Stillbirths and Infant Health Risks Higher in California’s Artificially Conceived Infants
A new study published in the Journal of Perinatology  online has found that in California from 2009-2011 there was a 24- to 27-fold increase in multiple births and significantly higher rates of preterm births, lower birth weights, fetal anomalies and stillbirth among infants born through assisted reproductive technologies (ART) or artificial insemination (AI) compared to babies conceived naturally.
The retrospective study was based on 2009-2011 data from the California Office of Statewide Health Planning and Development and conducted by researchers from the Loma Linda University School of Medicine.
The CDC’s Assisted Reproductive Technology Surveillance report for 2010 indicates that “ART-conceived births were highest in California, followed by Texas and New York,” and that nationwide that year, 46.4 percent of all ART births were multiples, compared to only three percent among naturally conceived infants.  While California has the most infertility clinics of any state in the country  the large increase in multiple births from ART/AI found in the study was higher than but not significantly different from those reported nationally. However, data from the Centers for Disease Control and Prevention (CDC) indicate that California’s rates of low- and very low-birth weight infants, as well as premature and very premature infants, exceed national averages.
According to the new Journal of Perinatology study, in 2009, 18,405 California women underwent ART cycles, which refers to procedures in which the egg and sperm are handled outside the body. Of the total number of women in California undergoing ART, only three percent of women underwent AI or intrauterine insemination. A total of 15,953 embryos were transferred, resulting in 7,155 pregnancies and 5,710 live births. Roughly 1,718 of these births—or 30.1 percent–– were multiple births consisting of twins, triplets or more.
The researchers found that when compared to naturally conceiving women, preterm labor and cesarean section were four times higher for women who underwent ART/AI, and their length of stay in hospital was twice as long. Compared to infants conceived naturally, among ART/AI pregnancies, there was a four- to five-fold increase in stillbirths, and a two to three-fold increase in fetal anomalies. These findings align with those from another California study conducted by researchers at UCLA and published in 2013 in the Journal of Pediatric Surgery.  Compared to naturally conceived babies, researchers found higher rates of congenital malformations among ART multiple babies––particularly of the eyes, neck, heart and urogenital tract.
In one case study highlighted in the Journal of Perinatology report, of 92 ART/AI infants born at Loma Linda Children’s Hospital over an 18-month period from 2012-2013, 10 very premature babies died on the first day. Seventeen were singleton births, with half requiring admission to the Neonatal Intensive Care Unit (NICU). Of the 27 pairs of ART/AI twins, one was stillborn, four deaths followed shortly after birth, and 22 sets were admitted to NICU. Three deaths occurred in two out of six sets of triplets and all surviving triplets required admission to the NICU. The average NICU hospitalization length of stay for these ART/AI babies averaged 38.4 days, with a range of anywhere from three to 138 days.
“We need to educate the public about these very serious risks,” Dr. Mitchell Goldstein of the Department of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine,who co-authored the report, said in an interview. “If elective single embryo transfers became a higher priority among infertility specialists, we would likely see significant reductions in these severe health and stillbirth rates among ART/AI infants and reduced risks for mothers.”
Throughout the United States, the higher incidence of multiple and preterm births linked to ART/AI remains a significant public health concern, particularly for older women and their babies. A 2013 article in the New England Journal of Medicine estimated that 36 percent of twin births and 77 percent of triplet and higher-order multiple births in the U.S. were attributable to medically assisted conceptions. The American Society for Assisted Reproductive Medicine recommends that reproductive endocrinologists transfer single embryos for most women, yet many doctors continue to transfer multiple embryos with the hope of procuring at least one live birth.
“Once a patient becomes pregnant through ART/AI,” explained Goldstein, “many reproductive endocrinologists lose touch with them and are then completely disconnected from any risks mother and infant may encounter. Neonatologists and infertility specialists must work together to reverse these trends and ensure the least harm.”
The findings from this study reflect one conducted by the University of Adelaide of roughly 300,000 patients in Southern Australia who had received assisted conception between January 1986 and December 2002. Published in January 2014 in PLOS ONE, it also found higher rates of stillbirth, prematurity, low birth weight and neonatal deaths among ART infants.
But in this Australia study, even singletons from assisted conception were more likely to be stillborn or have low birth weight than babies born from spontaneous conceptions. Outcomes varied by type of assisted conception. For example, very low and low birth weight, very preterm and preterm birth, and neonatal death were markedly more common in singleton births from IVF, and to a lesser degree, in births from intra-cytoplasmic sperm injection (ICSI) where the one sperm is injected directly into the egg. Using frozen-embryos eliminated all significant adverse outcomes associated with ICSI but not with IVF.
In my next post, I’ll look more closely at the financial costs of babies born through assisted technology and what this might mean for insurance coverage.
Image by TipsTimesAdmin via Flickr
Miriam Zoll is an independent journalist and the author of the new book, Cracked Open: Liberty, Fertility and the Pursuit of High-Tech Babies (Interlink-2013).
 “Impact of ART on Pregnancies in California: An Analysis of Maternity Outcomes and Insights into the added burden of Neonatal Intensive Care,” Journal of Perinatology, DOI: JP.2014.17, http://www.nature.com/jp/journal/vaop/ncurrent/full/jp201417a.html
 Surveillance Summaries, December 6, 2013 / 62(ss09);1-24, http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6209a1.htm?s_cid=ss6209a1_e
 Sunderam S, Kissin DM, Flower L, et al: Centers for Disease Control and Prevention (CDC). Assisted reproductive technology surveillance-United States, 2009. MMWR Surveill Summ. 2012; 61(7 ss7): 1-28.
 Kelley-Quon LI, Tseng CH, Janzen C, Shew SB, “Congential Malformations Associated with Assisted Reproductive Technologies: A California Statewide Analysis,” Journal of Pediatric Surgery, Volume 48, Issue 6, Pages 1218-1224, June 2013.
 Kulkami AD, Jamieson DJ, Hones HW, Kissin DM, Gallo MF, Macaluso M, Adashi EY, “Fertility Treatments and Multiple Births in the United States,” New England Journal of Medicine, 2013; 369: 2218-2225.