Results of in vitro fertilization attempts in women 40 years of age and older: the Norfolk experience

Positive and negative effects of cellular senescence during female reproductive aging and pregnancy

Cellular senescence is a phenomenon occurring when cells are no longer able to divide even after treatment with growth stimuli. Because senescent cells are typically associated with aging and age-related diseases, cellular senescence is hypothesized to contribute to the age-related decline in reproductive function. However, some data suggest that senescent cells may also be important for normal physiological functions during pregnancy. Herein, we review the positive and negative effects of cellular senescence on female reproductive aging and pregnancy. We discuss how senescent cells accelerate female reproductive aging by promoting the decline in the number of ovarian follicles and increasing complications during pregnancy. We also describe how cellular senescence plays an important role in placental and fetal development as a beneficial process, ensuring proper homeostasis during pregnancy.

Oocyte ageing and epigenetics

It has become a current social trend for women to delay childbearing. However, the quality of oocytes from older females is compromised and the pregnancy rate of older women is lower. With the increased rate of delayed childbearing, it is becoming more and more crucial to understand the mechanisms underlying the compromised quality of oocytes from older women, including mitochondrial dysfunctions, aneuploidy and epigenetic changes. Establishing proper epigenetic modifications during oogenesis and early embryo development is an important aspect in reproduction. The reprogramming process may be influenced by external and internal factors that result in improper epigenetic changes in germ cells. Furthermore, germ cell epigenetic changes might be inherited by the next generations. In this review, we briefly summarise the effects of ageing on oocyte quality. We focus on discussing the relationship between ageing and epigenetic modifications, highlighting the epigenetic changes in oocytes from advanced-age females and in post-ovulatory aged oocytes as well as the possible underlying mechanisms.

Inhibin and premature ovarian failure

BACKGROUND

Elucidation of the causes of premature ovarian failure (POF) is difficult due to the heterogeneity of the condition. Inhibin is a potential candidate gene for POF based on its dual actions on FSH secretion by the pituitary and gametogenesis in the gonads. A missense mutation in the inhibin alpha subunit gene (INHA G769A) is associated with POF in several populations. However, there is phenotypic heterogeneity in INHA G769A mutation carriers.

METHODS

Relevant studies were identified by searching PubMed and mutational frequencies combined for meta-analysis.

RESULTS

Meta-analysis of published studies revealed a risk difference of 0.04 (-0.030 to 0.11). The occurrence of asymptomatic carriers in populations suggests incomplete penetrance and/or a multi-genetic cause of POF. We propose that a decline in inhibin bioactivity caused by the mutation could increase FSH levels; and in a susceptible individual, the heightened sensitivity to gonadotrophins causes POF. Impaired paracrine effects of inhibin could impact folliculogenesis due to reduced antagonism of activin, bone morphogenetic protein 15 and growth differentiation factor 9. Functional studies of this mutation indicate normal production of dimeric inhibin A and B and impaired bioactivity of inhibin B.

CONCLUSIONS

The identification of an autosomal mutation in the inhibin alpha subunit gene that is significantly linked to POF in certain ethnic populations highlights the role of inhibin in the regulation of ovarian biology and fertility. Although the reduction of inhibin B bioactivity by the INHA G769A mutation is clearly not the only cause, evidence suggests that this change may serve as a susceptibility factor, increasing the likelihood of POF.

Live birth after IVF in a 46-year-old woman

Pregnancies after IVF have been reported in women aged > or =44 years, but nobody older than 45 years at oocyte retrieval delivered. We report a case of birth of a healthy child after IVF in a 46-year-old infertile woman. Ovarian stimulation was performed with clomiphene citrate, 150 mg daily for 5 days. Three oocytes were retrieved and one embryo was replaced. The patient delivered a healthy male infant after Caesarean section at 39 weeks. A successful pregnancy after IVF with homologous oocytes can be achieved in women older than 45 years. At this age IVF is not a cost-effective treatment compared with oocyte donation, but it may be offered in countries in which gamete donation is forbidden.

Optimum number of embryos to transfer in women more than 40 years of age undergoing treatment with assisted reproductive technologies

OBJECTIVE

To determine whether increasing the number of embryos transferred beyond five increases pregnancy rates in women aged > 40 years.

DESIGN

Retrospective analysis of cycles performed between January 1998 and July 2003.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Women aged > 40 years undergoing a fresh cycle with a day-3 ET (n = 863).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy, chemical pregnancy, miscarriage rates, number of viable fetuses at 12 weeks' gestation, live birth rates, and number of babies delivered.

RESULT(S)

Compared with patients with fewer than five embryos transferred, those having five or more embryos transferred had significantly increased pregnancy rates and live birth rates, more viable fetuses at 12 weeks, and significantly decreased miscarriage rates. None of these outcome variables differed between the five-embryo and more-than-five-embryo groups. There were no differences in outcome when only five embryos were transferred, regardless of whether five or more than five embryos were available. The number of embryos transferred did not significantly influence multiple birth rates.

CONCLUSION(S)

The present study demonstrates that in women aged > 40 years, five embryos is the optimum number to transfer, and transferring more than five does not confer any additional benefit to clinical outcome.

Egg production predicts a doubling of in vitro fertilization pregnancy rates even within defined age and ovarian reserve categories

OBJECTIVE

To examine the age-independent association of ovarian response and IVF outcome in women with normal and abnormal ovarian reserve.

DESIGN

Retrospective analysis.

SETTING

Academic IVF center.

PATIENT(S)

Four thousand eight hundred sixty-two consecutive IVF cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Outcome of IVF was analyzed as a function of ovarian response to controlled ovarian hyperstimulation and ovarian reserve.

RESULT(S)

The mean patient age was 36.2 +/- 4.5 years. Younger patients and patients with normal ovarian reserve were found to have better implantation and clinical pregnancy rates. Patients with normal ovarian reserve had a higher number of oocytes retrieved, mature oocytes, two-pronuclei embryos, and embryos transferred. A greater number of embryos were transferred for patients with higher ovarian response. Higher clinical pregnancy rates were seen in those patients who had more oocytes retrieved for all patients, regardless of age and ovarian reserve. In fact, clinical pregnancy rates more than doubled for specific patient groups.

CONCLUSION(S)

In an age-independent fashion, ovarian response is highly predictive of IVF outcome in women with normal and abnormal ovarian reserve. These findings highlight the importance of not solely relying on age when presenting and discussing IVF outcome data and are useful information when helping patients interpret their IVF cycle response.

Inclusion of standard and low-dose gonadotropin releasing hormone-analog (short protocol) in controlled ovarian hyperstimulation regimens in normogonadotropic patients aged 40-48 years who are undergoing in vitro fertilization

We aimed to compare the efficiency of three controlled ovarian hyperstimulation protocols in achieving superovulation in normogonadotropic patients aged 40 years or more, who were undergoing in vitro fertilization (IVF) treatment. This was a prospective randomized clinical study, carried out in the Infertility and IVF Unit of an academic tertiary hospital. A total of 219 normogonadotropic patients (serum follicular stimulating hormone level < 15 mIU/ml) aged 40-48 years, with regular menstrual cycles, were randomly allocated to one of three short follicular protocols: menotropins only (group A), menotropins plus a mini-dose of gonadotropin releasing hormone (GnRH)-analog (600 microg/ day) (group B), or menotropins plus a standard dose (900 microg/day) of a GnRH-analog (group C). Those cycles that reached the stage of oocyte retrieval (67, 70 and 71 cycles, respectively) were analyzed. The mean daily dose of menotropins needed for ovarian stimulation was higher when GnRH-analog was used (groups B and C) (p < 0.02; ANOVA), although there was no significant difference in the time of human chorionic gonadotropin injection (average: cycle day 11). Peak estradiol levels (p < 0.02), number of oocytes retrieved (3.9, 5.4 and 5.5 oocytes/cycle, respectively, p < 0.02) and number of embryos transferred (1.6, 1.8 and 2.1 embryos/cycle, respectively, p < 0.05) were higher when GnRH-analog was included in the controlled ovarian hyperstimulation protocol. The IVF treatment resulted in 19 pregnancies (9.1% implantation rate), with a similar distribution among all three groups (11.9%, 8.6% and 7.0%). However, a higher miscarriage rate was noted in the menotropins-only group (67.5% vs. 33.3% and 40.0% of pregnancies). No differences were observed in any of the aforementioned variables between the mini-dose and standard dose GnRH-analog groups (groups B and C). In conclusion, controlled ovarian hyperstimulation before IVF treatment in normogonadotropic patients aged 40 years or more is more effective when a GnRH-analog (short protocol) is included in the treatment regimen. In this selected group of patients, reducing the daily dose of GnRH-analog does not improve the treatment results.

Female age in ART: when to stop?

With increasing age the probability of ongoing pregnancy established by the use of assisted reproduction technology (ART) decreases. As a result the question arises whether age limits for the application of ART should be established. From a literature review and ongoing research data it appears that the costs per child born greatly increase after the age of 40 for both intrauterine insemination with mild ovarian stimulation and in vitro fertilisation treatment, while in cases of 44 and over, prognosis is flat zero. The willingness to pay for extra costs will greatly determine whether and at what age strict limits should be applied. Fortunately, predictive factors for success, like the antral follicle count, may enable the identification of women over 40 and under 44 that still have favourable prospects, thereby decreasing the necessary costs per childbirth and allowing couples into ART programs that are often denied based solely on female age.

Waiting for in vitro fertilization treatment: spontaneous and ART live births

This study analysed the live birth rates in 760 couples referred in 1994 to St Mary's Hospital, Manchester, a non-fee-paying National Health Service (NHS) centre, who had waited for up to 4 years for IVF treatment. These live birth rates were compared with those of 199 couples referred at a similar time to Manchester Fertility Services, a fee-paying unit, where they received IVF treatment shortly after referral. The waiting time was advantageous in that 17.8% (135 of 760) of the couples referred to St Mary's Hospital conceived without IVF treatment, 60% within one year of referral. However, the waiting time was detrimental to women aged 30-34 in whom treatment was delayed by 3-4 years. Only 26.8% (204 of 760) of couples originally referred eventually received NHS-funded IVF treatment at St Mary's. A waiting time not exceeding 18 months would allow most spontaneous conceptions and reduce the adverse effect of prolonged waiting on the take-up rate for treatment and on the chance of success in the older women.

Prediction of pregnancy rate of in vitro fertilization and embryo transfer in women aged 40 and over with basal uterine artery pulsatility index

PURPOSE

The purpose was to determine the effect of basal uterine perfusion on the pregnancy rates of in vitro fertilization and embryo transfer (IVF-ET) in women aged 40 and above.

METHODS

A total of 47 patient aged 40 and over underwent IVF-ET. The conception cycles and the nonconception cycles were compared.

RESULTS

Of the 47 patients, 4 patients were pregnant (8.5%). The mean age, basal follicle stimulating hormone (FSH), basal estradiol (E2) level, antral follicle count (AFC), number of ampoules of gonadotropin used, E2 levels and endometrial thickness on the day of human chorionic gonadotropin (hCG) administration, number of retrieved and fertilized oocytes, and number of transferred embryos were not statistically significant between the conception and nonconception cycles. However, the basal uterine artery pulsatility index (UA PI) was significantly lower in the conception cycles (P < 0.001). The receiver operating characteristics (ROC) curve analysis for basal FSH, AFC, and basal UA PI in predicting the pregnancy rate of IVF in patients aged > or = 40 were demonstrated. The best prediction rate was achieved by a pulsatility index cutoff of < 2.0 for a receptive uterus.

CONCLUSIONS

Increased uterine perfusion in the early follicular phase enhanced the pregnancy rate of IVF in women aged 40 and above. It is therefore essential that patients aged > or = 40 with poor basal uterine perfusion should be identified early in the early follicular phase of the menstrual cycle to apply appropriate intervention to improve the uterine circulation for the subsequent chance of pregnancy.

ICSI outcome in patients of 40 years age and over: a retrospective analysis

OBJECTIVE

To report and analyse our experience with ICSI treatment in infertile women >/=40 years of age, with the intention of contributing to current debates on the effect of aging on the reproductive potential.

STUDY DESIGN

107 infertile couples in which the female partner was aged >/=40 years and who received ICSI treatment between January 1996 and December 1998.

RESULTS

A total of 107 women underwent 171 treatment cycles during this period. Of 171 cycles initiated 33 were cancelled (cancellation rate=19.3%). In this way, 17 women did not have embryo transfer at all, while 90 patients had 138 cycles with oocyte retrieval and successful embryo transfer, with a mean number of embryos per transfer 2.36. Sixteen pregnancies occurred and eight of them ended in spontaneous abortion. The implantation rate was 4.9%, the pregnancy rate per initiated cycle was 9.35% and per transfer cycle 11.59%. The miscarriage rate was 50%. Moreover, 12 patients had supernumerary embryos, that were cryopreserved and transferred in 17 thawing cycles and resulted in two pregnancies ending in abortion. All pregnancies occurred when three embryos were available, except in two cases with two available embryos. The great majority of the total pregnancies (16 of 18) resulting in women aged between 40 and 42 years.

CONCLUSION

Our data show that women 40 and older with existing ovarian function may benefit from ICSI treatment, even when the indication for treatment is male factor infertility. Supernumerary embryos, that are cryopreserved and transferred in subsequent cycles can improve the overall pregnancy rates per oocyte retrieval, although these women should be aware of the very high risk of miscarriage.

Clinical usefulness of basal FSH as a prognostic factor in patients undergoing intracytoplasmic sperm injection

OBJECTIVE

To determine if basal serum follicle stimulating hormone (FSH) level could be a prognostic factor of the clinical outcome in intracytoplasmic sperm injection (ICSI) cycles in the couples with male factor infertility.

MATERIALS AND METHODS

From December 1995 to March 1998, total 118 patients underwent in vitro fertilization and embryo transfer (IVF-ET) with ICSI due to male factor infertility were included in this study. Patients were allocated to the low basal FSH group (< 8.5 mIU/ml) and the high basal FSH group (> or = 8.5 mIU/ml). The basal levels of FSH were measured in the 3rd day of menstrual cycle preceding ovarian stimulation cycle in total IVF cycles by immunoradiometric assay (IRMA). Statistical analysis was performed using Student's t-test, Fisher's exact test, and chi 2 test as appropriate. Statistical significance was defined as p < 0.05.

RESULTS

The total dose of exogeneous gonadotropin required in the high basal FSH group was significantly higher than that in the low basal FSH group. The numbers of retrieved oocytes and oocytes with grade I, II were significantly higher in the low basal FSH group. The clinical pregnancy rate per cycle in the low basal FSH group (16.2%) was significantly higher than that in the high basal FSH group (4.0%).

CONCLUSION

These results suggested that the basal serum FSH levels could be predictive of pregnancy outcome and the results of controlled ovarian hyperstimulation (COH) in ICSI cycles.

Fertility and infertility in aging women

Age is often a dominant factor for women wanting to conceive. The objective of this study was to examine the outcome of an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program in relation to a woman's age. Between January 1995 and June 1997 we stimulated 2511 cycles. The mean age of the women was 34 years, with 21.9% under 30, 45.9% between 30 and 35, 24.5% between 36 and 39, and 7.7% over 39 years. All patients aged > or = 40 years had day 3 serum follicle-stimulating hormone (FSH) concentrations < 20 IU/l. The stimulation regimen consisted of 150-450 IU of human menopausal gonadotropin (hMG) or FSH combined with either clomiphene citrate (CC) or gonadotropin-releasing hormone agonist (GnRHa) in a short or long protocol. Age had a significantly negative effect on the stimulation and fertilization failure rates. The clinical pregnancy rate per transfer and the embryo implantation rate declined significantly from 29.4% and 18.9% in women < 30 years to 19.8% and 14.3% in patients between 30 and 35 years, 17.1% and 9.0% between 36 and 39 years and to 12.8% and 7.4% in those aged > or = 40 years. The spontaneous abortion rate was 14.9%, 16.5%, 22.4% and 33.2%, respectively. The clinical pregnancy rate per transfer reflected only imperfectly the performance of the older women because the discharge rate during stimulation and spontaneous abortions reduced the 'take home baby' rate to about 7% per cycle in patients aged > or = 40 years. It is very important in fertility practice to recognize the major impact of advancing maternal age.

Genetics, age, and infertility

OBJECTIVE

To review the genetics of aging specifically as it pertains to human fertility, as well as the recent advancements in the diagnosis of genetic diseases prior to embryo implantation.

METHODS

A review of our own experience as well as the scientific literature with regards to the decline in female fertility with age, the success of IVF in women of older reproductive age, and the role of preimplantation genetic diagnosis (PGD) in the evaluation of the patient at risk for fetal genetic anomalies.

RESULTS

The decline in female fertility occurs primarily as a result of a decline in oocyte quality as well as quantity. The frequency of chromosomal anomalies in recognized abortuses increases in parallel with the age-specific rise in the incidence of spontaneous abortions. PGD is an accurate diagnostic tool for exclusion of genetically deficient embryos prior to initiation of pregnancy.

CONCLUSION

Reproductive failure in women of older age appears to be directly related to ovarian age. Recent techniques such as cytoplasmic or germinal vesicle transfer are designed to replace the senescent cellular machinery believed to be responsible for genetic errors that occur during early cell division. PGD can accurately identify embryos with genetic deficiencies prior to implantation.

The influence of advanced age on the outcome of assisted reproduction

PURPOSE

Our purpose was to determine the influence of age on the outcome of assisted reproduction, with particular interest in women aged 40 years or older.

METHODS

A retrospective review of the 779 patients enrolled in the Royal Hospital for Women Fertility Group fertility program between 1987 and 1994 was performed. The results for women aged 40 years or older were compared with those for women between 36 and 39 years and those younger than 36 years. The main outcome measures were pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response.

RESULTS

Compared with those in younger women, pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response to controlled ovarian stimulation were significantly worse in women aged 40 years or older.

CONCLUSIONS

The outcome of assisted reproduction in women of 40 years of age or older was extremely poor. Compared with those in younger women, pregnancy outcome and ovarian response to controlled ovarian stimulation were significantly worse in women of 40 years or more.

The antral follicle count predicts the outcome of pregnancy in a controlled ovarian hyperstimulation/intrauterine insemination program

PURPOSE

Our purpose was to test whether age-related changes in antral follicle counts can predict the pregnancy outcome in the early follicular phase of a controlled ovarian hyperstimulation/intrauterine insemination (COH/IUI) program.

METHODS

A selected group of 107 women (36 healthy women requesting child sex preselection, 52 women with unexplained infertility, and 19 with minimal endometriosis) who underwent controlled ovarian hyperstimulation with clomiphene citrate (CC) plus human menopausal gonadotrophin (hMG) and subsequent intrauterine insemination were enrolled in the study. Transvaginal ultrasonography (7.0 MHz) was used to determine the total number of antral follicles (2-8 mm) in the right and left ovaries. The association among the antral follicle count, age, dominant follicle, and estradiol (E2) level on the day of human chorionic gonadotropin (hCG) was analyzed. The association of the pregnancy rate and OHSS with the antral follicle count, dominant follicle count, and age was also examined.

RESULTS

The total antral follicle number decreased with age (P < 0.0001). Dominant follicle number increased with total antral follicle number in women who received CC plus hMG/ IUI(P < 0.0001). The pregnant group had a higher number of antral follicle and dominant follicles in comparison with the nonpregnant group (P < 0.01 and P < 0.02, respectively). The E2 level on the day of hCG injection increased positively with the total number of antral follicles (P < 0.0001) and the total number of dominant follicles (P < 0.0001). In women aged younger than 35 years, the pregnancy rate and dominant follicle number rose as the number of antral follicles increased (P < 0.03 and P < 0.0001, respectively). The pregnancy rate was low (2/39) in women aged older than 35 years regardless of the number of antral follicles (P < 0.05) and the extent of hMG administration (P < 0.02). Women aged older than 35 also produced fewer dominant follicles (P < 0.001). No pregnancy was achieved in a patient with an antral follicle number of less than five (17 cases).

CONCLUSIONS

Age-related changes in antral follicle count significantly predicted the dominant follicle count and the pregnancy outcome. In women with antral follicle counts of less than five or who are older than 35 years, the application of COH/IUI may not be indicated.

Age-related decline in fertility: a link to degenerative oocytes?

OBJECTIVE

To determine whether the age-related decline in fertility is due to degenerative oocytes or to aneuploidy.

DESIGN

Retrospective.

SETTING

Fertility center of a public and tertiary institution.

PATIENT(S)

One hundred fifty-one women (ages 24 to 44 years) undergoing 158 cycles of conventional IVF or IVF with intracytoplasmic sperm injection (ICSI) between January 1993 and December 1995 were divided into three age groups (group 1, < or = 34 years; group 2, between 35 and 39 years; and group 3, > or = 40 years). They were selected on the basis of available oocytes that remained unfertilized after IVF and that had analyzable chromosomes.

INTERVENTION(S)

Standard pituitary down-regulation and ovarian stimulation with FSH and hMG were done for both IVF and ICSI patients. In addition, all patients were given luteal phase support with P, administered orally, via pessaries, or by IM injections from the day of transfer.

MAIN OUTCOME MEASURE(S)

Fertilization rates and pregnancy rates (PRs), and cytogenetic analyses of unfertilized oocytes.

RESULT(S)

Although fertilization rates were not different among women in groups 1, 2, and 3 (50.9%, 49.3%, and 37.9%, respectively), PRs were significantly lower between groups 1 and 3 (43.2% versus 14.3%). A total of 383 oocytes were examined, of which 287 (75%) could be karyotyped. Of these, 201 oocytes showed a normal 23,X karyotype (70%), 40 (13.9%) were aneuploid, 24 (8.4%) were diploid, 12 (4.2%) had structural aberrations, and 13 (4.5%) had single chromatids only. No increase in the aneuploidy rate was detected between groups 1 and 2 (14.8% versus 12.4%). However, highly significant differences in the rate of oocyte chromosome degeneration, characterized by chromosomes splitting into unassociated chromatids, were observed with increasing age (group 1, 23.7%; group 2, 52.0%; and group 3, 95.8%).

CONCLUSION(S)

It seems that the age-related decline in fertility may be due more to degenerative oocytes than to aneuploidy. A decline in the number of oocytes retrieved with age may be of less importance than the decline in oocyte quality. Women in the older age group have a higher chance of achieving pregnancy from ovum-donation programs than by persisting in using their own aged oocytes, which have a very poor prognosis for success.

Basal and stimulated gonadotropin levels in the perimenopause

OBJECTIVE

We investigated whether perimenopausal menstrual cycle irregularity is associated with increased gonadotropin immunoactivity, bioactivity, or the bioactivity/immunoactivity ratio at baseline and after short-term stimulation with gonadotropin-releasing hormone.

STUDY DESIGN

Subjects consisted of four groups: (1) young regular cycling women (< 35 years old), older women (> 35 years) with (2) regular or (3) irregular menstrual cycles, and (4) postmenopausal women. Gonadotropin-releasing hormone stimulation tests (100 micrograms intravenous gonadotropin-releasing hormone) were performed in the National Institute of Mental Health outpatient clinic during the follicular phase of the menstrual cycle or randomly in postmenopausal women.

RESULTS

Perimenopausal women had baseline follicle-stimulating hormone and luteinizing hormone levels and stimulated follicle-stimulating hormone levels (area under the curve) that were similar to those of postmenopausal women and significantly greater than those of control (younger and older) women. Postmenopausal women had significantly greater baseline levels of luteinizing hormone bioactivity than did the other three groups. The bioactivity/immunoactivity ratio in the postmenopausal women was significantly greater than those in the perimenopausal and older cycling women, which were similar. No change in the bioactivity/immunoactivity ratio was seen after gonadotropin-releasing hormone stimulation in any group.

CONCLUSIONS

Although the perimenopause is associated with increases in baseline and stimulated gonadotropin levels similar to those seen after the menopause, significantly increased baseline luteinizing hormone bioactivity and the bioactivity/immunoactivity ratio are seen only after the menopause.

The initial flare-up induced by gonadotropin releasing hormone agonist may serve as a predictor of ovarian response in the current IVF-ET treatment cycle in normogonadotropic women aged 40-48 years

OBJECTIVE

Our purpose was to assess the potential role of the baseline hormone profile in combination with the initial pattern of response to gonadotropin releasing hormone (GnRH) analogue in predicting ovarian function and hence reproductive outcome in normogonadotropic patients aged 40 years or older undergoing IVF treatment.

PATIENTS AND METHODS

A retrospective analysis of 394 controlled ovarian hyperstimulation (COH) cycles that reached the stage of oocyte retrieval was conducted. The study included 163 normogonadotropic (serum FSH < or = 15 IUIL) patients aged between 40 and 48 years who had regular menstrual cycles. Superovulation was achieved using menotropins in combination with GnRH analog (short protocol, beginning on menstrual day 2). The ovarian response was monitored on the third cycle day, the day following the first GnRH analogue administration.

RESULTS

Cycle distribution by patient age was 175 (44.4%), 122 (30.9%), and 97 (24.7%), while the patient distribution was 85 (52.2%), 48 (29.5%), and 30 (18.3%) for age groups 40-41, 42-43, and 44-48 years, respectively. The mean total dose of menotropins needed for optimal COH was 1787 IU (range, 600-6000 IU). This dose increased with age, while the yield of oocytes and embryos declined (P < 0.05; ANOVA). A positive correlation was demonstrated between the E2 level on day 3 (GnRH analogue flare effect) and the outcome of the treatment cycle (number of oocytes and embryos). Using multiple stepwise regression analysis, it was demonstrated that the initial (day 3) serum E2 levels, combined with baseline FSH levels, patients's age and body mass index enabled early prediction of the ovarian response in the current IVF-ET treatment cycle (oocytes = 8.2 - 0.18 x Age + 0.17 x BMI - 0.12 x FSH + 0.0042 x E2).

CONCLUSIONS

Multiple-parameter analysis demonstrated that the use of the initial E2 response to GnRH analogue stimulation combined with basic clinical data may assist in the prediction of ovarian function and hence the reproductive outcome in normogonadotropic IVF patients aged 40 years or older. This may serve as a clinical tool for improving patient selection and treatment outcome in IVF-ET.

Achieving multiple-order embryo transfer identifies women over 40 years of age with improved in vitro fertilization outcome

OBJECTIVE

To define factors in patients > or = 40 years that may improve outcome and provide prognosis for success in IVF-ET.

DESIGN

Retrospective.

SETTING

University infertility center.

PATIENTS

Patients (n = 501) undergoing IVF-ET from 1987 to 1994.

INTERVENTIONS

IVF-ET (n = 713 cycles) with GnRH-analogue suppression and hMG stimulation.

MAIN OUTCOME MEASURES

We evaluated data including age, diagnosis, prestimulation (day 3) FSH and E2, hMG ampules used, days of monitoring, follicle number and size, maximum E2, ova retrieved, cancellation rate, clinical pregnancy, nidation, and miscarriage rates.

RESULTS

Overall, patients > or = 40 years had significantly decreased pregnancy rates (PRs), response to stimulation, and increased miscarriage rates. However, if these patients had four or more embryos transferred, their response and PRs (34.4% per ET) were not significantly different from younger women (47.7% per ET). The majority (77.8%) of pregnancies in women > or = 40 years occurred when four or more embryos were transferred.

CONCLUSION

A subset (49%) of women > or = 40 years undergoing IVF-ET will respond to ovarian stimulation well enough to result in four or more embryos available for transfer with a resultant PR similar to that observed in younger patients. We recommend consideration of an attempt at IVF-ET before recommending oocyte donation.

In vitro fertilization in women age 40 and older: the impact of assisted hatching

PURPOSE

To assess the impact of assisted hatching on in vitro fertilization (IVF) outcome in women age 40 and older.

METHODS

A retrospective analysis was performed to compare 28 cycles of IVF without assisted hatching to 38 cycles of IVF with assisted hatching. All patients in both groups were age 40 or older and the mean age was similar.

RESULTS

The delivery rate per oocyte retrieval was significantly higher in the assisted hatching group (18/38; 48%) compared to the nonhatched controls (3/28; 11%, P = 0.0003). The implantation rate of hatched embryos (40/175; 22%) was clearly enhanced, compared to the nonhatched embryos (7/126; 6%, P < 0.001). The fertilization rate, number of oocytes and the number of embryos per patient were comparable in the two groups.

CONCLUSIONS

Assisted hatching dramatically improves embryonic implantation and term pregnancy rates in women age 40 and older undergoing IVF.

Female aging and superovulation induction for IVF

The success of in vitro fertilization (IVF) has been reported to be adversely affected by increasing women's age. The main reason being that older women more frequently show a poorer response to stimulation. Information about such variability in ovarian responsiveness to stimulation is important for assessing the chances for successful pregnancy in older women undergoing assisted reproduction, because those with limited ovarian reserve should be counseled to consider other therapeutic options without delay. I present results demonstrating the ovarian response to gonadotropin stimulation and the success rate in 746 IVF cycles. A brief overview on current methods of evaluating ovarian reserve as a means to identify the poor responder, and a discussion on the efficacy of several stimulation regimens for old women with limited ovarian reserve is also provided.

In vitro fertilization and oocyte donation in women 45 years of age and older

OBJECTIVE

To assess the reproductive potential in women > or = 45 years of age.

DESIGN

Retrospective analysis.

SETTING

In vitro fertilization-embryo transfer unit, standard IVF and oocyte donation programs.

PATIENTS

One hundred twenty-seven patients > or = 45 years old who applied for treatment of infertility.

INTERVENTION

Thirty-one patients underwent 52 treatment cycles in standard IVF. Ninety-six patients underwent 220 oocyte donation cycles.

RESULTS

Of the 52 standard IVF cycles, oocytes were retrieved successfully in only 32. Of these, fertilization and ET were performed in 21 cycles. None of these treatment cycles resulted in a clinical pregnancy. Of the 220 oocyte donation cycles, fertilization and ET were accomplished in 189 cycles. These resulted in 33 (17.5% per transfer) clinical pregnancies.

CONCLUSIONS

These results suggest that oocyte donation may extend the reproductive potential in women > or = 45 years old when little hope is offered by standard IVF.

The use of the donor oocyte program to evaluate embryo implantation

Pregnancy rates (PRs) are generally higher in most IVF programs when embryos derived from donor oocytes are transferred compared to the PRs of women undergoing IVF-ET. DeZiegler et al., using the transfer of frozen embryos (either patient or donor derived) in natural cycles, found a higher PR following donor oocyte derived ET and thus concluded that the lower PR in the non-donor cycles was not related to the controlled ovarian hyperstimulation (COH) regimen. Their data thus suggested the improved PR with donor embryos may be related to better quality oocytes used for recipients; however, a more receptive endometrium in the oocyte recipients could also explain the data. The studies presented herein further evaluated the latter hypothesis of improved endometrial environment for recipients by comparing PRs in donors vs recipients in a shared oocyte program. Also the study would determine if endometrial echo patterns (EP) and/or thickness (ET) help predict better PRs as they do in stimulated cycles. Finally studies would be performed to compare PRs in older vs younger oocyte recipients to see if there may be a uterine senescence in humans as in other animals and to see if age has an adverse effect on the endometrium as evidenced by sonographic studies. Study 1 compared the clinical PRs in donors vs recipients in a shared program from 1/1/92 to 12/31/92. PR for donors was 23.6% (17 pregnant in 72 transfers) compared to 34.6% for recipients (26/75). Mean age of the donors was 32 compared to 39.8 for recipients. If recipients > 40 were eliminated the PR for recipients was 44.1% (15/34). Study 2 evaluated PRs according to ET and EP in 58 transfers using donor oocytes (44 patients). There were only 2 clinical pregnancies of 22 transfers (9%/cycle) when ET was < 10 mm at the time of the donor's hCG injection compared to 14 pregnant of 36 transfers (38.7%) when ET was > or = 10 mm (p < 0.01). However, there were no differences in PR when the endometrium compared to myometrium was hypoechogenic, isoechogenic, or hyperechogenic. The respective PRs were 16.7% (1/6), 31% (9/39) and 26.1% (6/23). Study 3 evaluated PRs in donor oocyte recipients according to age (< 40 vs > or = 40 years). After evaluating PRs after the first 58 ETs to recipients of shared oocytes we found a much lower PR in women > or = 40 (2/23, 8.6%/cycle) vs 14/55 (25.4%) in those < 40.(ABSTRACT TRUNCATED AT 400 WORDS)

Endometrial receptivity in the light of modern assisted reproductive technologies

OBJECTIVE

To review the different aspects of endometrial receptivity as it is reflected in the various modalities of modern assisted reproductive technologies.

DESIGN

The importance of endometrial receptivity and the factors that affect it such as the type of treatment, age, and ovarian function are discussed in this review. Novel approaches to determine receptivity such as Doppler ultrasonography and molecular biology are considered; assisted hatching is also discussed.

CONCLUSIONS

Endometrial receptivity cannot, as yet, be directly assessed. Circumstantial evidence suggests that receptivity declines with age, is adversely affected by controlled ovarian hyperstimulation, and is possibly affected by ovarian function. Future studies will have to focus on molecular cell biology and physiology of the endometrium.

Age-related decline in female fertility is not due to diminished capacity of the uterus to sustain embryo implantation

OBJECTIVE

To evaluate the contribution of the uterus to age-related reproductive failure in women.

PATIENTS

Thirty-eight ovum donors (30.2 +/- 4.9 years [mean +/- SD]) donating oocytes throughout 102 ovum donations. Fifty-one cycles were documented in "younger" recipients (35.8 +/- 3.1 years) and 51 in "older" recipients (44.0 +/- 3.1 years). The study was prospectively designed; same-cohort oocytes obtained from one young donor during a specific cycle were evenly distributed between "young" and "old" ovum recipients. Use of oocytes from a single source and a unique ovulatory cohort provides strict control over oocyte quality. Uterine age is varied by design, according to the age of the recipient at the time of ET. The role of the aging uterus in the decline of female fertility can be thus isolated and scrutinized.

RESULTS

No significant (NS) difference in the number of ova received (7.9 +/- 3.4 versus 7.0 +/- 3.5), ova fertilized (4.4 +/- 1.5 versus 4.5 +/- 2.3), or embryos transferred (4.1 +/- 1.5 versus 4.1 +/- 1.6) was observed between the < 40 and > or = 40 recipient age groups. A total of 23 pregnancies occurred among the 102 ETs (22.6%). Eleven clinical pregnancies (21.6%) resulting in 10 deliveries were observed in the < 40 recipient age group, and 12 clinical pregnancies (23.5%) leading to 10 deliveries occurred in the > or = 40 recipient age group (NS). The pregnancy loss rates were 9.1% (1 of 11) and 16.7% (2 of 12) for the two recipient age groups, respectively, (NS).

CONCLUSION

The capacity to conceive and to gestate a conception to term when oocyte quality is controlled appears to be independent of uterine aging through the fifth decade of life.

Endometrial receptivity: the age-related decline in pregnancy rates and the effect of ovarian function

OBJECTIVE

To assess the effect of age and ovarian function on endometrial receptivity.

DESIGN

Retrospective comparison between standard IVF and ovum donation in younger and older patients (< 40 and > or = 40 years of age, respectively).

PATIENTS

In standard IVF, there were 325 transfer cycles in older patients and 1,103 transfer cycles in younger ones. In ovum donation, there were 236 transfer cycles in older patients and 222 cycles in younger women. Ovum recipients were then redivided into two groups, according to ovarian function: ovarian failure group (219 cycles) and eugonadal group (239 cycles) in patients with retained ovarian function as manifested by regular menstrual cycles and normal gonadotropins.

RESULTS

In standard IVF, clinical pregnancy rates (PRs) were significantly lower in older patients (12.9% versus 23.8%, respectively). In ovum donation, clinical PRs were also significantly lower in older patients (21.2% versus 29.3%, respectively). A significantly higher clinical PR (31.1%) was noted in patients with ovarian failure, compared with both eugonadal patients undergoing ovum donation (19.7%) and standard IVF patients (21.3%).

CONCLUSIONS

The decrease in endometrial receptivity with age is responsible for the higher rate of implantation failure in older women. Patients with nonfunctioning ovaries do better than eugonadal patients in ovum donation programs.

Defining and interpreting pregnancy success rates for in vitro fertilization

OBJECTIVES

To review current practice in describing pregnancy success rates after IVF-ET, to identify issues associated with interpreting these rates, and to suggest useful methods of describing these rates in the future.

DESIGN

Review of literature concerning medical, epidemiologic, and statistical aspects of reporting IVF-ET pregnancy success rates.

SETTING

The United States.

PATIENTS

Infertile couples participating in IVF-ET.

MAIN OUTCOME MEASURES

Usefulness and accuracy of IVF-ET pregnancy reporting.

RESULTS

Several groups have collected information on the pregnancy success rates of IVF-ET clinics and have discussed appropriate definitions of pregnancy success. The largest of these groups in the United States is The American Fertility Society and its affiliate, the Society for Assisted Reproductive Technology. The number of live deliveries per 100 ET procedures and the number of live deliveries per 100 egg retrieval procedures are among the most commonly used definitions.

CONCLUSION

The most commonly used definitions are particularly useful for describing the probability that a live infant will be delivered after IVF-ET is completed. To measure the effectiveness of the IVF-ET procedures and the costs of undergoing IVF-ET, other definitions are also important. Success rates need to be stratified by patient characteristics, such as age, that affect the probability of success.

The effect of the age of the recipients on pregnancy rates following donor-oocyte replacement

PURPOSE

Besides waning ovarian function with advancing age, the question of a uterine senescence factor has been proposed as a cause of decreased fecundity. The replacement of oocytes from younger donors into older recipients allows further investigation into the aging endometrium.

RESULTS

The pregnancy rate was considerably lower, 8.5% in recipients in ovarian failure who were > or = 40 years old (n = 23) compared to younger recipients, < 40 years of age (n = 55), who were also in ovarian failure, which would support the uterine senescence theory.

CONCLUSION

The endometrial factor may be manifested by failure to generate a critical endometrial thickness of 10 mm by sonography in 61% of the older group, compared to only 29% of the younger group. Future studies should address methods of improving the endometrial thickness in the older group, to determine if improved pregnancy rates will occur and to evaluate whether increasing luteal support with extra progesterone may also improve pregnancy rates.

Conception rate after in vitro fertilization in patients who conceived in a previous cycle

OBJECTIVE

To evaluate whether a previously successful in vitro fertilization and embryo transfer (IVF-ET) cycle is a favorable prognostic factor for a subsequent cycle.

DESIGN

A retrospective comparison between current IVF patients who have previously conceived in an IVF versus natural cycle.

SETTING

The IVF unit of a university hospital.

PATIENTS

Group A consisted of 51 patients (70 cycles of IVF-ET) who previously conceived in an IVF-ET cycle, and group B included 141 patients (201 cycles of IVF-ET) who previously conceived in a natural cycle. All couples with male factor infertility were excluded. Ovulation induction protocol was identical for both groups and consisted of gonadotropin-releasing hormone agonist pretreatment followed by gonadotropin stimulation.

MAIN OUTCOME MEASURES

Pregnancy rate per ET, cumulative pregnancy rate, and livebirth rate in both groups.

RESULTS

The following parameters were comparable for both groups: age, menotropin dosage required for an adequate stimulation, ovarian response, mean number of oocytes retrieved per cycle, fertilization and cleavage rates, and the mean number of embryo transferred. Group A attained a significantly higher pregnancy rate (PR) than group B (31.4% versus 19.4%). Group A also achieved a significantly higher livebirth rate (22.9% versus 11.4%) than group B. Similarly, the cumulative PR curves and the cumulative livebirth rate curves for three consecutive IVF-ET cycles differed significantly between the two groups.

CONCLUSION

A previous successful IVF cycle is a positive prognostic factor for a repeated IVF attempt. This effect could be because of either an improved endometrial response or a better embryo quality. It may be that this patient population is relatively immune to the known untoward effects of ovulation induction on endometrial development and, therefore, may represent a potential clinical model that can be used to further identify the factors influencing uterine receptivity after ovulation induction.

Ovulation induction in women age 40 and older: the importance of basal follicle-stimulating hormone level and chronological age

OBJECTIVES

To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induction and to assess the impact of basal follicle-stimulating hormone (FSH) on outcome in these patients.

DESIGN

Prospective, observational.

SETTING

Fertility service of university medical center.

PATIENTS

Infertile couples in whom the female partner was age 40 or older referred for ovulation induction therapy.

INTERVENTION

Assessment of basal hormonal status; ovulation induction.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (PR), livebirth rate.

RESULTS

Analysis of 402 cycles in 85 women age 40 and older demonstrated a clinical PR of 3.5% per cycle (95% confidence interval [CI] 1.7% to 5.3%). The livebirth rate was 1.2% per cycle (95% CI 0.1% to 2.3%). Women with a basal FSH < 25 IU/L and age < 44 years had a clinical PR of 5.2% per cycle (95% CI 2.5% to 7.9%) compared with 0.0% per cycle (95% CI 0.0% to 2.1%) in cases in which either basal FSH was > or = 25 IU/L or age was > or = 44 (P < 0.005). The prognostic importance of basal FSH and chronological age was confirmed by multivariate logistic regression analysis. The predictive value of the resulting regression equation was high (R2 = 0.94; P < 0.01).

CONCLUSIONS

Pregnancy and livebirth rates are generally low during ovulation induction in women age 40 and older. In combination, basal FSH and chronological age are accurate predictors of PR, in these couples and can define a subset of patients with a more favorable prognosis. The spontaneous abortion rate in women who do conceive is high, substantially lowering the livebirth rate.

Prediction of response to controlled ovarian hyperstimulation: a comparison of basal and clomiphene citrate-stimulated follicle-stimulating hormone levels

OBJECTIVE

To test the ovarian reserve in a high-risk population before controlled ovarian hyperstimulation for in vitro fertilization (IVF).

DESIGN

A prospective study comparing the outcome of a clomiphene citrate (CC) challenge test to the outcome of subsequent IVF cycles.

SETTING

Unit for assisted reproductive technology in a university hospital.

PATIENTS, PARTICIPANTS

Ninety-one infertile women with an age of 35 years or more, who had previous ovarian surgery or who had been diagnosed with ovarian endometriosis.

MAIN OUTCOME MEASURE

Relate follicle-stimulating hormone (FSH) levels before and after CC to frequency of cancellation of an IVF cycle because of a poor follicular response.

RESULTS

Twenty-one patients had elevated basal levels of FSH. Thirty-seven patients, including 20 with high basal levels, showed an excessive FSH response to CC with an FSH level after CC above the 95% confidence limit. Clomiphene citrate-stimulated FSH levels correlated better than basal levels with response to controlled ovarian hyperstimulation. An excessive FSH response to CC predicted a poor response outcome of subsequent controlled ovarian hyperstimulation for IVF with 85% accuracy.

CONCLUSION

Follicle-stimulating hormone response to CC predicts subsequent follicular response to controlled ovarian hyperstimulation.

The gonadotropin-releasing hormone agonist stimulation test--a sensitive predictor of performance in the flare-up in vitro fertilization cycle

OBJECTIVE

To evaluate the initial versus early pattern of estradiol (E2) change after administration of a gonadotropin-releasing hormone agonist (GnRH-a), i.e., the GnRH-a stimulation test versus E2 pattern, respectively, as predictors of ovarian response and pregnancy in in vitro fertilization (IVF) patients stimulated with a flare-up protocol.

DESIGN

Prospective study in a consecutive group of patients.

SETTING

Tertiary care, institutional setting.

PATIENTS

Two hundred twenty-eight patients entered and completed the study. The only patients excluded from study were those anticipated to have polycystic ovarian disease, those with a single ovary, or those with an ovarian cyst(s).

INTERVENTIONS

Patients were stimulated with a GnRH-a flare-up protocol beginning on menstrual day 2.

MAIN OUTCOME

Evaluation of the GnRH-a stimulation test and the E2 pattern as predictors of the number of mature oocytes retrieved and pregnancy.

RESULTS

The GnRH-a stimulation test but not the E2 pattern was predictive of the number of mature oocytes retrieved (r = 0.53, P less than 1 X 10(-5) and pregnancy (chi 2 = 8.5, P = 0.04). The E2 pattern was predictive of the duration and number of ampules of gonadotropin required for stimulation.

CONCLUSION

The GnRH-a stimulation test is a sensitive predictor of performance in the flare-up IVF cycle.

Resources for infertility treatment

Infertility is common, a serious medical problem in both advanced and underdeveloped countries. At present, medical resources are often used very haphazardly and frequently extravagantly to combat fertility problems. Whilst it seems very unlikely that society will be able to prevent infertility effectively, there is no doubt that the resources available could be better organized for greater benefit. There is evidence of poor co-ordination of services, of inadequate financial planning by health managers, and squandering of limited resources by professionals. Better organization of in vitro fertilization (IVF), with the promotion of larger regional services, would be an effective use of finances. IVF is too often only available to the wealthy and the selection of patients for treatment is frequently arbitrary; many fertility treatments are of unproved value and are wasteful. It is argued, for example, that many patients receiving gamete intrafallopian transfer (GIFT) for so-called 'unexplained infertility' would be better treated by other, less expensive, methods which are often more effective. Many useful treatments, such as tubal surgery, are being disregarded or misused and there is need for better education of specialists who treat infertile patients. Better primary care of infertile patients should include non-medical counselling, and investigation and firm diagnosis before treatment is commenced. The heavy accent on high technology in the treatment of infertility is often misplaced, and we need to strike a careful balance if resources are to be properly allocated.

Age and pregnancy rates in in vitro fertilization

The influence of women's age on the results of in vitro fertilization (IVF) was analyzed in 1801 women undergoing the procedure. Advancing age was found to be related to significant reduced success rates from an average of 30.1% per transfer below the age of 36 years to 15.9% per transfer at 37 years or more (P less than 0.001). The decrease was related to a reduction in oocyte production (five at 25 years or less, four below the age of 40 years, three at 40 years or more, and two in the 43 to 47-year group) and probably due to reduced implantation. It is concluded that a woman's age must be considered an important prognostic factor when IVF is suggested.

Basal follicle-stimulating hormone level is a better predictor of in vitro fertilization performance than age

A study of 1,478 consecutive in vitro fertilization (IVF) cycles was made to determine if basal follicle-stimulating hormone (FSH) levels and age were independent predictors of IVF performance. Regression analyses indicated independent contributions of both basal FSH and age in predicting cancellation rate, peak estradiol, number of oocytes retrieved, fertilized, and transferred, and total and ongoing pregnancy rates. Miscarriage rate was unrelated to both age and basal FSH. Follicle-stimulating hormone level was a better predictor than age for all outcome variables examined and remained a significant predictor after accounting for age, etiology of infertility, and semen quality. The combined use of age and basal FSH in counseling patients improves the accuracy of prognosis, and may provide an index of functional ovarian reserve ("ovarian age").

A preliminary report on oocyte donation extending reproductive potential to women over 40

BACKGROUND

Fertility in women 40 years of age or older is decreased, and in those with ovarian failure it is thought to be irrevocably lost. The donation of oocytes to young (less than 35 years old) women with ovarian failure has allowed many considered infertile a chance to become pregnant. In these women gonadal hormone replacement results in an endometrium receptive to implantation. It is not known whether the endometrial response to such replacement is decreased in women over the age of 40.

METHODS

To test the efficacy of oocyte donation to older women, we enrolled seven women 40 to 44 years old with ovarian failure in a trial of hormone replacement and embryo transfer, using oocytes obtained from women undergoing ovarian hyperstimulation solely for gamete donation.

RESULTS

Seven stimulated cycles in the donors that were synchronized with nine cycles in the recipients resulted in eight embryo transfers. Five viable pregnancies were established, one with twins. A sixth pregnancy ended in miscarriage. Five normal infants were delivered by cesarean section, and one stillborn infant was delivered vaginally. The outcomes were compared with those in women under the age of 40 with ovarian failure who were also participating in our donor-oocyte program and in infertile ovulating women 40 or older who were undergoing standard in vitro fertilization. No significant differences in rates of implantation or ongoing pregnancy were noted in older women as compared with younger women receiving donated embryos. These rates, however, were higher than the rates in the infertile ovulating women of similar age who were undergoing standard in vitro fertilization.

CONCLUSIONS

These preliminary results suggest that the endometrium retains its ability to respond to gonadal steroids and provides a receptive environment for embryo implantation and gestation even in older women.

The impact of embryo quality on pregnancy outcome in elderly women undergoing in vitro fertilization-embryo transfer (IVF-ET)

Most IVF-ET units limit the procedure to women below age 38. Nevertheless, demands for infertility treatment, including IVF therapy, are more frequent nowadays. We compared 46 cycles for ovulation induction for IVF in 46 women aged 40 or more (Group I) to 51 induced cycles for this procedure in younger women of mean age 30.2 years (Group II). Cancellation rates due to early luteinization or ovulation were significantly higher in group I than in group II (28.2 and 17.6%, respectively) (P less than 0.001). Also, significantly higher abortion rates were observed in older women (62.5%), in comparison to the younger control group, (25%), (P less than 0.001). It is suggested that the high abortion rate considered to be due to genetic factors in older women, may possibly also be due to the aging uterine environment. Furthermore, while embryos with fragmentations may often produce clinical pregnancies in the young, the aging uterus in the elderly woman does not encourage the development of clinical pregnancies in such embryos. Consequently the higher abortion rate in the elderly woman.

Oocyte donation program using a simplified hormonal regimen

It has been well recognized that both the synchronization of luteinizing hormone (LH) surge between the donor and the recipient for normally cycling women and the complex steroid replacement regimen given on a sequential and incremental basis for women with primary or secondary ovarian failure are two important aspects in oocyte donation. In oocyte donation program at SNUH, a simplified hormonal regimen applicable both to normally cycling women and to those with ovarian failure which consisted of administering 2 mg estradiol (E2) valerate orally 3 times a day augmented with 100 mg progesterone (P) in oil intramuscularly daily starting on the day preceding the oocyte retrieval from the donor was utilized. From July 1988 to December 1989 at SNUH, 11 cycles of oocyte donation program in 10 infertile patients were undertaken and 5 patients succeeded in pregnancy.

Follicular depletion during the menopausal transition

From mid-fetal life, the human ovary steadily loses follicles. While age-related alterations at the level of the hypothalamus-pituitary appear to determine the timing of menarche, the number of follicles remaining in the mature ovary is the major determinant of the timing of both the perimenopause and the menopause. As the residual follicle reserve nears exhaustion, some of the remaining follicles appear to be defective, as evidenced by the higher incidence of chromosomal abnormalities in the ova of older women. It is presently not possible, however, to distinguish the specific contribution of the ovum to the age-related decrease in fecundity and higher abortion rate because of such confounding variables as aging sperm or changes in the endometrium. When follicle counts from peri- and postmenopausal ovaries are placed with those from previous studies of younger women and children there appears to be an acceleration in the rate of follicle loss in the decade preceding menopause. We hypothesize that the elevated FSH levels observed in normal women in the decade preceding the menopause may be responsible for this apparent acceleration in the rate of follicle loss.

Patient age and success in a human IVF programme

Previous studies suggest that at around 40 years of age, pregnancy rates achieved by IVF programmes fall and pregnancy loss rates increase. The actual age at which this occurs has not been clearly delineated. This study of 2,692 patients including 94 aged 41 or over shows that satisfactory pregnancy rates can be achieved up to and including age 40. As age 40 is approached the pregnancy loss rate increases to around 40%. In the 41 years and over group the pregnancy rate was poor at 6% (6/94) and the pregnancy loss rate very discouraging at 83% (5/6).

Effect of maternal age and number of in vitro fertilization procedures on pregnancy outcome

Five hundred twelve patients underwent 1,101 oocyte retrievals for in vitro fertilization (IVF) from July 1, 1985 to June 30, 1988. Eighty-four percent of all oocyte retrievals went on to transfer. The mean number of oocyte retrievals was 2.2 per patient, and the mean number of embryo transfers (ET) was 1.8 per patient. The pregnancy rate was 23% per retrieval, 27% per ET, and 49% per patient. There were 77 (31%) spontaneous abortions and five (2%) ectopic pregnancies. Linear regression analysis of the effect of women's age on the ongoing pregnancy rate per ET showed a highly significant negative linear correlation between age and ongoing pregnancy rate (P less than 0.005). Ongoing pregnancy rate per ET for patients younger than 30 years of age was 26%, as compared with 9% for patients aged 37 years (P less than 0.01). Patients aged 40 years or greater had a 50% miscarriage rate, compared with 29% in patients under the age of 40 (P greater than 0.05). The clinical pregnancy rate per ET for patients undergoing one to seven attempts was 25%, 29%, 28%, 33%, 35%, 30%, and two out of five, respectively. We conclude that women's age has a negative effect on IVF success that is more pronounced after the age of 36, and the pregnancy rate per ET is similar for at least seven attempts.

A prospective study of prognostic factors in in vitro fertilization and embryo transfer

Multiple factors influence the outcome of in vitro fertilization and embryo transfer (IVF-ET). This prospective study was designed to assess their relative importance, in order to improve prognostic ability and treatment success. Prior to IVF-ET, couples were divided into "good" (GP) and "poor" (PP) prognosis groups according to female age, semen quality, previous response to stimulation, and embryo quality. The data obtained from 716 consecutive treatment cycles then were evaluated using univariate statistics and logistic regression, a technique designed to assess the relative contribution of significant factors. The pregnancy rate per GP cycle was 14.7%, compared with 5.4% per PP cycle (chi 1(2) = 12.7, P less than 0.001). The most important prognostic factors were female age, the pregnancy rate showing a linear decline after the age of 25, and previous failed fertilization due to abnormal sperm. The rate of pregnancy also declined after 14 or more follicles were aspirated and/or nine oocytes were retrieved. A formula for the probability of pregnancy, derived from the logistic regression, provides patients with a more accurate prognosis before treatment.

Outcome in 242 in vitro fertilization-embryo replacement or gamete intrafallopian transfer-induced pregnancies

Two centers combined data on 152 in vitro fertilization embryo replacement and 90 gamete intrafallopian transfer generated pregnancies. The outcomes of the pregnancies with respect to abortion, ectopic gestation, and multiple gestation were evaluated independently by method and by center. Only with multiple gestation by center was a difference seen. Variables examined included estradiol levels, luteal phase support, maternal age, and prior reproductive history, and the number of eggs or embryos replaced.