Trying To Get Pregnant After 40 Years Old

For women trying to get pregnant after 40, CHR believes in an urgent and individualized treatment approach. Time is a very important factor with DOR, and the sooner treatment can be started, the higher a woman's pregnancy chances.

There are several available types of infertility treatment available to women over 40. However, it is important to keep in mind that some of the treatments offered by fertility centers may not be the best option specifically for women over 40 with DOR. In most cases, women over 40 benefit from standard IVF and egg donation far more than treatments like “mini IVF” and IUI that offer vastly lower pregnancy chances.

In Vitro Fertilization ("IVF")

For most women looking to get pregnant with their own eggs after age 40, IVF with ovarian stimulation is the quickest and most reliable treatment option. We recommend that older women attempting IVF be treated differently from younger women: for instance, they need larger doses of fertility medications to produce a good number of good-quality eggs. At CHR, women over 40 are typically supplemented with DHEA to readjust their ovarian environment to a more rejuvenated, youthful, androgen-rich state that allows eggs to undergo a healthier maturation process. Once the ovarian stimulation commences, physicians at CHR tailor the protocols to the needs of each patient and her ovaries; you will not find a one-size-fits-all protocol here at CHR. This approach has resulted in impressive pregnancy rates at CHR even for women at very advanced maternal ages up to age 47, as well as for those with severely diminished ovarian reserve.

DHEA Supplementation

DHEA supplementation was first introduced into fertility care by CHR physicians and has since spread worldwide with remarkable results. The major benefits of DHEA for fertility include:

• an increase in the quality and quantity of eggs and embryos
• increased spontaneous pregnancy rates
• increased IVF success rates
• decreased miscarriage rates, and
• lower incidence of chromosomal abnormalities in embryos.

We have seen many women who were advised by other fertility centers that their only chance of conception was with egg donation, who have conceived under our care using their own eggs. For women with DOR, DHEA supplementation combined with IVF protocols developed at CHR has proved a life-changing treatment option.

Early Egg Retrieval

One of the more recent innovations in fertility treatments by CHR physicians, early egg retrieval contributed substantially to the success of our center's patients over 40, particularly those over 43. Noticing that eggs of older women tended to be "overmature" at retrieval, CHR physicians ran an experiment where eggs were retrieved earlier, with some eggs fully mature and others still relatively immature. Immature eggs were matured in the laboratory in a process called IVM. This modification drastically improved the pregnancy chances, doubling or tripling depending them on the patient's age. Our physicians monitor each patients' ovarian response closely, and carefully determine the timing of egg retrieval in order to maximize the chance of good IVF outcomes for each patient.

Egg Donation

CHR believes that egg donation should remain the last recourse, and that women should be given other fertility treatment options first. In our experience, too many women who may still be able to conceive with their own eggs (given proper treatment) are pushed prematurely into egg donation. Indeed, fully one third of women who came to our center with previous recommendations of egg donation have conceived with their own eggs after treatment at CHR.

That said, for many women over 40, egg donation does remain a great treatment option, offering a much higher pregnancy rate than IVF cycles with their own eggs. To serve our patients better, CHR maintains its own extensive and diverse pool of egg donors, and can match most women with an excellent egg donor within a short time frame. When women over 40 decide that egg donation is what they want to pursue, CHR’s egg donor program is always here to offer wide range of donor options.

What Not to Do: Mini-IVF, IUI and PGS

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. The rationale often 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 published research has shown that low-intensity IVF results in better quality eggs. In fact, all available evidence shows the opposite: low-intensity IVF cycles clearly reduce pregnancy chances. As for the cost benefits claimed by proponents of mini-IVF, a recently published comparative cost analysis by CHR researchers demonstrated that, comparing the cost of having a take-home baby, standard IVF cycles are no more expensive than low-intensity IVF cycles.

Given the absence of properly conducted studies showing results comparable to standard IVF cycles, low-intensity IVF cycles should be considered experimental. Older women have little time for experimentation, and therefore, women over 40 with presumed DOR should not waste their time on wait-and-see approaches and low-chance treatments like mini-IVF or, even worse, intrauterine insemination (IUI).

We also caution against the uniform use of preimplantation genetic screening (PGS). PGS has been widely promoted as a way to weed out chromosomally abnormal embryos and to improve pregnancy rates in IVF. However, our center's analyses, as well as others in the last year or so, have shown that the concept of PGS does not work--particularly for women over 40 and those with DOR, PGS tends to reduce pregnancy chances without a clinical benefit. This is a costly addition to IVF that leads to self-correcting embryos with full potential for normal development being discarded as "abnormal."

About the Author:

Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned reproductive endocrinologist, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.

Author

Norbert Gleicher, MD, FACOG, FACS Norbert Gleicher, MD, FACOG, FACS, is an infertility specialist specializing in autoimmune diseases at the Center for Human Reproduction in the Upper East Side of Manhattan in New York City.