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EXPERT REVIEW
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 195-198

Clinical concern of the second pregnancy under the two-child policy


Center for Reproductive Medicine, Shandong University; National Research Center for Assisted Reproductive Technology and Reproductive Genetics; Key Laboratory of Reproductive Endocrinology, Ministry of Education, Shandong University; Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan 250001, Shandong, China

Date of Submission12-Nov-2019
Date of Web Publication2-Jan-2020

Correspondence Address:
Zi-Jiang Chen
Center for Reproductive Medicine, Shandong University, No. 157 Jingliu Road, Jinan 250001, Shandong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2096-2924.274552

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How to cite this article:
Chen ZJ. Clinical concern of the second pregnancy under the two-child policy. Reprod Dev Med 2019;3:195-8

How to cite this URL:
Chen ZJ. Clinical concern of the second pregnancy under the two-child policy. Reprod Dev Med [serial online] 2019 [cited 2020 Apr 1];3:195-8. Available from: http://www.repdevmed.org/text.asp?2019/3/4/195/274552





Zi-Jiang Chen is an Academician of Chinese Academy of Sciences. She is a professor of obstetrics and gynecology in Shandong University. She currently serves as the Dean of Cheeloo College of Medicine and the Vice President of Shandong University. She is the director of Center for Reproductive Medicine, Shandong University.

She serves as the Secretary General of International Federation of Fertility Societies, an Executive Member of Asia Pacific Initiative on Reproduction (ASPIRE, 2014–2016), a Board Member of Preimplantation Genetic Diagnosis International Society, and the Director of Gynecological Endocrinology Department of Obstetrics and Gynecology Society in Chinese Medical Association.

Prof. Chen has focused on reproductive endocrinology, reproductive genetics, and assisted reproductive technology (ART) for more than 30 years. She has made great achievements in ART clinics and academic research. She has published over 300 papers with more than 200 indexed by SCI, including N Engl J Med, Cell, Lancet, and Nat Genet and over 20 monographs/textbooks. Prof. Chen also serves as the Associate Editor of Human Reproduction Update, an international consultant of American Journal of Obstetrics and Gynecology, an editorial board member of Asia Journal of Andrology, and the deputy Editor-in-Chief of Chinese Journal of Obstetrics and Gynecology (Chinese).

The decree of two-child policy has brought more pressure and challenges for obstetrics and gynecology. Considering the declining fertility and the health of mothers of advanced age, clinicians need to communicate with them sufficiently, evaluate their individual fertility and physical status carefully, and implement effective assisted reproductive technologies. Moreover, it is necessary to establish a standardized protocol of prenatal care for women with scarred uterus due to cesarean section, and the health condition of the newborns should not be neglected. In conclusion, the clinical management of the second delivery will become a new focus, needing concern and specification.

With the implementation of the two-child policy in China, the medical field is facing many challenges. On the one hand, the capabilities of the obstetrics departments in the hospitals and the service capacities of maternity and child care institutions are limited. On the other hand, middle-aged women who were influenced by the previous family planning policy still desire to have a second child. Although they are benefiting from the two-child policy, still they are confronted with a series of clinical problems owing to their advanced ages, such as the increased risk of pregnancy complications, decreased fertility, increased birth defect rate, and special obstetric complications due to the so-called “postcesarean section era.”


  Management of Advanced-Age Pregnancy Top


Adverse effects of advanced age on fertility

Female fertility is closely related to age. It goes up to the peak and drops off as female ages.[1] According to a report, the infertility rates of women >34 and >39 years of age are approximately 11% and 33%, respectively, and women >45 years of age are no longer fertile basically.[2] One reason for this is the decrease in the number of ovarian follicles. In general, women have approximately 6–7 million follicles in the ovaries during the fetal period, which decrease to 1 million during the neonatal period and down to approximately 300,000 to 500,000 during puberty. Only 400–500 follicles can mature and ovulate during the reproductive period. Our previous study indicated that the ovarian reserve of Chinese women peaked at 18 years of age, and then gradually declined from 25 years of age, slumped at 43 years of age, and almost depleted at 50 years of age.[3] Another reason for reduced fertility is the impaired oocyte quality. Early in 1991, a study in The Lancet investigated 35 women aged 40 or older; two pregnancies (3.3%) were achieved in their self-oocyte in vitro fertilization (IVF) but without any live birth, while the pregnancy rate increased to 56% with 30% of live birth rate when using oocytes from young donors.[4] To further elucidate the association between age, oocyte quality, and fertility, the pregnancy outcomes between young donors and older recipients using oocyte from the same cohort were compared. The results indicated that there were no significant differences in the pregnancy rates and the live birth rates between young oocyte donors and older recipients, suggesting that the declined oocyte quality was an important factor affecting the fertility of advanced-age women.

Health status of advanced-age women

Many advanced-age women with secondary infertility possibly have histories of abortion, uterine cavity or pelvic surgery, or gynecological inflammation, etc. Some also suffer from obesity, diabetes mellitus, hyperlipidemia, hypertension, or other metabolic abnormalities. Gynecological endocrinology is closely related to metabolism, and metabolic abnormalities can cause many restrictions on routine ART and hormone administration.[5] Therefore, medical awareness of the histories should be collected in detail for advanced-age infertile women. Gestational histories are of special significance; histories of abortions and operations can benefit the primary evaluation of conditions of endometrium, inflammation, and gynecological diseases. For those with a history of cesarean section, information about the processes before and after the last surgery, time interval since the last operation, and healing condition of the uterine incision should be carefully investigated to evaluate the timing, delivery mode, and other cautions for the next pregnancy. The lower uterine segment and cervix should be carefully examined with transvaginal ultrasound. Preliminary diagnosis should be comprehensively considered, which will be of guiding significance for the therapy.

Evaluation of fertility in advanced-age women and effective reproductive assistance

Based on the traditional definition, infertility can be diagnosed as incapable of achieving pregnancy after 1-year regular sexual activity. To avoid overdiagnosis and overtreatment, the clinical guidelines for infertility point out that those patients who meet the definition of infertility are recommended for relevant examinations and treatments. Patients with suspicious symptoms or advanced ages can undergo examinations in advance, and the time period of trying to conceive for women of advanced age is shortened to 6 months. However, the above diagnostic criteria does not apply to all patients. For patients of extremely advanced ages, the ovarian reserve rapidly declines, and each ovulation may be the last one. Therefore, the original guidelines may not cover all situations due to the two-child policy. Time is precious for women of extremely advanced ages; therefore, early evaluation, accurate diagnosis, and timely and effective treatments are crucial.

Due to low ovarian reserve and poor ovarian response in elderly patients, the risk-to-benefit ratio should be fully considered during ovulation induction or controlled ovarian hyperstimulation in these patients. Reasonable treatment regimens should be selected based on the patients' conditions, such as natural cycle, mild stimulation, and luteal phase ovarian stimulation.[6] Hormone monitoring during medication and the timing of oocyte retrieval is also critical. In addition, the advantages of selective single blastocyst transfer should be fully considered. On the one hand, the blastocyst culture process has certain effect on screening and exclusion of the aneuploid embryos. On the other hand, it can reduce the multiple pregnancy rate, and thus lower the risk of complications during pregnancy and delivery caused by multiple pregnancies.

Strengthening the communication with advanced-age patients

Many studies indicated that advanced-age women had poor ovarian response, low pregnancy rate, high abortion rate, low live birth rate, and high birth defect rate.[7],[8] The European Society of Human Reproduction and Embryology reported the outcomes of IVF in >30 European countries between 2008 and 2010 and demonstrated that the clinical pregnancy rate and live birth rate were only 15% and 10%, respectively, in self-oocyte cycles among women >40 years of age. Those who were >45 years of age had much worse results; their clinical pregnancy rate, live birth rate, and abortion rate were 13.4%, 6.7%, and up to 75%, respectively.[9],[10],[11] Hence, should clinicians conduct ART for women of extremely advanced age and what is supposed to be the maximal age for IVF? Although there are some studies focusing on how to predict accurately the number of retrieved oocytes, oocyte quality, pregnancy rate, as well as live birth rate,[12],[13] there is still no convincing evidence to date. Based on the data from our center between 2013 and 2014,[14] the maximal age for possible live birth was 43 years of age. In advanced-age patients (≥40 years) with low anti-Müllerian hormone (AMH) (<0.48 ng/mL), the clinical pregnancy rate was 12%; the live birth rates of the first, second, third, and fourth oocyte retrieval cycles were 10.1%, 8.8%, 9.7%, and 0%, respectively, and the cumulative live birth rate was only 16.89%. Therefore, the feasibility of ART should be carefully considered for those aged >43 years and with AMH <0.48 ng/mL. Whether to continue IVF cycles for women older than 40 years old who failed in achieving live birth in more than three cycles should also be carefully considered.

Increased complications during pregnancy and delivery in advanced-age women

A recent cohort study in the United Kingdom suggested that the most common obstetric complications in women with advanced maternal age (≥48 years) including hypertensive disorders complicating pregnancy, gestational diabetes mellitus, postpartum hemorrhage, cesarean section, preterm birth, and the admission rate to an intensive care unit (ICU) were higher than those in younger women.[15] Advanced age is an independent risk factor for the increased incidence of gestational diabetes mellitus, cesarean section, and ICU admission rate. Compared with the low maternal age group, the risks of the above three diseases increased by 4.81, 2.78, and 33.53 folds, respectively, in advanced maternal age group. The increased rates of other complications were mainly attributed to the chain effects between advanced age, infertility, ART, and multiple pregnancies. Indeed, histories of previous diseases, uterine surgeries, and cesarean sections are etiological factors that cannot be ignored. Therefore, women of advanced age must undergo comprehensive evaluation and professional counseling before pregnancy.


  Re-Pregnancy Management in “the Postcesarean Section Era” Top


Due to the restriction of family planning policy in China, most women had only one child in the past. Because of the maturity of the clinician's skills of cesarean section, avoidance from pain during vaginal delivery, and some social factors, many pregnant women tend to choose cesarean section for delivery. According to a survey report published by the World Health Organization in 2010, the cesarean section rate in China reached 46.2% in 2007–2008 and exceeded 60% in some areas in China, one of the countries with the highest cesarean section rate in the world.[16] However, along with the two-child policy, the change of delivery mode due to the uterine scar after cesarean delivery and the increased rates of complications including cesarean scar pregnancy, placenta previa, placenta accreta, and placenta increta are becoming huge challenges for obstetricians.[17],[18] The choice of delivery mode is a controversial topic. The early viewpoint was that “cesarean section for once, cesarean section every time afterwards.” However, a recent study showed that in women with previous cesarean section, the incidence of complications was the lowest (2.4%) in those underwent vaginal delivery, followed by those received cesarean section (3.6%), and patients who switched to cesarean section after the failed trial of vaginal delivery had the highest rate of pregnancy complications.[19] The rates of complete and incomplete uterine ruptures were both 0.1% in women with vaginal delivery, 0% and 0.5% in women with re-cesarean section, and 2.3% and 2.1% in women with failed labor, respectively. Therefore, conditions that can benifit trial of labor after cesarean section are supposed to be assessed, including informed consent regarding the advantages and risks of vaginal delivery, no contraindication of vaginal delivery, past cesarean section for only once, transverse incision in the lower uterine segment, >2 years since the previous cesarean section, no indication of previous cesarean section, no history of uterine rupture, and emergency surgery available for delivery at hospital. Those with vaginal delivery, <40 years of age, low body mass index, full-term delivery history, and better cervical conditions are more likely to have a successful vaginal delivery.[20],[21]


  Management of Offspring Health of Elderly Women Top


Advanced age is an independent risk factor for adverse pregnancy outcomes. A large number of data have shown that the overall cancer incidence of ART offspring is similar to that of the general population; however, assisted pregnancy for couples of advanced ages may increase the risk of cancer among their offspring.[22] For scientists, birth defects in the offspring after ART have become a major concern.[23],[24],[25] With the increasing demands for ART in couples of advanced ages, the health of their offspring should not be neglected; otherwise, the population quality would be at stake. Birth defects affect not only the children's health and quality of life but also the quality of the whole country's population and the stock of healthy human resources, which will in turn influence the sound and sustainable development of economy and the society. Therefore, close attention should be paid to the health of the offspring of advanced-age couples.


  Conclusion Top


The two-child policy has shed new light to the clinical thinking in the field of obstetrics and gynecology while also brought about more requirements and challenges. The pre-pregnancy, pregnancy, intrapartum, and postpartum clinical management of the second pregnancy is becoming a new research topic, necessitating clinical attention and standardization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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