Success of intrauterine insemination in women aged 40-42 years

OBJECTIVE: To determine how advancing female age decreases successful outcomes of intrauterine insemination (IUI) alone or combined with ovarian stimulation. DESIGN: Retrospective review. SETTING: Academic fertility center. PATIENT(S): Infertile men and women. INTERVENTION(S): Intrauterine insemination alone or combined with ovarian stimulation. MAIN OUTCOME MEASURE(S): Pregnancy rates, miscarriage rates, and live birth rates per insemination cycle according to female age. RESULT(S): The 1,117 cycles of IUI resulted in 217 pregnancies, for an overall pregnancy rate for all female ages of 19.4% and a live birth rate of 12.9% per cycle inseminated. The overall live birth rate per insemination declined with advancing maternal age. CONCLUSION(S): Advancing female age decreases successful outcomes with IUI. The live birth rate with IUI for women 40-42 years old (n = 82) was 9.8% per insemination and may demonstrate that IUI is an appropriate treatment for this age group of women.     

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.     

Maternal serum screening for Down syndrome in women aged 40 years and over.

Two hundred and thirty-nine women aged 40 years were booked for delivery at Kettering General Hospital from 1992 to 1997. Six women were not eligible for the triple test (TT) as they booked too late. Eighty-eight women declined TT. The reasons were; fear and anxiety about the risk of miscarriage associated with amniocentesis if the test result were a high risk (70.5%), worries about the false negative result associated with the TT (20.5%) and reluctance to terminate the pregnancies if the fetus were abnormal (9%). One hundred and forty-five women (62.2%) elected for TT of whom 91 (62.8%) had received a high risk results. Of the women who received a high-risk result 61/91 (67%) had an amniocentesis. The study provides an accurate probability of receiving a high risk TT screening in women aged 40 years and highlights the need for a more sensitive screening test or a less invasive diagnostic test for the detection of Down syndrome.     

Ovarian stimulation and intrauterine insemination in women aged 40 years or more

Fertility decreases with advancing age. This study retrospectively reviewed the results of ovarian stimulation and intrauterine insemination (IUI) in women 40 years old with diminished ovarian reserve or unexplained infertility who underwent treatment with ovarian stimulation/IUI with clomiphene citrate or gonadotrophin and compared them with the results of IVF and in-vitro maturation (IVM) treatments. The main outcome measures were pregnancy and live-birth rates. The profiles of the patients in ovarian stimulation, IVM and IVF groups were comparable. There were no clinical pregnancies in the clomiphene citrate and IVM groups. The clinical-pregnancy rates in the gonadotrophin and IVF groups were 2.6% and 16.9% and the live-birth rates were 2.6% and 13.7%, respectively. Compared with ovarian stimulation, IVF is most effective for women aged 40 years or more. Attempting success with ovarian stimulation or IVM will delay conception unnecessarily.     

Sacrospinous ligament fixation for massive genital prolapse in women aged over 80 years

Objective To assess the feasibility of vaginal sacrospinous ligament fixation for women over 80 years of age with massive vaginal vault or uterovaginal prolapse.
Design Retrospective observational study with long term follow up.
Setting Department of Obstetrics and Gynaecology, Tampere University Hospital, Finland.
Sample and Methods The study group consisted of 25 women with a mean (SD) [range] age of 83 (3) [80-93] years: 13 had posthysterectomy vaginal vault prolapse and 12 had massive uterovaginal prolapse. All underwent vaginal sacrospinous ligament fixation with repair of pelvic floor relaxation. Women with uterovaginal prolapse also underwent concomitant vaginal hysterectomy. The long term outcome was assessed in 19 women. The mean follow up period was 33 (31) [2-113] months.
Main outcome measures Intra- and post-operative morbidity, mortality and recurrence of prolapse.
Results Sixteen of the 25 women (64 %) had no major intra- or post-operative complications. The mean estimated blood loss was 400 (280) mL, and seven women received blood transfusions. Four women (16%) had cardiovascular complications, and one died of pulmonary embolism. All four had a history of vascular disease. One woman had symptomatic recurrence of vault prolapse treated with a vaginal pessary; two women had asymptomatic cystocele and one had an enterocele requiring no treatment. The outcomes were similar for women with or without concurrent vaginal hysterectomy.
Conclusion Transvaginal sacrospinous ligament fixation is an effective treatment for massive vaginal vault or uterovaginal prolapse in aged women. Increased blood loss may elevate the risk of cardiovascular complications especially in elderly patients with a history of vascular disease, thus indicating the importance of intraoperative bleeding control.     

Cardiac surgery in patients aged at least 80 years.

Cardiac surgery in patients aged 80 years and over has become more acceptable with improvements in health care services and the steady increase in the number of octogenarians in the population. These demographic changes are reflected in an increasing number of octogenarians with advanced symptomatic disease undergoing complex cardiac intervention. We reviewed data from 62 articles on cardiac surgery in octogenarians. The medical and ethical issues involved in making the decision are complex. Long-term results of cardiac surgery in octogenarians show that these patients can withstand heart surgery with improved functional benefit and quality of life. Surgery is beneficial especially for patients undergoing coronary artery revascularization or isolated aortic valve surgery. The operative course in octogenarians is more complicated, which is reflected in longer postoperative hospitalization. In refutation of the assumption that mortality in octogenarians is related to multisystem failure, most deaths are cardiac in nature. Highly selective criteria (identifying risks and benefits individually) should be applied to octogenarians undergoing cardiac surgery to achieve a satisfactory result.     

Retrospective analysis of 1217 IVF cycles in women aged 40 years and older

Older women comprise an increasing portion of patients entering assisted reproduction programmes. This study is a retrospective summary of the files of all patients aged 40 years and older at advent of IVF, between 1995 and 2004, in the authors' centre. In all, 381 women underwent 1217 initiated treatment cycles. Embryo transfer was performed in 62.6% of initiated cycles. Success rates declined with each year after age 40; pregnancy and delivery rates were 13.9 and 9.1% at age 40 and 2.8 and 0.7% at age 45. There were no deliveries at an older age. Logistic regression analysis showed the following factors were independently and significantly related to higher pregnancy rates: younger age, lower dose of gonadotrophins, greater number of mature follicles, endometrial thickness, and number of embryos transferred; prior pregnancy did not influence success. Retrieving more than four oocytes increased pregnancy rates in all women over 40. Transferring 3 embryos or more increased pregnancy rates in all ages, but reached statistical significance only in women aged 40-41 (P < 0.000). It is concluded that in women between 40 and 41 years of age, ovarian response is a major determinant of success, but not in women older than that. Unrealistic expectations may be avoided if accurate data are provided regarding delivery rates per year after age 40.     

Endometrial carcinoma in women aged 40 years or younger: a Japanese experience

We report on the clinical and pathologic findings in 17 cases of endometrial carcinoma in Japanese women aged 40 years or younger. Age of the patients ranged from 16 to 40 years, with a median of 35 years. Nine of 17 tumors (52.9%) were stage I or II (FIGO 1988) but 8 (47.1%) were stage III. Four of the 8 patients with stage III disease had pelvic lymph node metastases and one also had para-aortic lymph node metastasis. One patient had metastasis to the ovary and peritoneal cytology was positive in 4 patients. Histologically, 13 of these 17 patients had endometrioid adenocarcinoma, 3 had adenoacanthoma and 1 had an undifferentiated carcinoma. Ten were well differentiated tumors (G1), 3 were moderately differentiated tumors (G2), and 4 were poorly differentiated tumors (G3). Nine of 17 (52.9%) showed deep myometrial invasion (more than a half of the myometrium) and 5 of 17 (29.4%) demonstrated lymphatic/vascular space invasion. Pelvic and para-aortic lymph node metastases were seen in 4 of 15 (26.7%) and 1 of 15 (6.7%), respectively. Two of these 17 patients died of disease in a relatively short follow-up period. In our experience there is no difference in the survival rates between patients aged 40 years or younger and those over 40 years.     

Results of in vitro fertilization cycles in women aged 43-45 years.

Our objective was to evaluate the results of in vitro fertilization (IVF) cycles in the elderly (43-45 years old) female population. All consecutive women aged 43-45 years admitted to our IVF unit from January 1996 to December 2001 were enrolled in the study. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed. Seven hundred and eight consecutive IVF cycles in 276 patients were evaluated. Two hundred and seven cycles were cancelled (cancellation rate 29.2%). Forty-seven patients achieved a clinical pregnancy (pregnancy rate 6.6% per cycle and 9.4% embryo transfer) with a 30% live birth rate. In patients who underwent embryo transfer, there were no differences between conception and non-conception cycles in patient's age, number of gonadotropin ampules used, length of ovarian stimulation, number of oocytes retrieved, fertilization rate or cleavage rate. However, the conception cycles were associated with a significantly lower peak estradiol level (p < 0.04) and higher number of total (p < 0.03) and good-quality (p < 0.005) embryos transferred, in addition to a lower ratio of estradiol level/number of follicles > 14 mm on day of human chorionic gonadotropin administration and of estradiol level/number of oocytes retrieved. We conclude that, although older female age is a major contributor to IVF failure, successful IVF cycles can be expected in patients aged 43-45 years in the presence of low ratios of peak estradiol to either number of follicles > 14 mm on day of human chorionic gonadotropin administration or number of oocytes retrieved that reach the stage of embryo transfer with at least two good-quality embryos.     

Clinicopathologic study of uterine endometrial carcinoma in young women aged 40 years and younger

To clarify what constitutes the adequate management of uterine endometrial carcinoma in young women, we reviewed clinicopathologically 31 patients aged 40 years and younger between January 1991 and June 2004. As a primary treatment, 12 cases chose hormonal treatment with medroxyprogesterone acetate (MPA; 600 mg/day) due to no findings of myometrial invasion and diagnosis of a grade 1, well-differentiated adenocarcinoma. In remaining 19 cases, surgery was performed. All the 19 patients who received surgery as a primary treatment are alive, with no evidence of a recurrence of the disease. In the 12 patients who received hormonal treatment, 8 patients eventually received a hysterectomy because of recurrence or no response to MPA. Of these eight patients, myometrial invasion was recognized in three patients. One of the eight patients died of the metastasized disease to the liver and brain after hysterectomy. After hormonal treatment, 4 of the 12 patients were exempted from surgery and showed no evidence of recurrence. Two patients had viable children. Progesterone receptor was negative in one case that died. Careful consideration should be given to hormonal treatment with MPA for the conservative management of endometrial carcinoma in young women. Moreover, MPA is not always a consistent management for every patient.     

Gynecologic problems among elderly women in comparison with women aged between 45-64 years

BACKGROUND: As women age, they face a variety of co-morbid medical problems as well as gynecologic problems that may differ from those of younger women. Clinicians should know how to screen and manage those problems among elderly women. OBJECTIVE: With this background, the study was designed to assess the gynecologic problems on admission among elderly women and women aged between 45-64 years. METHODS: A retrospective analysis of symptom distribution of 200 women aged over 65 years and 200 women aged between 45-64 years from January 1999 to December 2003 was performed in an university clinic. PARTICIPANTS: Geriatric women and women aged between 45-64 years with gynecologic complaints on admission to outpatient clinics between January 1999 and December 2003. Analyses of demographic data and data related to symptom distribution, using appropriate parametric and non-paramertic statistical tests, were performed. RESULTS: Geriatric women had a higher number of pregnancies (p < 0.01) but lower percentage of hormone replacement therapy use (p < 0.1) compared to women aged 45-64 years. No significant difference was observed in terms of the age at menopause. Vaginal fullness was felt most commonly by elderly women (p < 0.01) in contrast to menopausal vasomotor symptoms which were relevant in the younger age group (p < 0.01). As a clinical diagnosis, pelvic relaxation with uterine prolapse and genital malignancies were the common two diagnoses among geriatric women (p < 0.05). Postmenopausal vaginal bleeeding was observed more often among geriatric women compared to women aged 45-64 years (19.5% vs 12%, p = 0.03). Endometrial and ovarian cancer distribution did not differ among the two groups when the initial complaint was postmenopausal bleeding. CONCLUSION: Type and management of gynecologic problems in women aged over 65 can be challenging and differ from those for younger women. Thus, caring for these women in their reproductive years as well as in later life should be an aim for all obstetrician-gynecologists.     

Menopausal symptoms and health problems of women aged 50-65 years in southern Jordan.

OBJECTIVES: To identify menopausal symptoms and health disorders of women aged 50-65 years in under-privileged areas of southern Jordan. METHOD: A multistage, random-sampling design was applied to select a sample of households from three governorates. A total of 143 women were eligible to be included in the analysis. Women were asked about a list of symptoms (somatic, psychological and genitourinary) and about a list of morbidities such as hypertension, diabetes mellitus and urinary tract infection. Ever-screening by mammogram, regular breast self-examination, ever-screening by cervical smear, general medical check-up, physical activity, smoking habit, and ever-receiving information about menopause were also investigated. RESULTS: The median age of onset of natural menopause was 50 years; 77% of women were illiterate, and 59% of the couples were relatives. The most frequently reported somatic symptoms were joint aches/stiffness (89%), bone pains (74%) and paresthesia in the extremities (51%). Hot flushes were experienced by 62% and urinary incontinence by 30%. Almost 62% reported irritability and mood changes, 56% had high blood pressure, and 18% and 14% suffered from urinary tract infection and reproductive tract infection, respectively. Eight percent and 11% reported ever-screening by mammogram and cervical smear, respectively, and 11% reported performing breast self-examination regularly. Regular physical exercise was reported by 8%, and 81% were overweight or obese. One-quarter received information on menopause, and 58% reported the need to know 'everything' about menopause. CONCLUSION: Women in southern Jordan experienced multiple menopause-related symptoms and morbidities. The majority of them did not receive any health education about this phase of life. Preventive health practices and health-promoting behaviors are relatively uncommon. Effective health-care delivery systems responsive to menopausal women's health needs are highly recommended.     

Natural-cycle in vitro fertilization in women aged over 44 years.

Women who are 44 years of age or more are usually denied infertility treatment because of their low response to ovarian stimulation and the extremely low pregnancy rate that can be achieved. The object of this study was to assess the place of natural-cycle in vitro fertilization (IVF) in this population. From January 1996 to September 1997, all consecutive women aged 44-47 years who approached our unit seeking infertility treatment with their own oocytes were enrolled in the study. After a counselling session in which the advantage of egg donation was discussed, women who still wished to try to conceive by utilizing their own oocytes were treated according to the following protocol. Ultrasound and hormonal surveillance was carried out starting 5 days prior to the presumed ovulation day, based on previous menstrual history. Ovum pick-up was timed either by detection of the luteinizing hormone surge or by human chorionic gonadotropin administration. In total, 48 treatment cycles were conducted in 20 women. Oocyte retrieval was successful in 22 cycles. Fertilization and cleavage rates of 48% and 100%, respectively, were detected. Nine of the 12 embryos transferred were defined as grade A. One chemical and one ongoing pregnancy were achieved. We conclude that, despite the fact that high-quality embryos can be obtained in this population, the likelihood of pregnancy is low.