Assisted reproductive technology and hypertensive disorders of pregnancy: systematic review and meta-analyses.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) is one of the most common pregnancy complications and causes of maternal morbidity and mortality. Assisted reproductive technology (ART) has been associated with adverse pregnancy outcomes, including HDP. However, the impact of multiple pregnancies, oocyte donation, as well as fresh and frozen embryo transfer needs to be further studied. We conducted a systematic review and meta-analyses to evaluate the association between ART and HDP or preeclampsia relative to spontaneous conception (SC). METHODS: We identified studies from EMBASE, MEDLINE, and Cochrane Library (up to April 8, 2020) and manually using structured search strategies. Cohort studies that included pregnancies after in vitro fertilization (IVF) with or without intracytoplasmic sperm fertilization (ICSI) relative to SC with HDP or preeclampsia as the outcome of interest were included. The control group was women who conceived spontaneously without ART or fertility medications. The pooled results were reported in odds ratios (OR) with 95% confidence intervals based on random effects models. Numbers needed to harm (NNH) were calculated based on absolute risk differences between exposure and control groups. RESULTS: Eighty-five studies were included after a screening of 1879 abstracts and 283 full text articles. Compared to SC, IVF/ICSI singleton pregnancies (OR 1.70; 95% CI 1.60-1.80; I2 = 80%) and multiple pregnancies (OR 1.34; 95% CI 1.20-1.50; I2 = 76%) were both associated with higher odds of HDP. Singleton pregnancies with oocyte donation had the highest odds of HDP out of all groups analyzed (OR 4.42; 95% CI 3.00-6.51; I2 = 83%). Frozen embryo transfer resulted in higher odds of HDP (OR 1.74; 95% CI 1.58-1.92; I2 = 55%) than fresh embryo transfer (OR 1.43; 95% CI 1.33-1.53; I2 = 72%). The associations between IVF/ICSI pregnancies and SC were similar for preeclampsia. Most interventions had an NNH of 40 to 100, while singleton and multiple oocyte donation pregnancies had particularly low NNH for HDP (16 and 10, respectively). CONCLUSIONS: Our meta-analysis confirmed that IVF/ICSI pregnancies are at higher odds of HDP and preeclampsia than SC, irrespective of the plurality. The odds were especially high in frozen embryo transfer and oocyte donation pregnancies.

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

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.

Neonatal outcomes in singleton pregnancies conceived by fresh or frozen embryo transfer compared to spontaneous conceptions: a systematic review and meta-analysis.

PURPOSE: The use of assisted reproductive technology (ART) has increased in the last 2 decades and continuous surveillance is needed. This systematic review aims to assess the risk of adverse neonatal outcomes (preterm birth [PTB], low birth weight [LBW], small-for-gestationalage [SGA] and large for gestational-age [LGA]), in singleton pregnancies conceived by fresh or frozen embryo transfer (FET) compared to spontaneous conceptions. METHODS: Cohort studies were identified from MEDLINE, Embase, Cochrane Library (January 2019), and manual search. Meta-analyses were performed to estimate odds ratios (OR) using random effects models in RevMan 5.3 and I-squared (I2) test > 50% was considered as high heterogeneity. RESULTS: After 3142 titles and abstracts were screened, 1180 full-text articles were assessed, and 14 were eligible. For fresh embryo transfer, the pooled ORs were PTB 1.64 (95% CI 1.46, 1.84); I2 = 97%; LBW 1.67 (95% CI 1.52, 1.85); I2 = 94%; SGA 1.46 [95% CI 1.11, 1.92]; I2 = 99%, LGA 0.88 (95% CI 0.80, 0.87); I2 = 80%). For frozen, the pooled ORs were PTB 1.39 (95% CI 1.34, 1.44); I2 = 0%; LBW 1.38 (95% CI 0.91, 2.09); I2 = 98%; SGA 0.83 (95% CI 0.57, 1.19); I2 = 0%, LGA 1.57 (95% CI 1.48, 1.68); I2 = 22%). CONCLUSIONS: When compared with spontaneous pregnancies, fresh, but not frozen was associated with LBW and SGA. Both fresh and frozen were associated with PTB. Frozen was uniquely associated with LGA. Despite improvements in ART protocols in relation to pregnancy rates, attention is needed towards monitoring adverse neonatal outcomes in these pregnancies.

[Advances and challenges to the Brazilian policy of health technology management]. / Avanços e desafios da política nacional de gestão de tecnologias em saúde.

The Brazilian Ministry of Health has institutionalized two articulated processes in the field of health technology management: (i) the production, systematization and dissemination of health technology assessment, and (ii) the adoption of a flow for the incorporation, exclusion or alteration of new technologies by the Brazilian National Health System. Several advances have been made, such as standardization of methods; production and promotion of studies; institutional development and international cooperation in the area of health technology assessment; definition of the necessary requirements for the presentation of proposals; definition of deadlines; and expansion of the segments that compose the committee that is responsible for the analysis and recommendation. However, some difficulties remain: health technology assessment activities concentrated in the Ministry; low sustainability of the activities of production and dissemination of the assessments; low penetration of health technology assessment in health care institutions; activities of assessment/incorporation with low participation of users; non-transparent decision-making processes; and low integration of the health policy with the scientific and technological policy.

Avanços e desafios da política nacional de gestão de tecnologias em saúde / Advances and challenges to the Brazilian policy of health technology management / Avances y desafíos de la política nacional de gestión de tecnologías en salud

O Ministério da Saúde instituiu dois processos articulados no campo da gestão de tecnologias em saúde: (i) produção, sistematização e difusão de estudos de avaliação de tecnologias em saúde e (ii) adoção de um fluxo para incorporação, exclusão ou alteração de novas tecnologias pelo Sistema Único de Saúde. O artigo analisa a experiência brasileira na gestão de tecnologias sanitárias no âmbito do Sistema Único de Saúde, seus principais avanços e desafios. Dentre os avanços obtidos estão: padronização de métodos; produção e fomento de estudos; desenvolvimento institucional e cooperação internacional na área de avaliação de tecnologias em saúde; definição dos requisitos necessários para apresentação de propostas; definição de prazos; e ampliação dos segmentos que compõem o colegiado responsável pela análise e recomendação. Entretanto, algumas dificuldades permanecem: atividades de avaliação de tecnologias em saúde concentradas no Ministério; baixa sustentabilidade das atividades de produção e disseminação das avaliações; baixa penetração da avaliação de tecnologias em saúde nos estabelecimentos de saúde; atividades de avaliação/incorporação com baixa participação dos usuários; processos decisórios pouco transparentes; e baixa integração da política de saúde com a política cientifica e tecnológica.

The Brazilian Ministry of Health has institutionalized two articulated processes in the field of health technology management: (i) the production, systematization and dissemination of health technology assessment, and (ii) the adoption of a flow for the incorporation, exclusion or alteration of new technologies by the Brazilian National Health System. Several advances have been made, such as standardization of methods; production and promotion of studies; institutional development and international cooperation in the area of health technology assessment; definition of the necessary requirements for the presentation of proposals; definition of deadlines; and expansion of the segments that compose the committee that is responsible for the analysis and recommendation. However, some difficulties remain: health technology assessment activities concentrated in the Ministry; low sustainability of the activities of production and dissemination of the assessments; low penetration of health technology assessment in health care institutions; activities of assessment/incorporation with low participation of users; non-transparent decision-making processes; and low integration of the health policy with the scientific and technological policy.

El Ministerio de la Salud de Brasil instituyó dos procesos articulados en el campo de la gestión de tecnologías en salud: (i) producción, sistematización y difusión de estudios de evaluación de tecnologías en salud y (ii) adopción de un flujo para incorporación, exclusión o alteración de nuevas tecnologías por el Sistema Único de Salud. El artículo analiza la experiencia brasileña en la gestión de tecnologías sanitarias en el ámbito del Sistema Único de Salud, sus principales avances y desafíos. Entre los avances obtenidos están: estandarización de métodos; producción y fomento de estudios; desarrollo institucional y cooperación internacional en el área de evaluación de tecnologías en salud; definición de requisitos necesarios para presentación de propuestas; definición de plazos; y ampliación de los segmentos que componen el colegiado responsable por el análisis y recomendación. Mientras, algunas dificultades permanecen: actividades de evaluación de tecnologías en salud concentradas en el Ministerio; baja sustentabilidad de las actividades de producción y diseminación de las evaluaciones, baja penetración de la evaluación de tecnologías en salud en los establecimientos de salud; actividades de evaluación/incorporación con baja participación de los usuarios; procesos decisivos poco transparentes; y baja integración de la política de salud con la política científica y tecnológica.