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IVF Cycle Characteristics and Outcomes: 2017 Stats from CHR

IVF Cycle Characteristics and Outcomes

Age and functional ovarian reserve of patients

Here are CHR’s cumulative 2017 IVF cycle characteristics and outcomes. We reported already in the January issue of the VOICE  the unprecedented rise in the age of CHR’s patient population during 2017, increasing the median age between 2016 and 2017 by a full year, from 42 to 43 years. Figure 1 below demonstrates in a pie chart format the ages of CHR patients during 2017 who underwent IVF cycles. As the figure demonstrates, an almost unbelievable 59% of patients were over age 40. An even more unbelievably, 35% were, indeed, above age 45, while only 21% were between ages 41 and 43 years.

IVF Cycle Characteristics and Outcomes

Since CHR witnessed during 2017 a radical increase of patients above age 44, we assume the reason to be that only very few IVF centers in the U.S., Canada and overseas offer IVF with use of own eggs to patients above age 44. Women at ages 42-43, on the other hand, increasingly appear to receive treatments elsewhere and, therefore, proportionally declined at CHR in numbers in comparison to earlier years.

The year 2017, however, not only demonstrated a greater influx of older patients. CHR also, in parallel, witnessed a significant worsening in functional ovarian reserve in comparison to 2016. This was documented by significant increases in mean FSH and significant declines in mean AMH values of patients (data available upon request).

Among women above age 44 treated with use of their own eggs, were patients up to age 52. Though this may sound surprising, CHR physicians succeeded in retrieving eggs and producing transferrable embryos in a small number of women up to age 52. We are, however, still waiting for a first pregnancy and live birth above age 48. CHR’s (and likely the world’s) oldest patient to deliver with use of her own eggs to date was, still, a patient who was two months shy of her 48th birthday when she had her embryo transfer.

Autologous fresh IVF cycles stratified for age

Table 1 below summarizes CHR’s 2017 autologous fresh IVF cycles (cycles using the patients' own eggs) stratified for age. Please note that because CHR’s patient population is so severely adversely selected by age as well as functional ovarian reserve, 15% of started IVF cycles did not reach embryo transfer during this study year and, therefore, had no chance of pregnancy or live birth. Because in such an adversely selected patient population the number of embryos available for transfer, therefore, becomes a crucial predictor of pregnancy and live birth chances, we are presenting here statistics for only patients who reached embryo transfer (i.e., had at least 1 embryo available for transfer). Here reported outcomes, therefore, must be further reduced by 15% if outcomes with reference point cycle start (i.e., by “intent to treat”) are of interest.

IVF Cycle Characteristics and Outcomes

Considering how adversely selected CHR’s patients were during 2017, the relatively small number of cancelled cycles was somewhat of a surprise and significantly lower than in preceding years. There are, likely, a number of reasons for this observation, though it will take another 1-2 years of similar experiences to be certain about these explanations:

CHR physicians, in principle, do not, as many other IVF centers, cancel IVF cycles when patients do not develop a certain minimum number of follicles. We recommend egg retrieval even with only one follicle. The reason is that almost all CHR patients are already on maximal stimulation and, therefore, have little potential of improvement in subsequent cycles. The only patients with cancelled cycles, therefore, are women who do not respond to stimulation at all, have zero oocytes retrieved, no fertilization or no embryos that reach cleavage stage (day-3).

Furthermore, in poor prognosis patients, CHR never cultures embryos to blastocyst stage and, even in poor prognosis patients, embryos only rarely arrest before cleavage stage. We believe that we see in these lower cancellation rates effects of CHR newly introduced Highly Individualized Egg Retrieval (HIER) program.

Considering that virtually almost all of CHR’s patients, even at younger ages, present with low functional ovarian reserve (abnormally high FSH and/or abnormally low AMH), pregnancy rates at younger ages were remarkably excellent. Absence of pregnancies in age groups 42 -43 are, likely, a statistical artefact due to smaller patient numbers in these age groups than in preceding years, as already noted above. We again point at the age group of 44 and above, which included patients up to age 52, and still exceeded “futile” pregnancy rates more than twice, as defined by the American Society for Reproductive Medicine (ASRM).

Here reported pregnancy rates in this group of women at very old ages, however, require further explanation. As we previously noted in the VOICEabove age 43, the number of available embryos for transfer becomes a very important predictor of pregnancy and live birth chances. CHR reported in a number of publications in the literature that in this oldest patient population (and in even younger women with extremely low functional ovarian reserve), embryo numbers available for transfer are a crucial predictive prognostic factor. We further reported that such patients required at least three embryos to reach a “reasonable” pregnancy chance, which we define as a chance in the low double digits. Since only a relative small minority of women in this extreme age group meet this requirement, the large majority who produce only 1-2 embryos for transfer greatly dilute total pregnancy rates for this age group. New York’s Cornell group recently made the same point but at these ages considered 4 embryos a minimum for better chances.

In other words, women at these ages must be counseled correctly, which means that they must understand that their pregnancy chances will be in the low single digits with one embryo for transfer, will be in the higher single digits with two embryos and will only with three or more embryos reach double digits. Pregnancy rates in this age group, overall, will be quite low, and will be further reduced by an approximately 50% miscarriage rate.

Such poor prognoses, of course, must be weighed against much better pregnancy and live birth chances with young donor eggs (see CHR results in Table 2 below). Patients who, however, prefer using their own eggs must also understand that they will reach better pregnancy and live birth chances only by working toward a decent cumulative pregnancy chance from multiple cycle attempts. CHR, therefore, offers such patients a 4-cycle package, with almost 50% cost savings over standard per cycle costs (please contact our finance department for further details).

Frozen-thawed and donor egg recipient cycles

IVF Cycle Characteristics and Outcomes

Table 2 summarized clinical pregnancy rates from fresh donor egg cycles as well as from frozen-thawed cycles with embryos from autologous fresh and fresh donor egg cycles, and the numbers in 2017 again were quite exceptional. Especially surprising were not only the excellent outcomes from frozen-thawed autologous embryos but, considering CHR’s patient population, the mere fact that there even were frozen embryos for transfer.

CHR does not “bank” embryos because we strongly feel that every cryopreservation reduces to minor degrees pregnancy potential, and especially poor prognosis patients cannot afford any further “voluntary” reductions in already very low pregnancy chances. Therefore, practically all thaw cycles involve extra embryos (i.e., more embryos than we were willing to transfer in a fresh cycle). That CHR’s patient population still created such “extra” embryos is quite remarkable and, likely, at least partially also a consequence of the center’s new HIER program.

Summary

Considering the quite incredible increase in adverse selection in CHR’s patients in 2017 based on age and poor functional ovarian reserve, CHR’s outcomes must be considered beyond exceptional. If they were viewed without an explaining commentary, they would be considered to reflect outcomes of a good IVF center. That they were achieved in the oldest IVF patient population of any IVF center in the U.S. and younger women with, likely, the lowest functional ovarian reserve, and that over 90% of CHR’s patients before reaching out to CHR already had failed IVF cycles at other centers, make these results, however, rather exceptional. CHR is looking forward to 2018 fully expecting even more challenges, as the center’s patients will, undoubtedly, continue to get older and more challenging.

This is a part of the March 2018 issue of the CHR VOICE.

Norbert Gleicher, MD

Norbert Gleicher, MD, FACOG, FACS

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.

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