Infertility treatment and risk of severe maternal morbidity: a propensity score-matched cohort study

Natalie Dayan; K S Joseph; Deshayne B Fell; Carl A Laskin; Olga Basso; Alison L Park; Jin Luo; Jun Guan; Joel G Ray

doi:10.1503/cmaj.181124

Assisted Reproduction · Safety and Risks

Infertility treatment and risk of severe maternal morbidity: a propensity score-matched cohort study

Dayan N, Joseph KS, Fell DB, Laskin CA, Basso O, Park AL, Luo J, Guan J, Ray JG

Published February 4, 2019 CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne

DOI 10.1503/cmaj.181124 PMID 30718336 PMC PMC6351248

RRM Academy Synopsis

IVF pregnancies had a higher rate of severe maternal morbidity

A 2019 Ontario cohort study found severe maternal morbidity was more common in IVF pregnancies than in matched untreated pregnancies. In the IVF group, 39.3 per 1000 deliveries ended in severe morbidity or death, against 22.2 per 1000 untreated. Pregnancies after ovulation induction or intrauterine insemination had a similar rate, 21.7 per 1000.

Key Findings

Among 11 546 matched infertility treatment pregnancies and 47 553 untreated pregnancies, severe maternal morbidity or death occurred at 30.8 and 22.2 per 1000, a relative risk of 1.39 (95% CI 1.23–1.56).
Among pregnancies after invasive treatment (IVF with or without intracytoplasmic sperm injection), 235 had severe maternal morbidity or death (39.3 per 1000), an adjusted relative risk of 1.77 (95% CI 1.54–2.03).
Among pregnancies after noninvasive treatment (ovulation induction or intrauterine insemination), 121 had severe maternal morbidity or death (21.7 per 1000), an adjusted relative risk of 0.98 (95% CI 0.81–1.18).
Compared with untreated pregnancies, the adjusted odds ratio for 3 or more severe maternal morbidity indicators was 2.28 (95% CI 1.56–3.33) after invasive treatment and 0.99 (95% CI 0.57–1.72) after noninvasive.
Before matching, the relative risk for any infertility treatment was 2.17 (95% CI 1.96–2.40). After matching on maternal characteristics, the relative risk was 1.39.

Interpretation

Severe maternal morbidity means a near-fatal event during pregnancy or within 42 days after it. The study followed Ontario hospital deliveries from 2006 to 2012 and reports associations. Matching balanced the measured traits of the mothers, but multiple pregnancy stayed more common in the treated group (23.1% against 15.0%). The authors note that the severity of infertility and the details of ovarian stimulation were not captured. The authors write that it remains to be determined whether the procedure or the women who need it explains the higher rate.

RRM Context

Restorative reproductive medicine starts by finding why conception is not happening and treating that cause. IVF assists conception around the underlying condition and leaves it in place. The authors ask that comparisons of invasive and less invasive options look at maternal health outcomes as well as live birth rates.

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

Abstract

Background

The extent to which infertility treatment predicts severe maternal morbidity is not well known. We examined the association between infertility treatment and severe maternal morbidity in pregnancy and the postpartum period.

Methods

We conducted a cohort study using population-based registries from Ontario between 2006 and 2012. Pregnancies achieved using infertility treatment (ovulation induction, intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection) were compared with unassisted pregnancies using propensity score matching, based on demographic, reproductive and obstetric factors. The primary outcome was a validated composite of severe maternal morbidity or maternal death from 20 weeks' gestation to 42 days postpartum. We also calculated the odds ratio of a woman having 1, 2, or 3 or more severe maternal morbidity indicators in relation to invasive (e.g., in vitro fertilization) or noninvasive (e.g., intrauterine insemination) infertility treatment.

Results

We matched 11 546 infertility treatment pregnancies with 47 553 untreated pregnancies. Severe maternal morbidity or maternal death occurred in 356 infertility-treated pregnancies (30.8 per 1000 deliveries) versus 1054 untreated pregnancies (22.2 per 1000 deliveries); relative risk 1.39 (95% confidence interval [CI] 1.23-1.56). The likelihood of a woman having 3 or more severe maternal morbidity indicators was increased in women who received invasive infertility treatment (odds ratio [OR] 2.28, 95% CI 1.56-3.33) but not in those who received noninvasive infertility treatment (OR 0.99, 95% CI 0.57-1.72).

Interpretation

Women who undergo infertility treatment, particularly in vitro fertilization, are at somewhat higher risk of severe maternal morbidity or death. Efforts are needed to identify patient- and treatment-specific predictors of severe maternal morbidity that may influence the type of treatment a woman is offered.

Topics

Assisted Reproduction › Safety and Risks › Maternal Complications · Birth and Delivery › Birth Outcomes › Maternal Morbidity

Natalie Dayan, Deshayne B Fell, Carl A Laskin, Olga Basso, Alison L Park, Jin Luo, Jun Guan, Joel G Ray

N Dayan, D Fell, C Laskin, O Basso, A Park, J Luo, J Guan, J Ray

PMID 30718336 30718336 DOI 10.1503/cmaj.181124 10.1503/cmaj.181124 Dayan et al. 2019, Dayan 2019

Infertility treatment and risk of severe maternal morbidity: a propensity score-matched cohort study

IVF pregnancies had a higher rate of severe maternal morbidity

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

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