Donor insemination and oocyte donation

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Analogous to short periods of sperm exposure, artificial donor insemination has been reported by several investigators to result in a substantial increase in the incidence of pre-eclampsia (Schenker and Ezra, 1994). Concerning artificial donor insemination, the first major study was reported by Need et al. in 1983. They reported on 584 pregnancies following artificial donor insemination (ADI) in programs throughout Australia. The overall incidence of pre-eclampsia (proteinuric pregnancy-induced hypertension) was high (9.3%) compared with the expected incidence of 0.5—5%. The incidence was increased in both multigravid and primigravid women. The expected pre-eclampsia incidence in Australian primigravid women was 5%, while it was 10.1% in primigravid women pregnant after ADI. This increase in the incidence of pre-eclampsia in primigravid women after ADI supports the findings of Robillard et al. (1994), who demonstrated the protective effects of a prolonged period of sperm exposure. The expected pre-eclampsia incidence was 0.9% in multigravid patients, while it was 7.8% in the multigravid ADI patients. Thus, the expected protective effect of a previous pregnancy was not seen, and in fact there was a 47-fold increase in pre-eclampsia (observed versus expected) in ADI pregnancies after a previous full-term pregnancy, and a 15-fold increase after a pregnancy of shorter duration. The data from the multigravid patients who had ADI also tend to support the concept of primipaternity described by several independent groups of investigators (Feeney, 1980; Feeney and Scott 1980; Ikedife, 1980; Robillard et al., 1993; Trupin et al., 1996; Tubbergen et al., 1999). Grefenstette et al. (1990) described the outcome of 487 pregnancies conceived after ADI with frozen semen, and found a significantly increased incidence of pregnancy-induced hypertension when compared both with their control group, and with control group from the national study conducted by INSERM in France in 1981.

The first report concerning the effect of oocyte donation on the incidence of pregnancy-induced hypertensive disorders was by Serhal and Craft (1987). They reported that 5 of their first 10 pregnant patients with oocyte donation, all of whom were normotensive prior to pregnancy, developed proteinuric hypertension. Two years later, they published a series of 61 pregnancies following oocyte donation; the incidence of preeclampsia was 38% (Serhal and Craft, 1989). A similar incidence (32%) has been reported by Pados et al. (1994), and by Soderstrom-Anttila and Hovatta (1995) (41%). However, the impact of oocyte donation/ADI on the incidence of pre-eclampsia has not been consistently reported by others. Perkins (1993) followed a small series of 44 AID initiated pregnancies. The incidence of hypertensive complications in this group, 36 of whom were nulliparous, did not differ from the rate for all pregnancies at their institution. Friedman et al. (1996) compared perinatal outcomes in a small series of 22 consecutive ovum donor pregnancies. They were matched for age, parity and order of gestation with a control group of 22 women who underwent standard IVF embryo transfer during the same period. Both groups showed a similar rate of hypertensive disorders. Antinori et al. (1995) reporting on 44 pregnancies achieved after oocyte donation, found an incidence of pregnancy-induced hypertensive disorders of 13%, which is increased only modestly as compared to that in the literature, especially considering the relatively higher age of the women in this study. Hendler et al. (1997) compared pregnancy outcomes in 35 singleton pregnancies of at least 24 weeks duration conceived following oocyte donation at one reproductive center, with 95 singleton pregnancies conceived after IVF in women of similar maternal age who delivered during the same period (1988—1996). The incidence of pregnancy-induced hypertensive disorders was 25.7% in the oocyte donation group, versus 4.2% in the control group (P < 0.01). The comparable maternal age in the oocyte-donation women as compared to the regular IVF patients is an important feature of this study. This is because most studies reporting a high incidence of hypertensive complications in pregnancies following oocyte donation are confounded by the increased age of the patients, which in and of itself is associated with an increased risk of developing hypertension (Michalas et al., 1996). Salha et al. (1999) compared the effects of different types of donated gametes. In this retrospective cohort study, a total of 144 women were studied. Of these, 72 were infertility patients who had conceived as a result of sperm, ovum or embryo donation. The other 72 women were age- and parity-matched control patients who became pregnant with their own gametes, either spontaneously or following intrauterine insemination with their partner's spermatozoa. Study patients were divided into three groups depending on the origin of the donated gametes. Group 1 consisted of pregnancies achieved by intrauterine insemination with washed donor spermatozoa (n = 33). Group 2 comprised women who conceived using donated oocytes (n = 27), and group 3 consisted of women who conceived as a result of embryo donation (n = 12). The incidence of pregnancy-induced hypertension in the donated gametes study group was 12.5% (9/72) compared with 2.8% (2/72) in the control group. In addition, pre-eclampsia was diagnosed in 18.1% (13/72) of the donated gametes study group compared to 1.4% (1/72) in the age- and parity-matched controls.

In summary, in line with the immune maladaptation hypothesis, pregnancies conceived with donated gametes, and more specifically donor embryo pregnancies, are clearly at an increased risk of pre-eclampsia. With the likelihood of increased use of these reproductive techniques in the foreseeable future, clinical obstetricians need to adapt their antenatal care for these higher-risk pregnancies.

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