Fertility Treatments for Advanced Maternal Age

Nowadays, delaying pregnancy is quite common at least in urban India. Women try to have children in their late 30s and sometimes even in their 40s. Statistically, at least 20% of women wait to begin their families until after age 35. This could be owing to several factors including focus on career, financial security and also because some of them are unsure about parenthood.

The effect of advanced maternal age on fertility 

While the internet is filled with information about assisted reproductive technology, it is a proven biological fact that there is a decrease in fertility with advancing age. It is estimated that the chances of becoming pregnant in any one month is about 20% in women under 30, but only 5% in women over 40. Even with advanced infertility treatments, fertility decreases and the chance of miscarriage increases in women after age 40.

There are several explanations for this change in fertility, including medical conditions, changes in ovarian function, and alterations in the eggs released by the ovaries. The source of the decreased pregnancy rates in women over 40 is thought to be due, in large part, to the increase in the number of eggs with chromosomal problems.

As the woman ages, the remaining eggs in her ovaries also age, making them less capable of fertilization by sperm. In addition, fertilization of these eggs is associated with a higher risk of genetic disorders. For example, disorders involving the chromosomes, such as Down Syndrome, are more common in children born to older women.

There is a continuing increase in the risk of these chromosomal problems as women age. When eggs with chromosomal problems are fertilized, they are less likely to survive and grow. For this reason, women who are over 40 are at increased risk for miscarriage.

When eggs are collected from women in their 20s and 30s, fertilized, and placed in the uterus of a woman over 40, the chance for pregnancy in the older woman is much higher than she could expect if she had used her own eggs. The success of egg donation confirms that egg quality is the primary barrier to pregnancy in older women. Unfortunately, there is nothing that a woman can do to prevent the age-related decline in egg quality.

Evaluation

In women between 35 and 40 years of age, a fertility evaluation should be initiated after six months of unprotected intercourse without conception. If the woman is above 40 years of age, the evaluation should be immediate. Evaluation is also initiated sooner if the female partner has a history of oligomenorrhea/amenorrhea, pelvic infection, pelvic surgery, chemotherapy, radiation therapy, or endometriosis. Most infertility testing can be completed in one to three months, and appropriate treatment can be started immediately after the evaluation.

Treatment Options

Once the appropriate testing is completed, the fertility specialist will discuss the possible treatment plans. Modern infertility therapy allows women many more options than were possible in the past. However, these treatments may have significant financial, emotional, and social demands. If a cause for infertility is identified, then a specific treatment may be suggested which could be any of the gamut of treatments regularly suggested (Intra Uterine Insemination, IVF or ICSI).

However, sometimes no specific problem is identified and the infertility is unexplained. With unexplained infertility, or when traditional treatments have failed, advanced infertility therapies such as superovulation with timed intrauterine insemination (SO/IUI), IVF, or ICSI may be suggested. As with any treatment, age affects the chance for pregnancy. It is useful to ask the specialist to discuss the success rates of any recommended therapy and how many treatment cycles he or she would recommend.

The treatment options are limited for women over 40 who have not succeeded with other therapies. One option for older women involves the use of eggs donated by another woman. Eggs from a younger woman are more likely to result in pregnancy and less likely to end in miscarriage even when carried by an older woman. In a donor egg cycle, the woman donating eggs will be given medications to stimulate the production of multiple eggs. During the time that the egg donor is receiving these medications, the recipient will be given hormone therapy to prepare her uterus to receive the embryos. After the eggs are obtained from the donor, they are fertilized in the laboratory with sperm from the recipient’s partner (or donor sperm). One to two days after fertilization, the embryos are transferred to the recipient’s uterus. Any embryos which are not transferred may be frozen (cryopreserved). This allows another opportunity for a future pregnancy attempt.

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