PREGNANCIES BY OVUM DONATION - Comtecmed · 2014-04-29 · Gestational hypertension and...
Transcript of PREGNANCIES BY OVUM DONATION - Comtecmed · 2014-04-29 · Gestational hypertension and...
PREGNANCIES BY OVUM DONATION
Zeev Shoham, MD
Director of the Reproductive Medicine and IVF Unit
Department Ob/Gyn, Kaplan Medical Center
Rehovot , Israel
1.Premature ovarian failure 2.Poor responder 3.Menopause (surgical, radiotherapy, chemotherapy) 4.Advanced maternal age 5.Recurrent IVF failure 6.Poor oocyte quality 7.Genetic defects precluding normal pregnancy 8.Combined
Indications for egg donation
Ovum Donation
• Highest efficacy independent of age
• Highest efficacy independent of indication
• Proven safety
• Pragmatic solution
Cummulative pregnancy rates after
1, 2 and 3 attempts
Recipients
30-50 Years
OD: highest implantation rates in ART
(Cohen et al., 1999)
Delay in parenthood
Social revolution 60´s contraceptive pill
Female´s priorities:
Education and work
Divorces
New family models
TRENDS
• Recent decades have witnessed an increase in mean
maternal age at childbirth in most high-resourced
countries
• United States
• 1970- 1 out of 100 first births to women aged >35 years
• 2006 - 1 out of 12 first births to women aged >35 years
Martin et al. (2009) National Vital Statistics Reports
BIOLOGICAL CLOCK
Ovarian reserve
• The exact age at which a women can no longer conceive varies widely.
Females born with a finite pool of oocytes ( Zukerman 1951)
Live birth per transfer of fresh embryos from own and donor eggs, by age of
receopint.
HOW OLD?
Birth as old as 67 yrs. of age using ART have been reported.
(Unfortunately - 2 years later - cancer)
"Health | World's oldest mother dies at 69". BBC News. 2009-07-15. Retrieved 2012-11-08.
Oldest women to conceive naturally was 57 yrs. old.
"Oldest mother to conceive naturally". Guinnessworldrecords.com. 1997-08-20. Retrieved 2012-11-08.
Oocyte Donation
Only effective option for women over the age of 40 with
diminished ovarian function.
The risk of chromosomal abnormality correlates to the
age of the donor, but the risks of pregnancy complications
(DM, HTN) correlate to the recipient’s age.
Published by IVF-Spain
Types of gamete donation
• Altruistic donation
• Donation with payment to donor
• Sharing
• Reciprocal donation
Upcoming challenges, Leiderdorp, 04.10.2013 13
Pregnancies achieved using ED with unrelated donors are
unique, since the entire fetal genome is allogeneic to the mother.
• The first successful pregnancy achieved after egg
donation (ED) was reported in 1984 Lutjen et al. Nature 1984;307:174-175.
• The original indication was premature ovarian failure Bustillo et al. JAMA 1984;251:1171-1173.
1999 - Oocyte donation (USA) was performed in almost 10% of all ART
cycles carried out in US (CDC report, 1999)
2012 - Oocyte donation (USA) was performed in almost 12% of all ART
cycles carried out in US (CDC report, 2012)
Pregnancy rate
Delivery rate
One cycle 53.4% 42.6%
Four transfers 94.8 78.7%
Remohi et al. Fertil Steril. 1997;67:717-23.
What might be the medical
problem, related to pregnancy
from egg donation?
HYPERTENSION
The most frequent medical problem in pregnancy.
Older women have a two fold higher risk of being
diagnosed with HT.
Preeclampsia in general population is 3 to 4%. 5 to 10%
in women >40
Pecks et.al. Dtsch Arztebl Int.
Oocyte donation: a risk factor for pregnancy-induced hypertension: a meta-
analysis and case series.
28 publications were evaluated.
PIH in a total of 2308 deliveries after oocyte donation was 22.6%.
The calculated odds ratio for PIH after oocyte donation, compared to other women in the control group, was 6.60
(95% CI, 4.55-9.57).
• Am J Obstet Gynecol. 2014 Levron et al.
To determine the prevalence of placental complications in patients conceived through donor versus autologous oocytes.
The rate of placental complications including:
Preeclampsia
Gestational hypertension
Intra uterine growth restriction (IUGR)
A retrospective cohort study
Donor oocyte (n=139)
Autologous oocyte (n=126).
Only singleton gestations were included
Ovum donor recipients
Age: Older 45 vs 41, p<0.01
Gestational hypertension and preeclampsia 25% vs 10%, p<0.01
IUGR 9.3% vs 4%, p=0.08
Adjustment for maternal age, gravidity, parity and chronic hypertension revealed independently higher rate of hypertensive diseases of pregnancy (P=0.01).
• Am J Obstet Gynecol. 2014 Levron et al.
Bellver et al. Fertil Steril. 2013;100:1050
Obesity - uterine receptivity - ovum donation
Analyze the reproductive outcome of recipients of donated ova according BMI.
9,587 first cycles of ovum donation with ova from normoweight donors
Outcome was analyzed according to the BMI
BMI <20 kg/m(2) (n = 1,458; 15.2%)
Normo-weight with BMI 20-24.9 kg/m(2) (n = 5,706; 59.5%)
Overweight with BMI 25-29.9 kg/m(2) (n = 1,770; 18.5%)
Obese with BMI ≥30 kg/m(2) (n = 653; 6.8%).
Lean Normo-weigh Over-weight Obese
Implantation
40.4% 39.9% 38.5% 30.9%
Clinical pregnancy
56.9% 55.9% 54.3% 45.3%
Live-birth 38.6% 37.9% 34.9% 27.7%
Bellver et al. Fertil Steril. 2013;100:1050
Female obesity impairs the reproductive outcome of ovum donation probably as
a result of reduced uterine receptivity
Conclusions
• Pregnant woman who have conceived as a result of
oocyte donation are to be categorized as high risk
patients, with a substantial risk especially for hypertensive
disorders of pregnancy.
• The increased relative risk for hypertensive disorders of
pregnancy exists independently of the rate of multiple
pregnancies, maternal age, and the type of reproductive
treatment.
DIABETES
Prevalence increases with maternal age
Rates of pre-existing DM and gestational
DM increase 3-6 fold in women >40.
Incidence of gestational DM in general OB population is 3%.
~7-12% in women over age 40
~20% in women over age 50
Placental Problems
Abruptio placenta
Placenta previa
Nulliparous women >40 have a tenfold increased risk of
placenta previa compared to women 20-29 yrs. old.
Van der Hoorn et al. Hum Reprod Update 2010:16;704
Perinatal Morbidity
Advanced maternal age is responsible for a substantial
proportion of the increase in the rate of LBW babies and
preterm delivery in the last several years.
Van der Hoorn et al. Hum Reprod Update 2010:16;704
Dysfunctional Labor And Cesarean
Section
Women age >35 yrs. are more likely to be delivered by C-
section.
C-section rates in general population in U.S. are almost
30%
Rate is almost 50% in women age 40-45
Van der Hoorn et al. Hum Reprod Update 2010:16;704
MATERNAL MORTALITY
Risk of maternal mortality for women age 35-39 yrs. old is
more than twice that of women age 25-29 yrs. old.
(21 vs. 9/100,000 live births)
Risk for women over the age of 40 is 5 x higher
Van der Hoorn et al. Hum Reprod Update 2010:16;704
Shrim et al., J Perinat Med. 2010 Nov;38(6):645-50..
Complications of very advanced maternal age pregnancies ≥ 45 years with and without ED.
Preterm deliveries (OR 1.25)
Cesarean sections (OR 1.84)
Hypertension (OR 1.71)
Diabetes (OR 2.45).
Small for gestational age (OR 1.30)
High rates of respiratory distress syndrome (OR 1.66)
Neonatal intensive care admission (OR 1.40)
Perinatal/neonatal mortality (OR 1.83)
>50% cesarean section
Postpartum hemorrhage (OR 5.38)
Ethics
Argument in favor of egg donation:
Reproductive freedom – regardless of age or life expectancy
Argument against:
Natural limits to reproduction, the child and medical risks
Therefore:
For maternal safety: Age limit should be 55 y.o.
Transfer of a single embryo (strongly considered)
The age and the health of the partner should be considered
Controversial issue
Several psychological studies show no difference in development and
happiness perception between “natural”, “IVF’ and “ED” children
Anonymity protects children and donors against trauma in adolescence
Anonymity vs. non anonymity
ANONYMITY VS. NON ANNONYMITY
Countries promoting non- and anonymous donations
Germany,
Austria,
Switzerland,
Italy
Russia and
Eastern
Europe
Spain,
France,
Greece,
Cyprus
Arab
world,
Africa
UK, BeNeLux &
Scandinavia
USA Canada
Conclusion
Egg donation has the highest efficacy independent of age or indication
Patients that have conceived through oocyte donation should be
categorized as high risk patients
Age limit should be 55 y.o.
Singleton pregnancy
Anonymity protects children and donors against trauma in adolescence