Advanced reproductive age and fertility: no. 269, November 2011

ObjectiveTo improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging.OptionsThis guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility.OutcomesThe outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.EvidencePublished literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010.ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).Benefits, harms, and costsPrimary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology.     

Assessing fertility in women of advanced reproductive age

Reproductive capacity in women declines dramatically beyond the fourth decade of life. Oocyte quality seems to be the primary determinant of reproductive potential, although age-related uterine changes may also contribute. Underlying reasons for reproductive decline in women remain unclear, and both ovarian and neuroendocrine mechanisms have been proposed.A number of age-related endocrinologic changes precede menopause and predict diminished reproductive capacity. Thus, "ovarian reserve" screening may identify patients in whom attempts at conventional assisted reproduction is warranted before proceeding with ovum donation. Techniques to preserve the maternal genetic contribution to offspring (in lieu of egg donation), including germinal vesicle transfer and donor ooplasm, are under investigation.     

Oocyte cryopreservation: a feasible fertility preservation option for reproductive age cancer survivors

Purpose  

To compare oocyte cryopreservation cycles performed in cancer patients to those of infertile women.     

Advanced maternal age

Delayed childbearing is a growing trend in developed countries. Between 1982 and 2012, the number of live births to UK women over 40 more than quadrupled. This accelerating demographic shift is of major clinical and public health concern, because advanced maternal age has consistently been associated with adverse pregnancy outcomes. Current evidence suggests increased risk of miscarriage, ectopic pregnancy and stillbirth. Most studies also report elevated maternal morbidity resulting from hypertensive disorders and gestational diabetes. Many questions remain unanswered regarding the underlying mechanisms. The contribution of age per sé versus co-morbidities is unclear, as is the age threshold at which increased risks become significant. Despite the increased risks, there are potential psychological and social advantages to delaying childbirth and absolute numbers of complications are small. Further studies are required to develop effective strategies to reduce poor outcomes and provide optimal care for pregnant women of advanced age.     

Advanced maternal age

The average age of women at childbirth in industrialised nations has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (>40 years) should be given low dose aspirin (in the presence of an additional risk factor for pre-eclampsia) and offered serial ultrasounds for fetal growth and wellbeing; given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with the woman.     

Direct-to-consumer fertility testing: utilization and perceived utility among fertility patients and reproductive endocrinologists

Research QuestionWhat is the utilization of direct-to-consumer fertility tests (DTCFT) among fertility patients? How does the perceived utility of DTCFT differ between patients and reproductive endocrinologists (REI)?DesignInfertility patients visiting the Duke Fertility Center between December 2020 and December 2021 were sent an electronic invitation to participate in a patient survey. Members of the Society of Reproductive Endocrinology and Infertility were also sent e-mail invitations to participate in the REI survey. DTCFT were defined as tests not ordered by a physician or performed at a physician's office, including calendar methods of ovulation prediction, urinary ovulation prediction kits, basal body temperature (BBT) monitoring, hormone analysis, ovarian reserve testing and semen analysis. Patients and REI were asked how likely they were to recommend a given DTCFT, on a 0–10 Likert scale.ResultsIn total, 425 patients (response rate 50.5%) and 178 REI (response rate 21.4%) completed the surveys. Patients reported the utilization of calendar methods of ovulation prediction (83.8%), urinary ovulation prediction (78.8%), BBT monitoring (30.8%), hormone analysis (15.3%), semen analysis (10.1%) and ovarian reserve testing (9.2%). REI rated the utility of all DTCFT significantly lower than patients did (average discordance –4.2, P < 0.001), except for urinary ovulation prediction, which REI gave a significantly higher score (discordance +1.0, P < 0.001). Prior pregnancy was significantly associated with home ovulation prediction utilization among patients (adjusted odds ratio 3.21, 95% confidence interval 1.2–9.83).ConclusionsMethods of ovulation prediction are commonly used by fertility patients. Significant discordance exists in the perceived utility of DTCFT between patients and REI. Patient education and guidelines are needed to better inform individuals considering DTCFT.     

Heat stress on reproductive function and fertility in mammals

In most mammalian species including cattle, heat stress has deleterious effects on nutritional, physiological and reproductive functions. Exposure of animals to a hot environment causes an increase in body temperature in mammals, including domestic animals. High ambient temperature also causes a decrease in the length and intensity of estrus by disturbing ovarian function as well as decreasing pregnancy rate after artificial insemination. Therefore, it is important to understand the effects of heat stress on reproductive function in order to improve the production of domestic animals. Heat stress decreases appetite, weight gain, and milk yield in dairy cattle. It also adversely affects the reproductive performance of both sexes. In males, it reduces spermatogenic activity, while in females it adversely impacts oogenesis, oocyte maturation, fertilization development and implantation rate. Detection and evaluation of the deteriorating effects of heat stress on reproductive organs and cells can help to design measures to prevent them and improve reproductive functions. In this review, we discuss the impacts of heat stress on reproductive functions.     

Decreased fertility and today's possibility of examination in reproductive immunology

The aim of reproductive immunology is to look for a futher cause of decreased fertility, immunological reason, which depends on neuro-endocrine relationships. The article explains today's possibility of examination of cell and humoral immunity with regard to human fertility. Setting: Department of Gynecology & Obsterics Charels University and Faculty Hospital, Pilsen.     

Relationship of age at menarche and subsequent fertility.

We investigated retrospectively the relationship between the age at menarche and reproductive ability in 2278 married women. Those who had a pregnancy experienced menarche at a mean age (+/- SEM) of 13.7 +/- 0.1 years, and those who were infertile had menarche at a mean age of 14.0 +/- 0.2 years, difference in the times of onset of menarche being significant (P less than 0.05). Moreover, a group in whom menstruation started after the age of 18 years had a significantly higher rate of infertility (15.7%) than the others (5.0%). Irregular menstruations during the first few years after menarche was also related to decreased reproductive ability. These findings indicate the importance of menarche before the age of 18 for normal reproductive functioning.     

Histology and fertility effects of polydioxanone on rat reproductive tissue.

This prospective study compares the histology and fertility effects of the microsuture polydioxanone to nylon and polyglactin-910. Twelve rats underwent uterine horn microroeanatomoses with nylon (6 right horns), polyglactin-910 (6 right horns), and polydioxanone (12 left horns). After mating, there were no significant differences in gestational implantations or adhesions per uterine horn. Postoperative histologic evaluation of nylon showed persistent histiocytic reaction and fibrosis, occasional giant cells, and suture persistence at 100 days. Polyglactin-910 had initial histiocytic responses, no giant cells or fibrosis, and was resorbed by 60 days. Polydioxanone had initial histiocytic reaction and giant cells, no fibrosis, and was resorbed by 100 days. Our findings, and a review of the literature, confirmed mixed histologic reactions but no difference in fertility with these three microsutures. Because of its low reactivity and great strength, polydioxanone may be a good alternative suture material in reproductive microsurgery.     

Understanding the effects of age on female fertility

This review focuses on age-related changes occurring in the female reproductive system and their effect on reproductive material. Aging significantly impact the female reproductive system but, despite this fact, there is nowadays a trend to postpone pregnancy to pursue educational and vocational goals. Therefore a remarkable effort is now being made by the medical establishment to understand the effects of aging in women. The assessment and treatment of this decline in fertility is discussed, as well as assisted reproductive techniques and new therapeutic options.     

High-tech family planning: reproductive regulation through computerized fertility monitoring

Issues related to family planning have profound public health significance as they directly impact individuals, couples, and families throughout the world. A new method of family planning is now available using a computerized fertility monitor that accurately measures urinary surges in estrone-3-glucuronide (E3G) and luteinizing hormone (LH) prior to ovulation, thus identifying the short-lived fertile phase of the cycle and providing women with the choice to achieve or avoid conception. As well as ease of use and instruction, hand-held computerized fertility monitors are accurate and effective and can be used indefinitely. An algorithm for computerized monitoring is presented for use in situations of infrequent or irregular ovulation such as with polycystic ovarian syndrome and the post-partum period. Hormone-based fertility monitoring is compared to other computerized fertility monitoring techniques. A case series of seven reports reflecting varied clinical backgrounds and medical histories demonstrates broad-based success and high satisfaction with computerized monitoring for regulation of reproductive potential. Limitations of fertility monitoring are also discussed.     

Urinary reproductive hormone level differences between African American and Caucasian women of reproductive age

OBJECTIVE: To compare urinary levels of reproductive hormones in African American and Caucasian women. DESIGN: Cross-sectional study. SETTING: Ten United States Air Force (USAF) bases. PATIENT(S): African American (n = 33) and Caucasian (n = 65) women of reproductive age from a larger study of USAF women (n = 170). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Urinary endocrine end points: follicular luteinizing hormone (LH), preovulatory LH, level of LH surge peak, early follicular follicle stimulating hormone (FSH), follicular LH:FSH ratio, midluteal FSH, FSH rise before menses, early follicular estrone 3-glucuronide (E(1)3G), midfollicular E(1)3G, periovulatory E(1)3G peak, midluteal E(1)3G, early follicular pregnanediol 3-glucuronide (Pd3G), follicular Pd3G, rate of periovulatory Pd3G increase, E(1)3G:Pd3G on the day of luteal transition, slope of E(1)3G:Pd3G, and midluteal Pd3G. RESULT(S): Relative to Caucasians, African American women had significantly lower follicular phase LH:FSH ratios (mean +/- SD: 0.7 +/- 0.4 vs. 1.0 +/- 0.6), lower follicular phase Pd3G levels (1.0 +/- 0.5 vs. 1.2 +/- 0.8 microg/mg creatinine), and lower rates of periovulatory Pd3G increase (0.5 +/- 0.7 vs. 1.0 +/- 1.2 microg/mg creatinine). CONCLUSION(S): Findings of this analysis should be considered preliminary evidence of racial differences in hormone levels. Future studies are needed to determine whether these differences have clinical significance.