Retrospective analysis of 1217 IVF cycles in women aged 40 years and older

Facilitation of Ovarian Response by Mechanical Force-Latest Insight on Fertility Improvement in Women with Poor Ovarian Response or Primary Ovarian Insufficiency

The decline in fertility in aging women, especially those with poor ovarian response (POR) or primary ovarian insufficiency (POI), is a major concern for modern IVF centers. Fertility treatments have traditionally relied on gonadotropin- and steroid-hormone-based IVF practices, but these methods have limitations, especially for women with aging ovaries. Researchers have been motivated to explore alternative approaches. Ovarian aging is a complicated process, and the deterioration of oocytes, follicular cells, the extracellular matrix (ECM), and the stromal compartment can all contribute to declining fertility. Adjunct interventions that involve the use of hormones, steroids, and cofactors and gamete engineering are two major research areas aimed to improve fertility in aging women. Additionally, mechanical procedures including the In Vitro Activation (IVA) procedure, which combines pharmacological activators and fragmentation of ovarian strips, and the Whole Ovary Laparoscopic Incision (WOLI) procedure that solely relies on mechanical manipulation in vivo have shown promising results in improving follicle growth and fertility in women with POR and POI. Advances in the use of mechanical procedures have brought exciting opportunities to improve fertility outcomes in aging women with POR or POI. While the lack of a comprehensive understanding of the molecular mechanisms that lead to fertility decline in aging women remains a major challenge for further improvement of mechanical-manipulation-based approaches, recent progress has provided a better view of how these procedures promote folliculogenesis in the fibrotic and avascular aging ovaries. In this review, we first provide a brief overview of the potential mechanisms that contribute to ovarian aging in POI and POR patients, followed by a discussion of measures that aim to improve ovarian folliculogenesis in aging women. At last, we discuss the likely mechanisms that contribute to the outcomes of IVA and WOLI procedures and potential future directions.

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.

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.

Outcome of two sequential singleton pregnancies and twin pregnancies among primiparous women at advanced age undergoing IVF

PURPOSE

To compare the obstetrical and detailed neonatal outcomes of primipara of advanced maternal age conceiving two sequential singleton pregnancies by IVF with those of primipara conceiving twins by IVF.

METHODS

A retrospective study of all primiparous women aged ≤ 38 years and conceived by IVF who delivered sequential singletons or delivered twins at a single tertiary university affiliated medical center between 2011 and 2019. We performed two main comparisons: 1. First vs. second singleton pregnancies. 2. Two singleton pregnancies vs. twin pregnancies.

RESULTS

Overall, there were 63 women with consecutive singleton IVF pregnancies. The median age was 40.0 at first pregnancy and 42.0 in the second pregnancy. Pregnancy and delivery complications rates did not differ significantly between the first and the second singleton pregnancies, including gestational hypertensive disorders (7 (11.1%) vs. 4 (6.3%), p = 0.530), gestational diabetes mellitus (13 (20.6%) vs 18 (28.5%), p = 0.410), intrauterine growth restriction (6 (9.5%) vs. 4 (6.3%), p = 0.744), or cesarean delivery (25 (39.7%) vs. 29 (46%), p = 0.589). Rates of delivery before 32 weeks gestation were similar for both first and second singleton pregnancies (1.6%, p > 0.999). The proportion of neonatal adverse outcome in both first and second singleton pregnancies groups was low and did not differ between the groups. Compared with women who delivered sequential singletons, women with twin pregnancies had significantly higher cesarean delivery rates (113 (83.7%) vs. 29 (46%), p < 0.001) and lower gestational ages at delivery (36.2 vs. 38.4, p < 0.001) than women with two singleton deliveries. Adverse neonatal outcomes were significantly higher for twin pregnancies, including birthweight < 1500 g (17 (12.6%) vs. 2 (3.2%), p = 0.036), neonatal intensive care unit admission (57 (42.2%) vs. 4 (6.3%), p < 0.001), neonatal hypoglycemia (23 (17%) vs. 3 (4.8%), p = 0.017), and respiratory distress syndrome (14 (10.4%) vs. 1 (1.6%), p = 0.040). Length of neonatal hospitalization was significantly longer for twins (9 vs. 5 days, p < 0.001). The rate of gestational hypertensive disorders (preeclampsia and gestational hypertension) was similar between the groups, but the rates of severe preeclampsia trended higher among women who carried twins (8 (5.9%) vs. 0, p = 0.057).

CONCLUSIONS

Sequential singleton pregnancies at primipara women of advanced maternal age have an overall very good outcome, with no clinically significant difference between the pregnancies. In addition, their outcome is much better compared with twins.

Cancer in IVF patients treated at age 40 years and older: long term follow-up

RESEARCH QUESTION

Current knowledge of cancer risk among women who undergo IVF is based mainly on studies of women treated in their thirties, frequently with short follow-up periods. Therefore, information about cancer risk among infertile menopausal women is limited. We aimed to evaluate the risk of cancer among IVF patients treated at age 40 years and older, followed up for an extended period.

DESIGN

Historical cohort study of all IVF patients treated at the age of 40 years or older at two university-affiliated IVF units in Jerusalem, Israel, between 1994 and 2002. Data were cross-linked with the Israel National Cancer Registry to 2016. Standardized incidence ratios (SIR) and 95% confidence intervals were computed by comparing the observed number of cancer cases with the expected cancer rate in the general Israeli population adjusted for age and year of birth. In addition, Kaplan-Meier analysis was conducted to account for the length of follow-up.

RESULTS

A total of 501 patients were included in the analysis, with mean follow-up of 16.7 ± 3.7 years (range 2-22 years). Mean age at first IVF cycle was 42.3 years (±2.1). Mean number of IVF cycles was 3.2 ± 2.6 (range 1-15). Thirty-six women (7.2%) developed invasive cancer, compared with 47.2 expected cases; SIR 0.76 (95% CI 0.53 to 1.06); 22 women were diagnosed with invasive breast cancer, compared with 19.84 expected; SIR 1.11 (95% CI 0.69 to 1.68).

CONCLUSIONS

Older women undergoing IVF treatment were not significantly associated with an excess risk of cancer at long-term follow up. Further studies, however, are needed to confirm these findings.

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 and number of oocytes retrieved in women of advanced age. A single centre analysis including 4500 women ≥38 years old

STUDY QUESTION

Is there any relationship between the number of oocytes retrieved and cumulative live birth rates (CLBRs) in women of advanced age?

SUMMARY ANSWER

CLBRs increase with the number of oocytes retrieved in women of advanced reproductive age up to 41 years old, the added value is minimal in women more than 41 years and futile in women 44 years or older.

WHAT IS KNOWN ALREADY

CLBR is actually the most relevant outcome of IVF from patients' perspective. There are several studies that have analysed CLBR's but some of them have included several stimulation cycles, others have not included the frozen embryo transfers (FETs) in their analysis and none has focused on women of advanced reproductive age. We aimed to assess CLBR in women ≥38 years after a single stimulation cycle plus the subsequent frozen embryo transfers.

STUDY DESIGN, SIZE, DURATION

This is a retrospective analysis carried out in a University-affiliated tertiary centre between January 2000 and December 2013. Overall, 4570 infertile women aged ≥38 years who underwent their first cycle in our centre were included.

PARTICIPANT/MATERIALS, SETTING, METHODS

Patients were categorized in four age-groups: 38-39 years (G1 = 1875 cycles), 40-41 years (G2 = 1380 cycles), 42-43 years (G3 = 833 cycles) and ≥44 years (G4 = 482 cycles). CLBR's were evaluated by adding the pregnancies and live births achieved in the FET's to the ones obtained in the fresh cycle. In order to find out the actual effect of the number of oocytes retrieved in these patients, a predictive model of CLBR according to age and oocyte yield was built.

MAIN RESULTS AND THE ROLE OF CHANCE

CLBRs significantly decrease with increasing age among women ≥38 years of age, with the most prominent and clinically relevant decline observed at 42-43 years old, and clear evidence for futility in women aged ≥44 years (25.9% at 38-39 years, 16.4% at 40-41 years, 7% at 42-43 years and 1.2% from 44 years onwards). The higher the number of oocytes retrieved, the higher the CLBR; however, this is more evident up to 41 years old and no clear benefit is observed from 44 years and beyond.

LIMITATIONS, REASONS FOR CAUTION

Limitations are related to the retrospective nature of the study; however, no significant differences were observed in the treatment protocols used. Other potential limitations could be the fact that embryo cryopreservation was carried out with slow freezing in 80% of cases and that a small proportion of patients still have frozen embryos; nevertheless, we do not expect a relevant impact of these issues as slow freezing showed excellent results that did not differ significantly compared to vitrification and, on the other hand, the extra benefit coming from the FETs was very limited.

WIDER IMPLICATIONS OF THE FINDINGS

The number of oocytes retrieved is significantly associated with CLBR also in women of advanced reproductive age. However, the added benefit appears to be restricted mainly in women up to 41 years old. Women over 43 do not experience any benefit in CLBR irrespective of the number of oocytes retrieved, and thus should be discouraged from doing an IVF cycle with their own oocytes; for the other age-groups, recommendations should be given considering the age and the expected ovarian response.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NA.

The Effect of Advanced Maternal Age on Embryo Morphokinetics

Purpose: To compare the morphokinetic parameters of pre-implantation development between embryos of women of advanced maternal age (AMA) and young women. Methods: Time-lapse microscopy was used to compare morphokinetic variables between 495 embryos of AMA women ≥ age 42 years and 653 embryos of young patients (<age 38 years) who underwent IVF in our unit. Developmental events annotated and analyzed include observed cell divisions in correlation to the timing of fertilization, synchrony of the second (s2) and third cell cycles (s3) and the duration to the second (cc2) and third cleavages (cc3). Results: No significant differences were observed in cleavage times between the embryos of AMA and the control embryos. Interestingly, the older embryos appear to be more prone to developmental arrest (a higher percentage of embryos of older women arrested at 4-7 cells resulting in less embryos reaching the 8-cell stage (66% vs. 72%, respectively), though this difference did not reach a significance at least during the first 3 days of development (p > 0.05). Conclusions: While early morphokinetic parameters do not reflect dynamics unique to embryos of older women, a tendency toward developmental arrest was observed, which would likely be even more pronounced at later stages of development.

The expected cumulative incidence of live birth for patients starting IVF treatment at age 41 years or older

RESEARCH QUESTION

What is the cumulative incidence of live birth (CILB) for high-order consecutive IVF cycles, and which factors are associated with live birth in women aged ≥41 years using autologous oocytes?

DESIGN

A retrospective cohort study including 146 patients aged 41 years to <44 years who started their first IVF cycle attempt using autologous oocytes, between January 2006 and December 2013.

RESULTS

After 13 IVF cycles, CILB reached up to 33.6%. After six IVF cycles, 42 (28.8%) women delivered a live infant (85.7% of the total live birth). Mean live birth rate per cycle declined with age at the initial cycle (8% at 41 years; 5.8% at 42 years; and 4.1% at 43 years). Multivariable modified Poisson regression models identified patient's age (RR for 41 years versus 43 years: 0.47; 95% CI 0.25 to 0.87; P = 0.01), smoking status (RR 0.21; 95% CI 0.05 to 0.08; P = 0.02), and mean number of fertilized oocytes (RR 1.23; 95% CI 1.08 to 1.39; P < 0.01) as factors significantly associated with the probability of a live birth.

CONCLUSIONS

Multiple repeat IVF cycles in women aged 41-44 years offers a reasonable long-term success rate. After six cycles of treatment, about 29% of women of advanced reproductive age using autologous oocytes expected to achieve a live birth. This information might assist in fertility counselling and managing patients' expectations by adjusting the appropriate treatment strategy and number of IVF cycle attempts, especially in countries in which egg donation is prohibited or when multiple repeated IVF cycles attempts are financially affordable.

What should we focus on before preimplantation genetic diagnosis/screening?

INTRODUCTION

Preimplantation genetic diagnosis/screening (PGD/PGS) can effectively detect chromosomal abnormalities in an embryo but only if an embryo is available. However, not all couples can obtain an embryo that is available for testing. The purpose of this study was to identify factors which might affect the formation of PGD/PGS embryos to predict the possibility of obtaining embryos that could be detected.

MATERIAL AND METHODS

In a retrospective study, we included all couples who underwent PGD/PGS at our center from January 2015 to December 2016. We compared these patients according to the non-blastocyst group and the blastocyst group.

RESULTS

There were 302 couples who had blastocysts in their first PGD/PGS cycle. Fifty-seven couples had no blastocysts in their PGD/PGS cycles: 43 couples had no blastocysts in one cycle; 10 in two cycles; 4 in three cycles. The non-blastocyst group was older than the blastocyst group (32.37 vs. 30.69, p = 0.048). Anti-mullerian hormone (AMH, ng/ml) in the non-blastocyst group was significantly lower than in the blastocyst group (4.80 ±3.67 vs. 3.07 ±2.30, p = 0.00). Women whose chromosome were aneuploid (47, XXX or 45, X) had a similar AMH level compared with others, but the number of retrieved oocytes was much lower; the normal karyotype was 14.25 and aneuploidy was 5.40 (p = 0.01) in women < 30 years old. There was the same condition in women aged 30-38 years (14.60 vs. 3.44, p < 0.001). Male's different chromosome karyotype had no influence on double pronuclear number or the rate of blastocyst formation. Presence of endometriosis, polycystic ovary syndrome and tubal factor showed no difference between the blastocyst and non-blastocyst group. Nor did oligospermia and asthenospermia.

CONCLUSIONS

Elderly women, those with lower AMH and women with 47, XXX or 45, X have fewer ova, leading to the possibility of no blastocyst. These couples should be fully informed and weigh the advantages and disadvantages before undergoing PGD/PGS.

Reproductive ageing-turning back the clock?

BACKGROUND

Unintended childlessness is a distressing, and often unintended, consequence of delayed childbearing and reproductive ageing. The average maternal age at first birth has risen steadily in many industrialised countries since the 1980s. There are many societal factors involved in the decision to postpone motherhood. As a result, many women are postponing having children until it is too late. In this review, we aim to summarise the reasons behind delayed childbearing, the impact of delayed childbearing and the scientific advances that seek to reverse reproductive ageing and ensure reproductive autonomy for women.

METHODS

An extensive literature search of PubMed was conducted to include all published articles on delayed childbearing and the consequences of reproductive ageing. Secondary articles were identified from key paper reference listings.

CONCLUSION

If the current reproductive trends continue, many women will find themselves in the harrowing position of being unintentionally childless. In addition, many will inevitably turn to assisted reproductive technologies in an effort to protect and preserve their reproductive autonomy. However, it is not always possible to reverse the effects of reproductive ageing.

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.

Cumulative pregnancy and live birth rates through assisted reproduction in women 44-45 years of age: is there any hope?

PURPOSE

The purpose of the study is to calculate the cumulative pregnancy rate and cumulative live birth rate in women undergoing in vitro fertilization (IVF) at ages 44-45.

METHODS

The study calculated cumulative live pregnancy rate and cumulative live birth rate of 124 women aged 44 to 45 years old who commenced IVF treatment.

MAIN OUTCOME MEASURES

The main outcome measures are cumulative live pregnancy rate and cumulative live birth rate.

RESULTS

Cumulative live pregnancy rates following 1, 2, 3, and 4 cycles were 5.6, 11, 17, and 20%, respectively, with no additional pregnancies in further cycles. Cumulative live birth rates following 1, 2, and 3 cycles were 1.6, 3, and 7%, respectively, with no additional live births in further cycles.

CONCLUSIONS

The cumulative pregnancy rate rises during the first 4 cycles and cumulative live birth rate rises during the first 3 cycles, with no additional rise in pregnancies or deliveries thereafter, suggesting that it is futile to offer more than 3 cycles of treatment to 44-45-year-old women.

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.

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 retrospective study of the effect of increasing age on success rates of assisted reproductive technology

OBJECTIVE

To demonstrate the effect of increasing age on the outcome of assisted reproductive technology, particularly among women aged 40 years or older.

METHODS

A retrospective analysis was conducted using prospectively collected data for all in vitro fertilization and intracytoplasmic sperm injection cycles among women aged 30-35 years or 40-44 years conducted at Merrion Fertility Clinic, Dublin, Ireland, between January 1, 2010, and December 31, 2014. The relationship between age and treatment outcome was assessed.

RESULTS

Among women aged 30-35 years, 726 cycles led to 281 (38.7%) clinical pregnancies and 242 (33.3%) live births. By contrast, among women aged 40-44 years, 433 cycles led to 102 (23.6%) clinical pregnancies and 64 (14.8%) live births (both P<0.001). The live birth rate was particularly low after cycles among the women aged 42 years (5/89 [5.6%]) or 43 years (2/30 [6.7%]).

CONCLUSION

The success rates of assisted reproductive technology are decreased among women aged older than 40 years. Fertility clinics have a responsibility to fully inform this group about the limitations of assisted reproductive technology.

Live birth rates are satisfactory following multiple IVF treatment cycles in poor prognosis patients

This seven-year retrospective study analysed the live birth rate (LBR) for women undergoing IVF treatment with various antral follicle counts (AFC). The LBR decreased with lower AFC ratings, and in 290 treatment cycles for women in the poorest AFC category, ≤4 follicles (group E), the LBR was the lowest at 10.7%. The pregnancy loss rate (PLR) significantly increased with poorer AFC categories, from 21.8% in AFC group A (≥20 follicles), to 54.4% in AFC group E (p<0.0001). This trend was repeated with advancing age, from 21.6% for younger women (<35years), to 32.9, 48.5 and 100% for ages 35-39, 40-44 and ≥45 years, respectively (p<0.0001). However, LBR within the specific AFC group E cohort was also age-dependent and decreased significantly from 30.0% for <35 years old, to 13.3, 3.9 and 0% for patients aged 35-39, 40-44 and ≥45 years, respectively. Most, importantly, LBR rates within these age groups were not dependent on the number of IVF attempts (1st, 2nd, 3rd or ≥4 cycles), which indicated that cycle number should not be the primary deciding factor for cessation of IVF treatment in responding women <45years old.

The effect on pregnancy and multiples of transferring 1-3 embryos in women at least 40 years old

PURPOSE "CAPSULE" IS MANDATORY. PLEASE PROVIDE.SINGLE EMRBYO TRANSFER (SET) IN WOMEN ≥40 YEARS OLD APPEARS TO LOWER THE CHANCE OF A PREGNANCY. HOWEVER, IT MINIMIZES THE RISK OF MULTIPLE PREGNANCIES EVEN IN WOMEN OF ADVANCED MATERNAL AGE. THEREFORE, WOMEN 40 YEARS OF AGE OR OLDER SHOULD BE OFFERED (SET).: This study was performed to investigate the multiple pregnancies and live birth rates when 1-3 embryos are transferred at this age in women at least 40 years of age.

METHOD

A retrospective analysis of data which included 631 women aged 40 to 46 years, who underwent 901 cycles of IVF, from August 2010 to June 2012 was undertaken. These women underwent embryo transfer of 1-3 non-donor fresh embryo(s).

RESULTS

Results suggested that the average pregnancy rate when up to three embryos were transferred was 25 % for women 40 years old, 20 % for women 41 years old, 16 % for women 42 years old, 17 % for women 43 years old, 8 % for women 44 years old, 6 % for women 45 years old, and 0 % for women 46 years old. No live births occurred in women treated after their 44th birthday, and only patients younger than 42 years of age receiving double embryo transfer had a live birth of twins. Live birth rates increased as more embryos were transferred for 40- and 42-year-old subjects (p = 0.01 and 0.05, respectively).

CONCLUSIONS

From these results, it was concluded that SET in women ≥40 years old appears to lower the chance of a pregnancy. However, it minimizes the risk of multiple pregnancies even in women of advanced maternal age. Women 40 years of age or older should be offered single-embryo transfer. Further studies are needed to determine risk of multiple pregnancies in women 42 years of age or older when few embryos are transferred. Decisions on the number of embryos to transfer should be on a case by case basis, in discussion with the patient.

Predicting suitable timing for artificial reproductive technology treatment in aged infertile women

It has been widely accepted that the age of women plays a fundamental role in fecundity, and age-related fertility decline has one of the most significant and detrimental effects on the success rate of infertility treatment. Therefore, treatment cycles of non-in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment for infertile women of advanced aged have been limited due to their lack of efficacy, and they are often optimized, compared to IVF/ICSI treatment. Recent trends in infertility treatment apparently indicate that IVF/ICSI treatment, including egg donation, is frequently offered to aged women for first-line management, despite its heavy burden, but hasty IVF/ICSI treatment should be avoided, considering its socioeconomic problems. It is important to distinguish women who could conceive by non-IVF/ICSI treatment, although the optimization of non-IVF/ICSI treatment protocols remains poorly understood. This review focuses on extracting aged patients who have higher chance of conceiving with non-IVF/ICSI treatment and providing necessary and sufficient infertility treatment. After initial evaluation for fertility, including tubal factor, male factor, the presence of endometriosis and/or adenomyosis, and ovarian reserve, the outcomes of fertility treatment can be predicted to some extent in aged infertile women.

Younger poor ovarian response women achieved better pregnancy results in the first three IVF cycles

This retrospective cohort study observed the live birth rates as well as cumulative live birth rates in women with poor ovarian response (POR) undergoing IVF-embryo transfer treatment, stratified for age and cycle number. Four hundred and one patients with POR diagnosed according to the Bologna criteria were enrolled and 700 IVF-ET cycles were analysed. The overall live-birth rate per cycle was 18.3%. From cycle 1 up to cycle 3, the live-birth rates decreased significantly from 22.2% to 11.1%. The live-birth rate fell to 2.4% in cycles 4 and over. When age advanced, the live birth rates decreased obviously (P < 0.01): 30.0% for women < 35 years old, 17.0% for those 35-40 years old, and 9.0% for women older than 40 years. Similarly, the cumulative live birth rates dropped from 48.0% (< 35 years) to 16.9% (≥ 40 years) accordingly. Younger patients (< 35 years old) with POR achieved better pregnancy results compared with patients of advanced age. Extremely low live-birth rates could be anticipated after three unsuccessful cycles; therefore it may not be appropriate to suggest more IVF cycles in POR women.

Influence of late-age births on maternal longevity

PURPOSE

To examine the association between the mother's age at last birth and maternal long-term survival.

METHODS

Data from three national censuses (1972, 1983, and 1995) and national birth and death records (1972-2009) were used to examine the association between age at last birth and mortality while accounting for potential confounders, such as parity. Age-adjusted mortality rates and Cox proportional hazard models were used in the analysis.

RESULTS

A total of 887 women who delivered their last child after 45 years of age were identified from among 178,507 women (1,592,379 person-years). Age-adjusted mortality rates from 55 years of age were highest for childless women (9.2 per 1000) and decreased linearly (P < .001) for parous women with increased age at last birth (5.2 per 1000 for women aged ≥45 years at last birth). In models adjusted for age at first birth and parity, mortality risks were lowest among parous women with late-age births (≥45 years) compared with parous women with their last births before 35 years of age (hazard ratio, 0.58; 95% confidence interval, 0.40-0.86).

CONCLUSIONS

This study provides new empirical evidence that late-age births are associated with maternal longevity, although a direct causal relation cannot be established with the information available.

Effectiveness of in vitro fertilization in women with previous tubal sterilization

OBJECTIVE

The objective was to determine the effectiveness of in vitro fertilization (IVF) on live-delivery rates in women who had previously undergone tubal sterilization.

STUDY DESIGN

We examined first IVF live deliveries for women aged 20-44 years at their first embryo transfer (ET) with history of hospital admission for tubal sterilization in Western Australia (WA). The ET cycles (n=178) were ascertained over the period of 1996 to 2010 using WA hospital records. A control group of subfertile women matched by age was randomly selected (n=178). We used Kaplan-Meier curves and life-table analysis to evaluate the cumulative live-delivery rates.

RESULTS

An overall cumulative live-delivery rate in women who had undergone previous tubal sterilization (31%) was comparable to that of subfertile controls (34%) within the first 24 months. Younger women (aged 20-34 years) with previous sterilization (34%) were slightly more likely to deliver an IVF live baby than older women (aged 35-39 and 40-44 years) (33% and 22%, respectively), although this difference was not statistically significant (p=.449).

CONCLUSION

Women who desire fertility after a tubal sterilization procedure and undergo IVF have rates of pregnancy similar to age-matched subfertile IVF control patients.

IMPLICATIONS

In vitro fertilization success in women who had undergone previous tubal sterilization is similar to that of the subfertile controls and thus does not depend on past fertility. Age is the most important predictive factor in achieving pregnancy.

Beyond the American Society for Reproductive Medicine transfer guidelines: how many cleavage-stage embryos are safe to transfer in women ≥43 years old?

OBJECTIVE

To determine the number of cleavage-stage embryos that can be safely transferred in women ≥43 years old.

DESIGN

Retrospective cohort.

SETTING

Academic medical center.

PATIENT(S)

All patients ≥43 years old undergoing transfer of five or more cleavage-stage embryos during the period from January 2004 through April 2012.

INTERVENTION(S)

In vitro fertilization.

MAIN OUTCOME MEASURE(S)

A total of 567 cycles in 464 patients aged 43-45 years, whose IVF cycles were characterized by transfer of five to eight cleavage-stage embryos were identified. Clinical outcomes and risk of multiples were analyzed, stratifying by age and number of embryos transferred.

RESULT(S)

Live birth rates per transfer were 14.4%, 9.4%, and 1.3% for women aged 43, 44, and 45 years, respectively. In 43-year-old women, 2.9% (2/69) of pregnancies were triplet gestations (one selective reduction and one spontaneous reduction). Twin birth rate was 16.3%, 6.7%, and 0 (of all live births) for ages 43, 44, and 45 years, respectively. There was no higher order multiple births. Women aged 43 and 44 years having five or more embryos transferred experienced higher clinical pregnancy rates (PRs) than those patients receiving a transfer of three or four embryos. Clinical outcomes for patients undergoing transfer with six or more embryos were not better than those undergoing transfer with five embryos.

CONCLUSION(S)

Transferring five or more day 3 embryos may be a safe option for patients ≥43 years of age, as it is associated with an overall low rate of multiple gestations. Having more than five embryos available for transfer on day 5 is associated with improved IVF outcomes. Whether this benefit is from the additional embryo(s) for transfer or the inherently better prognosis of such patients remains to be determined.

Reproductive outcome of women 43 years and beyond undergoing ART treatment with their own oocytes in two Connecticut university programs

PURPOSE

The aim of this study was to analyze the outcomes of IVF/ICSI cycles in women aged 43 and beyond.

METHODS

Retrospective analysis of clinical pregnancy and live birth rates in 168 fresh, non donor, ART cycles performed in two Connecticut university IVF programs.

RESULTS

In women of 43 and 44 years the overall clinical pregnancy and live birth rates were 8.3% and 5.3% per initiated cycle, respectively. There were no clinical pregnancies in women ≥45 years old. First cycle characteristics were not different from repeated cycles in terms of duration of ovulation induction, number of collected oocytes and transferred embryos (p > 0.05).

CONCLUSIONS

Pregnancies can still be achieved with IVF/ICSI up to the age of 44. Since most pregnancies occurred within the first 3 cycles, another attempt may be a reasonable option before resorting to oocyte donation for patients who failed two previous cycles. Women 45 years and beyond do not benefit from ART procedures using their own oocytes.

Evaluation of the ovarian reserve in women transplanted with frozen and thawed ovarian cortical tissue

OBJECTIVE

To investigate ovarian reserve and ovarian function in women transplanted with frozen/thawed ovarian tissue.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

18 women transplanted with their own frozen/thawed ovarian tissue.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of antimüllerian hormone (AMH), duration of function of the transplanted ovarian tissue, outcome of assisted reproduction.

RESULT(S)

Of the 18 women who received transplanted ovarian tissue, levels of AMH were measured in 12 women; AMH never exceed a concentration of 1 ng/mL, and in several cases they were below the detection limit of the assay in combination with regular menstrual cycles. Two women with AMH below the detection limit conceived spontaneously. The duration of function of the transplants was between 9 months and 7 years and still functioning. Twelve women received assisted reproduction therapy; in 72 cycles, 65 oocytes were retrieved. The pregnancy rate and live-birth rate per cycle were 6.9% (5 of 72) and 2.8% (2 of 72), respectively.

CONCLUSION(S)

The relatively poor outcome of assisted reproduction in women transplanted with frozen/thawed ovarian tissue may reflect reduced follicular selection rather than defective or aged oocytes. In normal women, reduced follicular selection with age may be part of explaining the decline in female fecundity with increasing age.

Assisted reproductive technologies: a systematic review of safety and effectiveness to inform disinvestment policy

OBJECTIVE

Health policy relating to assisted reproductive technologies (ART) has been variably informed by clinical evidence, social values, political and fiscal considerations. This systematic review examined key factors associated with specific benefits and harms of ART to inform the development of a model for generating policy recommendations within an Australian disinvestment research agenda.

METHODS

Six databases were searched from 1994 to 2009. Included articles contained data on safety and/or effectiveness of in vitro fertilisation (IVF) or IVF with intracytoplasmic sperm injection with reference to female age, male age or cycle rank. Narrative descriptions of key outcomes (live birth, miscarriage) were constructed alongside tabular summaries.

RESULTS

Sixty-eight studies and one registry report were included. There was substantial heterogeneity present within the evidence-base which limited the strength and scope of conclusions that could be drawn. However, this review does affirm the differential effectiveness associated with the ageing of ART patients with regard to live birth and miscarriage.

CONCLUSION

From the available evidence, it was not possible to determine an explicit age or cycle rank that could be used to formulate defensible policy responsive to identified differential effectiveness. Stakeholder interpretation of this evidence-base may assist in developing policy that can incorporate uncertainty and reflect social values.

Cancellation of in vitro fertilization treatment cycles predicts treatment outcome in female infertility patients aged 40 years or older

Purpose

To investigate potential indicators of in vitro fertilization (IVF) treatment outcome for female infertility patients aged ≥ 40 years based on the clinical course.

Methods

We retrospectively examined results of 111 female infertility patients aged ≥ 40 years undergoing IVF treatment. We investigated the relationship between treatment cycle cancellation and the final outcome of IVF treatment in female infertility patients aged ≥ 40 years.

Results

A total of 44 pregnancies were achieved. Overall pregnancy rate per initiated treatment cycle was 12.1%, and 24 spontaneous abortions occurred (54.5%). No woman aged ≥ 45 years achieved pregnancy. No patients conceived after 10 treatment cycles while 42 (11.5%) oocyte pick-up cycles and 120 (33.0%) embryo transfer cycles were canceled. Investigation of correlation with treatment cycle cancellation revealed that patients who experienced embryo transfer cancellation had a high spontaneous abortion rate while only a few patients who experienced oocyte pick-up cancellation achieved pregnancy and even fewer achieved a successful outcome.

Conclusions

Our study suggests that, in addition to patient age and number of treatment cycles, cancellation of treatment cycle also provides another useful indicator for pregnancy outcome.

Multiplying recipients paired with oocyte donors optimizes the use of donated oocytes

OBJECTIVE

To review donor-egg assisted reproductive technology (ART) activity using young fertile donors (<37 years of age) paired with multiple recipients.

DESIGN

Age-matched cohort study.

SETTING

Tertiary ART center at Cochin Hospital, Paris.

PATIENT(S)

A total of 125 oocyte donors and 361 age-matched control subjects. Donated oocytes were attributed to 163 different recipients undertaking 258 transfer cycles.

INTERVENTION(S)

Donor-egg and regular ART.

MAIN OUTCOME MEASURE(S)

Controlled ovarian hyperstimulation (COH) outcome-oocytes provided-was compared in donors and control subjects. Clinical pregnancy (cPR), ongoing pregnancy (oPR), and implantation (IR) rates per transfer in recipients were compared with age-matched controls. IRs were analyzed in the various recipients as a function of the number of oocytes harvested.

RESULT(S)

COH outcome was similar in donors and control subjects. cPR (37.5%), oPR (28.4%), and IR (24.4%) were slightly but significantly lower in donor-egg recipients compared with control subjects (44.9%, 37.4%, and 31.8%, respectively). More embryos (average +2.06) were transferred fresh and fewer frozen. In recipients, IRs were independent from the number of oocytes received in the donor.

CONCLUSION(S)

Multiplying recipients paired with oocyte donors slightly lowered per-transfer outcome, but enabled more (average +2.06) embryos to be transferred fresh.

[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.

Routine morphological scoring systems in assisted reproduction treatment fail to reflect age-related impairment of oocyte and embryo quality

Routine morphological scoring systems in assisted reproduction treatment are based on parameters that presumably correlate with the biological quality of gametes and embryos, including chromosome abnormalities. Maternal age is a key factor predicting pregnancy and live birth, and it is therefore of considerable interest to identify age-related indicators of oocyte and embryo quality in assisted reproduction treatment. The purpose of this study was to examine whether routine morphological scoring systems reflect age-related impact on oocyte and embryo quality among 4587 couples undergoing their first assisted reproduction treatment. This study assessed over 43,000 oocytes, 25,000 embryos and 7900 transferred embryos and analysed the associations among the following parameters: number of oocytes retrieved, oocyte quality, including maturity, fertilization rates, embryo quality, based on morphological features, and treatment outcome. Advanced chronological age was found to be associated with fewer oocytes retrieved, fewer embryos available for cryopreservation, as well as lower pregnancy, implantation, live birth rates and a higher miscarriage rate. No age-related correlation was found between fertilization rates, oocyte or embryo quality. Routinely-used morphological scoring systems, such as assessment of blastomere count, shape and fragmentation, fail to reflect age-related impact on oocyte and embryo quality.

Predictive factors of successful pregnancy after assisted reproductive technology in women aged 40 years and older

Purpose

This study aimed to investigate the factors that predict successful pregnancy (live birth) in assisted reproductive technology (ART) for infertile women aged 40 and older.

Methods

Patients who underwent first ART treatments at the age of 40 and older at our institution were enrolled. Several factors which can be evaluated before the first treatments were retrospectively compared among those patients who did and did not achieve live birth.

Results

Nineteen of 119 patients delivered healthy babies. There was no significant difference of live-birth rate among age groups of 40, 41 and 42. No women who underwent the first treatment at age 43 or older achieved live birth. In the successful group, significantly more women held FSH levels under 12 mIU/ml and had regular menstrual cycles (26-32 days) than unsuccessful women of the same age group. In addition, significantly fewer women in the successful group had prior ovarian surgery.

Conclusions

Our results show that low FSH levels, regular menstrual cycles and absence of prior ovarian surgery were related to high live-birth rates and they are good prognostic factors in patients between 40 and 42 years of age. On the other hand, none of these parameters were correlated with success in women aged 43 and older.

Anti-Müllerian hormone and ovarian dysfunction

Anti-Müllerian hormone (AMH) has important roles in postnatal ovarian function. Produced by ovarian granulosa cells, AMH is involved in initial follicle development. In fact, serum AMH level correlates with ovarian follicle number. In patients with polycystic ovary syndrome (PCOS), AMH levels are elevated, which indicates its potential relevance in PCOS diagnosis and management. AMH represents a useful clinical marker for the assessment of ovarian reserve in cases of subfertility caused by advanced age in women. A potential role for AMH in dominant follicle selection has also been suggested. Future challenges comprise the availability of a well-standardized assay and the development of AMH agonists and antagonists as possible tools to manipulate ovarian function for contraception or ovarian longevity.