incinerators and crematoriums in Cumbria, north west England, 1956-93.

STUDY OBJECTIVE: To investigate the risk of stillbirth, neonatal death, and lethal congenital anomaly among babies of mothers living close to incinerators and crematoriums in Cumbria, north west England, 1956-93. DESIGN: Retrospective cohort study. Logistic regression was used to investigate the risk of each outcome in relation to proximity at birth to incinerators and crematoriums, adjusting for social class, year of birth, birth order, and multiple births. Continuous odds ratios for trend with proximity to sites were estimated. SETTING: All 3234 stillbirths, 2663 neonatal deaths, and 1569 lethal congenital anomalies among the 244 758 births to mothers living in Cumbria, 1956-1993. MAIN RESULTS: After adjustment for social class, year of birth, birth order, and multiple births, there was an increased risk of lethal congenital anomaly, in particular spina bifida (odds ratio 1.17, 95% CI: 1.07 to 1.28) and heart defects (odds ratio 1.12, 95% CI: 1.03 to 1.22) around incinerators and an increased risk of stillbirth (odds ratio 1.04, 95% CI: 1.01 to 1.07) and anencephalus (odds ratio 1.05, 95% CI: 1.00 to 1.10) around crematoriums. CONCLUSIONS: The authors cannot infer a causal effect from the statistical associations reported in this study. However, as there are few published studies with which to compare our results, the risk of spina bifida, heart defects, stillbirth, and anencephalus in relation to proximity to incinerators and crematoriums should be investigated further, in particular because of the increased use of incineration as a method of waste disposal.

Congenital Abnormalities↗
PubMed2005

Neonatal morbidity of very low birth weight infants from multiple pregnancies.

The epidemic of multiple births has translated into a marked rise in very low birth weight infants, who are at risk for major neonatal morbidity and mortality. Gestational age-adjusted comparisons of outcome between singletons and multiples have shown conflicting results. Comparisons that corrected for relevant confounding variables show that twins and singletons have similar risks for early morbidity and mortality. Very low birth weight triplets may have increased risk for neonatal mortality, however. Second-born very low birth weight twins seem to be at risk for increased respiratory morbidity, even in the era of routine antenatal corticosteroids and postnatal surfactant therapy.

Birth Order↗
PubMed2003

Role of fertility treatments in multiple pregnancy at National Women's Hospital from 1996 to 2001.

OBJECTIVE: To determine the influence of fertility treatments on multiple pregnancy rates. STUDY DESIGN: A retrospective audit of women with multiple pregnancies from 1996 to 2001 at National Women's Hospital (NWH), Auckland, New Zealand was conducted. Information was collected regarding the demographics, fertility treatment, outcome of the pregnancy and complications experienced by women discharged with multiple births as an discharge diagnosis. RESULTS: For the years 1996-2001 there were 1136 multiple births at NWH. Of these births, 201 (18%) were conceived following fertility treatment. Seventeen percent of twin births and 44% of triplet births were conceived following fertility treatment. There was a statistically significant increase in the number of births conceived following fertility treatment, from 9%, in 1996 to 24%, in 2001, although the proportion of births that were multiple overall did not change (20% in 1996 and 2.3%, in 2001). Sixty-three percent of all fertility conceived multiple births were following in vitro fertilization/intracytoplasmic sperm injection treatment. Sixty percent of these women had two embryos transferred and 31% had three embryos transferred. Ovulation induction with follicle-stimulating hormone accounted for 19% of all fertility conceived multiple births. Nineteen percent of fertility conceived multiple births followed clomiphene treatment alone. CONCLUSIONS: The proportion of multiple pregnancies as a result of fertility treatments has increased over the 6 years studied.

Adolescent↗
PubMed2004

The desire for multiple pregnancy in male and female infertility patients.

BACKGROUND: It is apparent that many fertility patients consider multiple birth an ideal treatment outcome. We wished to evaluate the desire for multiple birth among patients, and the effect of patient demographics and recognition of the increased fetal risks of multiple pregnancy on this desire. METHODS: This was a prospective questionnaire study completed by 801 male and female infertility patients attending a tertiary level Canadian university fertility clinic. Two logistic regression analyses were performed with desire for multiple birth with next fertility treatment and recognition of the increased fetal risks of multiple pregnancy as the dependent variables. RESULTS: 41% of patients desired a multiple birth. Increasing duration of infertility or previous assisted reproductive treatment increased, and having previous children or recognition of the increased fetal risks decreased, this desire. Patient age or sex did not affect desire for multiple birth. Previous assisted reproductive treatment was associated with increased recognition of the fetal risks of multiple pregnancy. CONCLUSIONS: A significant proportion of fertility patients considers multiple birth an ideal treatment outcome. Recognition of the increased fetal risks of multiple pregnancy significantly reduced this desire. Patient education may play an important role in assisting physicians in the quest to reduce the contribution of assisted reproductive treatment to multiple births and their attending complications.

Adult↗
PubMed1999

Preterm singleton births--United States, 1989-1996.

Preterm birth (birth at <37 completed weeks of gestation) is the second leading cause of neonatal mortality in the United States. Preterm birthrates differ by race; in 1996, black infants were 1.8 times more likely than white infants to be preterm. From 1989 through 1996, the overall rate of preterm birth (per 1000 live-born infants) increased 4%, and the rate of multiple births (e.g., twins, triplets, or other higher-order births) increased 19%. Multiple births are associated with preterm birth; trends in preterm births independent of the influence of multiple births have not been fully explored. To characterize race- and ethnicity-specific trends in preterm birth independent of multiple births, data from U.S. birth certificates for 1989-1996 were analyzed for singleton births only. This report summarizes the results of this analysis and indicates that although singleton preterm birthrates are stable overall, substantial changes in rates occurred in some racial/ethnic subgroups.

Birth Rate↗
PubMed1976

Twin pregnancy as a high risk pregnancy: new medical statistical data from the German Democratic Republic.

In 1972 the rate of multiple births showed a much more substantial decrease than in the years before. In the period 1963-1971 it dropped from 20.3% to 19.3% and in 1972 to 18.3%. The frequency of low birth weight in children from a multiple birth is 10 times higher than in all newborn children and the early neonatal mortality of children from a multiple birth is 8 times higher than that of all newborn infants. Cerebral damage is 30 times higher in children of low birth weight than in children of normal birth weight. In the period 1965-1967 perinatal death associated with cerebral damage (recorded on the death certificate) accounted for 5.7% of all children of low birth weight and for 0.2% of children weighing at birth over 2500 g. Early diagnosis of multiple pregnancy and early in-patient care of women with multiple pregnancy will improve the development of multiple fetuses and give children from a multiple birth much better chances in life. In all twin studies it has to be considered that a relatively high proportion of twins is affected to a higher or lesser degree by cerebral damage.

Brain Diseases↗
PubMed1999

Perinatal and obstetric outcomes of donor insemination using cryopreserved semen in Victoria, Australia.

This study compared the perinatal and obstetric outcomes of 1552 donor insemination pregnancies in Victoria, Australia, with a control group of 7717 normally conceived pregnancies from the general population. Data on the outcomes of pregnancies of at least 20 weeks gestation, for both groups, were obtained from the same population-based birth registry. The study showed that there were no significant differences between the donor insemination and control groups in the incidence of preterm birth, low birthweight, multiple birth, perinatal death and birth defects, or in the sex ratio. Pregnancies conceived by donor insemination were significantly more likely than controls to have an induced labour (OR = 1.6, 95% CI 1. 4-1.8), a forceps delivery (OR = 1.5, 95% CI 1.3-1.8) and/or a Caesarean section (OR = 1.6, 95% CI 1.4-1.9) and to develop pre-eclampsia (OR = 1.4, 95% CI 1.2-1.8) after adjusting for maternal age, multiple birth, parity and presentation. Reasons for the higher rate of induced and operative deliveries are not clear. Overall, the study's findings are reassuring for couples considering infertility treatment with donor insemination. The study illustrates the importance of complete follow-up in studies of pregnancy outcomes after assisted conception and the use of appropriate population-based control groups with comparable ascertainment of outcomes.

Case-Control Studies↗
PubMed1994

Twin language or phonological disorder?

The acquisition of language in the preschool years by multiple-birth children is often reported to be atypical. Some researchers have claimed that they use 'twin language', i.e. an autonomous language specific to a multiple-birth set. This claim was investigated by describing and comparing the phonological characteristics of the speech of 19 sets of two- to four-year-old multiple-birth children, and by measuring multiple-birth children's understanding of their twins' or triplets' context-free speech. The results indicated that multiple-birth children are prone to phonological disorder and consequently their speech is often unintelligible. Siblings' phonologies evidenced some similarities, although they were not identical. Multiple-birth children were better able to understand their siblings' mispronunciations than were other children of the same age, although that understanding was dependent on how closely the error form resembled the adult form. While these three factors conspire to give the impression that 'twin language' is common, none of these findings provided support for the claim that multiple-birth children use an autonomous language.

Articulation Disorders↗
PubMed2006

Cost of transferring one through five embryos per in vitro fertilization cycle from various payor perspectives.

OBJECTIVE: We sought to examine the costs of transferring one through five embryos per in vitro fertilization cycle from each of three perspectives: society, the infertile couple, and the insurer. METHODS: Data from the 2003 Assisted Reproductive Technology Report was used to create Markov decision analytic models stratified by maternal age subgroup. We modeled both total costs, cost-effectiveness (cost per live birth), and clinical outcomes: multiple births, preterm deliveries, and cerebral palsy. RESULTS: From a societal and insurer perspective, it was least expensive to transfer one embryo. For women aged younger than 35 years, it cost society 80% more to transfer five rather than one embryo at a time (total cost 39,212 dollars compared with 21,661 dollars). For women aged older than 42 years, it cost 13% more (29,102 dollars compared with 25,723 dollars). From a parental perspective, it was least expensive to transfer between two and five embryos, depending on maternal age. One-embryo transfers markedly improved clinical outcomes. For example, two compared with one-embryo transfers for women aged younger than 35 years reduced preterm birth and cerebral palsy rates by 55% and 41%, respectively. Univariable sensitivity analysis and Monte Carlo simulation showed our results to be robust. CONCLUSION: Transferring one embryo per cycle is the least expensive strategy from a societal perspective, especially for younger women, yet it is the most expensive option from a parental perspective. To reduce in vitro fertilization-associated multiple birth rates, public policy must address these disparate financial incentives.

Adult↗
PubMed1992

Birth spacing and child mortality in a Caribbean population.

Ten independent variables were used to predict death before the first birthday for 4411 births that took place from 1878 to 1976 to 978 women of native ancestry on the island of St. Barthélemy. Significant predictors of death include the death of the mother within a year, the birth year, multiple birth, whether the preceding child also died before 1 year of age, and whether the next child was conceived before the index child was 1 year old. Unlike most prior studies, birth-spacing variables were only weakly related to death in the first year. The relative absence of contraceptive techniques to control birth spacing in the study population and the use of vital records rather than survey data distinguish this project from others and may account at least partly for the unusual findings.

Birth Intervals↗
PubMed1993

Triplets and quadruplets born in Victoria between 1982 and 1990. The impact of IVF and GIFT on rising birthrates.

OBJECTIVES: To examine the perinatal characteristics of all higher order multiple births (133 sets of triplets and six sets of quadruplets) in the State of Victoria between 1982 and 1990. To compare the rising higher order multiple birth rates in Victoria with those in the other States of Australia, and to assess the impact of in-vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT) on these rising birth rates. DESIGN: Retrospective review of all higher order multiple births registered in Victoria and other States of Australia between 1982 and 1990, and in particular those resulting from IVF and GIFT. DATA SOURCES: Victorian Perinatal Data Collection Unit, Australian Bureau of Statistics, National Perinatal Statistics Unit, data from Victorian IVF and GIFT units. MAIN OUTCOME MEASURES: Higher order multiple birth rates and perinatal mortality rates. RESULTS: The higher order multiple birth rates in Victoria rose from 3.5 per 10,000 in 1982 to 10.9 per 10,000 in 1990. The average perinatal mortality rates for the Victorian triplets and quadruplets born during this period were 10.8% and 25.0%, respectively. The rates of caesarean section were 70% and 83%; the proportions of deliveries in level III hospitals, 75% and 100%; and the mean maternal lengths of stay in hospital, 32 and 57 days, respectively. Endotracheal intubation was performed at birth in 18.5% of all infants. The proportions of triplet and quadruplet pregnancies in Victoria owing to IVF and GIFT rose during this period, reaching a peak of 42% in 1990. In the other States, the birth rates for higher order multiples increased at 1.8 times the rate observed for Victoria, with IVF and GIFT contributing to an estimated 43% of these conceptions between 1985 and 1989. CONCLUSION: Restrictions on the numbers of embryos/oocytes transferred during IVF and GIFT should reduce the frequency of higher order multiple births.

Adult↗
PubMed2004

Twin births in Singapore: a population-based study using the National Birth Registry.

INTRODUCTION: Twin studies are a most effective method to analyse gene and environment interactions. Using data from the Singapore National Registry of Births and Deaths (SNRBD), this paper describes the number of twin and multiple births among different ethnic populations in Singapore. MATERIALS AND METHODS: All births recorded in the SNRBD from 1 January 1986 to 31 December 2001 were analysed. Outcomes measured were twin and triple birth rates (per 1000 maternities) of the 3 main ethnic groups in Singapore (Chinese, Malays and Asian Indians). Further outcomes were calculated using Weinberg's differential rule to estimate the number of monozygotic and dizygotic twins. RESULTS: Overall twin birth rates have steadily increased across all ethnic groups (7 to 9/1000). The largest increase in multiple births among the ethnic groups were twins born to Asian Indian fathers (6.9 to 9.9/1000) and Malay mothers (5.9 to 9.8/1000). A significant difference in birth rates between the ethnic groups was found during the years 1994 to 1997, where Chinese parents had the lowest multiple birth rates and Asian Indians the highest. Estimation and ratios of monozygotic and dizygotic twin births differed among the ethnic groups: Asian Indians had the highest ratios, followed by the Chinese and, lastly, the Malays. CONCLUSION: The SNRBD has provided an overview of multiple births in Singapore, although the establishment of a national twin register would enable more detailed analysis of genetic and environmental effects in multiple births.

Asian People↗
PubMed2006

Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003.

We conducted a retrospective analysis of perinatal mortality at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 in order to categorise/classify perinatal deaths as well as to identify key factors in perinatal care that could be improved. Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register. The study includes all foetuses weighing =500g. A modified Nordic-Baltic classification was used for classification of perinatal deaths. Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of 124 per 1000 births, 78% of which was labour related stillbirth. The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26% of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal mortality were birth asphyxia (37%) and prematurity (29%). Labour related deaths were more common in multiple pregnancies. The majority of the perinatal deaths should be essentially avoidable through improved quality of intrapartum care. Establishment of perinatal audit at MNH can help identify key actions for improved care.

Apgar Score↗
PubMed1998

Multivariate analysis of factors predictive of successful live births in in vitro fertilization (IVF) suggests strategies to improve IVF outcome.

PURPOSE: Our purpose was (1) to identify characteristics correlated with pregnancy outcome, (2) to use these characteristics to predict in vitro fertilization (IVF) outcome, and (3) to develop strategies that might improve IVF success. METHODS: Maternal age, cause for IVF, donor insemination, rank of attempt, serum estradiol and luteinizing hormone levels on the day of human chorionic gonadotropin administration, flexible vs rigid catheter, number of embryos transferred of each morphologic type, and cell number were analyzed by logistic regression. RESULTS: Variables positively correlated with success are as follows: (1) for pregnancy, endometriosis and 2-, 3-, and 4-cell good and 4-cell excellent embryos; (2) for live births, 2-, 3-, and 4-cell good and 4-cell excellent embryos and donor insemination; and (3) for multiple births, 2- and 4-cell good and 4-cell excellent embryos. Maternal age was negatively correlated with live births. CONCLUSIONS: Embryos derived from IVF have different potentials for implantation, live births, and multiple births. Transferring one additional good-quality embryo for each 5 years of incremental increase in maternal age is predicated to improve live birth rates without increasing multiple births.

Adult↗
PubMed1992

Season of birth in multiple sclerosis.

The monthly distribution of births of people who were later diagnosed with multiple sclerosis differed significantly from that of the general population in Denmark. The multiple sclerosis patients had an excess of births in March, April, May, and June, and fewer in the other months. Infection was suggested as a possible explanation.

Cross-Sectional Studies↗