Achieving Pregnancy Over 40
Infertility Diagnosis and Treatment for Women Getting Pregnant After 40
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Pregnancy over 40
A woman starting to consider having her first baby after she turns 40 is not unusual these days. Some of these women, indeed, get pregnant without a problem. Many, however, do find it difficult to conceive. They may have the same infertility problems as younger women, like blocked fallopian tubes, endometriosis-related issues, or even male factor infertility. However, once a woman is above age 40 and having trouble conceiving, her most likely cause of infertility is diminished ovarian reserve (DOR).
A diagnosis of DOR, especially in women over 40, needs to be made in timely fashion, so that effective treatment can be initiated quickly. Unfortunately, as "center of last resort" for women with often severe DOR, CHR sees many women who wasted considerable time, undergoing endless testing, waiting "for things to improve" when for women above 40 things can only go the other direction, and trying treatments that make little sense for older women. Indeed, not a day passes when our physicians don't hear patients say "doctor, I wish I'd known about your center years ago, when I was doing such and such..."
To help older women navigate often confusing information, here are a number of tips from CHR:
When to see a fertility specialist – trying for a pregnancy over 40
The American Society for Reproductive Medicine (ASRM) recommends that women over age 35 consult a fertility specialist when not conceiving in six months of regular, unprotected intercourse. Although infertility is technically defined as failure to conceive in twelve months, older women should not wait that long because they have less time left to waste!
Recognize the urgency of aggressive fertility treatment when you are above age 40!
Diminished ovarian reserve makes it more difficult to get pregnant over 40
The ability of the ovaries to produce good-quality eggs, which in turn result in good-quality embryos, declines with age. The speed of this age-related decline in ovarian reserve (OR) varies among women. By age 40, however, practically all women have lost enough of their OR to qualify for a diagnosis of DOR. DOR can be diagnosed relatively easily with a few blood tests, including follicle stimulating hormone (FSH) and anti-Müllerian hormone (AMH) levels. Some fertility centers also use antral follicle count (AFC) to gauge ovarian reserve. For a detailed explanation of ovarian reserve and a glimpse into the latest scientific developments, please see our ovarian reserve page. In the video below, Dr. Gleicher explain high FHS, a classic finding in women over 40 with difficulty conceiving.
Dr. Gleicher discusses high FSH, a classical finding suggestive of diminished ovarian reserve in women over 40 having difficulty conceiving. Also discussed are effects of high FHS on fertility and treatment options for women over 40 with diminished ovarian reserve.
Women with DOR do not produce as many eggs in an IVF cycle as younger women, and their eggs tend to be of poorer quality. Small number of eggs means small number of embryos to transfer, and poor-quality eggs often result in poor-quality embryos which can fail to implant. A well-designed fertility treatment plan for women in this age group must take this into account (see below for further details).
Insist on rapid diagnosis and a structured treatment plan.
Fertility evaluation for women over 40
Hormonal markers, FSH and AMH, indicate the status of a woman's OR. High FSH levels and low AMH levels indicate DOR, suggesting the need for aggressive fertility treatment.
Some fertility centers make their older patients "wait for the right test result" before they start an IVF cycle. Waiting for the "right result" makes no sense, because ovarian reserve never improves with time, and test results will only get worse. Such a "wait-and-see" approach only delays treatment, and wastes very precious time women over 40 have left to conceive.
Do not agree to endless testing to "wait for the right results;" Time is not on your side, and results will only get worse!
Fertility treatment options for women over 40
At CHR, we consider all women above age 40 to suffer from DOR and apply clinical protocols specifically designed to help at advanced ages. Treatment individualization is crucial at this age, and everybody should reconsider if they find themselves treated the same way as the 25-year old patients sitting in the adjacent chair in the waiting room. There are many differences how older women should be treated in comparison to younger patients: They need larger doses of fertility medications in order to produce a good number of good-quality eggs. Treatment at CHR also includes DHEA supplementation, which was first introduced into fertility care by CHR physicians, and has spread worldwide since then.
The figure shows three essential components of successful treatment for women with DOR, appropriate ovarian stimulation protocol for each patient's OR, individualized management and DHEA supplementation.
"Mini-IVF" for Pregnancy after 40 Does Not Make Sense!
Some fertility centers steer older women toward various forms of low-intensity IVF cycles, including "mini-IVF" and natural cycle IVF. These low-intensity IVF cycles utilize lower doses of fertility medications for ovarian stimulation, and aim for a smaller number of eggs. Often, the rationale offered to support this approach is that a "milder approach" results in better quality eggs. However, this claim is unsubstantiated in the medical literature. No research has been published to show that low-intensity IVF results in better quality eggs. In fact, all available research shows the opposite: low-intensity IVF cycles clearly reduce pregnancy chances.
Given the absence of properly conducted studies showing results comparable to standard IVF cycles, low-intensity IVF cycles should be considered "experimental." And as explained above, older women have little time to "experiment" when it comes to pregnancy attempts. In practical terms, it means that women over 40 with presumed DOR have no time to waste on low-chance treatments like "mini-IVF," or even worse, intrauterine insemination (IUI).
For most women over 40, standard IVF remains the quickest and most reliable treatment approach. A recently published comparative cost analysis by CHR researchers also demonstrated that standard IVF cycles were no more expensive than low-intensity IVF cycles, if the cost of having a take-home baby was considered.
It is very important that you insist on specific treatment goals that meet your expectations!
IVF pregnancy rates at CHR for women over age 40
CHR's excellent IVF pregnancy rates in women over 40, many of whom with severe DOR, are probably unmatched anywhere in the world. For our detailed guide on interpreting IVF pregnancy rates at different fertility centers, please refer to our "IVF success rates explained" page.
Second Opinion for Pregnancy over 40
As might be obvious by now, there are conflicting treatment approaches "out there" for older women struggling to get pregnant. It can be quite a bit difficult to decide whether the current treatment path is the right one. If in doubt, it never hurts to get a second opinion!
Written by Norbert Gleicher, MD
Last Updated: January 28, 2013