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Frozen embryo transfers in IVF linked to greater risk of maternal hypertension

Implications rise with increasing use of embryo freezing in assisted reproduction

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Concerns have been raised that pregnancies derived from frozen embryo transfers in IVF might increase the maternal risk of hypertensive disorders.

Pre-eclampsia is one such condition that causes high blood pressure during pregnancy and after labour and which may have severe consequences for both the mother and the foetus.

The concerns have been raised in recent observational studies comparing the outcomes of fresh and frozen transfers, which, by definition, are subject to statistically confounding variables. Sibling comparisons can remove much of this confounding.

The extensive study based on real-life registry data and a comparison of maternal complications in sibling pregnancies indicate that pregnancies following frozen embryo transfer (FET) do indeed have a substantially higher risk of hypertensive disorders than naturally conceived pregnancies.

This same raised risk was also found in a sub-group analysis of sibling births, which was designed to eliminate the effect of any parental factors in the results.

“Our findings are important because the number of FETs is rapidly increasing throughout the world,” says the study’s first author, Dr Sindre H. Petersen from the Norwegian University of Science and Technology.

He has presented the study results at the 38th annual meeting of ESHRE in Milan on behalf of the Committee of Nordic Assisted Reproductive Technology and Safety group which monitors the health of mothers and children born after assisted reproduction in the Nordic countries.

According to the latest registry report from ESHRE, the proportion of FET cycles relative to fresh is still on the rise in Europe. In 2017 the proportion was 49 per cent, against 38 per cent in 2014. Similar trends are present in the US and most high-income countries.

FETs are increasingly common because of improved cryopreservation methods, facilitation of single embryo transfer, reduction of ovarian hyperstimulation, and the elective freezing of all embryos.

The study analysed more than 4.5 million singleton pregnancies in the registries of three Nordic countries with delivery between 1988 and 2015. Of the conceptions following assisted reproduction, 78, 300 were after fresh embryo transfer and 18,037 were after FET.

The registry birth references – largely unique to the Nordic countries – also allowed the identification of 33,209 sibling deliveries following either fresh or frozen embryo transfer, and natural conception.

“This study was by far the largest sibling analysis to date investigating the association between assisted reproduction treatments and hypertensive disorders in pregnancy,” Dr Petersen adds.

Results of the study showed that the risk of hypertensive disorders in pregnancy were almost twice as high in the pregnancies following FET that in pregnancies following a natural conception. However, the risk of hypertensive disorders in pregnancies following fresh embryo transfer pregnancies was comparable to naturally conceived pregnancies.

Hypertensive disorders in pregnancy comprise gestational hypertension and pre-eclampsia, and the more rare but severe conditions of eclampsia and Hemolysis-Elevated-Liver-enzymes-Low-Platelets (HELLP) syndrome.

Adjustments for maternal body mass index, smoking and time between deliveries did not affect the end results, nor did other methods of assisted reproduction (IVF, ICSI, duration of embryo culture or number of embryos transferred).

Dr Petersen says that the design of the study was not able to assess the relative merits of embryo freezing against the higher risk of hypertensive disorders, but notes that “cryopreservation has facilitated the highly favourable single embryo transfer approach, improving foetal and maternal outcomes by avoiding multiple pregnancies”.

Recent studies have suggested that the risk of hypertensive disorders in FET pregnancies may be associated with therapies to prepare the uterus for embryo implantation. These are usually given in the form of hormone replacement therapy in what has become known as a ‘programmed’ or ‘artificial’ cycle – in which there is no naturally developing corpus luteum to provide hormonal support for the pregnancy.

The presence of a corpus luteum – a mass of cells that forms in an ovary responsible for the production of the hormone progesterone during early pregnancy – is one potentially important difference between natural conception and fresh embryo transfers, on the one hand and FETs, on the other, says Petersen.

He adds: “In our analysis all natural conceptions and fresh embryo transfer pregnancies had a corpus luteum, while a subset of the FET pregnancies did not.

“However, we expect from previous Danish and Swedish publications that in our study, only 15-30 per cent of FET pregnancies were in artificial cycles, which seems unlikely to drive the entirety of the strong association in our results.

“It thus seems possible that some inherent aspect of the freezing and thawing process, for example epigenetic changes, might be responsible as well.”

The doctor has pointed out that it is too early to recommend changes to treatment strategies based solely on this study, and that there are still good reasons why frozen embryo transfers are increasingly used, especially in their facilitation of single embryo transfer.

“I am confident that a well-grounded and individualised decision of whether to go for a fresh or a frozen cycle can be made after dialogue between the clinician and the couple,” he concludes.

“Our study can contribute to informed decision-making for patients and clinicians.”

Motherhood

Operate your breast pump from your phone – how cool!

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Mums can now have control of their breast pump from their smartphone.

The Ardo Alyssa breast pump can be operated using the specially designed MyArdo app.

So simple to use, mums can just download the MyArdo app on both Apple and Android phones, and pair with the Alyssa by scanning the QR code with your camera, quick and easy. Once it is set up they don’t have to do this again, saving precious time.

The app allows mums to control all functions of the breast pump remotely, giving them more flexibility when they express.

The Automatic Power Pumping is a unique feature on the Alyssa which helps to increase breast milk supply. Using the app, women can view the phase of the power pumping programme and see a live countdown of each phase.

The Memory Plus function means that mums can easily save a whole expressing session. By tapping the save button on the app, they can find the settings that suit them best.

They can also view a detailed history of the settings used, overwrite the old session with a new one and easily delete a session via the app.

Not only can they control the Alyssa breast pump, but they are also able to access lots of helpful information like how to increase what they express, breastmilk storage and the correct breast shell size, and change the language.

For more information, check out this video on YouTube.

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Motherhood

From OB/GYN to entrepreneur: the Kenyan doctor rethinking maternal health

Maternal and newborn deaths are still a major public health problem in Kenya

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Dr Lorraine Muluka, OB-GYN and founder of Malaica

Kenya has one of the highest maternal mortality rates in the world. In 2020, the maternal mortality ratio in the East African country was 530 deaths per 100,000 live births – much higher than the global average of 223 maternal deaths per 100,000 live births. The ratio of babies who die in the first month of life is also higher than the global average.

However, as Dr Lorraine Muluka, a Nairobi-based OB-GYN and founder of the health tech start-up Malaica, has found out, most of these deaths can be prevented if women have access to safe and affordable maternal health services.

Here, the consultant-turned-entrepreneur tells us why she thinks innovation will prove to be essential in bridging the health gaps in the Kenyan healthcare system.

Hi Lorraine, could you tell us a bit more about your background?

My name is Dr Lorraine Muluka and I am an OB-GYN. I am also the co-founder and CEO of Malaica, a health tech start-up that focuses on maternal health in Kenya. I hold a master’s degree in medicine in obstetrics and gynaecology from the University of Nairobi and have worked in various private and mission hospitals in Kenya’s maternal healthcare sector.

Over the past decade, I have been involved in several healthcare start-ups, driven by my passion for innovating and improving the Kenyan healthcare system. I have also been practising as a consultant obstetrician at my private practice in Nairobi. In 2021, I decided to fully commit to my vision of improving maternal health in Kenya by co-founding Malaica.

What inspired you to create Malaica?

The birth of Malaica was driven by a shared passion by the co-founders for safe motherhood and an aspiration to transform the narrative of maternal and neonatal mortality ratios in Sub-Saharan Africa.

Personally, as an OB-GYN several times it was very frustrating seeing mothers lose their lives to preventable causes. A need to fix the gaps and delays in maternal healthcare that lead to poor pregnancy outcomes is at the core of Malaica and the inspiration behind its creation.

The delays women experience begin with a woman’s decision to seek care, extend to her access to the appropriate healthcare facility and also the quality of care she receives once there. These gaps result from the various challenges women face which include limited access to quality care, lack of continuous support and high healthcare costs among others.

By recognising and addressing these gaps, Malaica aims to provide a holistic, affordable, and supportive environment for expectant mothers, ultimately improving maternal and neonatal health outcomes.

How would you describe Malaica in a few words?

Malaica provides a dedicated online support team for expectant mothers, making the journey of pregnancy happier, more affordable, and safer. With Malaica by their side, expectant mothers can rely on the invaluable companionship and guidance they need throughout their pregnancy.

What makes Malaica different?

Malaica offers a unique approach to pregnancy support that focuses on the holistic wellbeing of expectant mothers, including physical health, mental wellness, and delivery readiness. Our online platform offers personalised care for each woman at an affordable cost, with a personal nurse midwife assigned to provide support throughout pregnancy.

We provide access to obstetricians/gynaecologists, educational content, and a nurturing online community moderated by supamums for peer support. In Nairobi, we offer both virtual and in-person ANC clinics and birth preparation classes.

What sets us apart is our unwavering empathy, creating a warm and supportive environment for expectant mothers. Malaica adapts to evolving needs, making us the ideal choice for pregnancy support.

Women’s health comes with a lot of stigma. How has this impacted you as a founder?

In all my years of practising medicine, especially in obstetrics and gynaecology, I have noticed that there is a lot of stigma surrounding women’s health, especially during pregnancy. This stigma can take many forms, from societal taboos to misunderstandings about women’s health issues. Sometimes, it’s challenging to remove these barriers and create an open and supportive environment where soon-to-be mothers can access the care and assistance they need.

However, this awareness of the problem has become a powerful motivation for me. It has encouraged me to work even harder to break down these obstacles and create a safe space where women can receive the care and support, they require without being judged. It has reinforced Malaica’s commitment to empathy and understanding, ensuring that we remain a platform that is free from stigma, where mothers-to-be can access the care and guidance they need with dignity and respect.

What obstacles have you encountered on this journey?

As pioneers in the industry, we face a unique set of challenges as a remote company. One of our main challenges is proving to potential clients that our services are genuine and essential. We also strive to provide high-quality care while managing costs, which can be difficult for affordable programs like Malaica’s.

Providing physical services in remote or underserved areas poses a logistical challenge, especially considering the competitiveness of the healthcare and pregnancy support industry. Many other providers are offering similar services, so we must work hard to stand out.

As a tech company, we require ongoing technological investments and cybersecurity measures to maintain a reliable online platform for our subscription program and telehealth services.

Another challenge we face is health education. Educating expectant mothers about the importance of maternal health and the services available to them can be difficult, particularly in areas with limited health literacy.

Finally, ensuring the financial sustainability of the business, especially when offering affordable subscription programs, can be quite challenging. However, social enterprises like Malaica play a vital role in improving maternal health and supporting expectant mothers. Our dedication to our mission can lead to positive outcomes for both the business and the community it serves.

What lessons have you learned?

My journey as the founder of Malaica has taught me several vital lessons. I’ve come to understand that empathy is the cornerstone of effective support for mums-to-be. Recognising the diversity of experiences among our users and tailoring our services accordingly is crucial.

Building a strong community of support through supamums and support groups is powerful. The world of women’s health is ever-evolving, necessitating continuous adaptation and improvement.

Challenging the stigma surrounding women’s health is essential, and affordability should never be compromised. Collaboration with experts enhances the quality of care, and unwavering passion fuels dedication to our mission. These lessons guide our commitment to making pregnancy safe, convenient, and stigma-free for women worldwide.

Where are you with Malaica now?

Malaica has come a long way since its inception. We are now a reliable and easily accessible online platform for pregnancy support services, with a reach across the nation. Our commitment to providing comprehensive care, including access to nurse midwives, specialists like gynaecologists, paediatricians, psychologists, and support groups, has cemented our position as a go-to resource for expecting mothers. We strive to eliminate the stigma surrounding women’s health and continue to evolve and grow.

Malaica’s commitment to affordability and inclusivity ensures that we remain a beacon of support for women worldwide. Although our journey is ongoing, we are proud of the progress we have made.

Where do you see the company in the future?

We are committed to expanding Malaica’s reach and improving the pregnancy journey for expectant mothers in Kenya and beyond. Our ultimate goal is to ensure that even more mothers have access to better support and care throughout their pregnancy.

As a health tech company, we will continue to leverage advanced technology for telehealth services, making our services more accessible and convenient, especially for mothers in remote areas.

We also aim to foster connections among mothers and provide a strong network of emotional support through our expanding community of expectant mothers. Additionally, we are building partnerships with healthcare institutions, NGOs, and government bodies to strengthen our impact on maternal health and reach underserved populations.

Education and advocacy are major challenges in the pregnancy healthcare space, and we will continue to engage in initiatives that raise awareness about maternal health issues and promote healthy pregnancy practices.

Overall, we are optimistic about Malaica’s future as we adapt to the changing healthcare landscape and provide essential support to expectant mothers.

 

Dr Lorraine Muluka holds a master’s degree in medicine with a specialisation in obstetrics and gynaecology. Driven by a passion for improving the Kenyan healthcare system through innovation, Dr Muluka has played significant roles in several healthcare start-ups over the past decade, while also maintaining her role as a consultant obstetrician at her private practice in Nairobi. At the end of 2021, Muluka co-founded the health tech start-up Malaica. She is currently serving as the CEO of the company.

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NHS England to boost health support for new mums

New mums in England will benefit from personalised postnatal care to support their physical and mental health

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All new mums in England will receive better mental and physical check-ups from their GP in the weeks after giving birth, as part of a significant NHS guidance update. 


GPs will carry out the comprehensive postnatal check-up six to eight weeks after women give birth, covering a range of topics such as mental health, physical recovery and breastfeeding.

Around 600,000 women give birth in England every year and they are all entitled to a postnatal check-up after they give birth, in addition to the newborn check-up.

The new NHS guidance written in collaboration with the Royal College of GPs will ask family doctors to provide personalised postnatal care for their physical and mental health and support them with family planning.

One of the country’s most senior GPs said the guidance would boost postnatal care and encouraged women to attend the important check-up.

Dr Claire Fuller, NHS medical director for primary care and the NHS’ lead GP in England said:“More than 600,000 women give birth every year in England, and so it is vital that they can get the right NHS mental health and physical support at what can be a hugely pressured moment in their lives.

“GPs are perfectly placed to offer new mums a welfare checks six to eight weeks after giving birth – for not only their physical health but also their mental wellbeing and this new NHS guidance published today ensures that family doctors have the resources to provide this comprehensive support.

“If you are a new or expectant mum and struggling with your mental health, the NHS is here to help so please come forward through your GP practice or midwifery team”.

The routine check-up is hoped to be an opportunity for GPs to better assess and support women in their physical and mental recovery post-birth, making sure they can be referred, if necessary, to a specialist straight away.

Health and Social Care Secretary, Victoria Atkins, said: “Mothers should be supported after giving birth. This includes being able to get the mental and physical health support needed for a healthy recovery – while giving new-borns the best start in life. The postnatal check provides an important opportunity for GPs to listen to women in a discrete, supportive environment.

“This builds on part of a wider scheme of support – including making new maternal mental health services available across all areas of England by March 2024 and £25 million to expand women’s health hubs”.

Women’s Health Ambassador, Dame Lesley Regan, said: “Supporting GPs to advise on contraception after giving birth makes it more convenient and easier for women to make safe, effective choices about the many benefits of spacing their future pregnancies.

“This new advice for GPs around the long-term health implications of conditions that may first appear during pregnancy, such as gestational diabetes, hypertension, and depression, will mean women are offered guidance about conditions that may develop or become more severe later in life.

“This guidance will empower women to be able to make more informed decisions about their own health and their babies’ welfare.”

She added: “A major focus of our women’s health strategy is to make the healthcare system work better for women. Having access to a comprehensive post-natal check by a GP will mean women can get on with their day to day lives swiftly. I think this guidance is a great step in the right direction.”

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