Q: Are older women better or worse candidates for using lower amounts of ovulation stimulation drugs (gonadotropins)?
A: This question can’t be answered with a simple “better” or “worse”. We must first decide if we are looking at a group of women with diminished ovarian reserve or simply older women. What about younger women with diminished ovarian reserve? How do you define older? How do you define diminished ovarian reserve? The answer also depends on the patient’s diagnosis. There have been several studies looking at the effectiveness of minimal stimulation IVF on older women. A randomized clinical trial in women over 38 comparing minimal stimulation cycles to standard stimulation found a reduced number of embryos developed in the lower dose cycles. Embryo biopsy at the 8-cell stage revealed an equal number of genetically normal embryos. A recent meta-analysis comparing mild stimulation with conventional IVF failed to find a difference in cumulative live birth rate, ongoing pregnancy, or ovarianhyperstimulation syndrome. One recent retrospective study found that the modified natural cycle was less cost effective and had a lower cumulative live birth rate in comparison with conventional IVF. A prospective randomized trial combining clomiphene with gonadotropin found a higher cancellation rate and lower ongoing pregnancy rate when clomiphene was utilized. With the advent of embryo screening with PGS and mitochondrial screening, we can achieve superior pregnancy rates sooner and more cost-effectively with a reduced risk of miscarriage. While the evidence is strong that higher gonadotropin doses will not likely improve cycle outcome,the benefit of minimal stimulation is unproven and age does not seem to be a factor.
Answered by Dr. Perloe at Georgia Reproductive SpecialistsImage credit: Josef Seibel