Association of overweight and obesity with cumulative live birth rates according to women's age: A cohort study of 26 567 treatment cycles

OBJECTIVE

To evaluate the effect of age on the association between maternal body mass index (BMI) and cumulative live birth rates (CLBRs) following in vitro fertilization treatment.

METHOD

We retrospectively analyzed the data of 26 567 women undergoing in vitro fertilization/intracytoplasmic sperm injection from 2016 to 2019. We conducted multivariate regression analysis of the association between CLBRs and maternal BMI and age category.

RESULTS

A total of 16 626 (62.58%) patients achieved a live birth. Women with obesity had significantly decreased CLBRs compared with women who had normal weight (odds ratio [OR] 0.73 [95% confidence interval (CI), 0.66-0.80]). The significant interaction between age and BMI suggested that the impact of BMI on CLBRs was moderated by women's age (P interaction <0.001). The association between obesity and CLBRs was inverse among women aged <30 years (OR, 0.63 [95% CI, 0.54-0.73]), 30 to 34 years (OR, 0.79 [95% CI, 0.67-0.93]), and 35 to 37 years (OR, 0.71 [95% CI, 0.52-0.98]); however, decreases in CLBRs with obesity were not observed in women aged 38 to 40 years (OR, 1.17 [95% CI, 0.70-1.94]) and ≥ 41 years (OR, 1.25 [95% CI, 0.53-2.96]).

CONCLUSION

Maternal obesity was significantly associated with a lower likelihood of having a live birth, but the risk differed according to women's age. A higher BMI might have a less-pronounced detrimental effect with increasing age.

Correlation of female age with outcome of IVF in a low-resource setting

OBJECTIVE

To determine the effect of female age on pregnancy outcome after in vitro fertilization/embryo transfer (IVF-ET).

METHODS

A prospective study was conducted involving 266 women who had IVF-ET at Nisa Fertility and Genetic Center, Abuja, Nigeria. All eligible consenting women were recruited to the study. The main outcome measure was clinical pregnancy. Data were analyzed using IBM SPSS Statistics version 25. P < 0.05 at 95% confidence intervals was taken as significant.

RESULTS

A total of 266 patients were recruited and included in the study; 104 pregnancies were recorded, giving an overall pregnancy rate of 39.1%. The age range of the patient was 26-43 years (mean age 33.9 ± 2.41 years) while the mean number of embryo transfers per patient was 2.2. The clinical pregnancy rate for women aged below 30 years was 69.4% while the pregnancy rate for patients aged 30-34 years, 35-39 years, and 40-43 years was 52.6%, 24.7%, and 9.4%, respectively (P < 0.0001).

CONCLUSION

The study found that the success rate of IVF-ET decreases significantly in women aged over 34 years. Women should be counseled about the age-related risk of infertility and referred to a fertility center as early as possible.

The Impact of Assisted Hatching on Monozygotic Twinning is Related to Female Age and Insemination Method: A New Perspective

Whether assisted hatching (AH) is associated with a higher incidence of monozygotic twinning (MZT) in women undergoing assisted reproductive technology remains controversial; the aim of the study was to demonstrate the relationship between AH and MZT. A total of 8900 clinical pregnancies were selected among embryo transfer cycles from January 2011 to October 2019. Women receiving day (D) 3 embryos were divided into groups A-C: group A (n = 1651) and group B (n = 1045) included women aged ≤37 or ≥38 years, respectively, with zona pellucida (ZP) thinning; group C (n = 3865) included women aged ≤37 years without AH. Women aged ≤37 years who underwent blastocyst transfer and/or blastocyst ZP breaching were included in group D (n = 2339). The incidence of MZT was compared among groups A, B and C, and between groups C and D. The incidence of MZT in group B (2.2%) was significantly higher than in group A (1.0%), especially following intracytoplasmic sperm injection (ICSI), while the incidence of MZT in group A (1.0%) was significantly lower than in group C (2.2%). The MZT rate with in vitro fertilization was higher in group D (2.8%) than in group C (2.2%), but the MZT rate following ICSI was not significantly different between the two groups. ZP thinning of D3 embryos may increase the risk of MZT in older women (≥38 years), but decrease it in younger women (≤37 years). ZP breaching may be useful to reduce the incidence of MZT in ICSI-generated blastocysts.

The number and rate of euploid blastocysts in women undergoing IVF/ICSI cycles are strongly dependent on ovarian reserve and female age

STUDY QUESTION

Can the possibility of having at least one euploid blastocyst for embryo transfer and the total number of euploid blastocysts be predicted for couples before they enter the IVF programme?

SUMMARY ANSWER

Ovarian reserve and female age are the most important predictors of having at least one euploid blastocyst and the total number of euploid blastocysts.

WHAT IS KNOWN ALREADY

The blastocyst euploidy rate among women undergoing ART has already been shown to significantly decrease with increasing female age, and the total number of euploid embryos is dependent on the blastocyst cohort size. However, the vast majority of published studies are based on retrospective analysis of data.

STUDY DESIGN, SIZE, DURATION

This prospective analysis included 847 consecutively enrolled couples approaching their first preimplantation genetic testing for aneuploidies (PGT-A) cycle between 2017 and 2020. Only couples for whom ejaculated sperm was available and women with a BMI of <35 kg/m2 were included in the study. Only the first cycle was included for each patient.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study was conducted at an IVF centre where, for all patients, the planned treatment was to obtain embryos at the blastocyst stage for the PGT-A programme. The impact of the following covariates was investigated: a woman's serum AMH level, age, height, weight and BMI and a man's age, height, weight, BMI, sperm volume and sperm motility and morphology. The analysis was performed with a machine learning (ML) approach. Models were fit on the training set (677 patients) and their predictive performance was then evaluated on the test set (170 patients).

MAIN RESULTS AND ROLE OF CHANCE

After ovarian stimulation and oocyte insemination, 40.1% of couples had at least one blastocyst available for the PGT-A. Of 1068 blastocysts analysed, 33.6% were euploid. Two distinct ML models were fit: one for the probability of having at least one euploid blastocyst and one for the number of euploid blastocysts obtained. In the training set of patients, the variable importance plots of both models indicated that AMH and the woman's age are by far the most important predictors. Specifically, a positive association between the outcome and AMH and a negative association between the outcome and female age appeared. Gradient-boosted modelling offers a greater predictive performance than generalized additive models (GAMs).

LIMITATIONS, REASONS FOR CAUTION

The study was performed based on data from a single centre. While this provides a robust set of data with a constant ART process and laboratory practice, the model might be suitable only for the evaluated population, which may limit the generalization of the model to other populations.

WIDER IMPLICATIONS OF THE FINDINGS

ML models indicate that for couples entering the IVF/PGT-A programme, ovarian reserve, which is known to vary with age, is the most important predictor of having at least one euploid embryo. According to the GAM, the probability of a 30-year-old woman having at least one euploid embryo is 28% or 47% if her AMH level is 1 or 3 ng/ml, respectively; if the woman is 40 years old, this probability is 18% with an AMH of 1 ng/ml and 30% with an AMH of 3 ng/ml.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by an unrestricted grant from Gedeon Richter. The authors declared no conflict of interests.

TRIAL REGISTRATION NUMBER

N/A.

Evaluation of Ovarian Reserve Tests and Age in the Prediction of Poor Ovarian Response to Controlled Ovarian Stimulation-A Real-World Data Analysis of 89,002 Patients

Aims

This study aimed to explore the value of ovarian reserve tests (ORTs) for predicting poor ovary response (POR) and whether an age cutoff could improve this forecasting, so as to facilitate clinical decision-making for women undergoing in vitro fertilization (IVF).

Methods

A retrospective cohort study was conducted on poor ovary response (POR) patients using real-world data from five reproductive centers of university-affiliated hospitals or large academic hospitals in China. A total of 89,002 women with infertility undergoing their first traditional ovarian stimulation cycle for in vitro fertilization from January 2013 to December 2019 were included. The receiver operating characteristic (ROC) curve was performed to estimate the prediction value of POR by the following ORTs: anti-Mullerian hormone (AMH), antral follicle count (AFC), basal FSH (bFSH), as well as patient age.

Results

In this retrospective cohort, the frequency of POR in the first IVF cycle was 14.8%. Age, AFC, AMH, and bFSH were used as predicting factors for POR, of which AMH and AFC were the best indicators when using a single factor for prediction (AUC 0.862 and 0.842, respectively). The predictive values of the multivariate model included age and AMH (AUC 0.865), age and AFC (AUC 0.850), age and all three ORTs (AUC 0.873). Compared with using a single factor alone, the combinations of ORTs and female age can increase the predictive value of POR. Adding age to single AMH model improved the prediction accuracy compared with AMH alone (AUC 0.865 vs. 0.862), but the improvement was not significant. The AFC with age model significantly improved the prediction accuracy of the single AFC model (AUC 0.846 vs. 0.837). To reach 90% specificity for POR prediction, the cutoff point for age was 38 years old with a sensitivity of 40.7%, 5 for AFC with a sensitivity of 55.9%, and 1.18 ng/ml for AMH with a sensitivity of 63.3%.

Conclusion

AFC and AMH demonstrated a high accuracy when using ROC regression to predict POR. When testing is reliable, AMH can be used alone to forecast POR. When AFC is used as a prediction parameter, age is suggested to be considered as well. Based on the results of the cutoff threshold analysis, AFC ≤ 5 and AMH ≤ 1.18 ng/ml should be recommended to predict POR more accurately in IVF/ICSI patients.

Fertilization rate as a novel indicator for cumulative live birth rate: a multicenter retrospective cohort study of 9,394 complete in vitro fertilization cycles

OBJECTIVE

To appraise the fertilization rate as a predictive factor for cumulative live birth rate (CLBR).

DESIGN

Multicenter retrospective cohort study.

SETTING

Ten in vitro fertilization clinics, whose data were collected and processed by the assisted reproductive technology (ART) Italian National Registry.

PATIENT(S)

7,968 couples undergoing 9,394 complete intracytoplasmic sperm injection cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was the CLBR in association with the fertilization rate intervals (<65%-group 1; 65%-80%-group 2; and >80%-group 3). Further data stratification was performed on the basis of maternal age (<34, 35-38, and 39-42 years) and number of retrieved oocytes (5-7, 8-10, and > 10 oocytes).

RESULT(S)

The CLBR was progressively higher in relation to the fertilization rate in groups 1, 2, and 3 (20.1%, 34.7%, and 41.3%, respectively). The number of recovered oocytes, embryo number per cycle, and cumulative pregnancy rate followed the same trend. The decrease in CLBR with increasing maternal age was significantly correlated with the fertilization rate and CLBR in all 3 maternal age groups. Multivariate logistic regression analysis showed fertilization rate as a factor independently associated with CLBR.

CONCLUSION(S)

The present data indicated a positive association between the fertilization rate and the CLBR, suggesting the predictive clinical relevance of this parameter and its adoption as a key performance indicator.

Predicting the Likelihood of Live Birth in Assisted Reproductive Technology According to the Number of Oocytes Retrieved and Female Age Using a Generalized Additive Model: A Retrospective Cohort Analysis of 17,948 Cycles

CAPSULE

We designed a predictive reference model to evaluate how many stimulation cycles are needed for a patient to achieve an ideal live birth rate using assisted reproductive technology.

OBJECTIVE

To develop a counseling tool for women who wish to undergo assisted reproductive technology (ART) treatment to predict the likelihood of live birth based on age and number of oocytes retrieved.

METHODS

This was a 6-year population-based retrospective cohort analysis using individual patient ART data. Between 2012 and 2017, 17,948 women were analyzed from their single ovarian stimulation cycle until they had a live birth or had used all their embryos. All consecutive women between 20 and 49 years old undergoing their ovarian stimulation cycles for ART in our center were enrolled. The cumulative live birth rate (CLBR) was defined as the delivery of a live neonate born during fresh or subsequent frozen-thawed embryo transfer cycles. Only the first delivery was considered in the analysis. Binary logistic regression was performed to identify and adjust for factors known to affect the CLBR independently. A generalized additive model was used to build a predictive model of CLBR according to the woman's age and the number of oocytes retrieved.

RESULTS

An evidenced-based counseling tool was created to predict the probability of an individual woman having a live birth, based on her age and the number of oocytes retrieved in ART cycles. The model was verified by 10 times 10-fold cross-validation using the preprocessed data, and 100 area under the curve (AUC) values for receiver operating characteristic (ROC) curves were obtained on the test set. The mean AUC value was 0.7394. Our model predicts different CLBRs ranging from nearly 90% to less than 20% for women aged 20-49 years with at least 22 oocytes retrieved. The CLBRs of women aged 20-28 years were very similar, nearly on one trend line with a certain number of oocytes retrieved. Differences in the CLBR began to appear by the age of 29 years; these increased gradually in women aged >35 years.

CONCLUSION

A predictive model of the CLBR was designed to serve as a guide for physicians and for patients considering ART treatment. The number of oocytes needed to be retrieved to achieve a live birth depends on the woman's age.

Age and Serum AMH and FSH Levels as Predictors of the Number of Oocytes Retrieved from Chromosomal Translocation Carriers after Controlled Ovarian Hyperstimulation: Applicability and Limitations

We studied the impact of age and the serum anti-Müllerian hormone (AMH)/follicle-stimulating hormone (FSH) levels on the number of cumulus–oocyte complexes (COCs) retrieved from female reciprocal and Robertsonian translocation carriers after controlled ovarian hyperstimulation (COH). The number of COCs retrieved after COH was retrospectively analyzed in female translocation carriers and 46,XX partners of male translocation carriers from 100 couples. The median number of COCs varied from nine to 16 and did not differ among subgroups of women categorized by age, presence and type of a translocation. The number of COCs correlated negatively with the woman’s age in both the reciprocal and the Robertsonian translocation carriers, while in 46,XX women no correlation was detected. The number of COCs did not differ between the reciprocal and the Robertsonian translocation carriers aged either <35 or ≥35 years. In translocation carriers, the number of COCs correlated with the serum AMH level only in the younger-age subgroups; the correlation was strong positive in reciprocal and moderate positive in Robertsonian translocation carriers. The 46,XX women aged both <35 and ≥35 years showed similar moderate positive correlations. Across all subgroups, the number of COCs correlated moderately negatively with the serum FSH level only in Robertsonian translocation carriers aged <35 years. Our results suggest that chromosomal translocations per se do not increase the risk of poor oocyte retrieval outcome after COH. In translocation carriers, oocyte retrieval outcome depends to a large extent on their age. The serum AMH level strongly predicts oocyte retrieval outcomes only in young reciprocal translocation carriers, while the serum FSH level has a moderate predictive value in young Robertsonian translocation carriers.

Characteristics of the IVF Cycle that Contribute to the Incidence of Mosaicism

Highly sensitive next-generation sequencing (NGS) platforms applied to preimplantation genetic testing for aneuploidy (PGT-A) allow the classification of mosaicism in trophectoderm biopsies. However, the incidence of mosaicism reported by these tests can be affected by a wide number of analytical, biological, and clinical factors. With the use of a proprietary algorithm for automated diagnosis of aneuploidy and mosaicism, we retrospectively analyzed a large series of 115,368 trophectoderm biopsies from 27,436 PGT-A cycles to determine whether certain biological factors and in vitro fertilization (IVF) practices influence the incidence of overall aneuploidy, whole uniform aneuploidy, mosaicism, and TE biopsies with only segmental aneuploidy. Older female and male patients showed higher rates of high-mosaic degree and whole uniform aneuploidies and severe oligozoospermic patients had higher rates of mosaicism and only segmental aneuploidies. Logistic regression analysis identified a positive effect of female age but a negative effect of embryo vitrification on the incidence of overall aneuploid embryos. Female age increased whole uniform aneuploidy rates but decreased only segmental aneuploidy and mosaicism, mainly low-mosaics. Conversely, higher ovarian response decreased whole uniform aneuploidy rates but increased only segmental aneuploidies. Finally, embryo vitrification decreased whole uniform aneuploidy rates but increased mosaicism, mainly low-mosaics, compared to PGT-A cycles with fresh oocytes. These results could be useful for clinician’s management of the IVF cycles.

The number of oocytes associated with maximum cumulative live birth rates per aspiration depends on female age: a population study of 221 221 treatment cycles

STUDY QUESTION

What is the number of oocytes where the maximum cumulative live birth rate per aspiration (CLBR) is observed during ART in women of different ages?

SUMMARY ANSWER

The maximum CLBR was observed when around 25 oocytes were retrieved in women between 18-35 years of age, around 9 oocytes in women more than 45 years of age and continued to increase beyond 30 oocytes in women between 36-44 years of age.

WHAT IS KNOWN ALREADY

The live birth rate per fresh or frozen/thaw embryo transfer (FET) procedure has traditionally been the main measure of ART success. However, with the introduction of highly efficient embryo cryopreservation methods, CLBR encompassing live delivery outcomes from the fresh and all subsequent FET following a single ovarian stimulation and oocyte collection is increasingly viewed as a more meaningful measure of treatment success. There is evidence suggesting that larger oocyte yields are associated with increased likelihood of cumulative live birth per aspiration. Whether this association is the same across female ages has not yet been properly investigated.

STUDY DESIGN, SIZE, DURATION

This is a large retrospective population-based cohort study using data from the Australian and New Zealand Assisted Reproduction Database (ANZARD). ANZARD contains information from all ART treatment cycles carried out in all fertility centres in Australia and New Zealand. Overall, 221 221 autologous oocyte aspiration cycles carried out between January 2009 to December 2015 were included in the analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cumulative live birth per aspiration was defined as at least one liveborn baby at ≥20 weeks gestation resulting from an ART aspiration cycle, including all fresh and FET resulting from the associated ovarian stimulation, until one live birth occurred or all embryos were used. Cycles where no oocytes were retrieved were excluded from analysis as there is no possibility of live birth. Analyses of data were performed using generalized estimating equations to account for the clustered nature of data (multiple cycles undertaken by a woman). Univariate and multivariable regression analysis was performed to identify and adjust for factors known to independently affect cumulative live birth per aspiration. An interaction term between female age and the number of oocytes retrieved was included to assess whether the age of the women was associated with a different optimal number of oocytes to achieve at least one live birth from an aspiration cycle (i.e. the effect-modifying role of female age). The likelihood of cumulative live birth per aspiration was calculated as odds ratios (ORs) with 95% CI.

MAIN RESULTS AND THE ROLE OF CHANCE

The median number of oocytes retrieved was 7 (interquartile range, 4-12) and median age of patients was 36 (interquartile range, 33-40). The overall CLBR was 32.2%. The results from the multivariable regression analysis showedthat the number of oocytes retrieved remained a significant predictor (P < 0.001) of cumulative live birth per aspiration after adjusting for female age, parity and cycle count. Compared to the reference group of 10-14 oocytes retrieved, the adjusted odds for cumulative live birth per aspiration increased with the number of oocytes retrieved: 1-3 oocytes, 0.21 (95% CI, 0.20-0.22); 4-9 oocytes, 0.56 (95% CI, 0.55-0.58); 15-19 oocytes, 1.38 (95% CI, 1.34-1.43); 20-24 oocytes, 1.75 (95% CI, 1.67-1.84); and 2.10 (95% CI, 1.96-2.25) with more than 25 oocytes. After stratifying by female age group, the rate of increase in CLBR per additional oocyte retrieved was lower in the older age groups, indicating that higher oocyte yields were more beneficial in younger women. CLBR of patients in the <30 years and 30-34 years age groups appeared to reach a plateau (with only minimal increase in CLBR per additional oocyte retrieved) after retrieval of 25 oocytes at 73% and 72%, respectively, while CLBR of patients in the 35-39 years and 40-44 years age groups continued to increase with higher oocyte yields, reaching 68% and 40%, respectively, when 30 or more oocytes were retrieved. CLBR of patients aged 45 years and above remained consistently below 5%. Findings suggest that the number of oocytes retrieved where CLBR appears to be maximized is around 25 in women between 18-35 years, more than 30 in women between 36-44 years and around 9 in women 45 years and older. However, results for women aged 45 years and older may not be as robust due to the relatively small sample size available in this age group.

LIMITATIONS, REASONS FOR CAUTION

As with all large retrospective database studies, there are potential confounders that cannot be accounted for. Despite the current study being based on complete ascertainment of ART cycles across two countries, ovarian stimulation protocols, oocyte quality parameters and a number of important patient characteristics are not collected by ANZARD. Additionally, a small number of cycles were available for women over 45 years yielding more than 15 oocytes, making these estimates unreliable.

WIDER IMPLICATIONS OF THE FINDINGS

The results from this study demonstrate that the number of oocytes retrieved where the maximum CLBR is observed during ART is dependent on female age. This provides information for clinicians and patients to understand the modifying effect of age on the number of oocytes retrieved and the likelihood of success with ART.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The Fertility Society of Australia funds the National Perinatal Epidemiology and Statistics Unit to manage ANZARD and conduct national reporting of ART in Australia and New Zealand. Associate Professor Georgina Chambers (G.C.) is employed by the University of New South Wales (UNSW) and is director of the National Perinatal Epidemiology and Statistics Unit at UNSW. G.C. was also a paid member of the Australian governments Medicare Benefits Scheme taskforce on assisted reproductive technologies in 2017.

Treatment-independent live birth after in-vitro fertilisation: a retrospective cohort study of 2,133 women

STUDY QUESTION

What is the chance of a treatment-independent live birth following IVF (including ICSI) treatment?

SUMMARY ANSWER

Over 5 years of follow-up, the treatment-independent live birth rate was 17% in unsuccessfully treated women and 15% in those who had a live birth after IVF.

WHAT IS KNOWN ALREADY

A limited number of studies have investigated the chance of treatment-independent conception following completion of IVF, but most of them have been based on surveys with poor response rates and limited sample sizes.

STUDY DESIGN, SIZE, DURATION

This is a population-based, retrospective cohort study of 2133 women who received IVF treatment between 1998 and 2011 at a single regional IVF Unit and were followed for a minimum of 1 year and maximum of 15 years after their last IVF or ICSI treatment cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study included all women, residing in the north-east of the UK, who attended the Aberdeen Fertility Clinic and received IVF treatment between 1998 and 2011. Clinical and diagnostic information of all women was linked with treatment and pregnancy outcome data. A total of 2133 women were divided into two groups: (i) those who achieved a live birth following successful IVF or ICSI treatment (n = 1060) and (ii) those in whom treatment was unsuccessful i.e. resulted in either no pregnancy or pregnancy loss (n = 1073). The two groups were followed from the date of the last embryo transfer until the first treatment-independent live birth or 31 December 2012, whichever came first. The primary outcome was the treatment-independent live birth rate at 1, 2.5, 5 and 10 years of follow-up. Cox regression was used to determine factors associated with treatment-independent live birth in each group.

MAIN RESULTS AND THE ROLE OF CHANCE

Within 5 years of follow-up, the treatment-independent live birth rate was 17% (95% CI, 15-19%) among women whose IVF or ICSI treatment was unsuccessful and 15% (95% CI, 12-17%) among women whose treatment resulted in live birth. In both groups, shorter duration of infertility, younger female age and IVF as compared to ICSI were associated with a higher chance of achieving treatment-independent live birth. Among unsuccessfully treated women, the chance of post-IVF live birth was reduced in those with tubal factor infertility. Three or more previous IVF or ICSI embryo transfers were associated with a lower chance of treatment-independent live birth among successfully treated women.

LIMITATIONS, REASONS FOR CAUTION

The study was conducted in a single fertility centre, which could compromise the generalizability of the findings. Moreover, data were unavailable on the women's use of contraception or active attempts to get pregnant, both of which could influence treatment-independent live birth rates.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides a better understanding of the long-term prognosis for treatment-independent live birth after completion of IVF or ICSI treatment. The results will inform women of their chances of a treatment-independent live birth following failed or successful treatment and the factors that are associated with it.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by a Chief Scientist Office Postdoctoral Training Fellowship in Health Services Research and Health of the Public Research (Ref PDF/12/06). The views expressed here are those of the authors and not necessarily those of the Chief Scientist Office. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Cumulative live birth rates in low-prognosis women

STUDY QUESTION

Do cumulative live birth rates (CLBRs) over multiple IVF/ICSI cycles confirm the low prognosis in women stratified according to the POSEIDON criteria?

SUMMARY ANSWER

The CLBR of low-prognosis women is ~56% over 18 months of IVF/ICSI treatment and varies between the POSEIDON groups, which is primarily attributable to the impact of female age.

WHAT IS KNOWN ALREADY

The POSEIDON group recently proposed a new stratification for low-prognosis women in IVF/ICSI treatment, with the aim to define more homogenous populations for clinical trials and stimulate a patient-tailored therapeutic approach. These new criteria combine qualitative and quantitative parameters to create four groups of low-prognosis women with supposedly similar biologic characteristics.

STUDY DESIGN, SIZE, DURATION

This study analyzed the data of a Dutch multicenter observational cohort study including 551 low-prognosis women, aged <44 years, who initiated IVF/ICSI treatment between 2011 and 2014 and were treated with a fixed FSH dose of 150 IU/day in the first treatment cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Low-prognosis women were categorized into one of the POSEIDON groups based on their age (younger or older than 35 years), anti-Müllerian hormone (AMH) level (above or below 0.96 ng/ml), and the ovarian response (poor or suboptimal) in their first cycle of standard stimulation. The primary outcome was the CLBR over multiple complete IVF/ICSI cycles, including all subsequent fresh and frozen-thawed embryo transfers, within 18 months of treatment. Cumulative incidence curves were obtained using an optimistic and a conservative analytic approach.

MAIN RESULTS AND THE ROLE OF CHANCE

The CLBR of the low-prognosis women was on average ~56% over 18 months of IVF/ICSI treatment. Younger unexpected poor (n = 38) and suboptimal (n = 179) responders had a CLBR of ~65% and ~68%, respectively, and younger expected poor responders (n = 65) had a CLBR of ~59%. The CLBR of older unexpected poor (n = 41) and suboptimal responders (n = 102) was ~42% and ~54%, respectively, and of older expected poor responders (n = 126) ~39%. For comparison, the CLBR of younger (n = 164) and older (n = 78) normal responders with an adequate ovarian reserve was ~72% and ~58% over 18 months of treatment, respectively. No large differences were observed in the number of fresh treatment cycles between the POSEIDON groups, with an average of two fresh cycles per woman within 18 months of follow-up.

LIMITATIONS, REASONS FOR CAUTION

Small numbers in some (sub)groups reduced the precision of the estimates. However, our findings provide the first relevant indication of the CLBR of low-prognosis women in the POSEIDON groups. Small FSH dose adjustments between cycles were allowed, inducing therapeutic disparity. Yet, this is in accordance with current daily practice and increases the generalizability of our findings.

WIDER IMPLICATIONS OF THE FINDINGS

The CLBRs vary between the POSEIDON groups. This heterogeneity is primarily determined by a woman's age, reflecting the importance of oocyte quality. In younger women, current IVF/ICSI treatment reaches relatively high CLBR over multiple complete cycles, despite reduced quantitative parameters. In older women, the CLBR remains relatively low over multiple complete cycles, due to the co-occurring decline in quantitative and qualitative parameters. As no effective interventions exist to counteract this decline, clinical management currently relies on proper counselling.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were obtained for this study. J.A.L. is supported by a Research Fellowship grant and received an unrestricted personal grant from Merck BV. S.C.O., T.C.v.T., and H.L.T. received an unrestricted personal grant from Merck BV. C.B.L. received research grants from Merck, Ferring, and Guerbet. K.F. received unrestricted research grants from Merck Serono, Ferring, and GoodLife. She also received fees for lectures and consultancy from Ferring and GoodLife. A.H. declares that the Department of Obstetrics and Gynaecology, University Medical Centre Groningen received an unrestricted research grant from Ferring Pharmaceuticals BV, the Netherlands. J.S.E.L. has received unrestricted research grants from Ferring, Zon-MW, and The Dutch Heart Association. He also received travel grants and consultancy fees from Danone, Euroscreen, Ferring, AnshLabs, and Titus Healthcare. B.W.J.M. is supported by an National Health and Medical Research Council Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, and Guerbet. He also received a research grant from Merck BV and travel support from Guerbet. F.J.M.B. received monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands) and Ferring Pharmaceuticals BV (the Netherlands) for advisory work for Gedeon Richter (Belgium) and Roche Diagnostics on automated AMH assay development, and for a research cooperation with Ansh Labs (USA). All other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Prediction of in vitro fertilization outcome at different antral follicle count thresholds combined with female age, female cause of infertility, and ovarian response in a prospective cohort of 8269 women

Antral follicle count (AFC) has been widely investigated for the prediction of clinical pregnancy or live birth. This study discussed the effects of AFC quartile levels on pregnancy outcomes combined with female age, female cause of infertility, and ovarian response undergoing in vitro fertilization (IVF) treatment. At present, many research about AFC mainly discuss its impact on clinical practice at different thresholds, or the analyses of AFC with respect to assisted reproductive technology outcomes under using different ovarian stimulation protocols. Factors that include ovarian sensitivity index, female age, and infertility cause are all independent predictors of live birth undergoing IVF/intracytoplasmic sperm injection, while few researchers discussed influence of female-related factors for clinical outcomes in different AFC fields.A total of 8269 infertile women who were stimulated with a long protocol with normal menstrual cycles were enrolled in the study, and patients were categorized into 4 groups based on AFC quartiles (1-8, 9-12, 13-17, and ≥18 antral follicles).The clinical pregnancy rates increased in the 4 AFC groups (28.25% vs 35.38% vs 37.38% vs 40.13%), and there was a negative association between age and the 4 AFC groups. In addition, female cause of infertility like polycystic ovary syndrome, Tubal factor, and other causes had great significance on clinical outcome, and ovarian response in medium (9-16 oocytes retrieved) had the highest clinical pregnancy rate at AFC quartiles of 1 to 8, 9 to 12, 13 to 17, and ≥18 antral follicles.This study concludes that the female-related parameters (female cause of infertility, female age, and ovarian response) combined with AFC can be useful to estimate the probability of clinical pregnancy.

Do female age and body weight modify the effect of individualized FSH dosing in IVF/ICSI treatment? A secondary analysis of the OPTIMIST trial

INTRODUCTION

The OPTIMIST trial revealed that for women starting in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment, no substantial differences exist in first cycle and cumulative live birth rates between an antral follicle count (AFC)-based individualized follicle-stimulating hormone (FSH) dose and a standard dose. Female age and body weight have been suggested to cause heterogeneity in the effect of FSH dose individualization. The objective of the current study is to evaluate whether these patient characteristics modify the effect of AFC-based individualized FSH dosing in IVF/ICSI treatment.

MATERIAL AND METHODS

A secondary data-analysis of the OPTIMIST trial. Women initiating IVF/ICSI treatment were classified as predicted poor (AFC 0-7), suboptimal (AFC 8-10) or hyper responders (AFC >15), and randomly allocated to a standard FSH dose (150 IU/d) or an individualized FSH dose (450, 225 or 100 IU/d for predicted poor, suboptimal and hyper responders, respectively). In each predicted response category, logistic regression models with interaction terms were used to evaluate the presence of effect modification. The first cycle was analyzed, and the primary outcomes were first complete cycle live birth rate (including fresh plus frozen-thawed embryo transfers) and ovarian hyperstimulation syndrome (OHSS) risks.

RESULTS

No effect modification was revealed in the predicted poor (n = 234) and suboptimal (n = 277) responders. In the predicted hyper responders (n = 521), the effect of the individualized FSH dose on the first cycle live birth rate was modified by female age (P = 0.02) and the effect on OHSS risks was modified by body weight (P = 0.02). A dose reduction from 150 to 100 IU/d generally decreased the OHSS risks in predicted hyper responders, but also reduced the chance of a live birth in young women, and had no beneficial impact on OHSS risks in women with a relatively low body weight.

CONCLUSIONS

In women with a predicted hyper response undergoing IVF/ICSI treatment, female age and body weight seem to modify the effect of FSH dose individualization. Although a reduced FSH starting dose generally decreases the OHSS risks, it may also reduce the chance of a live birth, specifically for young women. Future studies could consider these findings when investigating the optimal approach to reduce OHSS risks while maintaining the probability of a live birth for predicted hyper responders in IVF/ICSI treatment.

A Novel Predictive Model to Estimate the Number of Mature Oocytes Required for Obtaining at Least One Euploid Blastocyst for Transfer in Couples Undergoing in vitro Fertilization/Intracytoplasmic Sperm Injection: The ART Calculator

The POSEIDON group (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) has introduced "the ability to retrieve the number of oocytes needed to achieve at least one euploid embryo for transfer" as an intermediate marker of successful outcome in IVF/ICSI cycles. This study aimed to develop a novel calculator to predict the POSEIDON marker. We analyzed clinical and embryonic data of infertile couples who underwent IVF/ICSI with the intention to have trophectoderm biopsy for preimplantation genetic testing for aneuploidy. We used the negative binomial distribution to model the number of euploid blastocysts and the adaptive LASSO (Least Absolute Shrinkage and Selection Operator) method for variable selection. The fitted model selected female age, sperm source used for ICSI, and the number of mature (metaphase II) oocytes as predictors (p < 0.0001). Female age was the most important factor for predicting the probability of a blastocyst being euploid given each mature oocyte (loglikelihood of age [adjusted for sperm source]: 30.9; df = 2; p < 0.0001). The final predictive model was developed using logistic regression analysis, and internally validated by the holdout method. The predictive ability of the model was assessed by the ROC curve, which resulted in an area under the curve of 0.716. Using the final model and mathematical equations, we calculated the individualized probability of blastocyst euploidy per mature retrieved oocyte and the minimum number of mature oocytes required to obtain ≥1 euploid blastocyst-with their 95% confidence interval [CI]-for different probabilities of success. The estimated predicted probabilities of a mature oocyte turn into a euploid blastocyst decreased progressively with female age and was negatively modulated overall by use of testicular sperm across age (p < 0.001). A calculator was developed to make two types of predictions automatically, one using pretreatment information to estimate the minimum number of mature oocytes to achieve ≥1 euploid blastocyst, and another based on the actual number of mature oocytes collected/accumulated to estimate the chances of having a euploid blastocyst using that oocyte cohort for IVF/ICSI. The new ART calculator may assist in clinical counseling and individualized treatment planning regarding the number of oocytes required for at least one euploid blastocyst in IVF/ICSI procedures.

FSH dose to stimulate different patient' ages: when less is more

Objective

To determine the effect of FSH doses on intracytoplasmic sperm injection (ICSI) outcomes according to the age of the patient.

Methods

Patients undergoing controlled ovarian stimulation (COS) for ICSI cycles in a university-affiliated in vitro fertilization center were split into age groups: ≤35 y.o. (n=1523); >35 and ≤38 y.o. (n=652); >38 and ≤40 y.o. (n=332); and >40 y.o. (n=370). The effect of FSH dose on COS, laboratorial and clinical outomes was determined by linear regression models.

Results

The FSH dose didn't affect the ovarian response in terms of total number of follicles, retrieved oocytes and mature oocytes within the age groups, but we found that the lower the age, the lower the FSH dose needed per oocyte retrieved. In the group of patients ≤35 y.o., we also found a positive effect of the FSH dose on oocyte yield. Despite that, for patients ≤38 y.o. there was a negative effect of the FSH dose on embryo quality and blastocyst formation rate, and an increase in the cycle's cancelation rate. In patients ≥39 y.o., there were no effects of the FSH doses on the analysed variables.

Conclusions

Ovarian stimulation with high doses of FSH is not recommended in younger women (≤38 y.o.), once we found a decrease in embryo quality and an increase in cycle's cancelation rate. Mild ovarian stimulation protocols may be more appropriate; however, it may not be applicable for women in advanced age, since a higher FSH dose is needed for oocyte retrieval in these patients.

Female age, serum antimüllerian hormone level, and number of oocytes affect the rate and number of euploid blastocysts in in vitro fertilization/intracytoplasmic sperm injection cycles

OBJECTIVE

To study the relative role of female age and ovarian reserve, measured through serum antimüllerian hormone (AMH) in determining the rate and number of euploid blastocysts in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Retrospective analysis of cycles performed in 2014-2015.

SETTING

Tertiary referral IVF center.

PATIENT(S)

A total of 578 infertile couples undergoing IVF/ICSI and preimplantation genetic screening (PGS) analysis.

INTERVENTIONS(S)

All embryos were cultured and biopsied at the blastocyst stage. The method involved whole-genome amplification followed by array comparative genome hybridization. Serum AMH was measured by means of the modified Beckman Coulter AMH Gen II assay.

MAIN OUTCOME MEASURES

The rate and number of euploid blastocysts and their correlation with ovarian reserve and response to stimulation.

RESULT(S)

The mean (±SD) age of patients was 37.6 ± 4.1 years, and the mean number of blastocysts per patient was 3.1 ± 2. The total number of blastocysts available to the analysis was 1,814, and 36% of them were euploid after PGS. Age and serum AMH were significantly and independently related to the rate of euploid blastocysts available for patients. As an effect of the cohort size, the number of mature oocytes positively affected the total number of euploid blastocysts per patient.

CONCLUSION(S)

A strong positive age-independent relationship between AMH level and the rate of euploid blastocysts was found. This confirms that the measurement of ovarian reserve by means of AMH has high relevance when counseling infertile patients.

Differential expression of pluripotent and germ cell markers in ovarian surface epithelium according to age in female mice

BACKGROUND

Many studies have proposed that putative ovarian stem cells (OSCs) derived from the ovarian surface epithelium (OSE) layer of adult mammalian ovaries can produce oocytes. Few studies have reported that ovaries of aged mammalian females including mice and women possess rare premeiotic germ cells that can generate oocytes. However, no studies have reported the changes of OSCs according to the age of the female. Therefore, this study evaluated pluripotent and germ cell marker expression in the intact ovary, scraped OSE, and postcultured OSE according to age in female mice.

METHODS

C57BL/6 female mice of 2 age groups (6-8 and 28-31 weeks) were superovulated by injection with 5 IU equine chorionic gonadotropin (eCG). Both ovaries were removed after 48 hours and scrapped to obtain OSE. Gene expressions of pluripotent (Oct-4, Sox-2, Nanog) and germ cell markers (c-Kit, GDF-9, and VASA) were evaluated by RT-PCR. VASA and GDF-9 were immune-localized in oocyte-like structures.

RESULTS

Expressions of germ cell markers in the intact ovary were significantly decreased in aged females, whereas expressions of pluripotent markers were not detected, regardless of age. Scraped OSE expression of all pluripotent and germ cell markers, except for c-Kit, was similar between both age groups. Three weeks postcultured OSE had significantly decreased expression of GDF-9 and VASA , but not c-Kit, in old mice, as compared to young mice; however there was no difference in the expression of other genes. The number of positively stained Oct-4 by immunohistochemistry in postcultured OSE was 2.5 times higher in young mice than aged mice. Oocyte-like structure was spontaneously produced in postcultured OSE. However, while that of young mice revealed a prominent nucleus, zona pellucida-like structure and cytoplasmic organelles, these features were not observed in old mice.

CONCLUSIONS

These results show that aged female mice have putative OSCs in OSE, but their differentiation potential, as well as the number of OSCs differs from those of young mice.

Cumulative live birth rate and assisted reproduction: impact of female age and transfer day

BACKGROUND

Many studies on assisted reproductive technology examine live birth rate per cycle. However, after a cycle fails, couples often want to know what their chances are of having a live birth if they continue treatment. From a patients' perspective, the cumulative probability of live birth is more informative.

MATERIALS AND METHODS

This study includes patients who underwent fresh, frozen and non-donor ICSI cycles at our IVF unit between 2006-2012. Patients were divided into two groups; Group 1 represented those who underwent only Day 5 transfers, Group 2 represented only Day 3 transfers. Patients who underwent both were excluded. -Cycles were analyzed until the first live birth or the end of the 3rd cycle. Using Kaplan-Meier analysis, we estimated the cumulative live birth rates for each group and according to female age.

RESULTS

The mean age for Group 1 was significantly lower than for Group 2. After 3 cycles, Group 1's CLBR was 79% versus 66% in Group 2. When analyzing the live births by age and group, there was a significant difference in the CLBR after 3 cycles with the women less than 35 years having the highest CLBR and the women 40 years or older having the lowest CLBR.

CONCLUSION

In women less than 35 years, excellent CLBR can be achieved irrespective of the transfer day. For women 40 years and above, better results of CLBR are observed with Day 5 transfers. Our findings may impact the counseling of couples considering IVF treatment.

Effects of age on female reproductive success in Drosophila bipectinata

Female age influence on mating success, courtship activities, mating latency, copulation duration, fecundity, ovarioles number, and wing length has been studied using isofemale lines of Drosophila bipectinata collected at three different localities. It was observed that in all localities, middle-aged D. bipectinata females had significantly greater mating success, showed less rejection responses to courting male, mated faster, copulated longer, and had greater fecundity and ovariole number than young and old-aged females. Further, old-aged females had comparatively less fitness traits than young age females. This research suggests the occurrence of age specific female reproductive success as follows: middle-aged > young > old-aged.