Fertility in women over 40
Infertility is defined as the inability to achieve clinical pregnancy after one year or more of regular unprotected sexual intercourse.
In 2015, the World Health Organization (WHO) described it as a disease.
Both women (30%) and men (30%) are responsible for its causes, while sometimes they are mixed (men – women approximately 20%) and sometimes unexplained, that is, no specific cause has been identified in almost 20% of cases.
Age has now been proven to be the primary predictor of the success of infertility treatments in women.
Once a woman reaches 40, the chances of getting pregnant naturally decrease, and amount to only 5% per cycle.
In women aged 40 to 44, the infertility rate reaches almost 30% compared to only 15% in women 30 to 34 years and 7% in women aged 20 to 25.
When a woman is born, her ovaries contain a certain number of oocytes, which will be available during her reproductive years.
Age-related infertility is essentially due to a decrease in the number of oocytes remaining available in the ovaries. As the egg reserves decrease, their quality also declines, due to genetic abnormalities that lead to abnormal embryos, which cannot implant and follow a healthy course during pregnancy.
In addition, it is not only difficult to achieve pregnancy in this age group, but the risk of miscarriage or giving birth to a child with chromosomal abnormalities is also greater. At the age of 20-25, the risk of miscarriage for a woman is 10%, at 30-35 the risk is 12%, at 40-44 it is 35%, and after the age of 45 the risk of miscarriage is almost 55% according to the ASRM (American Society for Reproductive Medicine).
The number of women over 40 who have difficulty conceiving naturally, and therefore receive treatment for infertility, has increased more than tenfold in the last 15 years.
A thorough examination by a specialist should be performed before treatment. Personal and family medical history is important to detect any individual or family conditions that may be related to infertility. A vaginal ultrasound is also important to rule out the possibility of anatomical pathologies, such as fibroids, polyps, ovarian cysts, etc.
In addition, the hormonal profile should be investigated to evaluate FSH, LH and estradiol, as well as thyroid function. The Anti-Müllerian Hormone (AMH) in combination with ultrasound can provide us with information about ovarian reserves.
As the types of treatments available to us are many and varied, treatment should be individualized according to each woman’s history and the causes of infertility.
Intrauterine insemination is a relatively painless and non-invasive procedure, which can be done either with a natural cycle or with hormonal ovarian stimulation.
In vitro fertilization is the most common and effective treatment for this age group. There are various protocols that can be used. During the natural cycle process, a single egg is retrieved by aspiration from the follicle, either under local anesthetic or under anesthesia, fertilized in the laboratory and transferred to the endometrial cavity, usually 3 to 5 days later. Embryos that reach day 5 (blastocyst) have a higher chance of implantation. Hormonal ovarian stimulation is more effective, as a greater number of oocytes/embryos are retrieved. The most common protocols are the long and short with antagonist and with an average of 9-10 days of stimulation. Embryo transfer at the blastocyst stage again increases the chances of success. Preimplantation genetic diagnosis for aneuploidy (PGS) is used to detect chromosomally euploid embryos. Embryos are biopsied, usually at the blastocyst stage, to ensure that only euploid (chromosomally healthy) embryos are used. This method increases the success rate in older women.
Oocyte donation is a very effective method for women with low egg quality, dysfunctional ovaries, or repeated implantation failures.
As fertility declines with age, the preservation of oocytes or follicular tissue for use in later stage is an effective method for women between 30-35 years old who are not considering pregnancy for medical or social reasons.
