Medically reviewed by Norbert Gleicher, MD, FACOG, FACS - Written by CHR Staff - Updated on Sep 03, 2020
For women trying to get pregnant after 40, CHR believes in an urgent and individualized treatment approach. Time is one of the most important factors with DOR, a condition most 40+ women face. The sooner treatment can be started, the higher a woman's pregnancy chances.
There are several 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 for women over 40 who have DOR. In most cases, women over 40 benefit from standard IVF and donor eggs far more than treatments like “mini IVF” and IUI that offer vastly lower pregnancy chances. As will become apparent below, at CHR, “standard” doesn’t mean an assembly line approach; rather, standard IVF means a proactive and aggressive treatment philosophy to maximize each woman’s chance of pregnancy.
In Vitro Fertilization ("IVF")
For most women looking to get pregnant with their own eggs after age 40, IVF with ovarian preparation and ovarian stimulation is the quickest and most reliable treatment option. Older women attempting IVF need to be treated differently from younger women. For instance, they need larger doses of fertility medications to produce a good number of high-quality eggs. At CHR, women over 40 typically get DHEA supplementation to readjust their ovarian environment to a more youthful, androgen-rich state even before the IVF cycle begins. This 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 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, but then, they 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, or Highly Individualized, Egg Retrieval
One of the more recent innovations in fertility treatments by CHR physicians, early egg retrieval contributed substantially to the success rates 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. A few years after the first introduction, this protocol has matured into what we call the Highly Individualized Egg Retrieval, where each patient’s hCG trigger target is individually determined.
CHR believes that egg donation should remain the last recourse, and that women should be able to try other fertility treatment options first if that’s the patients’ decision. In our experience, too many women who may still be able to conceive with their own eggs (given proper treatment) are pushed prematurely into using donor eggs. Indeed, 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 a wide range of donor options.
What Not to Do: Mini-IVF, IUI and PGS/PGT-A
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, even in women in this age range. As for the cost benefits claimed by proponents of mini-IVF, an analysis published by CHR researchers demonstrated that when you look at the total treatment cost -- until the patient has a baby to go home with -- standard IVF cycles are no more expensive than low-intensity IVF cycles. This is because it takes far fewer standard IVF cycles for a woman to give birth.
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 testing for anueploidy (PGT-A). Once called PGS, PGT-A 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 those conducted by others, have shown that the concept of PGT-A does not work. Particularly for women over 40 and those with DOR, PGT-A 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." For more information about PGS, see the PGT-A posts in the Fertility Updates section.
Managing Risks in Pregnancy Over 40
If you are in the over-40 age group and trying to conceive, you are probably concerned about pregnancy complications. Women over 40 are in the high-risk category for Down syndrome: According to the American College of Obstetricians and Gynecologists, the risk is 1 in 85 for 40-year-old mothers. These mothers also see an increased risk of developing gestational diabetes, as well as high blood pressure that may lead to preeclampsia. Unfortunately, there is also a higher risk of miscarriage and stillbirth, which leads to lower live birth rates. You may be worried about the delivery and the possibility of going into premature labor or needing a c-section (cesarean section surgery). These concerns are exacerbated for women trying to get pregnant for the first time. You wonder, how can I have a healthy pregnancy and do everything I can so that my baby is born healthy?
At CHR, healthy mothers and healthy babies are our priority. Highly individualized, proactive care for pregnant women over 40 is the key, and each of our fertility specialists takes it upon themselves to provide the highest level of care for women wishing to get pregnant at this time. We begin by discussing the risks with our patients and then create a personalized plan for how we will mitigate the risks and monitor their early pregnancy. We ensure that each and every one of our patients has an obstetrician who will take care of them once CHR discharges the pregnant patient. For a woman who we identify as particularly high risk, a high-risk obstetrician and maternal fetal medicine expert can be a part of the care team throughout the pregnancy. In addition to more frequent visits to the obstetrician (ob-gyn doctor) for pregnant women over 40, a very careful and preemptive approach to mitigating risks is essential.
Because age is one of the risk factors for genetic abnormalities, genetic counseling is an opportunity to discuss your specific risk. Working with a genetic counselor can help you understand age-related risks, like Down syndrome, as well as risks related to family history. The genetic counselor may suggest genetic testing (performed as a blood test) to check for certain high-risk genes that run in your family before you get pregnant, and in some cases, he or she may recommend that the male partner also be tested. The Centers for Disease Control and Prevention (CDC) explains that your doctor may refer you for genetic counseling before pregnancy or when you are already pregnant, because of abnormal test results or to screen your baby for a specific genetic condition.
With Pregnancy After 40, Time is of the Essence
We want to emphasize that pregnancy after 40 is an urgent matter. Because ovarian reserve and egg quality only decline with age, beginning sooner rather than later is very important for success.
Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, 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.