How old is too old for trying pregnancy with your own eggs?

The October 17, 2016 issue of the New York Times contained a disappointingly misleading article by Jane E. Brody, a usually well informed writer. Under the heading “The Misleading Promise of IVF for Women Over 40,” she basically berated women above age 40 for “being stupid” in believing that they really still had a reasonable chance of pregnancy and delivery with IVF. The fault is, however, not exclusively hers because she relied on the advice of (and in her piece extensively quoted) Mark Sauer, MD, until recently Vice-Chair of the Ob/Gyn Department at Columbia University and Chief of the Division for Reproductive Endocrinology and Infertility (and, therefore, Columbia’s IVF program).

CHR knows Dr. Sauer quite well. In full disclosure, in the late 1990, when CHR first opened a center in New York City, CHR contracted with Columbia University to provide staffing and administration for the center. With Dr. Sauer being responsible for Columbia’s fertility program, he also became the Medical Director of CHR’s program. The arrangement, however, lasted only for approximately one year, at which time Dr. Gleicher (then still full-time in Chicago) had to assume responsibility for CHR’s New York City center in December of 1999.

A quick review of Dr. Sauer’s’ publication list will reveal that most of his academic writing has been dedicated to third party egg donation. He, indeed, was widely considered one of the pioneers in human egg donation, and published some of the earliest studies in the world on this subject. This is important to note because for older women above age 40 who want to conceive, use of their own eggs and use of donor eggs are the two principal available treatment options.

Dr. Sauer has been in charge of Columbia’s IVF program since the late 1990. The program’s annual reports to CDC and SART demonstrate up to most recent years very clearly that the program only extremely rarely treated women above age 40, and certainly above age 42, with use of own (autologous) eggs. Not surprisingly, considering Dr. Sauer’s expertise with egg donations, the program, however, over all these many years performed disproportionally robust numbers of donor egg cycles. Infertile women in Dr. Sauer’s program, therefore, quite obviously were above age 40 discouraged from using their own eggs, and were encouraged to use donor eggs.

Dr. Sauer’s department over all of those years by no means was alone in favoring egg donation in women above age 40. There are many other IVF programs in the U.S. that follow similar treatment philosophies, principally based on the undisputed fact that pregnancy and live birth rates, of course, are much higher with use of donor eggs. The discrepancy, in addition, quickly increases with advancing patient age because chances with autologous eggs, of course, decline, while those with young donor eggs remain stable.

As we have noted repeatedly in these pages over the years, legally mandated public reporting of IVF outcomes in the U.S. has led to significant practice distortions because many IVF programs compete in the market place based on the pregnancy and live birth rates they report to CDC and SART. The best way to “manipulate” these rates is, of course, to filter out poor-prognosis patients by transferring them into the donor egg program. What then is left in the standard IVF program are better prognosis patients and the program, therefore, will look better in national outcome reports.

IVF centers, thus, have strong economic incentives to manipulate patient selection. But does such manipulation serve patients?

The options

If one reads and believes Brody’s piece in the New York Times, the obvious conclusion would be yes because, according to Sauer/Brody, pregnancy rates above age 40 are too low to make it worthwhile. We, here at CHR, quite obviously disagree with this conclusion on multiple levels:

First, we are surprised that a female writer, even if poorly advised by an “expert,” on her own does not understand the psychological burden a woman faces when having to decide whether to go for a much better chance with use of donor eggs or for a lower chance with own eggs. To assume that, when such a choice presents itself to a woman, it is a choice that should, simply, be made based on what will offer the better pregnancy and live birth chances, is not only naïve but, in many ways, insulting to women.

Based on CHR’s experience with hundreds or even thousands of women who have faced this choice, we know how difficult a decision making process this is and, often not only for the women. Though the choice between own and donor eggs is, of course, primarily affecting the female, it is actually quite surprising how often the women is willing to consider donor eggs but the partner is not.

Who should decide?

Some colleagues who strongly favor egg donation in women above age 40 argue that “making a decision for the patient” by “telling them that egg donation is really their only choice” serves them well “because it saves them from treatments with extremely low success.” We hear this argument not only from colleagues but also, on an almost daily basis from patients who received this advice and, frankly, find it shockingly wrong and self-serving.

We have made the point on many occasions before in these pages that CHR does not believe in telling patients how to live their lives. We do not consider this our responsibility, nor do we feel qualified to do so. We, however, do know that our responsibility is absolute honesty as to what patient chances are with their various treatment options, what we here at CHR have come to call “brutal honesty.” Then it is up to patients to decide what represents the right choice for them at that given moment.

Brody/Sauer in the article make the absolutely incorrect point that there “is hardly any age at which clinics now turn patients away.” That, indeed, may be true for the use of donor eggs but it certainly is anything but true for use of the patients’ own eggs. Indeed, had Brody studied the national CDC data (which she claimed to have reviewed herself) in more detail, she would have noted that only very few – really extremely few – IVF centers treat women above age 42 with use of their own eggs. Indeed, no center in the U.S. treats proportionally as many women above age 42 as CHR does!

One can obviously argue that for economic or psychological reason, IVF treatments with autologous eggs above a certain age are no longer “worth it.” But who is to determine that, and what is the “right” age? Interestingly, in, likely, the most “socially conscious” countries in the world, like Sweden and other Scandinavian countries, women above age 40-41 are for exactly those reasons excluded from IVF. Is that socially really fair?

And then there is another important consequence of not treating older women: If we don’t treat we don’t learn how to get better. In early IVF days, most IVF centers admitted only women up to age 38 into treatment cycles because older women, simply, did not conceive. Imagine, if that philosophy had been maintained; We till today would not know how to treat women above age 38!

Which brings us to our final criticism of the Brody piece in the New York Times: Though, as already noted before, IVF outcomes in older women are relatively poor in comparison to younger women and especially young donor egg cycles, and get poorer with advancing age, they are (i) not as poor as noted in the article; (ii) they, indeed, can be much better than even appreciated by colleagues (as published by CHR investigators) and (iii) are constantly getting better.

The latter point is of great importance because there is no better evidence for progress than the fact that older and older women conceive with use of their own eggs. Only less that 10 years ago, women above age 44 had no chances of conceptions at CHR. Nowadays, pregnancies at age 45 or 46 no longer are cause for celebration. The current age limit is at 47, and we this year almost breached it when a woman, a few days short of her 48th birthday, conceived but, unfortunately, a few weeks later experienced a miscarriage.

In medicine, like in many other areas of life, practice makes better! Unless our colleagues are willing to learn how to treat older women, they, of course, never will succeed, will continue to believe in excessively low IVF success rates, will continue to counsel their patients inaccurately and, therefore, will be responsible for many women going prematurely into egg donation, who may for the rest of their lives regret the decision, even if they have a beautiful child from egg donation because they feel that “they were not given the chance to at least try.”

This is the story Jane E, Brody should have written if she really wants to help older infertile women!

This is a part of the November 2016 CHR VOICE.