Key message
Despite being informed of low success rates, women of advanced maternal age (AMA) undergoing assisted reproductive technology treatment have
IVF and its related technologies have revolutionized infertility treatments. For women under the age of 40 years, the current cumulative birth rate after six IVF cycles is between 50 and 80% (Smith et al., 2015). The chances for success, however, remain low in certain subgroups of patients, such as women with low ovarian response (Esteves et al., 2018), women who fail to conceive after multiple IVF attempts (Somigliana et al., 2018) and women of advanced maternal age (AMA) (Smith et al., 2015; Fitzgerald et al., 2017). Assisted reproductive technology (ART) treatments may involve significant physical and psychological burden, risks and costs. Indeed, the reasons for discontinuing infertility treatments before exhausting the full potential for achieving a live birth include physical and psychological burden, alongside relational, personal and organizational problems (Gameiro et al., 2012).
The psychological burden was reported as the most important reason why insured women under the age of 43 years discontinued IVF treatment (Domar et al., 2018). This finding is supported by work from Israel, where, at least officially, treatments are cost-free: the authors referred to the psychological burden and lost hope of success as the main reasons for dropping out of IVF treatments (Lande et al., 2015). The fact that financial concerns were not mentioned as a leading cause for stopping treatments suggests that, in countries with varying financial policies regarding funding of IVF, financial cost is not the reason why women cease treatments.
Some infertile patients keep trying when their chances are low. For example, 8% of IVF cycles administered in the USA using fresh autologous oocytes were undertaken by women aged over 42 years (Center for Disease Control, 2018). According to national databases worldwide, the average IVF delivery rate per cycle is 5.0% at age 43 years and 2.0% at age 44 years (Fitzgerald et al., 2017; Centers for Disease Control, 2018; Human Fertilisation and Embryology Authority, 2018). Less is known about the cumulative delivery rates of patients in this age group. In the largest report on IVF among women over 42 years, the most optimistic estimate of cumulative delivery rate after five IVF cycles was 15.0% (Smith et al., 2015). According to Israeli single-centre reports, the cumulative delivery rate after six cycles for women aged 43 years was 20.0% (Lebovitz et al., 2018) and declined to 7.0% after three cycles for women at age 44 years (Raz et al., 2018).
It is unclear why women choose to undergo fertility treatments when their chances are statistically poor. Researchers have reported that patients who undergo ART estimate their chances of success as higher than the chances of success estimated by their doctors (Boivin and Takefman, 1995). What leads women to make this most often ineffective choice? An attempt to answer this question is made by examining informational, demographic, situational and other factors. The focus was on women with advanced maternal age (AMA) undergoing IVF treatments, with the aim of establishing why women who face very low success rates choose to continue these fertility treatments. The aim of the study was to examine the perception that women have of their chances of success in ART treatments, and their understanding of the odds of success, as communicated to them by their healthcare providers. Our main hypothesis was that women would overestimate their chances of successfully conceiving using ART, based on previous work that has shown this tendency (Boivin and Takefman, 1995).
The study was conducted at six public outpatient fertility clinics and three public in-hospital IVF units in Jerusalem, Israel between 2015 and 2016. All women aged 43–45 years who were about to start fertility treatment, or were at an ovarian stimulation phase of any type of fertility treatment (ovarian stimulation, intrauterine insemination or IVF, either with or without the use of donor spermatozoa), using their own oocytes were eligible for this study. Patients were asked to complete a
Overall, 130 women were eligible and invited to participate, and 91 women responded (response rate 70.0%). All of the women were Jewish. Forty-one women (45.1%) had a husband or partner, and 47 (51.6%) were single (three women [3.3%] did not respond). Forty-eight (52.7%) women were trying to conceive with their partner's spermatozoa, 42 (46.2%) with donor spermatozoa and one woman (1.1%) did not respond. Among the respondents, 47.3% reported that they already had a child or children and 89.0%
The present study shows that women of advanced maternal age (43–45 years) have unrealistic expectations of success of ART treatment and choose to undergo ART treatments with their own eggs, despite receiving information on their poor prognosis as a result of their age. We saw that women had subjective success estimates that were significantly higher than predictions based on national register data, and that having received success estimates from the doctor did not influence women's subjective
Presented in part at the 33rd Annual Meeting of the European Society of Human Reproduction and Embryology, Geneva, Switzerland, 2–5 July 2017. The study was supported by a grant from the Israel Institute of Health Policy Research to the first and last authors (grant #: 2014/15/7). The authors acknowledge the cooperation and candor of the women who responded to our study, and the excellent assistance of Nina Rabinowitz, and Myra Taylor who were both employed by Ono Academic College.
Dr Miron-Shatz is Associate Professor at the Ono Academic College, and a visiting researcher at the Winton Centre for Risk and Evidence Communication, Cambridge University. She specializes in medical decision making of both patients and physicians, focusing on understanding probabilities and other aspects of the patient journey. Key message Despite being informed of low success rates, women of advanced maternal age (AMA) undergoing assisted reproductive technology treatment have
Dr Miron-Shatz is Associate Professor at the Ono Academic College, and a visiting researcher at the Winton Centre for Risk and Evidence Communication, Cambridge University. She specializes in medical decision making of both patients and physicians, focusing on understanding probabilities and other aspects of the patient journey. Key message Despite being informed of low success rates, women of advanced maternal age (AMA) undergoing assisted reproductive technology treatment have unrealistically high expectations, essentially ignoring their estimated prognosis. Many women of AMA do not have set limits for how many treatments they are willing to undergo.