Outcome of twin ICSI pregnancy compared with spontaneous conceived twin pregnancy: a prospective, controlled, observational study

Objectives: to evaluate the relationship between the type of conception and progress of pregnancy and delivery Settings: Abha Maternity Hospital and the Saudi Center for Assisted Reproduction Design: A prospective cohort study from January, 2004 to January, 2006 Materials and methods: 35 ICSI twin pregnancies and 73 spontaneously conceived twin pregnancies were followed up. The primary outcome was gestational age at delivery, secondary outcome were maternal and neonatal complications and mode of deliveries Results: There was a trend toward preterm labor with ICSI twins than with naturally conceived twins but no significant difference between both groups regarding neonatal weight, Apgar score (A/S) and weight of the placenta. In addition, the post-natal/ neonatal period was similar in both groups. There was no difference in maternal outcomes in both groups. Conclusion(s): When compared to naturally conceived twins, ART-conceived twins are more or less similar to those conceived naturally. A trend towards increased preterm labor should be further investigated in larger studies Multiple gestational pregnancies are now recognized as a major epidemiological concern associated with both assisted reproductive technologies (ART) and ovulation induction therapies. Today by far the greatest number of multiple gestation pregnancies is due to some type of assisted procreation. The number of twins associated with ART has been estimated to be as high as 32% (1). This trend has a great degree of importance to clinicians involved in assisted reproduction since studies have shown that not only is multiple gestations more common in ART Corresponding author: Dr. Mamdoh A. Eskandar FRCSC, Associate Professor, Consultant Obstetrics and Gynecology, Department of Obstetrics and Gynecology and Reproductive Medicine, King Khalid University, College of Medicine, Abha, Saudi Arabia, PO Box 641, Telephone Number: +996 7 2284635, Fax Number: +996 7 2257201, E-mail: { HYPERLINK "mailto:[email protected]" } conceptions, but that when compared to spontaneous conceptions (SC), ART conceptions have demonstrated a higher chance of detrimental effects for both mothers and neonates (2-4). Many of the perinatal complications that are seen in infants, from multiple pregnancies, are attributable to the fact that they are more likely to be born more prematurely and with a lower birth weight than their singleton counterparts. Moreover, the fact still remains that even with the medical breakthroughs in maternal/ fetal medicine, multiple gestation pregnancies are considered to be a higher-risk type of pregnancy than singletons, being associated with a high incidence of maternal and neonatal complications. Naturally this increased incidence increases exponentially with the number of gestations. In the present study we prospectively followed up a cohort of women with multiple gestations Middle East Fertility Society Journal Vol. 12, No. 2, 2007 Copyright © Middle East Fertility Society Vol. 12, No. 2, 2007 Eskandar Outcome of twin ICSI pregnancy 97 attending for pregnancy follow-up at our center. The intention was to investigate the relationship between the type of conception and progress of pregnancy and delivery. MATERIALS AND METHODS The study was conducted at Abha Maternity Hospital facilitied to King Khalid University Medical School in the Southwestern area of Saudi Arabia Between January 2004 and January 2006. Institutional ethical committee approval was not attained since this study was an observational study and no intervention was introduced. However, the risks of multiple pregnancies were thoroughly explained to patients at the first counseling session and given instructions on how to prevent complications. Patient population: This is a prospective, cohort observational study of 35 ICSI twin pregnancies compared to a control group of 73 spontaneously conceived twin pregnancies. Demographic and clinical data were analyzed as follows: ART-obtained pregnancies (intracytoplasmic sperm injection) [ICSI] were compared with spontaneous conceived twin pregnancies. Since the most common maternal complications with multiple pregnancies are the development of gestational diabetes, hypertension, and preterm labor, these were closely monitored. Diagnosis of gestational diabetes mellitus (GDM) was based on a 3-hour 100g oral glucose tolerance test. Diagnosis of pregnancy induced hypertension (PIH) was defined as persistent blood pressure of ≥140/ 90 after 20 weeks of gestation in previously normotensive women. Pre-eclampsia was diagnosed whenever PIH was accompanied by proteinuria of ≥100 mg/dL by urine analysis or ≥300 mg/24 hours. Preterm uterine contraction (PMC) was defined as regular uterine contractions that required tocolytic intervention. According to the protocol used at our department, administration of tocolytic treatment requires regular uterine contractions, which are <5 –8 minutes apart and are accompanied by progressive cervical dilatation and/or effacement, and/or the presence of cervical dilatation >1 cm at admission. Preterm birth was considered as such whenever labor occurred before 37 weeks’ gestation. Gestational age for the ART-conceived twin pregnancies was calculated from the date of embryo transfer (+2 weeks). In the natural conception conceived twins, it was calculated from the date of the last menstrual period and confirmed by the first trimester ultrasound estimation. In addition, as part of the routine pregnancy follow-up, all women underwent a detailed anatomy scan at 16 – 20 weeks, using a (2101 Falcon, B-K medical, Japan) machine. In case of difficulty in proper visualization of any fetal part, either due to difficult fetal position or due to maternal obesity, a repeat scan was requested within 3 – 4 weeks. Table 1. Patient demographics and delivery characteristics. Natural Conception (Mean ± SD) ICSI (Mean ± SD) Significance No. of patients 73 35 Patient Age 26.44 ± 5.24 28.29 ± 4.96 P = 0.08 Demographics Obstetric history Gravida 1.38 – 1.67 1.71 ± 2.16 P = 0.39 Para 0.78 – 1.07 0.34 ± 0.59 P = 0.08 Delivery Gestational age estimated at delivery 34.36 ± 4.53 31.51 ± 7.15 P = 0.07 Average weight 1.99 ± 0.63 1.70 ± 0.73 P = 0.36 Average A/S 7.93 ± 2.13 7.37 ± 2.76 P = 0.27 Weight of placenta 0.87 ± 0.21 0.76 ± 0.29 P = 0.13 96 Eskandar Outcome of twin ICSI pregnancy MEFSJ Table 2. Distribution of neonatal complications. Natural Conception N (%) ICSI N (%) Clinical diagnosis requiring ventilation 1 (3.85%) 1 (4.55%) Sepsis 1 (3.85%) 0 (0.00%) RDS 1 (3.85%) 2 (9.09%) Phototherapy 1 (3.85%) 1 (4.55%) Dead 22 (84.62%) 18 (81.82%) At birth all patients had a detailed neonatal examination and documentation of mode of delivery, gestational age, weight, length, and head circumference. A detailed analysis of neonatal complications was also recorded.