Human Reproduction, Vol.25, No.5 pp.

1312– 1316, 2010

Advanced Access publication on February 23, 2010 doi:10.1093/humrep/deq023

ORIGINAL ARTICLE Reproductive epidemiology

IVF and stillbirth: a prospective

follow-up study
K. Wisborg 1,*, H.J. Ingerslev 2, and T.B. Henriksen 1
1
Department of Paediatrics, Perinatal Epidemiology Research Unit, Aarhus University Hospital, Brendstrugaardsvej 100, Skejby,
DK-8200 Aarhus, Denmark 2Fertility Clinic, Aarhus University Hospital, Skejby, Aarhus, Denmark

*Correspondence address. Tel: þ45-89496375; Fax: þ45-89496373; E-mail: kirstenwisborg@dadlnet.dk

Submitted on October 3, 2009; resubmitted on January 2, 2010; accepted on January 13, 2010

background: Previous studies have indicated that the risk of stillbirth is increased in singleton pregnancies achieved after assisted
reproduction technology (ART). However, no previous study fully accounted for factors with potential influence on the risk of stillbirth.
Further, whether fertility treatment, the possible reproductive pathology of the infertile couples or other characteristics related to being sub-
fertile may explain a possible association with stillbirth remains unclear. This study compares the risk of stillbirth in women pregnant after
fertility treatment (IVF/ICSI and non-IVF ART) and subfertile women with that in fertile women.
methods: We used prospectively collected data from the Aarhus Birth Cohort, Denmark and included information about 20 166
singleton pregnancies (1989– 2006). Outcome measure was stillbirth.
results: The risk of stillbirth in women who conceived after IVF/ICSI was 16.2 per thousand (‰) and in women who conceived after
non-IVF ART 2.3‰. In fertile and subfertile women, the risk of stillbirth was 3.7‰ and 5.4‰, respectively. Compared with fertile women,
women who conceived after IVF/ICSI had more than four times the risk of stillbirth [odds ratio (OR): 4.44, 95% confidence interval (CI):
2.38 –8.28], and adjustments for maternal age, BMI, education, smoking habits and alcohol and coffee intake during pregnancy had only minor
impact on the findings (OR: 4.08; 95% CI: 2.11 –7.93). The risk of stillbirth in women who conceived after non-IVF ART and in women who
conceived spontaneously with a waiting time to pregnancy of a year or more was not significantly different from the risk in women with a
shorter time to pregnancy.
conclusions: Compared with fertile women, women who conceived by IVF/ICSI had an increased risk of stillbirth that was not
explained by confounding. Our results indicate that the increased risk of stillbirth seen after fertility treatment is a result of the fertility treat-
ment or unknown factors pertaining to couples who undergo IVF/ICSI.
Key words: assisted reproduction / IVF/ICSI outcome / infertility / stillbirth / epidemiology

Introduction
Since the first child was born after fertility treatment 30 years ago, the
number of assisted pregnancies has increased steadily (Adamson et al.,
2006). In European countries, up to 4% of all deliveries now result
from fertility treatment (Andersen et al., 2007). Much interest has
been put into the efficacy of assisted reproduction technology
(ART) (Pandian et al., 2003), but more and more research now
focuses on the safety (Ludwig et al., 2006). Safety studies are impor-
tant not only to be able to provide the couple evidence-based infor-
mation but also to bring into focus potentially preventable adverse
outcomes.
Two register-based studies (Gissler et al., 1995; De Neubourg et al.,
2006) and several small case –control studies (Howe et al., 1990;
Tanbo et al., 1995; Verlaenen et al., 1995; Reubinoff et al., 1997;
Dhont et al., 1999; Nuojua-Huttunen et al., 1999; Westergaard
et al., 1999; Koudstaal et al., 2000a, b; Isaksson et al., 2002) have indi-
cated that the risk of perinatal mortality is increased in singleton preg-
nancies achieved after ART. However, many previous studies have not
had the statistical power to study mortality (Helmerhorst et al., 2004),
only a few studies have studied stillbirth (Reubinoff et al., 1997; Koud-
staal et al., 2000a, b; Kallen et al., 2005; De Neubourg et al., 2006) and
no previous study fully accounted for factors with potential influence
on the risk of stillbirth. Thus, whether fertility treatment including
hormone stimulation and mechanical procedures, the possible repro-
ductive pathology of the infertile couples or other characteristics
related to being subfertile may explain a possible association with still-
birth remains unclear.
The aim of this prospective cohort study was to compare the risk of
stillbirth in singleton pregnancies in women pregnant after IVF/ICSI
with the risk of stillbirth in women who conceived in less than 1
year. To explore the effect of fertility treatment versus the effect of

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IVF/ICSI and stillbirth
infertility, we also included information about women who conceived
after non-IVF ART and subfertile women with a time to pregnancy of
1 year or more.
Study population and methods
All women booking for delivery at the Department of Obstetrics and
Gynaecology, Aarhus University Hospital, Denmark, are asked to par-
ticipate in the Aarhus Birth Cohort. The Aarhus Birth Cohort is a
longitudinal cohort of unselected pregnant women that are consecu-
tively recruited in early pregnancy through the antenatal healthcare
services (Wisborg et al., 2003). Nearly all women in the area
comply with the antenatal care programme. Women who agree to
participate (75%), complete two questionnaires before the first
routine antenatal care visit at 16 weeks of gestation. The first ques-
tionnaire provides information for the hospital records and for study
purposes, the second questionnaire only for study purposes. Infor-
mation from these questionnaires is linked, using the women’s
unique personal identification number, to information about delivery
and the newborn. In the present study, we included information on
women booking for delivery from 1 August 1989 to 31 October
2006. The Danish Data Protection Agency, acting as the ethics com-
mittee for studies, granted authorization for the implementation of the
project.
The first questionnaire provided information on medical and obste-
tric history, including waiting time to pregnancy and fertility treatment,
maternal age, smoking habits before pregnancy and during the first tri-
mester and alcohol intake during pregnancy. The second questionnaire
provided information on intake of coffee, marital status, education and
any psychological problems. The women were asked whether the
pregnancy was planned, and if planned, about waiting time to preg-
nancy in years and months. We also asked the women to provide
information about consultations due to infertility and about infertility
treatment. Women who conceived after fertility treatment were cate-
gorized into two groups according to treatment (IVF/ICSI and non-IVF
ART). The non-IVF ART group included women who conceived after
hormone stimulation (n ¼ 352) and insemination (n ¼ 527). No differ-
ence in the risk estimate of the outcome of interest was found
between these two groups. Women who conceived spontaneously
were categorized into two groups according to waiting time to preg-
nancy, 0–11 months (fertile women) and 12þ months (subfertile
women). Women with unplanned pregnancies were categorized as
fertile.
Information about delivery was obtained from birth registration
forms filled in by the attending midwife immediately after delivery.
Before data entry, all birth registration forms were manually checked
and compared with the medical records by a research midwife. Gesta-
tional age, measured in completed weeks, was based on early fetal
ultrasound measures or detailed information on the woman’s last
menstrual period. Information about stillbirths was obtained from
the birth registration forms and validated with information from the
Danish Medical Birth Register through record linkage, using the
mother’s unique personal identification number. During the study
period, the National Board of Health changed the definition of still-
birth. Until April 2004, stillbirth was defined as delivery of a dead
child at 28 completed weeks of gestation or later, and after that
1313
time, as delivery of a dead child at 22 completed weeks of gestation
or later.
The study population was restricted to primiparous, Danish-
speaking women with a singleton pregnancy who filled in the first
questionnaire (n ¼ 27 072). Women with chronic illnesses (cardiovas-
cular, pulmonary or kidney diseases, diabetes or other metabolic dis-
eases, or epilepsy) (n ¼ 4268) and with missing information on waiting
time to pregnancy and infertility treatment (n ¼ 2638) were excluded
from the study.
Statistical analyses
The association between fertility treatment and stillbirth is presented
as odds ratio (OR) with 95% confidence interval (CI). Potential con-
founding factors were coded as in Table I and entered into the multi-
variate logistic regression analyses as a number of dummy variables
equal to the number of categories 2 1. Missing values were included
as a separate category for each variable. Interaction was tested by
Mantel –Haenszel analyses. Statistical significance was defined as a
two-sided P-value of ,0.05.
The study was approved by the Regional Ethics Committee, the
Danish National Board of Health and the Danish Data Protection
Agency.
Results
In this study of 20 166 primiparous, singleton pregnancies, 16 525
(82%) conceived spontaneously after less than 12 months, 2020
(10%) after more than 1 year of trying, 879 (4%) conceived after
non-IVF ART and 742 (4%) conceived after IVF/ICSI. The overall
risk of stillbirth was 4.3‰ (n ¼ 86).
Characteristics of fertile women, subfertile women and women
who conceived after fertility treatment are shown in Table I. Com-
pared with fertile women, women who conceived after IVF/ICSI
were older (P , 0.01), more often cohabiting (P , 0.01), had a
higher BMI (P ¼ 0.02), and fewer women who conceived after IVF/
ICSI drank alcohol during pregnancy (P ¼ 0.01). Women who
conceived after non-IVF ART were older (P , 0.01), had a
higher BMI (P , 0.01) and a higher intake of coffee during pregnancy
(P , 0.01). Compared with fertile women, subfertile women were
older (P , 0.01), more often cohabiting (P , 0.01), had a higher BMI
(P , 0.01) and a shorter education (P , 0.01). There were also more
smokers among subfertile women (P , 0.01) and they had a higher
intake of alcohol (P , 0.01) and coffee during pregnancy (P , 0.01).
The risk of stillbirth was 16.2‰ in women who conceived after IVF/
ICSI and 2.3‰ in women who conceived after non-IVF ART. In fertile
and subfertile women, the risk was 3.7‰ and 5.4‰, respectively
(Table II). After adjustment for maternal age, BMI, education,
smoking habits and alcohol and coffee intake during pregnancy, we
found a significantly increased risk of stillbirth in women who con-
ceived after IVF/ICSI compared with fertile women (OR: 4.08; 95%
CI: 2.11 –7.93). The risk of stillbirth in subfertile women and
women who conceived after non-IVF ART was not statistically signifi-
cantly different from the risk in fertile women. Compared with women
pregnant after IVF/ICSI, fertile women (OR: 0.25; 95% CI: 0.13 –
0.48), subfertile (OR: 0.33; 95% CI: 0.14 –0.76) and women pregnant
1314 Wisborg et al.

Table I Characteristics of primiparous fertile women, subfertile women and women who conceived after non-IVF ART
or IVF/ICSI with singleton pregnancies, Aarhus, Denmark, 1989–2006.

Fertile* (n 5 16 525) [n (%)] Subfertile** (n 5 2020) [n (%)] Non-IVF ART (n 5 879) [n (%)] IVF/ICSI (n 5 742) [n (%)]
.............................................................................................................................................................................................
Maternal age (years)
15–24 3020 (18) 252 (13) 37 (4) 5 (1)
25–34 12 678 (77) 1583 (78) 664 (76) 498 (67)
35þ 827 (5) 185 (9) 178 (20) 239 (32)
Marital status
Cohabiting 15 113 (92) 1850 (92) 816 (92) 713 (96)
Single 325 (2) 19 (1) 17 (2) 5 (1)
Missing 1087 (7) 151 (8) 46 (5) 24 (3)
Years of education
7– 10 1120 (7) 188 (9) 51 (6) 44 (6)
11þ 13 738 (83) 1571 (78) 736 (84) 646 (87)
Missing 1667 (10) 261 (13) 92 (11) 52 (7)
Cigarettes/day
0 13 762 (83) 1531 (76) 737 (84) 633 (85)
1– 9 1583 (10) 262 (13) 85 (10) 62 (8)
10þ 1128 (7) 220 (11) 54 (6) 44 (6)
Missing 52 (0.3) 7 (0.3) 3 (0.3) 3 (0.4)
Alcohol intake during pregnancy (drinks/week)
,1 12 883 (78) 1534 (76) 704 (80) 614 (83)
1– 2 2716 (16) 319 (16) 118 (13) 95 (13)
3þ 674 (4) 133 (7) 50 (6) 27 (4)
Missing 252 (1) 34 (2) 7 (1) 6 (1)
Coffee (cups/day)
0– 3 12 551 (76) 1365 (68) 624 (71) 585 (79)
4þ 2210 (13) 381 (19) 155 (18) 105 (14)
Missing 1764 (11) 274 (14) 100 (11) 52 (7)
Maternal BMI (kg/m2) before pregnancy
,20 3583 (22) 458 (23) 152 (17) 145 (20)
20–24 9949 (60) 1105 (55) 498 (57) 429 (58)
25–29 1975 (12) 296 (15) 143 (16) 108 (15)
30þ 688 (4) 122 (6) 66 (8) 44 (6)
Missing 330 (2) 39 (2) 20 (2) 16 (2)

*Fertile: waiting time to pregnancy ,12 months.

**Subfertile: waiting time to pregnancy 12þ months.

Table II Fertility and risk of stillbirth, Aarhus, Denmark, 1989 –2006.

Fertility Births Stillbirths (‰) Unadjusted OR (95% CI) Adjusted OR (95% CI)*
.............................................................................................................................................................................................
Fertile 16 525 61 (3.7) Reference Reference
Subfertile 2020 11 (5.4) 1.48 (0.78 –2.81) 1.33 (0.70–2.56)
Non-IVF ART 879 2 (2.3) 0.62 (0.15 –2.52) 0.53 (0.13–2.18)
IVF/ICSI 742 12 (16.2) 4.44 (2.38 –8.28) 4.08 (2.11–7.93)

‰, number of stillbirths per thousand; OR, odds ratio; CI, confidence interval.
*Adjusted for maternal age, education, marital status, BMI and intrauterine exposure to tobacco smoke, alcohol and coffee.
IVF/ICSI and stillbirth
after non-IVF ART (OR: 0.13; 95% CI: 0.03 –0.58) all had a statistically
significantly lower risk of stillbirth.
Mean gestational age at delivery was lower in stillborn infants of IVF
pregnant women (32 weeks) compared with stillborn infants of
women who conceived spontaneously (36 weeks) (P , 0.05).
During the study period, the number of assisted pregnancies
increased, and in May 2004, the National Board of Health changed
the definition of stillbirth. However, compared with fertile women,
we found an increased risk of stillbirth in IVF/ICSI conceptions both
before (OR: 4.03; 95% CI: 1.90– 8.56) and after (OR: 5.55; 95% CI:
1.77 –17.36) the change in stillbirth definition (test of homogeneity
between strata P ¼ 0.65).
Discussion
In this prospective cohort study, we found that compared with spon-
taneously conceived singleton pregnancies, singleton IVF/ICSI preg-
nancies had more than 4-fold increased risk of stillbirth. It has been
speculated that the increased risk of adverse outcomes in assisted
pregnancies is due to factors related to the underlying infertility of
the couples (Romundstad et al., 2008). However, we found that
couples with a waiting time to pregnancy of 1 year or more and
women who conceived after non-IVF ART had a risk of stillbirth
similar to that of fertile couples and statistically significantly lower
than women pregnant after IVF/ICSI, which may indicate that the
increased risk of stillbirth is not explained by infertility.
Confounding
In agreement with previous studies (Gissler et al., 1995), we found that
women with assisted pregnancies differed from other women in a
number of characteristics with potential influence on the outcome
of interest. To account for differences in parity and pre-existing
disease between women with assisted pregnancies and spontaneously
conceived pregnancies, we included only primiparous women with no
pre-pregnancy diseases. Furthermore, owing to careful prospective
collection of information about a number of factors, we could evaluate
variables with potential influence on our results (i.e. maternal age,
smoking and socioeconomic factors). None of these factors seemed
to explain our results, but residual confounding from crude categoriz-
ation of variables or confounding from unknown variables cannot be
ruled out. IVF and ICSI patients represent a group resistant to low-
technology infertility treatment and have a longer infertility period
and may accordingly be selected by unknown factors associated
with an increased risk of stillbirth.
Vanishing twins
Several previous studies have found that assisted conceptions are at
higher risk of adverse outcomes than are spontaneously conceived
pregnancies (Helmerhorst et al., 2004; Jackson et al., 2004).
However, much of the increased risk is explained by multiple pregnan-
cies in assisted conceptions, and from 1998 to 2005 the average
number of embryos transferred decreased from 2.0 to 1.75 in
Denmark. In our study, we included only singleton deliveries, but pre-
vious studies have shown that 10% of IVF singletons originate from
twin gestations because of the transfer of two or more embryos
(Pinborg et al., 2005). Compared with singleton conceptions, these
1315
pregnancies carry an increased risk of very preterm delivery and low
birthweight (Pinborg et al., 2007). The increased risk of stillbirth in sin-
gleton IVF/ICSI pregnancies that we found in our study may therefore,
to some extent, be explained by a higher number of twin gestations in
early pregnancy. However, the risk of stillbirth in non-IVF ART preg-
nancies was significantly lower than that in IVF/ICSI pregnancies and
comparable with the risk in fertile women. As for preterm delivery
(Schieve et al., 2002), the vanishing twins are probably not the sole
contributor to the increased risk of stillbirth in IVF singletons.
Preterm delivery
Compared with women who conceive spontaneously, women with
pregnancies after IVF/ICSI treatment have an increased risk of
preterm delivery which cannot be explained solely by a higher
number of twin pregnancies (Jackson et al., 2004; Halliday, 2007).
Preterm delivery is associated with a higher risk of morbidity and
mortality (Gardosi et al., 1998) and may be one of the reasons for
an increased risk of perinatal mortality in IVF pregnancies. It is also
possible that in women pregnant after fertility treatment, there is a
shared aetiology leading to either stillbirth or delivery of a live born
preterm infant. Compared with stillborn infants of women who con-
ceived spontaneously, we found that mean gestational age at stillbirth
was lower for infants of women pregnant after fertility treatment,
which might indicate different aetiologies of stillbirth. However,
despite the size of the study, we had limited possibilities to fully
explore the causes of death, and this needs further investigation in
even larger datasets.
During the study period, the National Board of Health changed the
definition of stillbirth. However, analysing data according to the two
periods defined by different definitions of stillbirth showed an
increased risk of stillbirth in IVF/ICSI conceptions both before and
after the change in stillbirth definition.
In conclusion, we found that compared with women who conceived
spontaneously and women who conceive after non-IVF ART, women
who conceived after IVF/ICSI had an increased risk of stillbirth that
was not explained by confounding from age, lifestyle habits or socio-
economic factors. Future studies should focus on further exploration
of this finding so that the information given to infertile couples
seeking treatment can be differentiated to the individual couples.
Authors’ roles
The authors qualify for authorship by having contributed substantially
to this work, as specified by criteria (a), (b) and (c) of the Uniform
Requirements for Manuscripts Submitted to Biomedical Journals, and
they are able to accept public responsibility for it. They have reviewed
the final version of the manuscript and approve it for publication.
Ethics
Ethical approval not required for this study. The Aarhus Birth Cohort
is approved by the Danish Data Protection Agency.
Funding
The study was supported with grants from the Dagmar Marshall’s
Fund.
1316
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