IVF, Age and Low Responders
Tags: Best Ivf Practices Treating Difficult Infertility Patients
It is fair to say that the majority of infertile couples with access to care can be successful in achieving a pregnancy given the right combination of patience, determination, and good treatment. However, there is a sub-group of patients who may not achieve success in spite of their best efforts. This sub-group of patients is often referred to as “poor responders”, this term being broadly applied to patients who do not respond vigorously to ovarian stimulation. It is important to define this group clearly so that information obtained from multiple centers may be compared and looked at cumulatively. At the present time, many investigators favor the application of “Bologna Criteria” to identify poor responders. The “Bologna Criteria” requires that at least 2 of the following criteria be met:
1) The patient produces 3 or fewer oocytes in response to vigorous ovarian stimulation
2) The woman is above age 40
3) The anti-mullerian hormone level (AMH) is less than 1.1 ng/ml
A recent study published in Fertility and Sterility, Dec 2015 (Gleicher et.al) looked at the live birth rates among 752 IVF treatment cycles in patients who met the “Bologna Criteria” qualifying as poor responders.
ABOUT THIS STUDY
It is important to note that the only patients included in the statistical analysis were those who made it to embryo replacement. Of the 768 cycles that were studied, 381 made it to embryo transfer and were therefore included in the study statistics. Importantly, 371 (48%) cycles did not make it to embryo transfer and were therefore excluded from results calculations.
All embryos were transferred at the cleavage stage (day 3) of development, rather than the blastocyst (day 5) stage.
The reporting group routinely took patients who were very poor responders to retrieval with only one developing follicles.
The study looked at “live birth rate” rather than pregnancy rates. In this manner, miscarriages, biochemical pregnancies, and ectopic pregnancies are not viewed as successful results.
RESULTS OF THE STUDY
Age Group Single Embryo 2 Embryos 3 or more embryos
Less than 35 2/6 (33.3%) 1/3 (33.3%) 0/1
35-37 2/13 (15.4%) 0/6 (0%) 0/1
38-40 2/24 (8.3%) 5/30 (16.7%) 6/20 (30%)
41-42 2/31 (6.4%) 1/18 (5.6%) 3/51 (5.9%)
43 or older 0/55 (0.0%) 1/54 (1.8%) 5/68 (7.4%)
Simplifying the data by looking at live birth rates for each age groups, and basing statistics on only those cycles that made it to embryo transfer:
Less Than 35 (3/10) 30%
35-37 (2/20) 10%
38-40 (13/74) 18%
41-42 (6/100) 6%
43 or older 3.4%
REVIEW OF RESULTS AND IMPORTANT FACTS FROM THIS STUDY
1) IVF live birth rates in this group of poor responders were best when increased numbers of embryos were available for transfer. Even patients 43 years of age or older achieved modest live birth rates (7.4%) when 3 or more embryos were available for transfer.
2) In this group of patients, approximately 50% were unable to achieve embryos for transfer, in this study (371 of 768). These patients either failed to have a single mature follicle, or the eggs retrieved did not fertilize, or their embryos arrested.
3) In this study, at practically all ages up to the mid 40’s, only patients who no longer were able to produce embryos had no chance of pregnancy at all. Stated differently, all patients who are able to produce embryos had an opportunity to achieve a live birth, irrespective of age and ovarian reserve.
4) The authors of this study noted that the possibility of not reaching embryo transfer often encouraged poor-prognosis patients to attempt treatment because the costs of a failed cycle were modest if the cycle was cancelled before egg retrieval.
5) The two factors the seemed to predict the greatest likelihood of success in this study were age and number of embryos available for transfer, with the best prognosis in the younger patients and those who had a greater number of embryos for transfer.