Ovulation Induction with Oral Agents for Women 38 Years and Older Yields Low Live Birth Rates with Intrauterine Insemination Regardless of Ovarian Reserve

Although it is well supported that clinical pregnancy rates (CPR) decline with increasing age, prior studies have suggested older women with robust ovarian reserve still have reasonable success undergoing fertility therapies [1]. Furthermore, most studies report CPR rather than live birth rates (LBR) [2]. The purpose of this study was to evaluate the effects of chronological age and ovarian reserve, as well as mode of ovulation induction (OI), on LBR in women aged ≥38 undergoing intrauterine insemination (IUI). All women ≥38 undergoing IUI from 1/1/2005-12/31/2013 at Mayo Clinic who gave IRB consent were included. Data regarding ovarian reserve and OI were collected. Ovarian reserve was determined by day 3 follicle-stimulating hormone (FSH) and estradiol (E2), anti-Müllerian hormone (AMH), and antral follicle count (AFC). Normal ovarian reserve was defined as FSH ≤10 IU/L, E2 ≤50 pg/mL, AMH ≥ 1.0 ng/mL, and AFC ≥10; diminished ovarian reserve was defined as falling outside of ≥1 of these parameters. Regression models were used to identify independent factors associated with LBR. A total of 198 women who underwent 548 IUI cycles were included. Overall, 8.4% of cycles resulted in a positive pregnancy test. CPR and LBRs were 7.6% (n=42) and 4.6% (n=25). Women with a successful live birth were chronologically younger (p=0.01). Ovarian reserve was not a significant prognostic factor for LBR. In the final multivariate model, maternal age and stimulation protocol (oral agent versus gonadotropin) were independently associated with LBR with adjusted odds ratios (95%CI) of 0.79 (0.62-0.97) and 0.16 (0.01-0.86) respectively. Women using exclusively oral medication for OI had a poor pregnancy rate of 0.8%, with only one cycle out of 129 achieving live birth. In our cohort, LBR was significantly correlated with younger age. Ovarian reserve was not a significant factor in predicting LBR after IUI. When choosing a stimulation protocol for IUI in women ≥38, OI with oral agents appears ineffective.