Assisted reproduction using donor spermatozoa in women aged 40 and above: the high road or the low road?

The effect of age on outcome is one of the most intriguing areas in the assisted reproduction field. In older patients using donor spermatozoa to reproduce, it remains undefined as to which is the treatment of choice: intrauterine insemination (IUI) or IVF/intracytoplasmic sperm injection (ICSI). Since life-table analysis provides data that are easy to use for patient counselling, this study analysed cumulative delivery rates (CDR) in patients using donor spermatozoa undergoing either primarily IUI or IVF/ICSI and patients who eventually switched from IUI to IVF/ICSI. Crude and expected CDR after six IUI cycles and three primary ICSI cycles (no previous IUI) were similar in both groups (24% versus 26% and 29% versus 35%, respectively). Since time-to pregnancy is an important factor in these older patients, ICSI treatment is advised to be started immediately, since a single cycle of ICSI will achieve the same success rate as a much longer period with at least six IUI cycles. If patients switch to ICSI after failed IUI, this only adds marginal benefit in CDR. Nearly all deliveries in the primary ICSI group were achieved in the first cycle.The effect of age on assisted reproduction outcome is one of the most intriguing areas in fertility. In older patients using donor spermatozoa to reproduce, it remains undefined as to which is the treatment of choice: intrauterine insemination (IUI) or IVF/intracytoplasmic sperm injection (ICSI). Since life-table analysis provides data that are easy to use for patient counselling, our study aimed at analysing cumulative success rates in patients using donor spermatozoa performing either primarily IUI or IVF/ICSI and in patients who eventually switched from IUI to IVF/ICSI. We analysed data on 150 women aged 40 years or more undergoing primarily 764 IUI cycles with donor spermatozoa and data on 175 IVF/ICSI cycles in 86 patients, including 63 switchers from IUI to IVF/ICSI. Any delivery after 25 weeks of gestation after a maximum of 12 IUI cycles and seven ICSI cycles was taken as the primary endpoint. Crude and expected cumulative delivery rates (CDR) were calculated. Previous failed IUI cycles were taken into account. Crude and expected CDR after six IUI cycles and three primary ICSI cycles (no previous IUI) were similar in both groups. Most deliveries in the primary ICSI group were achieved in the first cycle. Since time-to pregnancy is an important factor for older patients, we may advise to start immediate ICSI treatment since a single cycle of ICSI will achieve the same success rate as a much longer period with at least six IUI cycles. If patients switch to ICSI after failed IUI, this only adds marginal benefit in CDR.