Pregnancy rates in donor oocyte cycles compared to similar autologous in vitro fertilization cycles An analysis of 26457 fresh cycles from the Society for Assisted Reproductive Technology

Capsule:
We discuss how data from the Society for Assisted Reproductive Technology registry suggests that fresh autologous stimulation decreases endometrial receptivity in a model that compares donor oocyte cycles with similar autologous cycles.

Authors:
Jason S. Yeh, M.D., Ryan G. Steward, M.D., Annie M. Dude, M.D., Ph.D., Anish A. Shah, M.D., M.H.S., James M. Goldfarb, M.D., Suheil J. Muasher, M.D.

Volume 102, Issue 2, Pages 399–404

Abstract:

Objective:
To use a large US IVF database and compare pregnancy outcomes in fresh donor oocyte versus autologous IVF cycles in women age 20–30 years.

Design:
Retrospective cohort study.

Setting:
Not applicable.

Patient(s):
Women undergoing fresh autologous ovarian stimulation, and oocyte donors and recipients in the United States between 2008 and 2010.

Intervention(s):
None.

Main Outcome Measure(s):
Implantation, clinical pregnancy (CP), and live birth (LB) rates.

Result(s):
Despite similar demographics, stimulation, and embryo parameters, donor oocyte recipients had significantly higher rates of implantation, CP, and LB compared to those undergoing fresh autologous cycles. Odds ratios for implantation, CP, and LB significantly favored the donor oocyte group in all comparisons, including those limited to intracytoplasmic sperm injection cycles, intracytoplasmic sperm injection with male factor, unexplained infertility, cleavage stage embryo transfer, blastocyst transfer, elective single blastocyst transfer, and autologous patients with prior tubal ligation.

Conclusion(s):
Recent US data suggest that the hormonal environment resulting from autologous ovarian stimulation lowers IVF success rates. Further research is needed to determine when to avoid fresh embryo transfer in autologous patients.

  • Lauren Johnson

    Thank you for your thorough response! I found your comments to be very helpful, and I am sure that others will as well. Your ASRM abstract looking at those with low/average response is definitely intriguing, and it will be a nice compliment to your current manuscript. I look forward to your presentation at ASRM!

  • Jason Yeh

    Hi Lauren! It is always great to hear from you and thank you so much for your comment.

    Our objective when designing this study was to examine the effect of supraphysiologic hormone levels on fresh IVF cycle outcomes. In order to isolate this variable in a different manner from the more standard comparison of fresh versus frozen cycles, we chose to compare fresh cycle outcomes between oocyte recipients (lower hormonal environment) to autologous patients (high hormonal environment). In order to “maximize” the difference in circulating hormonal milieu, we focused our analysis on autologous and donor oocyte cycles demonstrating ample oocyte yield.

    While it is true that these two cohorts are dissimilar from the standpoint of fertility (autologous patients being, by definition, infertile and donors being likely fertile), not all donors should be considered automatically fertile since many of them are nulligravid. That being said, the exact number of infertile oocyte donors, while unknowable, cannot possibly be as high as the number of infertile women in the autologous cohort (~40%). With regard to your question, we did consider a few ways of addressing this incongruity between groups when designing our study. One approach would have been, as you said, to have stratified our analysis based on the number of oocytes retrieved. Doing so, in our opinion, would not have necessarily addressed differences in “fertility status” as much as it would have incorporated a wider range of peak estradiol levels in both cohorts. The resulting data, I think, would have been helpful to speculate on how various hormone levels could affect the autologous uterine environment and affect potential for pregnancy. Furthermore, we felt that inclusion of young patients (20-30 years old) with extremely low yield (between 1-5) or even low-normal yield (6-9) could have introduced additional concerns of poor oocyte/embryo quality that we could not accurately characterize with retrospective data. You might find it interesting, though, that one of the abstracts we will be presenting at ASRM 2014 is related to your suggestion to compare rates between oocyte donors and autologous patients with low/average response (1-9 oocytes). We conducted this analysis this not to tease out any differences between fertile vs. infertile outcomes, but to compare two groups with similar peak estradiol levels. In brief, we found that unlike this study, pregnancy outcomes were not significantly different between groups when fewer oocytes were retrieved (and circulating hormone levels were not as high).

    As you likely saw, the main way we decided to address the limitation you mentioned was our inclusion of a secondary analysis which incorporated autologous patients who had previously undergone a tubal ligation. Since patients with tubal ligation were almost certainly fertile at one point in their life, we felt that isolating these patients and comparing them to the entire recipient cohort was the closest we could get to comparing outcomes between two “fertile” groups (although the total number of autologous cycles done for tubal ligation-related infertility was not as large as we would have hoped). Finally, another idea we had (also mentioned in the publication) was to identify split cycles in which oocytes from either donor or autologous patients are shared with another party, but these are rare events and we weren’t able to find enough for a meaningful publication.

    • Lauren Johnson

      Thank you for your thorough response! I found your comments to be very helpful, and I am sure that others will as well. Your ASRM abstract looking at those with low/average response is definitely intriguing, and it will be a nice compliment to your current manuscript. I look forward to your presentation at ASRM!

  • Lauren Johnson

    Congratulations to Jason and colleagues on this well-done analysis comparing pregnancy outcomes between autologous and donor cycles from the SART database. The impact of supraphysiologic E2 levels is an important and timely topic that warrants further investigation. In contrast to previous manuscripts examining the impact of supraphysiologic hormone levels on implantation, this manuscript includes only fresh cycles, thus avoiding potential bias associated with differences in embryo quality between fresh and frozen cycles. However, one limitation of this study design is that oocytes in the donor group are derived from women who, by definition, are not infertile. Thus, I wonder if the improved outcomes that were observed in the donor group reflect not only differences in the hormonal milieu but also underlying differences between a fertile and an infertile population. One way to tease out these factors might be to stratify the analysis on number of oocytes retrieved (instead of controlling for this variable.) Did the authors consider this approach?

  • Forest Garner

    It seems the title of this forum discussion: “Pregnancy rates are lower in donor oocyte cycles
    when compared to similar autologous in vitro fertilization cycles An
    analysis of 26457 fresh cycles from the Society for Assisted
    Reproductive Technology” is not the same as that of the corresponding manuscript: “Pregnancy
    rates in donor oocyte cycles compared to similar autologous in vitro
    fertilization cycles: an analysis of 26,457 fresh cycles from the
    Society for Assisted Reproductive Technology”. Perhaps the title was revised during review?

    Anyway, an interesting article. There are now reports that success rates and birth weights are greater in oocyte donation cycles, gestational carrier cycles, and FET cycles when compared to fresh autologous cycles.

    • Thea Ryan

      Thank you for your comment. This post has been edited to reflect the article’s most current title: “Pregnancy rates in donor oocyte cycles compared to similar autologous in vitro fertilization cycles: an analysis of 26,457 fresh cycles from the Society for Assisted Reproductive Technology.”

  • Forest Garner

    Pardon me, I may be confused. The article title and the Results don’t seem to match. “Pregnancy rates are lower in donor oocyte cycles” in title vs “donor oocyte recipients had significantly higher rates of implantation, CP, and LB” in Results.

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