1. How Old is Too Old? Age, Genetics and Reproduction Marcelle I. Cedars, M.D. Director, Division of Reproductive Endocrinology UCSF

7. Normal Biological Decline Gougeon, Maturitas, 30:137-142, 1998

8. Percent Increase in Birthrates CDC Vital and Health Statistics 2000 1976 1980 1985 1990 1995 35-39 30-34 40+ 15-19 25-29 20-24

10. Concurrent Loss in Quantity AND Quality

12. Abnormalities in oocytes increase with age

25. Antral follicle count AFC = 18 AFC= 4

31. FSH Predicts Quantity, but not Quality P=0.3 P=0.05 P=0.06 P=0.01

32. AFC Predicts Quantity and Quality p=0.014 p=0.048 p<0.001 p<0.001

33. Age is the Best Predictor of Quality IR = 28.4 IR = 15.9 p<0.001 PR = 28.7 PR = 46.7 p<0.001

34. Quantity and Quality IR 21.6% 22.6% P=0.78 IR  Poor Responders 38.9% 14.5% P = 0.001

35. Decreased AFC 10 20 30 40 AFC Age # Follicles Reproductive window

40. Estradiol Priming addition of luteal phase GnRH antagonist

42. Minimal Stimulation

43. Minimal Stimulation Stimulation Mild: closed Conventional: open

45. Androgen Pretreatment Balasch et al., 2006 Transdermal testosterone 2.5mg over 5 days

51. IVF – Pregnancy and Livebirth CDC 2004

55. Thank you for your attention