Pregnancy outcomes in very advanced maternal age pregnancies The impact of assisted reproductive technology

Capsule:
Very advanced maternal aged women using ART are more likely to be primiparous or undergo elective cesarean delivery, and are at increased risk of retained placenta. Oocyte source does not affect outcomes.

Authors:
Sherri Jackson, M.D., M.P.H., Connie Hong, M.D., Erica T. Wang, M.D., M.A.S., Carolyn Alexander, M.D., Kimberly D. Gregory, M.D., M.P.H., Margareta D. Pisarska, M.D.

Volume 103, Issue 1, Pages 76-80

Abstract:

Objective:
To determine whether there are differences in adverse pregnancy outcomes in very advanced maternal age (vAMA) women who conceived with assisted reproductive technologies (ART) compared with spontaneous conceptions.

Design:
Retrospective cohort study.

Setting:
Academic tertiary care medical center.

Patient(s):
A total of 472 women aged ≥45 years who delivered at one institution.

Intervention(s):
Mode of conception.

Main Outcome Measure(s):
Maternal and neonatal outcomes.

Result(s):
For singleton pregnancies, vAMA women who conceived with ART were significantly older (47.0 ± 2.3 vs. 45.6 ± 0.1 years), more likely to be white (88.1% vs. 75.6%), and less parous (0.4 ± 0.9 vs. 1.2 ± 1.8) than vAMA women who conceived spontaneously. They were at significantly increased risk for cesarean delivery (CD) (75.1% vs. 49.7%) and were more likely to undergo elective primary CD without labor (25.4% vs. 9.4%). Risk of retained placenta was also significantly higher (2.7% vs. 0%). Rates of other maternal complications and neonatal outcomes were similar. Subgroup analysis of ART singleton pregnancies did not demonstrate differences in women using autologous oocytes versus donor oocytes.

Conclusion(s):
Very advanced maternal age women who conceive after ART are more likely to be white, older, primiparous, and are more likely to proceed with an elective CD compared with vAMA women who conceive spontaneously. The increased risk of retained placenta in women who conceive with ART may indicate an underlying risk for placentation defects.

  • Micah Hill

    Thank you for the article and the wonderful online journal club discussion this week! As discussed online and in the paper, one limit is the assumption that patients >44 years old without a documented ART pregnancy were assumed to be spontaneous conceptions. I have several questions which would help me frame how to interpret your results better.

    1. In your discussion, you state that “many” patients in the spontaneous pregnancy group did not have documentation of conception method and so were assumed to be spontaneous. I’m curious how many of the 150 spontaneous pregnancies in the control cohort met this assumption? And if you performed a sensitivity analysis excluding these assumed pregnancies, are the results of higher Cesarean section rates and retained placenta still statistically significant?

    2. The largest contributor to the Cesarean rate in the ART population were elective Cesareans. Conversely, the largest contributor to the Cesarean rate in the spontaneous pregnancies were failure to progress. If you exclude elective Cesareans, are the rates of clinically indicated Cesareans different or are the groups then similar?

    3. The ART cohort was older and had a much lower parity. Did you consider controlling for these factors in regression modelling or other analyses? I’m curious if you control for these baseline differences in the groups, which are associated with Cesarean risk, do you still see a difference in Cesarean rates?

    4. Finally, what are your thoughts on retained placenta as a significant clinical complication? All other abnormal placentation complications were similar between the groups and could be considered much more clinically significant outcomes.

    I would appreciate the authors thoughts on these issues. Since the ART cohort appeared to be at baseline a higher risk group for Cesarean and most of their Cesareans ended up being elective, I am not convinced ART itself was an independent risk factor for clinically indicated Cesarean. I’m also not certain I would classify retained placenta as a clinically significant abnormal placentation event. At least not on the significance level of hypertensive disorders, pre-eclampsia, acreta, or abruption.

  • ranjithrama

    Women with AMA will likely have men with APA (advanced paternal age) as well. Did the authors look at paternal age as a factor that could influence outcomes?

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