Analysis of 2,386 consecutive cycles of in vitro fertilization or intracytoplasmic sperm injection using autologous oocytes in women aged 40 years and above

Metabolic Profiles of Offspring Born From Biopsied Embryos from Toddlerhood to Preschool Age

CONTEXT

Embryo biopsy, which is necessary for preimplantation genetic testing (PGT), has not been fully investigated regarding its potential influences and safety. Previous studies of children born from biopsied embryos (PGT children) have primarily centered around their growth and neuropsychological development, while there remains limited knowledge concerning their endocrine and metabolic parameters.

OBJECTIVE

This study aims to examine the effect of trophectoderm (TE) biopsy on metabolic outcomes for PGT children.

METHODS

A total of 1267 children from the Center for Reproductive Medicine, Shandong University, who were conceived through in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) with and without PGT, were analyzed in this study. Three sets of measurements pertaining to growth and metabolism were taken at each predetermined follow-up time point. The linear regression models within a generalized estimating equation were employed to examine the associations between the PGT and each outcome measure and the approach of false discovery rate was used to correct for multiple comparisons.

RESULTS

After controlling for confounding factors and correcting for multiple comparisons, no statistically significant difference was identified in any of the measured variables between the PGT children and children conceived by IVF alone (IVF children) and children conceived through IVF using ICSI (ICSI children). The same is true also for age- or sex-based subgroup analyses.

CONCLUSION

Between the ages of 1 and 5 years, there are no clinically adverse metabolic outcomes observed in PGT children, and their metabolic profiles are essentially identical to those of IVF children and ICSI children.

Cumulative live birth rates with autologous oocytes plateau with fewer number of cycles for each year of age > 42

OBJECTIVE

To disaggregate the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) age category of " > 42" and compare age-stratified cumulative live birth rates (CLBR) > 42 years old.

DESIGN

Retrospective cohort study of autologous linked ART cycles.

SETTING

United States (US) National ART Database.

PATIENT(S)

Women > 42 years old without a history of prior ART cycles who underwent ART between 2014-2020 as reported to the SART CORS database.

INTERVENTION(S)

Disaggregate the SART CORS age category of " > 42" into age-stratified cumulative live birth rates (CLBR).

MAIN OUTCOME MEASURE(S)

Age-stratified cumulative live birth rates (CLBR) for women ≥ 43 years old.

RESULTS

Between 2014-2020, 24,650 women > 42 years old without history of prior ART underwent 58,132 cycles, resulting in 1,982 live births. Women ages 43, 44, 45, 46, 47, 48, 49, ≥ 50 achieved maximal CLBR of 9.7%, 8.6%, 5.0%, 3.6%, 2.5%, 1.5%, 2.7%, 1.3%, respectively. CLBR for women between 43-45 were significantly higher compared to those 46 and older (p < 0.05). Among women 46 and older, CLBR were not significantly different. Women ages 43 and 44 did not exhibit a significant increase in CLBR beyond the 5th cycle. Age 45 and 46 reached CLBR plateau by the 3rd cycle. Age ≥ 47 CLBR plateaued after the first cycle. After adjusting for age, race/ethnicity, BMI, nulliparity, etiology of infertility, number of oocytes retrieved, embryos transferred, blastocyst transfer, use of ICSI, PGT, and ART treatment cycle number, there was no association between markers of ovarian reserve (day 3 FSH and random AMH levels) and live birth for women > 42.

CONCLUSIONS

While CLBR of autologous cycles from women 42 or younger generally plateau by cycle number 5, age-stratified cycles from women > 42 plateau after fewer cycles to maximize CLBR. Patient and physician expectations for maximum CLBR beyond 42 may be practically based on fewer planned cycles before reaching an age-specific CLBR plateau than may have been previously expected.

Serum levels of anti-Müllerian hormone influence pregnancy outcomes associated with gonadotropin-releasing hormone antagonist treatment: a retrospective cohort study

As a specific predictor of ovarian reserve, serum anti-Müllerian hormone (AMH) has become an area of intense research interest in the field of assisted reproductive technology. We assessed the relationship between AMH levels and pregnancy outcomes in Chinese patients and investigate the influencing factors of cumulative live birth in patients with high AMH levels. A total of 1379 patients starting their IVF/ICSI cycle were divided into normal (Group A, 1.1-4.0 ng/ml, n = 639) and high (Group B, > 4.0 ng/ml, n = 740) groups by serum AMH levels. Live birth rate (LBR), cumulative live birth rate (CLBR) and cumulative clinical pregnancy rate (CCPR) were also investigated. Compared with Group A, Group B had a significantly higher CLBR (65.80% vs. 43.95%) and CCPR (76.77% vs. 57.14%), respectively. Binomial logistic regression analysis showed that age over 40 years, LH/FSH > 2.5, total Gn dose and Gn duration, and greater than 4000 ng/ml serum E2 levels on HCG day were significantly associated with CLBR in Group B. The AUC value of CLBR averaged 0.664 (ranging from 0.621 to 0.706) (p < 0.001). The patients with high AMH levels had higher CPR, higher LBR, and lower MR with no statistically significant differences, although there were significant improvements in CLBR. Advanced age (> 40 years) still impacted CLBR, even in women with good ovarian reserves. Consequently, it is still recommended that patients over 40 years old with high AMH levels actively receive IVF treatment if they seek to become pregnant. PCOS diagnoses did not influence the CLBR. In summary, this study showed that serum AMH levels could positively predict patient ovarian responses and further affect pregnancy outcomes.

A decision tree analysis applied to women aged 43-45: who should be referred for ovum donation?

RESEARCH QUESTION

In women at the advanced age of 43-45 years undergoing repeated IVF cycles with autologous oocytes, who has the highest chance for birth and who should be referred early to receive donor oocytes?

DESIGN

A retrospective cohort study was conducted at a university hospital reproductive centre. The computerized database of 394 women aged 43-45 years undergoing 1528 non-donor IVF or intracytoplasmic sperm injection cycles between 2010 and 2019 was analysed. A decision tree was developed, enabling a comprehensive study of a set of clinical parameters and the expected outcomes.

RESULTS

The cumulative clinical pregnancy rate was 15.0% (59/394) and the cumulative live birth rate was 8.4% (33/394). The decision tree developed to predict women who should be offered egg donation included age, poor ovarian response to stimulation, the number of top-quality embryos, dominant follicles, previous pregnancy or live birth, fertilized oocytes and body mass index. The model showed that a good ovarian response in the first cycle was the best predictor for live birth (13.3% gave birth). However, among women with poor responses, 7.1% of those who were younger than 43.5 years gave birth, and none of the women who were older than 43.5 years did.

CONCLUSIONS

Women over 43.5 years old with fewer than four oocytes collected in their first IVF cycle should be offered ovum donation, since their live birth rate in subsequent cycles is negligible.

The impact of religion and culture on medically assisted reproduction in the Middle East and Europe

Infertility is a medico-socio-cultural problem associated with gender-based suffering. Infertility treatment, including assisted reproductive technology (ART), is a human right. Culture and religion were among the stumbling blocks to early acceptance of ART, particularly in the Middle East and to a lesser extent in Europe. This was mostly due to the different cultural and religious perspectives on the moral status of the embryo in the two regions and the concerns about what could be done with human embryos in the laboratory. There is an increased demand for ART in both the Middle East and Europe, although the reasons for this increased demand are not always the same. Although Europe leads the world in ART, there is an unmet need for ART in many countries in the Middle East. Where ART is not supported by governments or insurance companies, a large percentage of couples paying for ART themselves will stop before they succeed in having a baby. There are similarities and differences in ART practices in the two regions. If a healthcare provider has a conscientious objection to a certain ART modality, he/she is ethically obliged to refer the patient to where they could have it done, provided it is legal.

Retrospective outcome in women aged 45 years and older undergoing natural cycle IVF treatment

RESEARCH QUESTION

Is natural cycle IVF treatment beneficial to middle-aged women with poor ovarian response?

DESIGN

Retrospective investigation of outcomes in women aged 45 years and older, who underwent natural cycle IVF treatment between 2009 and 2018 in a single assisted reproduction clinic with the aim of reporting several successful outcomes.

RESULTS

In total, 2408 IVF retrievals in women aged 45 years and older were included in this study. Mean serum FSH level on day 3 was 21.4 ± 12.5 (range: 0.3-93.7) IU/ml. One fresh cleavage-stage embryo was transferred in 37.4% (900/2408) of the initiated cycles. The overall clinical pregnancy rate and live birth rate per fresh embryo transfer were 2.8% (25/900) and 0.8% (7/900), respectively. Natural cycle IVF treatment led to seven successful deliveries during the period. All seven women who successfully delivered were poor ovarian responders who met the diagnostic Bologna criteria and, among them, three had elevated serum FSH levels on day 3 (range: 39.0-47.1 mIU/ml). All seven had full-term delivery, and no congenital abnormalities were observed in their infants. No significant difference was found in serum FSH level on day 3 between those with and without positive beta-HCG test results.

CONCLUSIONS

These findings suggest that natural cycle IVF treatment could be an option for older poor responders in countries that do not permit egg donation. Careful counselling is required, however, because of the low probability of live births after IVF in middle-aged women.

Premature ovarian insufficiency patients with viable embryos derived from autologous oocytes through repeated oocyte retrievals could obtain reasonable cumulative pregnancy outcomes following frozen-embryo transfer

Background

Women with premature ovarian insufficiency (POI) are often discouraged from using autologous oocytes; however, some patients have a strong desire to be genetically linked to their offspring. In the present study, we aimed to estimate cumulative pregnancy outcomes following frozen-embryo transfer (FET) in POI patients who could obtain viable embryos with their eggs during in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatments.

Methods

In this matched-retrospective cohort study, only patients undergoing IVF/ICSI treatments with a freeze-all strategy were screened, and 103 POI patients were matched with 515 normal controls in terms of the same number of viable embryos obtained at the same age. The primary outcome was the cumulative clinical pregnancy rate (CCPR) following FET per patient.

Results

Patients with POI and normal ovarian reserve had comparable CCPRs of 62.14% (64/103) and 65.24% (336/515), respectively (P=0.547), and no statistical difference was found in the cumulative live-birth rate (CLBR) between the study group (43.69%) and the control group (53.01%). Based on binary logistic regression, the CCPR and CLBR showed no association with the type of ovarian function (POI or normal ovarian reserve). The number of embryos per transfer and the sum of all viable embryos per patient were positively associated with the CCPR and CLBR. The clinical pregnancy rate (CPR) per FET cycle was 38.17% for the study group and 52.1% for the control group, while the CPRs per oocyte retrieval cycle in the 2 groups were 11.25% and 69.9%, respectively, and both were statistically different (P<0.05). Moreover, POI patients had a lower implantation rate (27.8% vs. 37.94%) and a higher early miscarriage rate per transfer (26.76% vs. 15%) than patients in the control group (P<0.05).

Conclusions

Cumulative pregnancy outcomes following FET were reasonable for POI patients using viable embryos derived from autologous oocytes through repeated oocyte retrievals.

IVF in women aged 43 years and older: a 20-year experience

RESEARCH QUESTION

What are the reproductive outcomes of women aged 43 years and older undergoing IVF and intracytoplasmic sperm injection (ICSI) treatment using their own eggs.

DESIGN

Retrospective study of 833 woman aged 43 years or older undergoing their first IVF and ICSI cycle using autologous oocytes at a tertiary referral hospital between January 1995 and December 2019. Live birth rate (LBR) after 24 weeks' gestation was the primary outcome.

RESULTS

Ninety-five out of 833 (11.4%) had a positive HCG, whereas 59 (62.1% per positive HCG) had a miscarriage before 12 weeks' gestation and 36 (4.3%) live births were achieved. Analysis by age showed that the number of cumulus-oocyte complexes retrieved was significantly different between the four age groups: 43 years (5 [3-9]); 44 years (5 [2-7]); 45 years (3 [2-8)]); ≥45 years (2.5 [2-6]); P < 0.01; the number of metaphase II oocytes, however, was similar. Positive HCG rates remained low: 43 years (78/580 [13.4%]); 44 years (14/192 [7.3%]); 45 years (1/39 [2.6%]; and ≥46 years (2/22 [9.1%]); P = 0.03, as did LBR: 43 years (28 [4.8%]); 44 (7 [3.6%]); 45 years (0 [0%]); and ≥46 years (1 [4.5%]); P = 0.5. Multivariate regression analysis revealed that only number of metaphase II was significantly associated with LBR, when age was considered as a continuous (OR 1.08, 96% CI 1.004 to 1.16) or categorical variable (OR 1.08, 95% CI 1.005 to 1.16).

CONCLUSION

The chances of achieving a live birth in patients aged 43 years and older undergoing IVF/ICSI with their own gametes are low, even in cases of patients with a relatively 'normal' ovarian reserve for their age.

Comparative Effectiveness of Mild or Conventional GnRH-Antagonist Protocols for Ovarian Stimulation in Poor Responders (Poseidon Group 4)

Background and Aims: A panel of experts (the Poseidon Group) introduced a new and more detailed stratification for poor ovarian responders in order to predict the prognosis of IVF outcome according to the sensitivity to FSH. However, various arguments about the management strategy of these patients still remain, including the convenience and the cost. Therefore, this study was conducted to compare the efficacy of mild and conventional GnRH antagonist ovarian stimulation prescribed in patients classified in Poseidon Group 4.

Methods: This retrospective cohort study included 359 poor responder patients (Poseidon Group 4) treated with mild or conventional GnRH antagonist stimulation regimens from 8/2017 to 7/2019 at Tam Anh Hospital ART Center. The main outcomes were the index of Follicular Output Rate (FORT) or Follicle to Oocyte Index (FOI), the number of day-2 embryos and top-quality embryos obtained. The t-test and Mann–Whitney U test in SPSS v25.0 was used to analyze the continuous data and Chi-squared/Exact test was used for binary variables. Multiple linear regression analysis was done by using Stata versions 15.0 to measure association between primary endpoints with stimulation regimen controlled for covariates and possible confounding factors.

Results: In the overall group of poor responders, the conventional GnRH antagonist protocol performed better than the mild protocol. Subsequently, data were analyzed according to the AFC. In women with AFC &lt; 3, no significant differences were observed between the 2 regimens regarding FORT (p = 0.71), FOI (p = 0.12), the number of day-2-embryos (p = 0.052) and the number of top-quality embryos (p = 0.26). In contrast, in women with AFC ≥ 3, mild stimulation regimen resulted in significantly poorer outcome compared to the conventional GnRH antagonist regimen, regarding FORT (p &lt; 0.01), FOI (p &lt; 0.01), the number of day-2-embryos (p &lt; 0.01) and top-quality embryos (p = 0.01).

Conclusions: Considering poor responders classified in Poseidon Group 4, both ovarian stimulation regimens resulted in similar outcome for patients with a very low ovarian reserve (AFC &lt; 3). In contrast, the GnRH conventional antagonist protocol with maximum initial FSH dose (300–375 IU/day) and supplementary LH (75–150 IU/day) was more effective than the mild one for patients whose ovarian reserve was less reduced. The Clinical Trial was approved by the Ethnical Biomedical Research Committee Tam Anh General Hospital.

Cumulative live-birth, perinatal and obstetric outcomes for POSEIDON groups after IVF/ICSI cycles: a single-center retrospective study

Recently, perinatal outcomes and cumulative live birth rate (CLBR) have widely been utilized to assess the fertility outcomes and safety of assisted reproductive technology (ART), but more robust research is needed to address the success rates of live-healthy births resulting from this procedure, particularly for patients with low prognosis. This study aims to assess and comparative perinatal outcomes and CLBR per cycle of in vitro fertilization/Intracytoplasmic sperm injection (IVF/ICSI) between four groups of low prognosis characterized by POSEIDON criteria. A retrospective assessment was done among infertile women with a low prognosis undergoing IVF/ICSI at a reproductive center in China. Data were collected between January 2011 and December 2015 with a follow-up of at least two years, and censoring was defined by three-cycle completion, discontinuation, or having a live birth. Participants were grouped into 4 groups according to the POSEIDON classification (POSEIDON1, POSEIDON2, POSEIDON3, and POSEIDON4). The main outcomes were perinatal and obstetric outcomes with CLBR per cycle after IVF/ICSI procedure. And IVF/ICSI-technique outcomes as a secondary outcome. Statistical analyses were performed by SPSS, and a p value of < 0.05 was considered significant. A total of 461 eligible participants underwent a total of 825 IVF/ICSI cycles. POSEIDON1 had the best perinatal outcomes in terms of live births (≥ 28w) (54.8%). POSEIDON4 had a higher risk for perinatal and obstetric complications with abortion rate (9.8%); LBW (11.7%), PTD (23.5%), PROM (11.7%), and gestational diabetes (17.6%). POSEIDON2 had a high rate for malpresentation (14.2%), and cesarean delivery(57.2%), while POSEIDON3 was much associated with the occurrences of placenta previa (9.3%) compared to other groups (p value = 0.001). After adjusting odds ratio by age and BMI, POSEIDON4 had the least odds for biochemical pregnancy (p value = 0.019); and the least odds for clinical pregnancy (p value = 0.001) of the four groups. CLBR per cycle was better in POSEIDON1 and increased with an increasing number of cycles in all groups during the three cycles. Conservative CLBR after three complete cycles were 77.27%, 42.52%, 51.4% and 22.34%, while optimistic CLBR were 79.01%, 51.19%, 58.59% and 34.46% in POSEIDON1 to POSEIDON4, respectively. Younger women with low prognosis and normal ovarian reserve have a higher probability for live births and better perinatal outcomes compared with older women with poor or normal ovarian reserve. Besides, young women with low prognosis, despite ovarian reserve status, can increase their probability of conception and get relatively higher CLBR by undergoing multiple cycles of IVF/ICSI. Age is therefore considered as a critical parameter in predicting the perinatal outcome and CLBR.

Association of serum anti-Müllerian hormone and other factors with cumulative live birth rate following IVF

RESEARCH QUESTION

What are the optimal values of maternal age and body mass index (BMI), paternal age and BMI, number of oocytes retrieved, and serum AMH concentrations for cumulative live birth rate (CLBR) in IVF and embryo transfer (IVF-ET)?

DESIGN

This retrospective cohort study included 9494 women who underwent their first IVF-ET cycle between January 2017 and July 2018. The primary outcome was the CLBR within one complete cycle. Cox regression analysis was used to test the hazard ratio, with 95% confidence intervals.

RESULTS

CLBR was significantly lower when maternal age was over 35 (adjusted P < 0.01 for age 36-38 years, adjusted P < 0.00001 for all age groups above 38 years). CBLR increased with increasing serum AMH concentrations and number of retrieved oocytes up to peak values at 5-7 ng/ml AMH and 16-20 oocytes in all women. CLBR was significantly increased when serum AMH concentrations were 3-7 ng/ml (adjusted P < 0.001) and number of oocytes retrieved was more than five (adjusted P < 0.00001). Overweight had a negative effect on CLBR compared with normal BMI in women under 35 years of age (adjusted P = 0.037). In women aged over 35 years, paternal overweight had a negative effect on CLBR compared with normal paternal BMI (adjusted P < 0.01).

CONCLUSIONS

Maternal age had an impact on optimal serum AMH concentrations and number of oocytes retrieved. Maternal overweight negatively affected CLBR in women under 35 years of age, and paternal overweight negatively affected CLBR in women over 35 years.

Predictive Factors for Live Birth in Autologous in Vitro Fertilization Cycles in Women Aged 40 Years and Older

Background

The aim of the study was to determine predictive factors for live birth after in vitro fertilization with autologous oocytes in women ≥40 years of age.

Methods

Authors conducted a retrospective analysis of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles performed at the Department of Reproductive Medicine and Gynecologic Endocrinology, University Medical Centre Maribor, Slovenia between January 2006 and December 2015 in women aged 40 or more. The characteristics of patients and cycles were compared regarding live birth as the final outcome.

Results

A total of 1920 IVF/ICSI cycles with egg retrieval in women ≥40 years of age were performed leading to 1591 embryo transfers. The live birth rate per embryo transfer was 17.3% at 40, 11.6% at 41, 8.2% at 42, 7.9% at 43, 1.9% at 44 and 0.0% at ≥45 years of age. The multivariate logistic regression model showed that besides women’s age (OR 0.66, 95% CI: 0.55–0.78), the number of previous cycles (OR 0.88, 95% CI: 0.82–0.95), number of good quality embryos on day 2 (OR 1.19, 95% CI: 1.05-1.36), number of embryos transferred (OR 1.57, 95% CI: 1.19–2.07) and day 5 embryo transfer (OR 2.21, 95% CI: 1.37–3.55) were also independent prognostic factors for live birth.

Conclusions

The chance of in vitro fertilization success in women ≥40 years of age should not be estimated only on the woman’s age, but also on other predictive factors: number of previous cycles, number of good quality embryos on day 2, number of transferred embryos and blastocyst embry transfer.

Cumulative live birth rates in more than 3,000 patients with poor ovarian response: a 15-year survey of final in vitro fertilization outcome

OBJECTIVE

To estimate the cumulative live birth rates (CLBRs) in women with poor ovarian response (POR) diagnosed according to the Bologna criteria.

DESIGN

A 15-year population-based observational cohort study.

SETTING

Teaching hospital.

PATIENT(S)

Between 2002 and 2016 a total of 3,391 women with POR were followed from their first fresh, nondonor IVF cycle until they had a live birth or discontinued treatment. All IVF and intracytoplasmic sperm injection (ICSI) cycles and cryocycles were included.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth rates per initiated cycle, the conservative and optimistic CLBR for multiple IVF cycles.

RESULT(S)

The CLBRs after six IVF cycles were 14.9% for the conservative and 35.3% for the optimistic estimate. The CLBR decreased from 22% for women ≤30 years to 18.3% for women aged 31-34 years, 17.2% for 35-37 years, 13.5% for 38-40 years, 10.5% for 41-43 years, and 4.4% among women >43 years in the conservative analysis. There was a significant decreased CLBR starting at age 38 years compared with women <35 years. After adjusting for age, antral follicle count, basal FSH level, and IVF cycle number, natural cycles were associated with the lowest CLBR among all the protocols, and this difference was significant compared with the other protocols.

CONCLUSION(S)

For women with POR, the CLBR declined with increasing age. Women with advanced age (≥38 years) achieved a significantly lower CLBR than young poor responders (<35 years). Very low CLBR was associated with women aged >43 years old. Natural cycle IVF is of no benefit for these patients.

Poor ovarian response as a predictor for live birth in older women undergoing IVF

Women of advanced age present a major challenge for fertility treatments. This study was designed to assess whether poor ovarian response (POR) according to the Bologna criteria is a significant predictor for live birth in women over 40. The outcomes of subsequent IVF cycles were also studied. The results of 1870 fresh IVF cycles in 1212 women were retrospectively analysed. The live birth per cycle was 3.3 times higher (11.61% versus 3.54%, P < 0.001) in good responders with more than three oocytes collected compared with women with less. Ovarian response defined by oocytes collected, but not by the number of follicles, was independently associated with live birth (odds ratio, 2.0; 95% confidence interval, 1.18 to 3.54; P = 0.009). The occurrence of POR in subsequent IVF cycles was only 55%. No differences in live births were found in persistent POR compared with women with at least one good response. A single episode of POR in a first IVF cycle in older women has a limited predictive value for the outcomes of subsequent cycles. POR in women aged 40-43 years, defined by the number of oocytes retrieved, is a predictor for live birth in IVF.

One thousand seventy-eight autologous IVF cycles in women 45 years and older: the largest single-center cohort to date

PURPOSE

The purpose of this study was to determine IVF outcomes in women 45 years and older using autologous oocytes.

METHODS

This is a retrospective cohort study reviewing all IVF cycles in women ≥ 45 years old from January 1995 to June 2015 that were conducted at one academic medical center. One thousand seventy-eight fresh, autologous IVF cycles met inclusion criteria. PGD/S, natural IVF, and donor egg cycles were excluded. Outcomes were analyzed for the different age groups (age 45, n = 773; age 46, n = 221; age 47, n = 57; age 48, n = 22; age 49, n = 5). Primary outcome measures included IVF cycle characteristics, total pregnancy loss, clinical pregnancy, and live birth rates, and were stratified according to patient age.

RESULTS

Mean age of patients in the study cohort was 45.4 ± 0.72. 11.7% of patients did not start due to an elevated FSH or cyst and 28.5% of patients were canceled prior to oocyte retrieval. The overall pregnancy rate per transfer was 18.7% (117/626), of which 82.1% ended in a pregnancy loss. The overall clinical pregnancy and live birth rates per transfer were 9.6 and 3.4%, respectively, which did not differ between age groups. Per cycle start women aged 45 had significantly higher positive pregnancy rates compared to women aged 46 and 47 (14.1 vs. 8.6 vs. 5.9%, p = 0.04). For women 45 years old, the live birth rate was 2.9% per cycle start and was 4.4% per embryo transfer. Of the 21 live births, 20 were in women aged 45 and one live birth was in a 46-year-old woman. There were no live births in any patient with ≤ 4 oocytes retrieved.

CONCLUSION

Autologous IVF in women aged 45 with acceptable ovarian reserve is not futile; however, it does carry very low prognosis. Patients aged 46 and older should be counseled appropriately that a live birth seems highly unlikely.

Predictors of live birth and pregnancy success after in vitro fertilization in infertile women aged 40 and over

Objective

The aim of this study was to evaluate pregnancy outcomes and the live birth rate at 1-year age increments in women aged ≥40 years undergoing fresh non-donor in vitro fertilization (IVF) and embryo transfer (ET), and to identify predictors of success in these patients.

Methods

This retrospective study was performed among women ≥40 years of age between 2004 and 2011. Of the 2,362 cycles that were conducted, ET was performed in 1,532 (73.1%).

Results

The clinical pregnancy rate and live birth rate in women ≥40 years significantly decreased with each year of increased age (p<0.001). Maternal age (odds ratio [OR], 0.644; 95% confidence interval [CI], 0.540–0.769; p<0.001), basal follicle-stimulating hormone (FSH) levels (OR, 0.950; 95% CI, 0.903–0.999; p=0.047), the number of high-quality embryos (OR, 1.258; 95% CI, 1.005 –1.575; p=0.045), and the number of transferred embryos (OR, 1.291; 95% CI, 1.064 –1.566; p=0.009) were significant predictors of live birth. A statistically significant increase in live birth rates was seen when ≥3 embryos were transferred in patients 40 to 41 years of age, whereas poor pregnancy outcomes were seen in patients ≥43 years of age, regardless of the number of transferred embryos. Moreover, the cumulative live birth rate increased in patients 40 to 42 years of age with repeated IVF cycles, but the follicle-stimulating hormone in those ≥43 years of age rarely showed an increase.

Conclusion

IVF-ET has acceptable outcomes in those <43 years of age when a patient's own oocytes are used. Maternal age, basal FSH levels, and the number of high-quality embryos and transferred embryos are useful predictors of live birth.

No. 346-Advanced Reproductive Age and Fertility

OBJECTIVE

To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART), provide recommendations for their management, and to review investigations in the assessment of ovarian aging.

OPTIONS

This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility.

OUTCOMES

The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.

EVIDENCE

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words ("ovarian aging," "ovarian reserve," "advanced maternal age," "advanced paternal age," and "assisted reproductive technology"). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

BENEFITS, HARMS, AND COSTS

Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for ART.

RECOMMENDATIONS

N o 346-Âge génésique avancé et fertilité

OBJECTIFS

Sensibiliser la population à la baisse naturelle de la fertilité avec l'âge, chez les femmes et les hommes, et à l'égard de la reproduction naturelle et des technologies de procréation assistée (TPA); formuler des recommandations de prise en charge; et analyser les méthodes d'évaluation du vieillissement ovarien.

OPTIONS

La présente directive clinique passe en revue les options offertes pour l'évaluation de la réserve ovarienne et pour le traitement de l'infertilité faisant appel aux TPA chez les femmes d'âge génésique avancé infertiles.

ISSUES

Les issues mesurées sont les valeurs prédictives de l'évaluation de la réserve ovarienne et les taux de grossesse découlant de la fertilité naturelle et de la fertilité assistée. DONNéES: Nous avons examiné des études publiées récupérées au moyen de recherches dans PubMed, Medline, CINAHL et la Bibliothèque Cochrane en juin 2010 à l'aide de mots-clés appropriés (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, et assisted reproductive technology). Nous n'avons tenu compte que des résultats provenant de revues systématiques, d'essais cliniques, randomisés ou non, et d'études observationnelles. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en décembre 2010.

VALEURS

La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations quant à la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: Les patientes et les fournisseurs de soins primaires et spécialisés seront mieux renseignés sur le vieillissement ovarien, la baisse de la fertilité naturelle liée à l'âge et les TPA.

RECOMMENDATIONS

National trends and outcomes of autologous in vitro fertilization cycles among women ages 40 years and older

PURPOSE

The purpose of the study was to describe trends in and investigate variables associated with clinical pregnancy and live birth in autologous in vitro fertilization (IVF) cycles among women ≥40 years.

METHODS

We used autologous IVF cycle data from the National ART Surveillance System (NASS) for women ≥40 years at cycle start. We assessed trends in fresh and frozen cycles (n = 371,536) from 1996 to 2013. We reported perinatal outcomes and determined variables associated with clinical pregnancy and live birth in fresh cycles between 2007 and 2013.

RESULTS

From 1996 to 2013, the total number of cycles in women ≥40 years increased from 8672 to 28,883 (p < 0.0001), with frozen cycles almost tripling in the last 8 years. Cycles in women ≥40 years accounted for 16.0% of all cycles in 1996 and 21.0% in 2013 (p < 0.0001). For fresh cycles from 2007 to 2013 (n = 157,890), the cancelation rate was 17.1%. Among cycles resulting in transfer (n = 112,414), the live birth rate was 16.1%. The following were associated with higher live birth rates: multiparity, fewer prior ART cycles, use of standard agonist or antagonist stimulation, lower gonadotropin dose, ovarian hyperstimulation syndrome, more oocytes retrieved, use of pre-implantation genetic screening/diagnosis, transferring more and/or blastocyst stage embryos, and cryopreserving more supernumerary embryos. Of the singleton infants born (n = 14,992), 86.9% were full term and 88.3% normal birth weight.

CONCLUSIONS

The NASS allows for a comprehensive description of IVF cycles in women ≥40 years in the USA. Although live birth rate is less than 20%, identifying factors associated with IVF success can facilitate treatment option counseling.

A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF: a multicenter randomized non-inferiority trial

STUDY QUESTION

In subfertile women with poor ovarian reserve undergoing IVF does a mild ovarian stimulation strategy lead to comparable ongoing pregnancy rates in comparison to a conventional ovarian stimulation strategy?

SUMMARY ANSWER

A mild ovarian stimulation strategy in women with poor ovarian reserve undergoing IVF leads to similar ongoing pregnancy rates as a conventional ovarian stimulation strategy.

WHAT IS KNOWN ALREADY

Women diagnosed with poor ovarian reserve are treated with a conventional ovarian stimulation strategy consisting of high-dose gonadotropins and pituitary downregulation with a long mid-luteal start GnRH-agonist protocol. Previous studies comparing a conventional strategy with a mild ovarian stimulation strategy consisting of low-dose gonadotropins and pituitary downregulation with a GnRH-antagonist have been under powered and their effectiveness is inconclusive.

STUDY DESIGN, SIZE, DURATION

This open label multicenter randomized trial was designed to compare one cycle of a mild ovarian stimulation strategy consisting of low-dose gonadotropins (150 IU FSH) and pituitary downregulation with a GnRH-antagonist to one cycle of a conventional ovarian stimulation strategy consisting of high-dose gonadotropins (450 IU HMG) and pituitary downregulation with a long mid-luteal GnRH-agonist in women of advanced maternal age and/or women with poor ovarian reserve undergoing IVF between May 2011 and April 2014.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Couples seeking infertility treatment were eligible if they fulfilled the following inclusion criteria: female age ≥35 years, a raised basal FSH level >10 IU/ml irrespective of age, a low antral follicular count of ≤5 follicles or poor ovarian response or cycle cancellation during a previous IVF cycle irrespective of age. The primary outcome was ongoing pregnancy rate per woman randomized. Analyses were on an intention-to-treat basis. We randomly assigned 195 women to the mild ovarian stimulation strategy and 199 women to the conventional ovarian stimulation strategy.

MAIN RESULTS AND THE ROLE OF CHANCE

Ongoing pregnancy rate was 12.8% (25/195) for mild ovarian stimulation versus 13.6% (27/199) for conventional ovarian stimulation leading to a risk ratio of 0.95 (95% CI: 0.57-1.57), representing an absolute difference of -0.7% (95% CI: -7.4 to 5.9). This 95% CI does not extend below the predefined threshold of 10% for inferiority. The duration of ovarian stimulation was significantly lower in the mild ovarian stimulation strategy than in the conventional ovarian stimulation strategy (mean difference -1.2 days, 95% CI: -1.88 to -0.62). Also, a significantly lower amount of gonadotropins was used in the mild simulation strategy, with a mean difference of 3135 IU (95% CI: -3331 to -2940).

LIMITATIONS, REASONS FOR CAUTION

A limitation of our study was the lack of data concerning the cryopreservation of surplus embryos, so we are not informed on cumulative pregnancy rates. Another limitation is that we were not able to follow up on the ongoing pregnancies in all centers, so we are not informed on live birth rates.

WIDER IMPLICATIONS OF THE FINDINGS

The results are directly applicable in daily clinical practice and may lead to considerable cost savings as high dosages of gonadotropins are not necessary in women with poor ovarian reserve undergoing IVF. A health economic analysis of our data planned to test the hypothesis that mild ovarian stimulation strategy is more cost-effective than the conventional ovarian stimulation strategy is underway.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by NUFFIC scholarship (the Netherlands) and STDF short-term fellowship (Egypt).

TRIAL REGISTRATION NUMBER

NTR2788 (Trialregister.nl).

TRIAL REGISTER DATE

01 March 2011.

DATE OF FIRST PATIENT'S ENROLMENT

May 2011.

Pregnancy outcomes and maternal and perinatal complications of pregnancies following in vitro fertilization/intracytoplasmic sperm injection using own oocytes, donor oocytes, and vitrified embryos: A prospective follow-up study

BACKGROUND

Several global studies have assessed maternal and perinatal outcomes and complications with the type of embryo transfer (ET) following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The present study assessed the incidence of maternal and perinatal outcomes and complications following IVF/ICSI associated with the type of embryo transferred.

METHODOLOGY

A total of 2112 ETs were performed in 2092 female patients aged 21-50 years between January 1 and December 31, 2014 (Group A: Fresh ET using self-oocytes: 691; Group B: Fresh ET using donor oocytes: 810; and Group C: Thaw ET using vitrified-warmed embryos: 611).

RESULTS

Incidence of clinical pregnancy rate, abortion rate, ectopic pregnancy rate, multiple pregnancy rate, live birth rate, and maternal complications was: Group A: 40.8%, 15.9%, 2.8%, 27.3%, 31.9%, and 17.7%; Group B: 50.2%, 21.8%, 1.6%, 32.5%, 36.9%, and 23.7%; and Group C: 42.9%, 25.2%, 1.1%, 31.3%, 29.6%, and 17.8%, respectively. Incidence of prematurity (<36 weeks of pregnancy), lower birth weight (<2500 g), perinatal mortality, and congenital abnormalities was as follows: Group A (29.52%, 36.2%, 5.22%, and 1.39%), Group B (42.58%, 46.2%, 4.6%, and 1.32%), and Group C (35.74%, 32.4%, 7.85%, and 0.94%), respectively.

CONCLUSION

The higher incidence of the pregnancy outcomes in oocyte donation (OD) cycles can mainly be attributed to the younger age of oocyte donors. The higher incidence of complications in OD cycles could be due to advanced maternal age, different placentation, and immune tolerance.

[Infertility over forty: Pros and cons of IVF]

The population attempting pregnancy and having babies is ageing. The declining fertility potential and the late age of motherhood are increasing significantly the number of patients over forty consulting infertility specialists. Assisted reproductive technologies (ART) cannot compensate the natural decline in fertility with age. In France, in public hospital, ART is free of charge for women until 43 years, over 43, social insurance does not reimburse ART. Hence, 43 years is the usual limit, but between 40 and 42 is ART useful? The answer varies according to physicians, couples or society. On medical level, the etiology of the infertility must be taken into account. If there is an explanation to infertility (male or tubal infertility) ART is better than abstention. If the infertility is only due to age the question is raised. In France, the reimbursement by the society of a technique with very low results is discussed. However efficacy is not absolutely compulsory in Medicine. On the opposite to give false hopes may be discussed too. To obtain a reasonable consensus is rather difficult.

Corifollitropin alfa followed by hpHMG in GnRH agonist protocols. Two prospective feasibility studies in poor ovarian responders

In two prospective uncontrolled feasibility trials, we examined the effect of corifollitropin alfa (CFA) followed by highly purified human menopausal gonadotrophin (hpHMG) in a short flare-up gonadotropin-releasing hormone (GnRH) agonist and a long GnRH agonist protocol for women with poor ovarian response. Overall, 45 patients were treated with short flare-up and 47 patients with the long agonist protocol. All patients received a single dose of 150 μg CFA, followed by 300 IU hpHMG 7 days later, triggering with 10 000 IU hCG, CSI and day 3 embryo transfer. Ongoing pregnancy rates (OPRs) did not differ between the short 15.6% and the long 17% agonist protocol (p = 0.85). Among patients treated with the short flare-up protocol, OPRs were 20% for younger patients (<40 years old) and 12% in older women (≥40 years old), p = 0.68. Similarly, in patients treated with the long agonist protocol younger women had an OPR of 26.7% versus 12.5% in older women, p = 0.23. Among patients treated with the short flare-up, live births rate were 15% and 4.3% for younger (<40 years old) and older patients (≥40 years old), respectively, p = 0.32. Similarly, in patients treated with the long agonist protocol, live births rate were 25% and 12.9% for younger (<40 years old) and older patients (≥40 years old), respectively, p = 0.41. None of the patients reported any serious adverse event related to treatment. According to our results, CFA followed by hpHMG in a short flare-up or long GnRH agonist protocol appears to be a feasible option for poor ovarian responders. Large phase III trials are mandatory prior to introduction in clinical practice.

Neonatal risks from in vitro fertilization and delayed motherhood

Delayed childbearing (DC) is common in most Western countries. The average age of first-time mothers increased in United States from 21.4 years in 1970 to 25.0 years in 2006 and from 25.4 to 30.8 years in Australia in the same period. It is commonly believed that this has no ominous consequences. But several negative consequences of this behavior are described: stillbirth, prematurity, twins, birth anomalies. Age also decreases women’s fertility, thus many couples undergo in vitro fertilization. And we highlight a paradox: medical reproduction techniques decreases their effectiveness with maternal age, but their availability can be an incentive to postpone parenthood. Of course the risks of delayed parenthood involve a minority of cases, but are parents entitled to accept any risk on the behalf of their baby A complete information would make people cautious before deciding to postpone childbearing, though this is often an obliged rather that a free choice: the consumerist society pressure and the difficulty to find an employment have their heavy weight in this choice. But if this choice is not really free, people’s interest is to overcome these pressures and to claim for a real broad choice on when becoming parent, despite the pressures made by their cultural environment to postpone parenthood. Moreover, even reproductive techniques have some risks. Unfortunately, mass media often praise and endorse DC, disregarding the increase of premature babies born because of DC, a real alarm for public health. Pediatricians should discourage the culture that makes DC a normal event.

[Prognosis criteria for the management of the infertile couple]

Advanced maternal age, obesity and cigarette smoking are associated with decreased fertility, adverse Assisted Reproductive Technologies (ART) outcomes and fetal and neonatal complications. IVF failures increase dramatically in women aged between 42-43 years. Advanced paternal age is associated with fetal and neonatal adverse outcomes. However, it remains uncertain that advanced paternal age could impair IVF results. Obesity (Body mass index more than 30 kg/m(2)) is associated with lower fecundity, pregnancy complications and adverse ART results. The rate of complications is increasing with higher BMI. Cigarette smoking is associated with longer time to conceive and decreased IVF results. In case of infertility associated with obesity or cigarette smoking, physicians have to inform their patient about the benefits of smoking cessation and weight loss. However, maternal age had to be considered as the main prognosis factor before delaying ART because of dietary or smoking cessation program.