OUTLINE Maternal age statistics and trends Multiple Assisted - PowerPoint PPT Presentation

10/15/2015 Advanced Maternal Age Management of Pregnancy in I have nothing to disclose. Women over 40 Kirsten E. Salmeen, MD Assistant Professor Obstetrics, Gynecology & Reproductive Sciences Maternal-Fetal Medicine OUTLINE • Maternal age statistics and trends Multiple • Assisted reproductive technologies (ART) Age Gestations • Aneuploidy & Miscarriage Risk Infertility Infertility • Underlying health problems • Perinatal morbidity Assisted Medical • Management Reproductive Co-Morbidities Technology 1

10/15/2015 MATERNAL AGE – STATISTICS AND TRENDS Age US Birth Rates Among Women ≥ 35 What percent of births in the United States would 12% you estimate are in women over age 40? 12% 10% A. < 5% 39% Deliveries to Women 35-39 Years 8% 28% 6% Deliveries to Women ≥ 40 Years B. 5 – 10% 22% 4% C. 10 – 15% 3% 11% 2% D. > 15% 0% 1997 2002 2008 2013 % % % % 5 0 5 5 < 1 1 1 – – > 5 0 1 CDC, National Center for Health Statistics, National Vital Statistics System. http://www.cdc.gov/nchs/nvss.htm 2

10/15/2015 1997 2013 Total # of Births in US 3,880,894 3,932,181 Age 40-44 Years 93% Age # of Births (%) 76,084 (2) 109,484 (2.8) Age 45-49 Years Infertility Infertility # of Births (%) 3,333 (0.09) 7,495 (0.19) Age ≥ 50 Years # of Births (%) 144 (0.004) 677 (0.017) CDC, National Center for Health Statistics, National Vital Statistics System. http://www.cdc.gov/nchs/nvss.htm Age and Fertility Age and Fertility Births Resulting from ART Procedures National Vital Statistics Data 2011 By age 40 it is ~ 5% per cycle Maternal Age Number of Number of Known Percent Births ART-Births < 35 2,273,953 19,285 0.85 At age 30, a woman’s 35-37 228,392 7,949 3.48 chance of conception is ~ 20% per cycle 38-40 117,937 5,905 5.01 41-42 33,299 2,354 7.07 43-44 11,717 1,379 11.77 ≥ 45 5,247 1,624 30.95 Data from multiple non-contracepting communities over many decades Practice Committee Committee Opinion No 589 Fertil Steril 2014 National Vital Statistics Reports, Vol. 63, No. 8, December 2014 3

10/15/2015 Age RISKS ASSOCIATED WITH ASSISTED Infertility Infertility REPRODUCTIVE TECHNOLOGIES Assisted Reproductive Technology ART & Multiple Gestation • Multiple 25 – 30% of ART pregnancies are twins Age Gestations • 1.5 – 3% of ART pregnancies are triplets or more • Infertility Infertility Monozygotic twinning: 1.7 – 2.5% (vs 0.5%) Assisted Reproductive Technology Kanter et al Trends and correlates of monozygotic twinning after single embryo transfer Ob Gyn 2015; cdc.gov Assisted Reproductive Technology (ART) National Summary Report 2010 4

10/15/2015 ART & Birth Defects ART is an independent risk factor for which of the following? 301 Infants 89% A. Birth defects 837 Infants B. Cesarean section 4,000 Infants C. Placenta previa 4% 3% 2% 1% D. Pre-eclampsia Birth defects Cesarean section Pre-eclampsia All of the above Placenta previa E. All of the above Figure 1. Cumulative prevalence of diagnosed major birth defects in singleton infants, according to age at diagnosis Hansen et al. NEJM 346:725-30, 2002 ART & Birth Defects ART & Birth Defects Multiple Births Singleton Births Assisted Conception Spontaneous Conception Adjusted Odds Assisted Conception Spontaneous Conception Adjusted Odds (N = 4333) (N = 295,220) Ratio (N = 1,830) (N = 7,591) Ratio Any Defect 361 (8.3) 16,989 (5.8) 1.30 (1.16 – 1.45) Any Defect 152 (8.3) 557 (7.3) 1.16 (0.91 – 1.49) Multiple Defects 95 (2.2) 4,690 (1.6) 1.24 (1.00 – 1.54) Multiple Defects 55 (3.0) 188 (2.5) 1.10 (0.73 – 1.64) Cardiovascular 78 (1.8) 3,472 (1.2) 1.36 (1.08 – 1.72) Cardiovascular 30 (1.6) 142 (1.9) 0.99 (0.60 – 1.64) Musculoskeletal 130 (3.0) 4,776 (1.6) 1.50 (1.24 – 1.80) Musculoskeletal 25 (1.4) 102 (1.3) 0.92 (0.54 – 1.57) Urogenital 95 (2.2) 4,872 (1.7) 1.25 (1.01 – 1.55) Urogenital 50 (2.7) 173 (2.3) 1.10 (0.74 – 1.65) Gastrointestinal 34 (0.8) 1832 (0.6) 1.18 (0.83 – 1.68) Gastrointestinal 23 (1.3) 88 (1.2) 1.13 (0.59 – 2.26) Central nervous system 22 (0.5) 1,104 (0.4) 1.34 (0.86 – 2.07) Central nervous system 10 (0.5) 42 (0.6) 1.08 (0.39 – 2.96) Cerebral Palsy 17 (0.4) 496 (0.2) 2.22 (1.35 – 3.63) Cerebral Palsy 16 (0.9) 50 (0.7) 1.39 (0.69 – 2.77) Adjusted for age, parity, fetal sex, year, race/ethnicity, country of birth, maternal conditions in pregnancy, Adjusted for age, parity, fetal sex, year, race/ethnicity, country of birth, maternal conditions in pregnancy, maternal smoking during pregnancy, socioeconomic status and maternal and paternal occupation maternal smoking during pregnancy, socioeconomic status and maternal and paternal occupation Davies et al. NEJM 366:1803-13, 2012 Davies et al. NEJM 366:1803-13, 2012 5

10/15/2015 ART & Perinatal Risk ANEUPLOIDY & MISCARRIAGE RISK Reddy et al. Infertility, assisted reproductive technology, and adverse pregnancy outcomes. Ob Gyn 2007. Miscarriage Risk Risk of Chromosomal Abnormalities Risk of Spontaneous Abortion According to Maternal Age at Conception Risk at Live Birth, According to Maternal Age Risk of Spontaneous Abortion (%) 80% Risk of Any Maternal Age at Risk of Down Chromosomal Delivery (years) Syndrome Abnormality 40% 20 1/1667 1/526 35 1/378 1/192 40 1/106 1/66 45 1/30 1/21 Maternal Age at Conception (Years) Hook EB, Cross PK, Schreinemachers DM. Chromosomal abnormality rates at amniocentesis and in live-born infants. Nybo Anderson AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: population JAMA 1983;249:2034-8 based register linkage study. BMJ 2000;320:1708–12 . 6

10/15/2015 ART Modifies Miscarriage Risk Donor Oocytes Further Modify SAB Risk ~ 65% ~ 30% ~ 50% cdc.gov Assisted Reproductive Technology (ART) National Summary Report 2010 cdc.gov Assisted Reproductive Technology (ART) National Summary Report 2010 Multiple Age UNDERLYING HEALTH Gestations PROBLEMS Infertility Infertility Assisted Medical Reproductive Co-Morbidities Technology 7

10/15/2015 Percent of US Women With Obesity Risk of Death Increases with Age (BMI > 30) 2007 35% Number of Deaths/100,000 US Females 2010 30% 400 25% 350 300 20% 250 15% 200 150 10% 100 5% 50 0% 0 25-29 30-34 35-39 40-44 45-49 50-54 18-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs Age - Years CDC, National Center for Health Statistics, National Vital Statistics System. http://www.cdc.gov/nchs/nvss.htm cdc.gov NHANES 2006-2007 Percent of US Females With Hypertension Diabetes & Prediabetes NHANES 1999-2008 Women ≥ 18, 2007-2010 aOR = 8.2 (5.0 – 13.3) 20% Total 10.6% 39.7% 18% 16% 14% aOR = 3.3 (2.1 – 5.2) 12% 18-44 Yrs 3.1% 39.7% 10% 8% 6% 4% 45-54 Yrs 11.1% 51.1% 2% 0% 20-34 35-39 40-44 0% 10% 20% 30% 40% 50% 60% Diabetes Prediabetes Adjusted for: race/ethnicity, diabetes, chronic kidney disease, alcohol use, OCP use, BMI Bateman et al. Hypertension in Women of Reproductive Age in the United States: NHANES 1999-2008. PLoS ONE 2012 cdc.gov NHANES 2007-2010 8

10/15/2015 Chance of Being Diagnosed with Breast or Colon Cancer in the Next 10 Years 2.50% Colon Cancer 2.00% Breast Cancer PERINATAL MORBIDITY 1.50% 1.00% 0.50% 0.00% 30-39 yrs 40-49 yrs 50-59 yrs http://www.cancer.org; http://www.cdc.gov/cancer/colorectal/statistics/age.htm 150 Multiple Age 100 Gestations Perinatal Infertility Infertility Risk 50 Assisted Medical 0 Reproductive Co-Morbidities 20 25 30 35 40 45 50 Technology Age (Years) 9