How risky is a pregnancy in women in their 40s and 50s?
As risks of pregnancy in 40s and 50s are higher, proactive management becomes key
Pregnancies in 40s and 50s are becoming more common
Just before the summer break, the news media were filled with reports about record low birth rates in the U.S., especially over the last decade. One of the more remarkable developments receiving much less attention, however, was the fact that birth rates have been plummeting only in younger women; in older women, and especially in women above age 40, birth rates have actually been increasing to quite surprising degrees.
Especially in more prosperous countries, national birth rates have been plummeting for quite some time, often falling significantly below population replacement rates. Among most affected countries are economically developed countries, like Japan, South Korea and Italy. The U.S. population has continued to grow only because of immigration. In absence of new immigrants, the U.S. population would have stagnated for quite some time. Except for Africa, even in the developing world, birth rates have been declining. China, indeed, reversed her one-child policy because of a rapidly aging population, fearsome that in the not too distant future a decline in working age adults could cause severe economic difficulties for the country.
In the U.S. women above age 40 have, proportionally, been the most rapidly growing age group having children. This trend has been even more marked at CHR, where the median age of IVF patients was 43 in 2017. Not surprisingly, trends like this are widely considered to predict an economic boom for the fertility industry because they promise continuous growth in treatment cycles over many years to come. Increasingly, non-physician financial interests, therefore, have been entering the industry, and hardly a week passes without a new announcement in the U.S. of an investor group purchasing a fertility center outright or, at least, making investments and assuming management responsibilities. In Australia, where this kind of consolidation is most advanced, 80-90% of IVF centers are controlled by only three major companies. In the U.S., the most recent developments are purchases of centers by Chinese, German and Spanish commercial entities. A rapidly evolving consolidation of fertility centers in the U.S., therefore, increasingly appears unavoidable.
All risks associated with pregnancy increase with age
We are raising this subject here because aging patient populations in IVF centers require significantly more attention than younger patients. Above-noted consolidation trends in Australia and elsewhere, proved not very promising for patients who require more individualized medical care. Indeed, such patients in consolidated practice areas often fall between the cracks in routine protocols and standardized treatment protocols. And nothing is as important in providing fertility services to older women than individualization of care, not only when it comes to fertility treatments but also in preparing patients for a potential pregnancy.
The principal reasons for this statement are obvious: Pregnancy creates functional stress on every organ of a woman’s body. CHR’s Medical Director and Chief Scientist, Norbert Gleicher, MD, who for many years, and over a number of different editions, was the editor of the principal textbook on medical problems in pregnancy (Principle & Practice of Medical Therapy in Pregnancy), therefore, coined the phrase, “pregnancy is a universal stress test on the female body.” Practically, this means that any bodily function (the skeleton included) is at risk of decompensating during pregnancy if, prior to pregnancy, it already is only marginal in function.
Heightened risks of pregnancy in 40s and 50s
Examples of higher risks of pregnancy in your 40s and 50s abound:
- Women who are pre-diabetic, very likely will become outright diabetic during pregnancy (so-called gestational diabetes);
- Borderline hypertension often leads to hypertension in pregnancy, including preeclampsia/eclampsia;
- Women with cardiac problems run the risk of seeing their hearts decompensate, leading to congestive heart failure; autoimmune diseases, while usually mostly improving during pregnancy, at very high likelihood flare at end of pregnancy and, especially, in the postpartum period; and
- Spinal problems like lower back pain, often, get much worse in pregnancy because pregnancy hormones loosen ligaments, thereby increasing the chances of disc problems.
In addition, maternal medical problems during pregnancy, of course, can, and in most cases will, affect pregnancies: Having to go through surgery uniformly increases the risk of premature labor; practically all significant medical problems, indeed, are associated with increased risks for premature delivery, including hypertensive disease of pregnancy, cardiac diseases and, of course, autoimmune diseases. And the prevalence of all medical problems increases with advancing female age.
Should women in their 40s avoid pregnancy because of higher risks?
All of this, however, does not mean that older women should not get pregnant. It also does not mean that all women with known medical problems should be refused fertility treatments. To the contrary! Referring to almost all medical problems, studies have clearly demonstrated that most women can safely go through pregnancy if they are properly prepared and properly monitored during pregnancy and into the postpartum period (there, of course, are exceptions, and there are a limited number of medical conditions where pregnancy is clearly contraindicated). But this also means that such a patient must receive individualized diagnostic work ups before conception that do not only relate to their fertility problems. In other words, in CHR’s opinion, the fertility center’s responsibility is not only to help older patients to conceive but, also, to ensure that their pregnancy will be as uncomplicated as possible.
This, of course, applies whether an older woman conceives with her own or with third party donor eggs. The “stress” on the mother’s body remains, in principle, the same, though immunological problems in pregnancy, for example, preeclampsia, and premature deliveries, may, indeed, be further enhanced in donor egg cycles since the maternal immune system now must deal not only with a 50% semi-allograft but a 100% complete allograft.
Pregnancy in older women in their late 40 and early 50s, in summary, is clearly riskier than at younger ages and risks, indeed, gradually increase with maternal age. Most older women, can, however, be still safely managed through pregnancy.
How to manage risks associated with pregnancy in older women
- If at all possible, potential medical problems should be identified in advance, so that patients can be proactively placed under appropriate medical co-management by specialists. Proactive management is always preferable!
- Patients must also be informed that neonatal complications increase in parallel with advancing age, though those in a large majority can also be satisfactorily addressed with proper proactive pregnancy management.
- Older patients should automatically be advised that their pregnancy will, therefore, be considered relatively high-risk and should be delivered in a tertiary-care hospital, with appropriate maternal and neonatal services available to manage complicated pregnancies and their offspring.
- More so than younger patients, older women also must be more carefully monitored into the postpartum period, with some pregnancy-associated complications manifesting themselves up to 4-5 months postpartum.
- There are women who should no longer go through pregnancy, and such women, indeed, should be strongly discouraged from attempting pregnancy. These cases are rare and, mostly, include women with cardiac problems, like decompensating valvular heart disease, pulmonary hypertension, Eisenmenger syndrome and prior myocardial infarction (as recently reported, an increasing cause of the rising U.S. maternal mortality rate).
- At the same time, management of medical problems in pregnancy is constantly improving. A good example is HIV, which at one time was considered an absolute contraindication for pregnancy but today, in most instances, is no longer a barrier to normal and healthy delivery. An even more remarkable example is diabetes, which before insulin became available for treatment, was characterized by extremely high pregnancy loss rates. Diabetic women, indeed, rarely ever delivered. Nowadays pregnancy outcomes of diabetic women are hardly different from those of non-diabetic patients.
This is a part of the September 2018 CHR VOICE.
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.
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