Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

Nakeisha A Lodge-Tulloch; Flavia T S Elias; Jessica Pudwell; Laura Gaudet; Mark Walker; Graeme N Smith; Maria P Velez

doi:10.1186/s12884-021-03711-x

Birth and Delivery · Cesarean Birth

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

Lodge-Tulloch NA, Elias FTS, Pudwell J, Gaudet L, Walker M, Smith GN, Velez MP

Published March 22, 2021 BMC pregnancy and childbirth

DOI 10.1186/s12884-021-03711-x PMID 33752633 PMC PMC7986269

RRM Academy Synopsis

IVF and ICSI singleton pregnancies carry higher odds of cesarean

A meta-analysis of 34 cohort studies found that singleton pregnancies after IVF or ICSI had 1.90-fold higher odds of cesarean delivery than spontaneous conceptions (95% CI 1.76, 2.06). It included 164,603 IVF/ICSI pregnancies and 3,845,643 spontaneous conceptions.

Key Findings

The search identified 1750 studies, and 34 cohort studies met the inclusion criteria: 17 matched cohorts and 17 unmatched cohorts, with autologous oocytes and singleton pregnancies only.
The pooled odds ratio for cesarean section after IVF/ICSI versus spontaneous conception was 1.90 (95% CI 1.76, 2.06), with high heterogeneity (I2 = 96%).
Against spontaneous conception, the pooled odds ratio after IVF/ICSI was 1.91 (95% CI 1.37, 2.67) for elective cesarean in ten studies and 1.38 (95% CI 1.09, 1.75) for emergent cesarean in eight.
Compared with spontaneous conception, the pooled odds ratio was 2.07 (95% CI 1.86, 2.30) for IVF in fourteen studies and 1.66 (95% CI 1.28, 2.15) for ICSI in six studies.
The pooled odds ratio was 1.55 (95% CI 1.41, 1.69) after fresh embryo transfer in seven studies and 1.82 (95% CI 1.65, 2.01) after frozen embryo transfer in six studies.

Interpretation

The review pools observational cohort studies: twenty-nine retrospective and five prospective. The findings show association. Heterogeneity was high in every analysis. The authors say variations in outcome definitions, inclusion criteria, maternal age, treatment type and infertility diagnosis, among others, can explain it. GRADE rated the evidence moderate for the overall, elective, emergent, IVF and ICSI results, and low for fresh and frozen transfer. Donor gametes, twins and multiples were excluded. The authors say the reasons for the higher odds remain to be determined.

RRM Context

Restorative reproductive medicine evaluates both partners, finds the cause of infertility and treats it. Conception can then follow from the couple's own reproductive function. IVF bypasses the question of why a couple has not conceived.

Our editorial summary of this paper, not the article's abstract.

Abstract

Background

Caesarean section rates are higher among pregnancies conceived by assisted reproductive technology (ART) compared to spontaneous conceptions (SC), implying an increase in neonatal and maternal morbidity. We aimed to compare caesarean section rates in ART pregnancies versus SC, overall, by indication (elective versus emergent), and by type of ART treatment (in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), fresh embryo transfer, frozen embryo transfer) in a systematic review and meta-analysis.

Methods

We searched Medline, EMBASE and CINAHL databases using the OVID Platform from 1993 to 2019, and the search was completed in January 2020. The eligibility criteria were cohort studies with singleton conceptions after in-vitro fertilization and/or intracytoplasmic sperm injection using autologous oocytes versus spontaneous conceptions. The study quality was assessed using the Newcastle Ottawa Scale and GRADE approach. Meta-analyses were performed using odds ratios (OR) with a 95% confidence interval (CI) using random effect models in RevMan 5.3, and I-squared (I2) test > 75% was considered as high heterogeneity.

Results

One thousand seven hundred fifty studies were identified from the search of which 34 met the inclusion criteria. Compared to spontaneous conceptions, IVF/ICSI pregnancies were associated with a 1.90-fold increase of odds of caesarean section (95% CI 1.76, 2.06). When stratified by indication, IVF/ICSI pregnancies were associated with a 1.91-fold increase of odds of elective caesarean section (95% CI 1.37, 2.67) and 1.38-fold increase of odds of emergent caesarean section (95% CI 1.09, 1.75). The heterogeneity of the studies was high and the GRADE assessment moderate to low, which can be explained by the observational design of the included studies.

Conclusions

The odds of delivering by caesarean section are greater for ART singleton pregnancies compared to spontaneous conceptions. Preconception and pregnancy care plans should focus on minimizing the risks that may lead to emergency caesarean sections and finding strategies to understand and decrease the rate of elective caesarean sections.

Topics

Birth and Delivery › Cesarean Birth › Cesarean Indications and Rates · Assisted Reproduction › Safety and Risks › Neonatal and Birth Outcomes

Nakeisha A Lodge-Tulloch, Flavia T S Elias, Jessica Pudwell, Laura Gaudet, Mark Walker, Graeme N Smith, Maria P Velez

N Lodge-Tulloch, F Elias, Jess Pudwell, J Pudwell, L Gaudet, M Walker, G Smith, M Velez

PMID 33752633 33752633 DOI 10.1186/s12884-021-03711-x 10.1186/s12884-021-03711-x Lodge-Tulloch et al. 2021, Lodge-Tulloch 2021

Caesarean section in pregnancies conceived by assisted reproductive technology: a systematic review and meta-analysis

IVF and ICSI singleton pregnancies carry higher odds of cesarean

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

Related research