Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
SHORT COMMUNICATIONS
LOS ANGELES,
sented different populations. This report details the observed differences and discusses the impact such characteristics may have on the performance of oocyte donation services.
CALIFORNIA
Demographic Differences Between Younger and Older Recipients Seeking Oocyte Donation
MATERIALS AND METHODS The medical records of all w o m e n seeking oocyte donation at the University of Southern California from July 1987 through July 1991 were surveyed. Data regarding the demography of these patients were extracted from initial physician interviews. For purposes of analysis, all women were arbitrarily assigned to one of two groups (Group I, women 40 years). Comparisons were performed using nonparametric analysis for proportions (Fisher's exact test), with significance designated as a P value 40 years old). It subsequently became apparent that the older and the younger recipients repre-
1058-0468/92/0800-0400506.50/0© 1992 Plenum Publishing Corporation
RESULTS Table I describes the personal characteristics of the women studied. An obvious age difference, approximately 10 years, existed between the two groups. Women of advanced reproductive age were more likely to be divorced and remarried, although the duration of the present marriage was similar in the two groups. Many women over age 40 had undergone previous cosmetic surgery, usually breast augmentations, blepharoplasties, and rhinoplasties, compared to a low frequency of plastic procedures in the younger women. Patients of older age were also more likely to be professionally educated.
400
SHORT COMMUNICATIONS
401
Table I. Personal Characteristics of Women Seeking Oocyte Donation Women 40 years (n = 104)
34.3 --- 0.7 ~ 24-38
44.6 -+ 0.3* 40-59
No. remarried
6 (11.3%)
53 (51.0%)*
Duration of marriage (years) Range
4.8 --- 0.3 1-9
5.4 -+ 1.3 1-30
Age (years) Range
No. cosmetic surgery
2 (3.8%)
21 (20.2%)*
Preferred anonymity
13 (24.5%)
63 (60.6%)*
* P < 0.05. Values are means -+ SE.
Table II compares the reproductive histories of the two groups. Most women with premature ovarian failure had never experienced pregnancy, while many women over 40 had achieved at least one conception. Likewise, significantly more older women had electively terminated a pregnancy earlier in life, compared with few (5.7%) elective abortions reported by the younger recipients. Women of advanced reproductive age had, in most cases, undergone attempts at in vitro fertilization using their own oocytes, while few of the younger patients had previously considered assisted reproduction.
DISCUSSION A new population of patients has begun seeking fertility care as a result of the method of oocyte donation being offered to women of advanced reproductive age. In general, these patients are welleducated, experienced individuals who lead successful lives and are accustomed to achieving self-directed goals. As a group, they have been Table II. Previous Reproductive Experiences of Women Seeking Oocyte Donation Women 40 years (n = 104) 41 34 37 51
(39.4%)* (32.7%)* (35.6%)* (49.0%)*
* P < 0.05.
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
frustrated by attempts at achieving pregnancy. In many cases they have invested considerable time and money on methods known to have low probabilities for success. Patients interested in oocyte donation have chosen to look beyond genetic parenting and usually envision oocyte donation as an option offering a more reasonable chance for success. In comparison with other alternatives, such as surrogacy or adoption, oocyte donation in many respects is the least encumbered, both medically and legally, while simultaneously providing the greatest degree of "control" over the pregnancy to the recipient couple. At this time, oocyte donation may in fact be the easiest and most accessible method for attaining parenthood in older couples. The previous life experiences of many of the women of advanced reproductive age often impact upon the dynamics of their present participation in oocyte donation. Many have personally experienced ovarian hyperstimulation and either in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). First-hand knowledge of the requisite time invested by donors, the inherent difficulties in using parenterally administered drugs, and the importance of a good stimulation as it relates to oocyte quality and quantity contributes to an overall keen understanding of the method involved. These women have had to cope with repetitive reminders of their dismal prognosis with conventional therapy. We have been impressed by how the older women are encouraged and enthusiastic about the prospect of attaining a reasonable probability for success with the use of donor oocytes. Unlike women with premature ovarian failure, few older individuals seemed interested in further trials of stimulation of their own ovaries and seemed reconciled to the finality represented by this method. Many older patients had previously electively terminated pregnancies. While these data are not quantifiable, we have observed guilt and remorse over the perceived lost opportunity for motherhood. A desire to recapture this opportunity was referred to by several patients as an "obsession." The prevalence of cosmetic surgery, most often breast implants or blepharoplasties, further underscores the perceived importance of the maintenance of a youthful appearance in these individuals. It is possible that pregnancy further represents another aspect of a youthful and active self-image. In general, the older patients are better educated to the process of oocyte donation and usually more
402
demanding of their caretakers. Questions about the past reproductive performance of donors are usually asked based upon the underlying assumption that pregnancy rates in the future are likely to correlate with previous successful ovarian hyperstimulation and embryo transfer. The recipients' own past experience, in many cases coupled with multiple consultations with respect to their own failed ART cycles, have educated these individuals and led to certain expectations. At times unrealistic expectations regarding donor performance arise from misinterpretations and extrapolations from previously gained information. Unfortunately the professional service rendered may, in such circumstances, be perceived as a de facto purchased commodity.
SUMMARY An older population of women is now increasingly seeking infertility care. The number of these patients may in fact eclipse those of younger patients for whom the method of oocyte donation was initially designed and previously offered. As a group, these older individuals appear to be energetic and demanding, with high expectations regarding the performance and the effectiveness of their fertility care. Physicians need to exercise vigilance in order to emphasize that eggs are not being bought and sold as a commodity and that guarantees of pregnancies cannot be made. Nevertheless, whereas oocyte donation requires all parties, donor, recipient, and doctor, to work together toward a common goal, it still offers women of advanced reproductive age perhaps their best chance at conception, pregnancy, and parenthood.
REFERENCES 1. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renou P: The establishment and maintenance of pregnancy using in vitro fertilization and embryo donation in a patient with primary ovarian failure. Nature 1984;307:174--175 2. Sauer MV, Paulson RJ: Human oocyte and preembryo donation: An evolving method for the treatment of infertility. Am J Obstet Gynecol 1990;163:1421-1424 3. Medical Research International; Society for Assisted Reproductive Technology, The American Fertility Society. In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF-ET Registry. Fertil Steril 1992;57:15-24
SHORT COMMUNICATIONS
4. Saner MV, Paulson RJ, Lobo RA: A preliminary report on oocyte donation extending reproductive potential to women over 40. N Engl J Med 1990;323:1157-1160 5. Sauer MV, Paulson RJ, Macaso TM, Francis MM, Lobo RA: Establishment of a nonanonymous donor oocyte program: preliminary experience at the University of Southern California. Fertil Steril 1989;52:433-436
Mark V. Sauer 1 Richard J. Paulson Department of Obstetrics and Gynecology Division of Reproductive Endocrinology University of Southern California Los Angeles, California 90021 1 To whom correspondence should be addressed at Women's Hospital, 1240 North Mission Road, Room L946, Los Angeles, California 90033.
KIEL, GERMANY Pregnancies Following Transvaginal Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and T u b a l E m b r y o - S t a g e T r a n s f e r ( T E S T ) in an in Vitro F e r t i l i z a t i o n ( I V F ) P r o g r a m
Submitted: March 11, 1992 Accepted: March 19, 1992
We report on the first pregnancies achieved at our clinic following transvaginal GIFT, ZIFT, and TEST. Our study population consisted of 15 patients in 17 treatment cycles. The mean age and duration of infertility were 32 and 5.4 years, respectively. The indications were male factor in eight cycles, unexplained infertility in seven cycles, and endometriosis in two cycles. Hormonal stimulation was performed with gonadotropin-releasing hormone analogue (Gn-RHa), human menopausal gonadotropin (hMG), and human chorionic gonadotropin (hCG) according to the protocol described by MacNamee et al. (1). Follicular aspiration and other laboratory maneuvers for semen preparation, insemination, and embryo culture were performed exactly as described previously (2). For the transvagJournal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
SHORT COMMUNICATIONS
LOS ANGELES,
sented different populations. This report details the observed differences and discusses the impact such characteristics may have on the performance of oocyte donation services.
CALIFORNIA
Demographic Differences Between Younger and Older Recipients Seeking Oocyte Donation
MATERIALS AND METHODS The medical records of all w o m e n seeking oocyte donation at the University of Southern California from July 1987 through July 1991 were surveyed. Data regarding the demography of these patients were extracted from initial physician interviews. For purposes of analysis, all women were arbitrarily assigned to one of two groups (Group I, women 40 years). Comparisons were performed using nonparametric analysis for proportions (Fisher's exact test), with significance designated as a P value 40 years old). It subsequently became apparent that the older and the younger recipients repre-
1058-0468/92/0800-0400506.50/0© 1992 Plenum Publishing Corporation
RESULTS Table I describes the personal characteristics of the women studied. An obvious age difference, approximately 10 years, existed between the two groups. Women of advanced reproductive age were more likely to be divorced and remarried, although the duration of the present marriage was similar in the two groups. Many women over age 40 had undergone previous cosmetic surgery, usually breast augmentations, blepharoplasties, and rhinoplasties, compared to a low frequency of plastic procedures in the younger women. Patients of older age were also more likely to be professionally educated.
400
SHORT COMMUNICATIONS
401
Table I. Personal Characteristics of Women Seeking Oocyte Donation Women 40 years (n = 104)
34.3 --- 0.7 ~ 24-38
44.6 -+ 0.3* 40-59
No. remarried
6 (11.3%)
53 (51.0%)*
Duration of marriage (years) Range
4.8 --- 0.3 1-9
5.4 -+ 1.3 1-30
Age (years) Range
No. cosmetic surgery
2 (3.8%)
21 (20.2%)*
Preferred anonymity
13 (24.5%)
63 (60.6%)*
* P < 0.05. Values are means -+ SE.
Table II compares the reproductive histories of the two groups. Most women with premature ovarian failure had never experienced pregnancy, while many women over 40 had achieved at least one conception. Likewise, significantly more older women had electively terminated a pregnancy earlier in life, compared with few (5.7%) elective abortions reported by the younger recipients. Women of advanced reproductive age had, in most cases, undergone attempts at in vitro fertilization using their own oocytes, while few of the younger patients had previously considered assisted reproduction.
DISCUSSION A new population of patients has begun seeking fertility care as a result of the method of oocyte donation being offered to women of advanced reproductive age. In general, these patients are welleducated, experienced individuals who lead successful lives and are accustomed to achieving self-directed goals. As a group, they have been Table II. Previous Reproductive Experiences of Women Seeking Oocyte Donation Women 40 years (n = 104) 41 34 37 51
(39.4%)* (32.7%)* (35.6%)* (49.0%)*
* P < 0.05.
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
frustrated by attempts at achieving pregnancy. In many cases they have invested considerable time and money on methods known to have low probabilities for success. Patients interested in oocyte donation have chosen to look beyond genetic parenting and usually envision oocyte donation as an option offering a more reasonable chance for success. In comparison with other alternatives, such as surrogacy or adoption, oocyte donation in many respects is the least encumbered, both medically and legally, while simultaneously providing the greatest degree of "control" over the pregnancy to the recipient couple. At this time, oocyte donation may in fact be the easiest and most accessible method for attaining parenthood in older couples. The previous life experiences of many of the women of advanced reproductive age often impact upon the dynamics of their present participation in oocyte donation. Many have personally experienced ovarian hyperstimulation and either in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). First-hand knowledge of the requisite time invested by donors, the inherent difficulties in using parenterally administered drugs, and the importance of a good stimulation as it relates to oocyte quality and quantity contributes to an overall keen understanding of the method involved. These women have had to cope with repetitive reminders of their dismal prognosis with conventional therapy. We have been impressed by how the older women are encouraged and enthusiastic about the prospect of attaining a reasonable probability for success with the use of donor oocytes. Unlike women with premature ovarian failure, few older individuals seemed interested in further trials of stimulation of their own ovaries and seemed reconciled to the finality represented by this method. Many older patients had previously electively terminated pregnancies. While these data are not quantifiable, we have observed guilt and remorse over the perceived lost opportunity for motherhood. A desire to recapture this opportunity was referred to by several patients as an "obsession." The prevalence of cosmetic surgery, most often breast implants or blepharoplasties, further underscores the perceived importance of the maintenance of a youthful appearance in these individuals. It is possible that pregnancy further represents another aspect of a youthful and active self-image. In general, the older patients are better educated to the process of oocyte donation and usually more
402
demanding of their caretakers. Questions about the past reproductive performance of donors are usually asked based upon the underlying assumption that pregnancy rates in the future are likely to correlate with previous successful ovarian hyperstimulation and embryo transfer. The recipients' own past experience, in many cases coupled with multiple consultations with respect to their own failed ART cycles, have educated these individuals and led to certain expectations. At times unrealistic expectations regarding donor performance arise from misinterpretations and extrapolations from previously gained information. Unfortunately the professional service rendered may, in such circumstances, be perceived as a de facto purchased commodity.
SUMMARY An older population of women is now increasingly seeking infertility care. The number of these patients may in fact eclipse those of younger patients for whom the method of oocyte donation was initially designed and previously offered. As a group, these older individuals appear to be energetic and demanding, with high expectations regarding the performance and the effectiveness of their fertility care. Physicians need to exercise vigilance in order to emphasize that eggs are not being bought and sold as a commodity and that guarantees of pregnancies cannot be made. Nevertheless, whereas oocyte donation requires all parties, donor, recipient, and doctor, to work together toward a common goal, it still offers women of advanced reproductive age perhaps their best chance at conception, pregnancy, and parenthood.
REFERENCES 1. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renou P: The establishment and maintenance of pregnancy using in vitro fertilization and embryo donation in a patient with primary ovarian failure. Nature 1984;307:174--175 2. Sauer MV, Paulson RJ: Human oocyte and preembryo donation: An evolving method for the treatment of infertility. Am J Obstet Gynecol 1990;163:1421-1424 3. Medical Research International; Society for Assisted Reproductive Technology, The American Fertility Society. In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1990 results from the IVF-ET Registry. Fertil Steril 1992;57:15-24
SHORT COMMUNICATIONS
4. Saner MV, Paulson RJ, Lobo RA: A preliminary report on oocyte donation extending reproductive potential to women over 40. N Engl J Med 1990;323:1157-1160 5. Sauer MV, Paulson RJ, Macaso TM, Francis MM, Lobo RA: Establishment of a nonanonymous donor oocyte program: preliminary experience at the University of Southern California. Fertil Steril 1989;52:433-436
Mark V. Sauer 1 Richard J. Paulson Department of Obstetrics and Gynecology Division of Reproductive Endocrinology University of Southern California Los Angeles, California 90021 1 To whom correspondence should be addressed at Women's Hospital, 1240 North Mission Road, Room L946, Los Angeles, California 90033.
KIEL, GERMANY Pregnancies Following Transvaginal Gamete Intrafallopian Transfer (GIFT), Zygote Intrafallopian Transfer (ZIFT), and T u b a l E m b r y o - S t a g e T r a n s f e r ( T E S T ) in an in Vitro F e r t i l i z a t i o n ( I V F ) P r o g r a m
Submitted: March 11, 1992 Accepted: March 19, 1992
We report on the first pregnancies achieved at our clinic following transvaginal GIFT, ZIFT, and TEST. Our study population consisted of 15 patients in 17 treatment cycles. The mean age and duration of infertility were 32 and 5.4 years, respectively. The indications were male factor in eight cycles, unexplained infertility in seven cycles, and endometriosis in two cycles. Hormonal stimulation was performed with gonadotropin-releasing hormone analogue (Gn-RHa), human menopausal gonadotropin (hMG), and human chorionic gonadotropin (hCG) according to the protocol described by MacNamee et al. (1). Follicular aspiration and other laboratory maneuvers for semen preparation, insemination, and embryo culture were performed exactly as described previously (2). For the transvagJournal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
