The IVF program at RMA of Michigan attributes its IVF success rates to a variety of factors including the experience and dedication of our physician and laboratory teams, individualized IVF protocols, laboratory conditions and techniques and breakthrough technologies. When it comes to IVF, the roles of the physicians and those of the embryologists in the laboratory are distinctly different, yet equally important.
A comparison of clinic success rates may not be meaningful because patient medical characteristics, treatment approaches and entrance criteria for ART may vary from clinic to clinic. Visit www.sart.org for more info.
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One of the major factors when it comes to choosing an IVF center is their success rates. Patients look for centers that have high success rates. These rates can be confusing and it is important that you understand how to interpret them. First you want to look for clinics that are performing a significant number of IVF cycles a year. Typically 200 or more total IVF cycles or more per year is an adequate amount to determine success rates by age group. When there are small numbers per age group success rates will vary greatly based on a difference of only one or two pregnancies.
Women under 35 years of age have the best chance of success with IVF. When you are looking at the SART data you will see that this age group almost always has the highest rate of success. The age group 35-37 also has good IVF outcomes and a fairly high rate of success. The age group 38-40 will often have lower rates of success. Anyone 41 and older, have a very low chance of success unless they decide to use an egg donor.
RMA of Michigan will take on the more difficult patients who have failed previously at other infertility centers. We understand that taking on the challenging cases may impact our success rates negatively. We feel it is more important that we care for all patients who want to conceive a child. Patient selection can be used to select out the best candidates for a successful outcome. Some centers may decide not to treat patients that have a low probability of success.
The most important number to look at is the percentage of transfers resulting in live births. It tells you how many cycles with transfers resulted in a baby. This number indicates how successful the center is at IVF based on that particular patient population. Please note that success rates are listed as a fraction when the total number of cycles in a segment is less than 20. Otherwise you get a skewed perception of what the centers success rates are. For example, a clinic that performed a single cycle would have either a 100% or 0% success rate.
The average number of embryos transferred varies from age group to age group. There are a number of factors that influence how many embryos are transferred. Age, diagnosis and your prior history all have an impact on the number of embryos transferred. The national average in 2006 was 2.3 embryos in the age groups up to 37 years old. Patients need to be aware that the transfer of multiple embryos increases pregnancy success, but also increases the risk of multiple births. Multiple rates should be looked at when doing your research. Centers that have higher twin and triplet rates typically indicate that they are transferring a greater number of embryos to ensure a pregnancy is achieved. Having a multiple pregnancy increases the health risks to the mother and the babies. At RMA we counsel our patients so they are aware of the risks involved with a multiple pregnancy and encourage our patients with a good prognosis to undergo an elective single embryo transfer.
There is no doubt that age is the single most important factor in determining your chance of achieving a successful conception through IVF. As the oocyte (egg) ages, it undergoes changes that render it less and less fertile as a woman advances through her 30’s and 40’s. As a woman’s age advances, her chance of conceiving through IVF decreases. Furthermore, her risk of early pregnancy loss increases during this same time period, mainly related to the increasing frequency of chromosomal abnormalities within the oocyte and thus the developing embryo. Pre implantation genetic diagnosis (PGD) is a promising procedure designed to help identify genetically problematic embryos prior transfer back to the uterus. PGD may help to reduce the risk of early pregnancy loss related to the chromosomal abnormalities (aneuploidy) frequently found in embryos produced from aging oocytes.
Day 3 follicle-stimulating hormone (FSH) levels are also critically important in evaluating your potential for successful conception in an assisted reproductive technology program. This blood test is typically drawn on the third day of a woman’s menstrual cycle. Day 3 FSH levels have been shown to be an incredibly accurate predictor of IVF success, independent of age. Essentially, an elevated Day 3 FSH value indicates a very poor prognosis for conception through IVF and a high risk of pregnancy loss should the rare conception occur. Unfortunately, if you ever exhibit an elevated FSH value, having a normal value at a later time does not favorably change this prognosis. Every IVF program establishes a “threshold” FSH value unique to their laboratory, above which pregnancies are very rarely conceived despite great effort and repeated IVF attempts. At RMA, we have determined that an FSH value of 15 or higher predicts that IVF will be of no value in helping to achieve pregnancy. FSH values over 14.5 have produced only rare pregnancies in our program. Prior to initiation of any IVF cycle, Day 3 FSH values are evaluated. Many factors can artificially depress FSH values but only diminished ovarian fertility reserve can cause an elevated FSH level. Ovum donation is generally recommended as the most potentially successful treatment option in the setting of elevated FSH levels, especially when associated with age beyond 35.
The clomiphene citrate challenge test can also be used to determine the extent of your ovarian fertility reserve. This test was designed to “unmask” undiagnosed cases of diminished ovarian reserve when Day 3 FSH values are apparently normal – the equivalent of a “stress test” for the ovaries. During the CCCT, a Day 3 FSH value is assessed. If normal, 100 mg/day of clomiphene citrate (Clomid, Serophene) is administered from days 5-9 of your menstrual cycle. An FSH level is then assessed on Day 10. If either the Day 3 or Day 10 FSH value is elevated, the test is considered abnormal and predicts a poor prognosis for IVF outcome.
Aging is a normal, inescapable process. As we age, various components of our bodies develop limited function or cease to function altogether. Changes in our reproductive processes are some of the more subtle changes that take place. However, as societal changes have resulted in many women delaying childbearing, these nearly silent changes can have a huge impact on a woman’s life. The scientific community had recognized for quite some time that a woman’s reproductive potential declines with age.
Unfortunately, there are few, if any, outward signs of decline in reproductive potential for most women. A woman may continue to have regular cycles until she nearly reaches menopause but her chance of conception starts to decline at a much younger age (Figure 1), generally around 30 years old. This results in a situation where nearly 1/3 of the couples with the woman 35 or older will have problems with fertility. It has been estimated that only 10-30% of women over 40 are able to become pregnant on their own. In addition, a woman’s chance of miscarriage also increases with age.
Ovarian reserve is the term that we use to describe where a woman’s ovaries are in the aging process. Age is an important determinant of ovarian reserve. As we have previously discussed, the chances of conception clearly decrease with age. However, not all women of the same age have the same reproductive potential. The further evaluation of ovarian reserve is accomplished by tests that measure important components of the reproductive system.
The standard screening test is the measurement of the hormones FSH (Follicle Stimulating Hormone), LH (Luteinizing Hormone) and Estradiol on cycle day 2, 3 or 4. (Day one of your cycle is the first full day of full menstrual flow). The FSH level is the most important of the three tests, with the measurement of LH and estradiol modifying how we look at the FSH level. It has been clearly demonstrated that there are subtle rises in the FSH level as a woman ages and that women with abnormal FSH levels can have considerable difficulty conceiving using their own oocyte.
Another test that can be incorporated into the evaluation of ovarian reserve is the Clomiphene Citrate Challenge Test (CCCT). In this test, the cycle day 3 labs are followed by 5 days of the ovulation induction agent clomiphene citrate (Clomid, Serophene). On cycle day 10, the FSH and estradiol are re-drawn. We expect the FSH level to be in a certain range, due to the feedback from the follicle (s) developing under the stimulation by the clomiphene citrate. If the FSH is not in the correct range, the test is abnormal and the live birth rate for these patients is extremely poor. This test picks up another 30% of the patients with abnormal ovarian reserve.
A simple test of ovarian reserve that can be employed is the Basal Follicle Count. Early in the cycle, the small follicles that can be seen with ultrasound are counted. A low number of follicles can predict the increased likelihood of a poor response to therapy and decreased chance of live birth. Very high numbers of small follicles suggests a tendency to over respond to hormonal stimulation.
It is important to understand that none of these tests individually are absolute when test results are normal or equivocal. (A markedly elevated FSH level, indicating a loss of reproductive potential, is as close to certainty as we get.) However, they can be part of a picture, combined with the patient’s age and response to previous treatment that gives the physician a pretty good idea where the patient’s ovarian function stands.
Age, FSH level and ovarian reserve are three key factors that can all impact IVF success rates.