Disclosures. Win Fertility UpToDate

Transcription

1

2 Disclosures Win Fertility UpToDate

3 Excess preterm birth Low birth weight Small for gestational age infants Neonatal death But prior studies limited by: Lack of statistical power Inaccurate vital records with regard to ART Limited data or child or maternal outcomes beyond birth Lack of subfertility (non-art) control group

4 MOSART Collaboration BUSPH Candice Belanoff Howard Cabral Eugene Declercq Milt Kotelchuck (MGH) SART Mark Hornstein (BWH) Barbara Luke (MSU) Judy Stern (Dartmouth) Mass DPH Marlene Anderka Bruce Cohen Hafsatou Diop CDC Wanda Barfield Dmitry Kissin (SMART) Principal Investigators

5 SART Clinic Outcome Reporting System (CORS) Pregnancy to Early Life Longitudinal and data screening (PELL) All children born to Massachusetts residents Massachusetts hospitals July 1, 2004 December 31, 2008 All Massachusetts IVF clinics > 99% of Massachusetts births and fetal deaths

6 ART ART deliveries from SART CORS Subfertility Birth certificates fertility drugs or ART Hospital utilization using infertility ICD-9 codes Fertile Controls Births not included in groups above

7 Massachusetts Clinics Clinic City Brigham & Women's Hospital Center for Assisted Reproduction Massachusetts General Hospital Fertility Center Fertility Solutions, P.C. / Mass. Fertility Center, LLC Reproductive Science Center Fertility Centers of New England Baystate Reproductive Medicine Cardone Reproductive Medicine & Infertility LLC Boston IVF Boston Boston Dedham Lexington Reading Springfield Stoneham Waltham

8 Data Sources for SUBFERTILITY Deliveries to Massachusetts Residents in a Massachusetts Hospital July 1, 2004-December 31, 2008 Birth Certificate: Deliveries with subfertility indicator on current or past BC 8,019 Hospital Utilization: Deliveries with subfertility indicator on current or past hospital record 2,777 ART Data: Deliveries w/ prior ART cycle not associated with an index delivery 1,571 Eliminating ART deliveries Total Eligible for Inclusion After De-duplication 10,764 ART 9,092 deliveries SUBFERTILITY 6,238 deliveries FERTILE 318,822 deliveries

9 How do the deliveries in the SUBFERTILITY group compare to those in the ART and FERTILE groups?

10

11 Comparing the SUBFERTILE, FERTILE & ART Groups

12 % COMPARISON OF MOTHERS CHARACTERISTICS IN FERTILE, SUBFERTILE, AND ART DELIVERIES Non-Hispanic Bachelor or FERTILE White Post-graduate SUBFERTILITY ART Not Married Private Insurance

13 Perinatal Outcome Measures Preterm Birth (<37 completed weeks gestation) Low Birthweight (LBW) (<2500 gms) Small for Gestational Age (SGA) (<10 th percentile for all Mass. births ) Birth Defects (yes/no on whether infant identified in the Mass. Birth Defects registry) Perinatal Death (fetal deaths + deaths in first 27 days)

14 Overall Outcomes Singletons Massachusetts FERTILE SUBFERTILE ART Preterm Birth 6.4% 8.1% 10.3% Low Birthweight 5.4% 5.7% 7.8% Small for Gest. Age 8.1% 6.5% 8.1% Birth Defects (per 1,000) Perinatal Deaths (per 1,000)

15 Gestational Age Distribution, by Fertility Groups, SINGLETONS 35% 30% 25% 20% 15% FERTILE SUBFERTILE ART 10% 5% 0% Completed Weeks Gestation

16 Birthweight Distribution, by Fertility groups, SINGLETONS 45% 40% 35% 30% 25% FERTILE SUBFERTILE ART 20% 15% 10% 5% 0% <500 gm Birthweight

17 Overall Outcomes Twins Massachusetts FERTILE SUBFERTILE ART Preterm Birth 53.0% 56.4% 53.7% Low Birthweight 53.0% 50.5% 50.3% Small for Gest. Age 20.6% 16.9% 17.9% Birth Defects (per 1,000) Perinatal Death (per 1,000)

18 Gestational Age Distribution, by Fertility Groups, TWINS 25% 20% 15% FERTILE SUBFERTILE ART 10% 5% 0% Completed Weeks Gestation

19 Figure 2 Birthweight Distribution, by Fertility groups, TWINS 40% 30% 20% FERTILE SUBFERTILE ART 10% 0% <500 gm Birthweight

20 Covariates Included in Final Model Maternal age Race/ethnicity, Martial status Education Payer for delivery (private/ public) Smoking Prenatal Care Parity Hypertension (chronic & preg ind.) Other fertility related condition Infant Gender

21 Adjusted Odds Ratios for Outcomes across Fertility Groups: SINGLETONS FERTILE SUBFERTILE ART Preterm (<37 wks) LBW (<2500 gms) b ( ) b ( ) 1.53 b ( ) 1.51 b ( ) SGA ( ) Birth Defects ( ) Perinatal Death ( ) 1.05 ( ) 1.12 ( ) 0.96 ( ) ART Adjusted Odds Ratio significantly higher than SUBFERTILITY a p<.05; b p<.01 for differences in comparison to the fertile group

22 Adjusted Odds Ratios for Outcomes across Fertility Groups: TWINS FERTILE SUBFERTILE ART Preterm (<37 wks) LBW (<2500 gms) ( ) ( ) 0.89 ( ) 0.98 ( ) SGA a ( ) Birth Defects ( ) Perinatal Death b ( ) 0.85 b ( ) 1.13 ( ) 0.55 b ( ) ART Adjusted Odds Ratio significantly lower than SUBFERTILITY a p<.05; b p<.01 for differences in comparison to the fertile group

23 CONCLUSIONS The SUBFERTILITY measure is a valuable first step in developing a needed comparison group for examining outcomes of ART assisted births. Need for continual refinement of the measure, particularly as access to additional data sources arises.

24 CONCLUSIONS After controlling for covariates, twin births to women with ART were not at significantly greater risk than those in the SUBFERTILE group. In the cases of preterm birth and low birthweight among singletons, ART births were at greater risk than those in the SUBFERTILE group. There were no differences in the risk of birth defects or small for gestational age births among singletons or twins. Twins born from ART had significantly lower rates of perinatal death than either those from the SUBFERTILE OR FERTILE groups.

25