Results of in vitro fertilization attempts in women 40 years of age and older: the Norfolk experience

FERTILITY AND STERILITY Copyright c 1987 The American Fertility Society

Vol. 47, No.1, January 1987 Printed in U.SA.

Results of in vitro fertilization attempts in women 40 years of age and older: the Norfolk experience

Alberto Romeu, M.D. Suheil J. Muasher, M.D.* Anibal A. Acosta, M.D. Lucinda L. Veeck, M.L.T. Jose Diaz, M.D. Georgeanna S. Jones, M.D. Howard W. Jones, Jr., M.D. Zev Rosenwaks, M.D. Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia

Twenty-nine patients 40 years of age or older were stimulated with gonadotropins, starting on day 3 of the cycle, in a total of 64 cycles (January 1983 to June 1985) for multiple follicular development for in vitro fertilization. Most patients' infertility was due to tubal disease (n = 8) or pelvic endometriosis (n = 14). The mean number of preovulatory and immature oocytes recovered per laparoscopy was 2.53 ± 1.73 and 1.57 ± 1.58, respectively. There were no statistically significant differences between the number of preovulatory and immature oocytes harvested, fertilized, or transferred in this group and the number in patients younger than 40 years of age. No statistically significant differences were observed between peripheral estradiol and progesterone levels in patients 40 years of age or older and levels in patients 39 years of age or younger. There were 15 pregnancies in this group of patients, for a pregnancy rate of23.4% per stimulated cycle, 27.7% per laparoscopy, and 29.4% per transfer. The ongoing pregnancy rate (12%) was lower, and the total abortion rate (60%) was higher, in patients 40 years of age or older in comparison with patients 39 years of age or younger. Patients 40 years of age or older should be counseled regarding the high abortion rate in this group. Fertil Steril47:000, 1986

The acceptance of women who are 40 years of age or older into a program of in vitro fertilization (lVF) is controversial. Many IVF programs restrict the age of the woman to 39 years or younger as a requirement for acceptance. 1 - 3 Moreover, other programs do not specify this aspect in their reports, and it seems that few if any patients 40 years of age or older are accepted. 4 -6 The reasons Received May 19, 1986; revised and accepted September 12, 1986. *Reprint requests: Suheil J. Muasher, M.D., Eastern Virginia Medical School, Hofheimer Hall, 825 Fairfax Avenue, 6th Floor, Norfolk, Virginia 23507.

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Horneu et al. IVF in women 40 years or older

generally given for establishing such age restriction policies include the expectation of the natural decline of fecundity with increasing age and increased incidence of genetic abnormalities among offspring in the older age group (40 years or older). Edwards et al. 5 considered that implantation is impaired in older women, particularly in those older than 40 years of age; they reported 7 that maternal age is one of two significant factors in the analysis of success of IVF programs. Specifically, in their experience the abortion rate was higher with increased maternal age (> 40). Kerin et aLB accepted only patients younger than 41 Fertility and Sterility

years of age because, in their experience, older women showed a poor response to stimulation, and the cancellation rate per cycle was high. Although patients in the older age group were able to respond to stimulation and achieve pregnancy, Fishel et al. 9 reported a reduced long-term viability of these pregnancies compared with pregnancies achieved in younger women. Furthermore, Johnston et al. l pointed out that there is an increased incidence of autosomal-dominant genetic diseases contributed by the male partner in older couples. This article presents the experiences of the Norfolk IVF program with women age 40 or older. MATERIALS AND METHODS

From January 1983 to June 1985 (Norfolk Series 8 to 19), 29 women 40 years of age or older (range, 40 to 44 years of age) were stimulated with gonadotropins in a total of 64 cycles (age 40, n = 22; age 41, n = 18; age 42, n = 15; age 43, n = 4; age 44, n = 5 cycles) for multiple follicular development for IVF. These patients represented 4.78% and 5.6% of the total number of patients and the total number of cycles, respectively, treated for IVF during that period. Nine of the patients had undergone previous IVF attempts in Norfolk when they were younger than 40 years of age. The remaining 20 patients had experienced their first IVF attempt when they were older than 40 years of age. Eighteen patients complained of primary infertility ranging from 2 to 13 years in duration, and 11 patients complained of secondary infertility ranging from 1 to 11 years in duration. The primary diagnosis for infertility was pelvic endometriosis in 14, uncorrectable tubal disease in 8, male factor in 2, immunologic factor in 1, and unexplained infertility in 4 patients. Thirteen patients underwent only one treatment cycle, 7 patients underwent two treatment cycles, 3 patients underwent three treatment cycles, 4 patients underwent four treatment cycles, 1 patient underwent five treatment cycles, and 1 patient underwent seven treatment cycles after 40 years of age. Thirty-two cycles were stimulated with a combination of follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) followed by human chorionic gonadotropin (hCG) for multiple follicular development, as previously reported.lO In brief, 2 ampules FSH (Metrodin, SerVol. 47, No.1, January 1987

ono Laboratories, Inc., Randolph, MA) containing 75 IV human urinary FSH and < 1 IV luteinizing hormone (LH) in each ampule, and 2 ampules hMG (Pergonal, Serono Laboratories, Inc.) containing 75 IV FSH and 75 IV LH in each ampule, were administered intramuscularly on days 3 and 4 of the cycle. Stimulation was continued with hMG alone from cycle day 5 onward, usually in the dose of 2 ampules daily. The cycles were monitored according to a previously published protocol,11 with minor modifications when necessary, according to the individual response. Twenty-two cycles were stimulated with pure FSH alone followed by hCG for multiple follicular development for IVF, as previously reported. 12 In brief, 4 ampules FSH was administered intramuscularly on cycle days 3 and 4. Stimulation was usually continued from cycle day 5 onward with 2 ampules FSH daily. Seven cycles were stimulated with hMG alone followed by hCG for multiple follicular development, as previously described. 11 In brief, 2 or 3 ampules hMG was administered intramuscularly on cycle days 3 and 4. Stimulation was usually continued from cycle day 5 onward with 2 ampules hMG daily. Three cycles were stimulated with pulsatile intravenous gonadotropin-releasing hormone, usually in the dosage of 10 f.Lcg every 90 to 120 minutes, followed by hCG, for multiple follicular development for IVF. Serum was obtained daily, starting on day 3 of the cycle, for determination of estradiol (E 2) by radioimmunoassay (RIA). Daily ultrasound and pelvic examinations were begun on cycle day 6. The purpose of the pelvic examination was to observe the occurrence of the biologic shift of E2 in the cervical mucus and vaginal cells, as previously described. 11 If the possibility of an early endogenous LH surge was suspected because of previous response to gonadotropins, serum LH levels were assayed every 4 hours by RIA beginning on cycle day 7. Stimulation with gonadotropins was discontinued according to previously published criteria;11 10,000 IV hCG was administered intramuscularly 52 to 60 hours after the last dose of hMG or FSH. This was defined as a long hMGIhCG or FSHIhCG interval. On occasion, hCG was administered 28 to 36 hours after the last dose of hMG or FSH. This was defined as a short hMGIhCG or FSHIhCG interval. The guidelines for resorting to a short interval have been reported previously.lO Romeu et al. IVF in women 40 years or older

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Laparoscopy with follicular aspiration was performed 34 to 36 hours after hCG was given. Oocyte retrieval, insemination, and transfer techniques have been reported previouslyy,13 All patients who underwent conceptus transfer received supplemental progesterone (P)-usually 12.5 mg P in oil-intramuscularly daily, starting on the day of transfer or the previous day and continuing until a negative l3-hCG test was obtained on luteal days 11 to 13. Serum was obtained every other day during the luteal phase for measurement of E2 and P by RIA. If the l3-hCG test was positive, the patient was given Delalutin (E.R. Squibb and Sons, Inc., Princeton, NJ), 250 mg intramuscularly weekly until the 18th week of pregnancy. Ultrasound was required at 8 to 10 weeks of pregnancy for determination of viability and detection of multiple pregnancies. All pregnancy patients were advised to have a second-trimester amniocentesis for genetic studies. All miscarriages were classified preclinical or clinical, according to previously published criteria. 14 Ongoing pregnancies are those that progressed beyond the 20th week of gestation and subsequently resulted in a live birth. Statistical analysis was performed with the Student's t-test and chi-square analysis.

RESULTS Ten of the 64 stimulated cycles were canceled before laparoscopy; 3 of the 54 cycles with laparoscopy did not have a transfer. There were 51 cycles with transfer; 49 (96.1%) of these were preembryos developed from at least one preovulatory oocyte. There were 15 pregnancies, resulting in a pregnancy rate of 23.4% per stimulated cycle, 27.7% per laparoscopy, and 29.4% per transfer. PREGNANCY RATE

The pregnancy rate per transfer cycle varied from 13.5% in series 9 (April to May 1983) to 45.9% in series 12 (November to December 1983). The pregnancy rate distribution for patients of all ages during the same period is shown in Figure 1. Neither the pregnancy rate nor the ongoing pregnancy rate in the different age groups showed any statistically significant differences, although patients 40 years of age or older showed a lower ongoing pregnancy rate. 132

Rorneu et al. IVF in women 40 years or older

30 ;--

-

-

r-

;--

-

r-

AB

AB

AB

AM

Age Groups 2&30

31-35

36-39

:?40

Figure 1 Pregnancy rate (A) and ongoing pregnancy rate (B) per transfer according to different age groups. No statistically significant differences were observed between the rates among the different age groups. (Number of transfers by age group: 26 to 30, 162; 31 to 35, 406; 36 to 39, 211; 40 and older, 51).

CANCELLATION RATE

The cancellation rate of stimulated cycles before laparoscopy was 15.6% (n = 10). Six patients had a single canceled cycle, and two patients had two canceled cycles. The reasons for cancellation were as follows: (1) poor E2 response to stimulation, where E2 was lower than 100 pg/ml after 5 days of gonadotropin treatment (n = 2); (2) a decrease in E2 > 30% from the previous day's value on the morning after hCG was given, or a decrease in E2 for two consecutive days immediately before laparoscopy (n = 3); and (3) a decrease in E2 > 30% and sonographic indications compatible with ovulation on the day after hCG administration (n = 5). The two patients whose cycles were canceled because of a poor response showed a good response to stimulation of a subsequent cycle. CYCLES WITHOUT TRANSFER

Of the cycles with laparoscopy, three (5.6%) did not progress to transfer because of a lack of retrieval of fertilizable oocytes. In two cases, fractured zona and atretic oocytes were recovered. In the third case, only fractured zona oocytes were recovered. NUMBER AND CLASSIFICATION OF OOCYTES

Oocytes were recovered from 83.2% of aspirated follicles; 48.6% of these were classified as preovulatory. The mean number of preovulatory oocytes per laparoscopy was 2.53 ± 1.73 standard deviation (SD). The fertilization rate of preovulatory oocytes was 93.3%. The mean number of fertilized preovulatory oocytes per laparoscopy was 2.31 ± Fertility and Sterility

1.64 SD. Polyspermia accounted for 4% of the fertilized preovulatory oocytes. All preovulatory 00cytes that were fertilized normally were transferred after evidence of preembryo cleavage. Of the total aspirated oocytes, 30.1% were classified as immature because of an intact germinal vesicle or other morphologic features. The mean number of immature oocytes per laparoscopy was 1.57 ± 1.58 SD. Of these, 77.6% were inseminated after in vitro maturation, and 78.8% of these were fertilized. Polyspermia accounted for 7.7% of the fertilized immature oocytes. All oocytes that were fertilized normally were transferred, some with cleavage (43~9%) and some before the first cleavage division had occurred (27.3%), in the two-pronuclei status. There were no statistically significant differences between the number of preovulatory and immature oocytes harvested, fertilized, or transferred in the study group and the number in patients younger than 40 years of age undergoing IVF during the same period. However, the total number of preembryos transferred to patients 40 years of age or older was significantly higher (P < 0.05) than that of younger patients (Table 1). Fractured zona oocytes constituted 12.4% of the total collected oocytes in patients 40 years of age or older, and atresia was noted in 8.9% of the oocytes. The number of fractured zona oocytes was significantly higher (P < 0.05) than in younger patients (Table 1).

Table 2. Number and Classification ofOocytes Aspirated and Fertilized with Preembryos Transferred as Well as the Pregnancy Rates per Transfer in New Versus Previously Stimulated Patients :;" 40 Years of Age Oocytes/laparoscopy

Preovulatory Aspirated Fertilized Transferred Immature Aspirated Fertilized Total preembryos transferred Pregnancy rate/ transfer

New patients (n = 20)

Patients with prior IVF attempts (n = 44)

mean::t SD

mean ± SD

2.75 ± 2.11 2.31 ± 2.15 2.19 ± 2.04

2.45 ± 1.57 2.32 ± 1.42 2.18 ± 1.47

1.19 ± 1.38 0.67 ± 0.95 2.94 ± 0.95

1.74 ± 1.66 1.08 ± 1.46 3.15 ± 1.95

35.7%

27%

NEW VERSUS PREVIOUSLY STIMULATED PATIENTS

Twenty patients had not undergone previous IVF attempts; 9 patients in 44 cycles had had at least one previous attempt. The cancellation rate per stimulated cycle was 20% for new patients and 13.6% for previously stimulated patients. There were no statistically significant differences between the number of oocytes aspirated and transferred or the pregnancy rate of new patients and these data in previously stimulated patients (Table 2). LONG VERSUS SHORT HMGIHCG OR FSH/HCG INTERVAL

Table 1. Distribution and Classification ofOocytes Retrieved, Fertilized, and Transferred in Patients:;" 40 Versus Patients < 40 Years of Age Cycles of patients aged;", 40 years (n = 54)

mean ± SD

Oocytes/laparoscopy Preovulatory Immature Fractured zona Atretic Oocytes fertilized!laparoscopy Preovulatory Immature Preembryos transferred! transfer Preovulatory origin Total

2.53 1.57 0.64 1.11

± 1.73

± 1.58 ± 0.93~ ± 1.07

Cycles of patients aged < 40 years (n

= 915)

mean ± SD

2.34 1.97 0.38 1.14

± ± ± ±

1.79 2.15 0.74 1.42

2.31 ± 1.64 0.96 ± 1.33

1.97 ± 1.60 0.95 ± 1.4

2.31 ± 1.6 3.27 ± 1.95a

2.01 ± 1.42 2.93 ± 1.73

ap < 0.05. Vol. 47, No.1, January 1987

The number of preovulatory oocytes recovered (53.2% versus 44.1 %) and transferred (90.3% versus 85%) was slightly higher in the short-interval group. The number of immature oocytes retrieved (26.2% versus 35.3%) and transferred (56% versus 80.5%) was lower in the short-interval group. The pregnancy rate was lower in the short-interval group (24% versus 37.5%). These differences were not statistically significant. TRANSFER OF MULTIPLE CONCEPTUSES

There were no statistically significant differences in the pregnancy rate per transfer with increased numbers of conceptuses transferred (Table 3). In contrast, the pregnancy rates in patients 39 years of age or younger increase with multiple transfers (Table 3). There were no statistically significant differences between the two groups when the same number of conceptuses was transferred (Table 3). Romeu et al. IVF in women 40 years or older

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Table 3. Pregnancy Rate with Multiple Transfers in Patients ;;. 40 Years of Age Versus Patients < 40 Years of Age No. Preembryos transferred (preovulatory origin)

No. of transfers

No. of pregnancies

Pregnancy rate

;;. 40 3 3 3 6

<40 ;;.40 14.7 25 20.1 37.5 29.6a 25 34.9 b 31.5

%

< 40 169 223 145 246

1 2 3 ;;.4

;;. 40 12 8 12 19

< 40 25 45 43 86

ap < 0.02, compared with single embryo transfer. bp < 0.01, compared with single embryo transfer. ABORTION RATE

Of 15 pregnancies there were five preclinical abortions (33%) and four first-trimester abortions (26.6%), with a 60% total abortion rate. The ongoing pregnancy rate was 11.7%. The preclinical abortion rate, the clinical abortion rate « 20 weeks), and the total abortion rate distribution for patients of all ages during the same time period is shown in Figure 2. Although these rates were higher in patients 40 years of age or older, no statistically significant differences from patients younger than 40 years of age were observed. The oldest patient who achieved an ongoing pregnancy that subsequently resulted in a live birth was 42 years and 2 months of age at the time of oocyte retrieval.

30

Figure 3 Serum E2 values in cycles of patients 40 years of age or older (n = 51 cases with embryo transfer) compared with values in patients 39 years of age or younger (n = 783 cases with embryo transfer). Values are plotted as mean ± SD. Day of laparoscopy is normalized to day 14. No statistically significant differences are observed in the daily mean values between the two age groups.

patients. P peripheral levels of the same patients during the luteal phase are shown in Figure 4. No statistically significant differences were observed between the two groups of patients

HORMONAL RESPONSE

E2 peripheral levels of patients older and younger than 40 years of age are shown in Figure 3. No statistically significant differences in E2 levels were observed between the two groups of 70 60

50 0

rr-

20

r-

r-

IC d:3

Age Groups

26-30

en :34)

1 2 3 31-35 (n :112)

r:

23 36-39 :58)

en

o 1 2 3 ,:>40 (n :15)

Figure 2 Preclinical (1), clinical (2), and total abortion rate (3) according to different age groups. The preclinical and total abortion rates are notably higher in patients 40 years of age or older than in the other age groups, but the differences are not statistically significant. 134

Romeu et aI. IVF in women 40 years or older

5

10

15

20

25

30

Day

Figure 4 Serum P values in the luteal phase in cycles of patients 40 years of age or older (n = 51 cases with embryo transfer) compared with values in patients 39 years of age or younger (n = 783 cases with embryo transfer). Values are plotted as mean ± SD. Day of laparoscopy is normalized to day 14. No statistically significant differences are observed in the daily mean values between the two age groups.

Fertility and Sterility

ECTOPIC PREGNANCIES

There were no ectopic pregnancies. MULTIPLE PREGNANCIES

One patient had a twin intrauterine gestation resulting from the transfer of one 2-cell preembryo and one 4-cell preembryo, both of preovulatory origin. She subsequently was delivered of twins at term. AMNIOCENTESIS

Five of the six patients with continuing pregnancies underwent amniocentesis for genetic evaluation in the second trimester. Normal karyotypes-46,XX or 46,XY- were obtained in each case. The patient with a twin gestation declined amniocentesis.

DISCUSSION

The results of64 stimulated cycles for IVF in 29 patients 40 years of age or older have been compared with those obtained from 1068 stimulated cycles in women younger than 40 years of age in the same program during the same time period. In general we found that patients 40 years of age or older exhibit an ovarian response to stimulation not significantly different from that in younger women. Nor did pregnancy and abortion rates differ significantly between the two groups. Nevertheless, these results should be considered carefully. The cancellation rate by cycle in women 40 years of age or older was higher than that previously reported for this program lO but is comparable with other cancellation rates in the literature,3, 8 even for women younger than 40 years of age. Stimulation was canceled in only two patients because of a poor ovarian response to stimulation; with subsequent modifications in the stimulation, both these patients demonstrated a better response, leading to laparoscopy. These results do not agree with those of Kerin et al.,8 who reported a poorer response to stimulation in women older than 40 years of age. The ability of older patients in this study to respond to ovarian stimulation was also evident in that there were no significant differences between either the peripheral E2 and P levels or the number and classification of recovered oocytes and those in younger women. However, the sigVol. 47, No.1, January 1987

nificant increase in the incidence of fractured zona oocytes in the older age group may reflect changes in oocyte quality, perhaps due to impending ovarian deficiency. The dose of gonadotropins needed to achieve a good response was no higher in the higher age group. The ongoing pregnancy rate in the group of patients 40 years of age or older was lower (11.7%) than the rates observed in younger groups, even though the differences were not statistically significant. This result agrees with the concept of decreased fecundity and a higher incidence of miscarriage in the higher age group.1, 15 Studies on older experimental animals show that fertility may decrease because (1) the number of follicles recruited by gonadotropins diminishes with advancing age, (2) the fertilization rate decreases in oocytes obtained from those animals, and (3) the uterine environment may hinder implantation. Furthermore, the uterus becomes fibrous, microvilli density at endometrial level is reduced, vascular supply is poorer, and the ability to synthesize prostaglandins is reduced with advanced maternal age. 16 These experimental findings regarding oocyte recruitment and fertilizability are not consistent with our results in human beings: 51 of 54 cycles had fertilizable oocytes, and no differences were observed in number and classification of oocytes harvested and fertilized or pre embryos transferred. Our results are more consistent with those ofFeichtinger and Kemeter,17 who found that age does not seem to influence IVF success rates after ovarian stimulation therapy. Although Edwards et al. 5 also found that women older than 40 years of age were able to respond to stimulation, only 37% of these women received two or more preembryos at the time oftransfer. In our experience 66.4% of the preembryo transfers in this age group consisted of at least two preovulatory oocytes. No statistically significant differences between the number and classification of retrieved oocytes from the new patients and those of patients who had had prior stimulated cycles for IVF were observed. The pregnancy rate was slightly higher in the group of new patients. The number of immature oocytes harvested, as well as the number of oocytes that were fertilized and transferred, was higher in the group of patients having a long interval between the last FSHlhMG administration and the heG administration than in patients having a short interval. Romeu et al. IVF in women 40 years or older

135

This finding could reflect a better cytoplasmic maturation and might playa role in the improved pregnancy rate (37.5% versus 24%). Nevertheless, the difference between the two groups shows no statistical significance. An increased pregnancy rate was not observed with the increase in number of preembryos transferred, whereas this phenomenon is observed in women 39 years of age. This finding agrees with experimental studies in animals. I6 In our experience the results in pregnancy outcome seem to be more important. Fifteen pregnancies resulted in five preclinical abortions (33.3% preclinical abortion rate) and four firsttrimester abortions (26.6% abortion rate), with a total abortion rate of 60%. These results showed no statistically significant difference from other age groups. Nevertheless, the preclinical abortion rate was significantly higher (P < 0.05) in patients 40 years of age or older than in the younger groups, when the rate by transfer was considered. This increased loss of preembryos might reflect a poor preembryo quality: the viability of preembryos from older women might be reduced from those of younger women. 9 Alternatively, a poor uterine environment in older women could result in their difficulty in achieving a pregnancy.I6 For older women, the risk of bearing a child with congenital abnormalities can be reduced by genetic counseling, with prenatal diagnosis and cytogenetic studies. All patients 40 years of age or older with established pregnancies should be advised of these options. In our experience all patients who had amniocentesis showed normal karyotypes and subsequently were delivered of normal children. Despite the increased number of abortions, the responses to stimulation and the pregnancy rates in older women were comparable with those in younger patients. Nevertheless, patients 40 years of age or older should be advised of the higher abortion rates and lower ongoing pregnancy rates in this age group and should be counseled thoroughly before being admitted to an IVF program. REFERENCES

2. Utian WH, Goldfarb JM, Sheean LA: Implementation of an in vitro fertilization program. J In Vitro Fertil Embryo Transfer 1:72, 1984 3. Laufer N, Decherney AH, Haseltine FP, Polan ML, Tarlatzis BC, Dugli AM, Naftolin F: Human in vitro fertilization employing individualized ovulation induction by human menopausal gonadotropins. J In Vitro Fertil Embryo Transfer 1:56, 1984 4. Quigley MM, Wolf DP: Human in vitro fertilization and embryo transfer at the University of Texas, Houston. J In Vitro Fertil Embryo Transfer 1:29, 1984 5. Edwards RG, Fishel SB, Cohen J, Fehilly CB, Purdy JM, Slater JM, Steptoe PC, Webster JM: Factors influencing the success of in vitro fertilization for alleviating human infertility. J In Vitro Fertil Embryo Transfer 1:3, 1984 6. Belaisch-Allart JC, Frydman R, Testart J, Guillet-Rosso F, Lasalle B, Volante M, Papiernik E: In vitro fertilization and embryo transfer program in Clamart, France. J In Vitro Fertil Embryo Transfer 1:51, 1984. 7. Edwards RG: In vitro fertilization and embryo replacement: opening lecture. Ann NY Acad Sci 442:1, 1984 8. Kerin FJ, Warnes GM, Quinn P, Kirby C, Jeffrey R, Matthews CD, Seamark RF, Texler K, Antonas B, Cox LW: In vitro fertilization and embryo transfer program. J In Vitro Fertil Embryo Transfer 1:63, 1984 9. Fishel SB, Cohen J, Fehilly G, Purdy JM, Eurofwalters D, Edwards RG: Factors influencing human embryonic development in vitro. Ann NY Acad Sci 442:342, 1984 10. Muasher SJ, Garcia JE, Rosenwaks Z: The combination of follicle-stimulating hormone and human menopausal gonadotropin for the induction of multiple follicular maturation for in vitro fertilization. Fertil Steril 44:62, 1984 11. Jones HW Jr, Jones GS, Andrews MC, Acosta AA, Bundren C, Garcia J, Sandow B, Veeck L, Wilkes C, Witmyer J, Wortham JE, Wright G: The program for in vitro fertilization at Norfolk. Fertil Steril 38:14, 1982 12. Jones GS, Acosta AA, Garcia JE, Bernardus RE, Rosenwaks Z: The effect of follicle-stimulating hormone without additional luteinizing hormone on follicular stimulation and oocyte development in normal ovulatory women. Fertil Steril 43:696, 1985 13. Veeck LL: Extracorporeal maturation: Norfolk, 1984. Ann NY Acad Sci 442:357, 1984 14. Jones HW Jr, Acosta AA, Andrews MC, Garcia JE, Jones GS, Mantzavinos T, McDowell J, Sandow BA, Veeck L, Whibley TW, Wilkes CA, Wright GL Jr: What is a pregnancy? a question for programs of in vitro fertilization. Fertil Steril 40:728, 1983 15. Schulman JD, Dorfmann A, Evans MI: Genetic aspects of in vitro fertilization. Ann NY Acad Sci 442:466, 1984 16. Gosden RG: Maternal age: a major factor affecting the prospects and outcome of pregnancy. Ann NY Acad Sci 442:45, 1984 17. Feichtinger W, Kemeter P: Organization and computerized analysis of in vitro fertilization and embryo transfer programs. J In Vitro Fertil Embryo Transfer 1:34, 1984

1. Johnston WIH, Oke K, Speirs A, Clarke GA, McBain J, Bayly C, Hunt J, Clarke GN: Patient selection for in vitro fertilization: physical and psychological aspects. Ann NY Acad Sci 442:490, 1985

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