1. Pediatric consequences of Assisted Reproductive Technologies

2. Outline Review of outcome studies regarding ART
Comparison of different countries
Multiple gestations
Are there impacts of ART among singletons?

3. Twins and Singletons
Among singletons there is an increase in prematurity and of growth restriction, leading to an increase in low birth weight
Increased perinatal and neonatal mortality
« Risks » of requiring ART increase with age and with some chronic illness, and are higher in older primigravidae
Statistical correction for parity and age suggest residual impacts of ART
Those residual impacts may be related to a history of subfertility

4. Singletons In one systematic review,
Increased risks among singletons after ART, compared to adjusted risks (for age and parity) of all the adverse outcomes, persisted after adjustment for a history of subfertility
In another review
Risks were no longer significantly different.

5. Singletons
For neonatologists the message is that the risks are increased compared to the general population
This will increase pressure on NICU beds
No evidence of other specific neonatal illnesses which are increased by ART
Except for congenital anomalies
Mothers are older, therefore more Gestational Diabetes, hypertension etc.

6. « Who’s my Dad? » Not just a question for the child
Family history may be uncertain in a case of gamete donation (egg or sperm)
Family history may be important for numerous neonatal issues
If donors are anonymous obtaining family history may be impossible.
Even if donors are identifiable, it may be extremely difficult to obtain the information.

7. Multiple problems
Among twin pregnancies, the gestational age at birth is lower for those conceived by IVF than for spontaneous twins.
In part because of a higher proportion of IVF mothers being primigravid,
primigravidae carrying twins deliver earlier than multigravidae,
even among spontaneous pregnancies

8. The more embryos you transfer the more babies are born

9. Transferring more embryos does not increase pregnancy rates

10. Trasnferring 3 or more embryos dramatically increases multiple deliveries

11. If you never transfer 3 embryos you (almost) never get triplets

12. Cost of irresponsibility Janvier A, Spelke B, and Barrington K
Cost of irresponsibility Janvier A, Spelke B, and Barrington K. J Pediatr 2011
We analyzed data from our NICU, from when there was little regulation in Québec
At that time 30% of IVF pregnancies were multiples, triplets were not rare
ART multiples accounted for nearly 20% of all our NICU admissions
There were also frequent fetal reductions, from 4 or 3 to twins
Those infants required intensive care, ventilation, TPN, etc
Developed complications…

13. Human cost of irresponsible practices
Morbidities Saved
With Universal SET
Selective SET
NICU Admissions 67 63
Retinal Examinations
270
253
Patient-days of assisted ventilation
260
244
Patient-days of CPAP
171
160
Patient-days of Oxygen
643
604
Patient-days of TPN
950
893
Patient-days of gavage feeding
2001
1881
Patient-days of hospitalisation
3082
2897
Calculated the morbidities that would have been saved if those IVF procedures had all been SET
Accounted for 2% twins, increased age and morbidities among mothers and increased prematurity even among singletons

14. We extrapolated those result to the whole of Canada. Pop. 23 million
840 NICU admissions per year
7300 ventilator patient days
4800 patient CPAP days
40 deaths
46 severe IVH
20 RoP surgeries
Would be avoided by responsible single embryo transfers

15. Don’t forget maternal impact of multiples
Hypertension
Diabetes
Antepartum hemorrhage
Post-partum hemorrhage
Cesarean delivery
Pre-eclampsia
Eclampsia
Maternal depression
Divorce

16. The long term?
In the main, the long term impacts of ART are due to increased prematurity, and increased extreme prematurity
Among ART singletons there may be an increase in cerebral palsy, probably also because of the increase in prematurity (mostly late preterms, with increased risk in the population of CP)
Increase in epilepsy among ART singleton infants delivered at term
(single study)

17. Conclusion ART is an enormous benefit to childless couples
Unregulated ART carries huge risks to the babies, (and mothers) mostly as a result of multiple gestation
Even singleton pregnancies are at higher risk, but those higher risks are mostly due to demographics and not due to the procedures
Regulating multiple embryo transfers can be done effectively with very little impact on pregnancy rates and dramatic reductions in multiples
Leads to dramatic reduction in NICU admissions, NICU costs, and baby complications