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

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

OBJECTIVE

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

DESIGN

Retrospective cohort study of autologous linked ART cycles.

SETTING

United States (US) National ART Database.

PATIENT(S)

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

The Prediction of IVF Outcomes with Autologous Oocytes and the Optimal MII Oocyte/Embryo Number for Live Birth at Advanced Maternal Age

Background and Objectives: Delayed childbearing in advanced age might be associated with a low prognosis for achieving pregnancy. Therefore, it is important to establish a predictive tool that will optimize the likelihood of a live birth at advanced age. Material and Methods: The retrospective study was conducted at the Ferona Fertility Clinic in Novi Sad (Republic of Serbia), between January 2020 and May 2021. The survey included 491 women aged ≥35 who met the inclusion criteria and who were subjected to an IVF (in vitro fertilization) treatment cycle. Results: The average number of retrieved oocytes, MII (metaphase II) oocytes, and developed embryos significantly decreased in advanced age. Age was also found to have a significant adverse effect on pregnancy and live birth rates. In women aged ≥35, 10/12 MII oocytes or 10/11 embryos are required for reaching an optimal live birth rate/cumulative live birth rate. Optimal CLBR (cumulative live birth rate) per one oocyte was achieved when 9 MII oocyte were retrieved. Conclusions: The study indicates that the cut-off for increased risk is ≥42 year. However, despite low live birth rates, autologous IVF for these women is not futile. An increase in the number of retrieved mature oocytes and a generation of surplus cryopreserved embryos could reinforce LBR (live birth rate) and CLBR. Clinicians should be very cautious in counseling, as autologous IVF may only be applicable to women with good ovarian reserve.

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

STUDY OBJECTIVE

Women with adenomyosis may show a lower pregnancy rate and a higher miscarriage rate than healthy women. There is also a general agreement that leiomyomas, either submucosal or intramural, negatively affect fertility, when compared with women without myomas. Some of these women may benefit from adenomyomectomy, however this cytoreductive procedure is considered invasive and technically challenging especially in severe diffuse cases. The study aimed to compare the clinical and reproductive outcomes of patients who underwent adenomyomectomy with those of patients who underwent intramural myomectomy.

DESIGN

A retrospective study.

SETTING

Department of Obstetrics & Gynecology, Center of Gynecological Endoscopy and Minimally Invasive surgery, First Faculty of Medicine, General University Hospital in Prague.

PATIENTS

A total of 55 women who underwent surgical resection of uterine adenomyosis and 55 patients who underwent myomectomy for intramural uterine myomas were included in this study. All study participants wished to retain and possibly improve their reproductive potential.

INTERVENTIONS

Between 2004 and 2019, 110 women underwent laparoscopic or open uterus-sparing surgery for clinically significant uterine adenomyosis (group A) or myomas (group B), respectively.

MEASUREMENTS AND MAIN RESULTS

Two groups of women who underwent different fertility-saving procedures were compared. Although all women entering the study had declared their wish to conceive, only 28 patients in group A (group A1) and 24 women in group B (group B1) finally aimed toward pregnancy. The mean age and follow-up period was 35.0 years and 76.81 months, respectively, in group A and 34.8 years and 72.5 months, respectively, in group B. The pregnancy and delivery rates were 75.0% and 46.4%, respectively, in group A1 vs 96.0% and 70.8%, respectively, in group B1, with no significant differences between the 2 groups. The open surgical approach was significantly more frequently employed in group A (47.3% vs 16.4%; p <.01).

CONCLUSION

In this study, women who underwent surgery involving the uterine muscularity, including myomectomy or adenomyomectomy, had comparable reproductive outcomes, with no significant differences.

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.

Androgens and Anti-Müllerian Hormone in Infertile Patients

To investigate whether there is an association between androgens and ovarian reserve, expressed through anti-Mullerian hormone. This is a retrospective cross-sectional analysis of all consecutive women attending a tertiary fertility center, who presented with regular menstrual cycles. Patients had their AMH values measured with the same AMH assay (Immunotech (IOT) Beckmann Coulter assay), the same day in which androgens sampling was performed. Women with PCOS or other forms of androgen excess or untreated endocrine or metabolic disorders were excluded. A total of 942 women were included. Significant correlation was observed between total testosterone/free androgens index (FAI)/DHEAS and AMH (Spearman's r = 0.20/0.14/0.13, P value < 0.001, P value < 0.001, and P value < 0.001, respectively). After multiple linear regression analysis adjusting for confounders (age, BMI, cause of infertility, day of the menstrual cycle when the blood sample was performed), the regression slope in all participants for total testosterone predicting logAMH was 0.20 (P value < 0.001). Similarly, FAI was significantly associated with logAMH (regression coefficient = 0.04, P value = 0.04). In contrast, DHEAS was not significantly associated with logAMH. There was a significant, but weak relation between testosterone and AMH, while no significant association was observed between DHEAS and AMH. Future research is needed to elucidate whether testosterone supplementation may have any effect on ovarian function.