Fertility Journal

Fertility and the older woman

I have a very demanding career and would prefer to delay having a family.  Is this risky?

Well it may be.  You are born with all the eggs you will ever have.  The majority of these are lost before puberty.  Of the remaining 400,000 eggs, you will lose about 1,000 per month.   As a result fertility generally begins to diminish gently from the age of 30 and with greater speed from the age of 35.  The most rapid egg loss is between the ages of 37 and 39.

You decision should therefore be an informed one and take into account  your current age group and the age you plan to be when you hope to get pregnant.  If you defer trying until you are 40, there will be some fertility treatment options that will no longer be available to you

Obviously not all women will have the opportunity of trying for a baby at an earlier and more fertile age.  The right partner may not have presented himself.  Other women who do have the choice of having a baby while their fertility is reasonably high may deliberately choose to defer having a family for a number of reasons.   Sadly some couples will put off the decision to at last try for a baby for so long that the chances of natural conception and even assisted conception being successful are remote in the extreme.

There can often be conflict between career and starting a family. Some women feel that it would be unfair on their employers if they were to apply for a promotion (e.g a head teacher’s post) and then become pregnant and need to take maternity leave.   If you want the job, apply for that promotion while trying for a baby.  The opportunity for that plum job may never arise again.  If you do get pregnant shortly after landing the job, you have reached that particular level in your career and can always take maternity leave.   If you don’t get pregnant straight away, you have the career to get on with until you do.   Many women are highly successful in combining both.

Sometimes it must seem that it is never going to be the right time!   If you are in a loving relationship and a pregnancy would not be a total disaster, your decision to let your career come first may be the wrong one and could be subsequently regretted at leisure.

I’m in my early 40s.  Why should it be more difficult for me to conceive?

For the woman in her 40s, her age is likely to be the most significant cause of   reduced fertility.

Some very fertile women have a high ovarian reserve and continue to have pregnancies into their mid-40s. We have all heard of women in their late forties who thought that they were menopausal and then went into labour.  But to expect that to happen is really living on false hope.

Many women in their early 40s struggle to conceive.   Why should this happen? After all if there are still eggs present in the ovaries and the partner is fertile and there are no other problems, surely a pregnancy should just be a matter of course.   Well it’s not quite that simple.  In the older woman, the number of eggs available for maturation and eventually ovulation each cycle will be reduced. Even though eggs may be present, they undergo degeneration. There is an increased chance of egg abnormalities.   Another suggestion has been that the zona pelucida  layer around the older egg is harder and thicker than in the younger woman.  This could lead to difficulties with the natural “hatching” out of the embryo from the surrounding zona that occurs just before implantation.

Is having a baby in my 40s going to be more dangerous for me?

While many women in your age group sail through their pregnancies without difficulty, that is not always the case.   Getting pregnant in your 40s is the first trick.  Hanging onto that pregnancy is the next main problem to overcome. If you do succeed in becoming pregnant a series of hurdles await:

the chance of miscarriage ranges between 50 – 75%;
there is an increased chance of the baby being affected by Down’s Syndrome and other so-called trisomies (which can of course be screened for);
antenatal problems such as becoming diabetic during the pregnancy or having raised blood pressure are commoner in the older patient;
for many older women their pregnancy may represent the only chance of having a baby and nothing must go wrong;  therefore antenatal problems may mean that a normal delivery will not be safe and an operative delivery by a planned or elective Caesarean Section is carried out; difficulties arising in labour  may lead to an  emergency operative delivery.

I am 40 and have decided to have a baby now.  Can I get IVF if I turn out to have infertility problems?

IVF may well become one of the options available to you, but not through the NHS.

In 2004, NICE (National Institute of Clinical Excellence) recommended that couples should be eligible to receive state-funded infertility treatment if the woman was between the ages of 23 and 39, and if there was either a diagnosed cause of infertility or at least three years of “unexplained” infertility.  The recommendations included up to 6 cycles of Intra-Uterine Insemination (IUI), 3 IVF cycles and possibly a further 3 cycles using frozen  embryos.

In response to this, John Reid the Secretary of State for Health at that time announced that after April 2005, couples that met the NICE criteria  would be offered just one cycle of IVF although he expected the NHS to make progress towards full implementation of the NICE guidance.  Priority would be given to couples who did not already have a child living with them.  At a local level the PCTs (Primary Care Trusts) would be expected to fund the costs of implementation.

The subsequent post-code lottery is well known to the infertile community.

So as you can see, assisted conception options through the NHS are already closed to you.  The choices can become very stark indeed:

keep trying in the hope that eventually a pregnancy will occur;
at least attend an NHS infertility clinic to be investigated;  it may be possible to correct problems that are reducing your fertility;  if not,  all future options can at least be  discussed with you;
consider receiving assisted conception in the private sector;
adoption.

What are my chances of being successful through assisted conception in my 40s?

Women in their early 40s can and do succeed in becoming pregnant through techniques such as IUI and IVF.  But the majority of assisted conception units will not achieve a successful outcome from IVF for a woman in her mid 40s using her own eggs.

The problems that arise for a woman in her mid-40s are that IVF cycles are abandoned for a number of reasons:

a cycle may not commence owing to a raised Follicle Stimulating Hormone (FSH) level  indicating that egg retrieval in that cycle would be unlikely to be successful;
the commonest cause for abandoning a cycle before egg retrieval is due to a failure to stimulate adequate egg follicle growth;  although a few mature egg follicles may develop, this does not necessarily mean that  eggs can be retrieved;
if eggs can be retrieved their quality may be so poor that fertilisation does not occur, or if it does, poor quality embryos result;
finally if a pregnancy does result, the miscarriage rate is very high.

So what are my options in my mid-40s?

keep trying but be realistic;
egg donation;
embryo donation;
adoption.

Younger eggs do very much better than older eggs. The older woman can carry a pregnancy very successfully when the eggs are much younger than her own.  If the egg that has led to the pregnancy is from a much younger donor, then as far as the pregnancy is concerned  the baby is that of a younger woman with a reduced risk of miscarriage and genetic abnormality.
This means that there is a demand for young egg donors.

Anonymous egg donors must be under the age of 36 years at the time of their donation.    The big stumbling block is that altruistic egg donors are few and far between.  Advertisements in magazines for that elusive donor are sadly a common sight.  If you are fortunate to have a younger sister or friend who is happy to donate eggs for you, there can be no greater act of love from that uniquely special person than to give you the opportunity of becoming a parent.  When the donor is known to you, it is possible to use a donor who is older than 36.  To use a donor who is already herself in her 40s is probably going to be a pointless exercise.

I am in my late 30s.  I don’t want to have a baby yet but I have heard that it is possible for me to store my eggs for later use and so prevent infertility in my 40s.  Is this true and how do I set about it?

Some women are taking out “fertility insurance”.  While still in your 30s it is possible to store eggs, embryos or even ovarian tissue.

Assisted Conception Units regularly face the request to try and preserve fertility for young women.  The vast majority are for women who are about to receive chemotherapy or radiotherapy for their malignant diseases.  For such women survival is the top priority. The very fact that we are looking ahead to a future pregnancy after cancer can give such women a very positive outlook on the prospects of overcoming their serious illness.   Other women may face the loss of a their only ovary through surgery for a benign non-malignant condition and wish to preserve their fertility.

Fortunately this is not the problem you are facing.  If you do not have a partner it is possible for you to go through an IVF procedure and have eggs frozen and stored for your future use.  Until very recently the freezing of unfertilised eggs has been very unsuccessful with few pregnancies resulting from thawed frozen eggs.  Cell size has been the significant factor.  The egg is the largest cell in the human body in contrast to the sperm (which freezes and thaws very well) which is the smallest cell.  Recent freezing developments have led to a vastly improved survival of thawed eggs.  The techniques of “slow freezing” and of “vitrification” are proving to be remarkably successful.   But you must appreciate that not all eggs will survive even these methods of freezing and storage.

If you do have a partner with whom you are planning to have a baby, but not yet, it is possible to go through a complete IVF cycle and have embryos frozen after the eggs have been fertilised by your partner’s sperm.   As with egg freezing, not all embryos will survive freezing and thawing and occasionally none will survive.

It is possible to freeze and store ovarian tissue.  Such tissue contains dormant eggs that have not yet been stimulated to become mature.  It remains to be seen whether or not these eggs can be stimulated to grow to maturity in the laboratory.  The technology for “harvesting” such eggs for IVF is not yet available.   The alternative is the thawing and surgical replacement by auto-grafting of ovarian tissue back into the woman’s pelvis.  It is essential that the freezing of ovarian tissue is regarded as experimental.

Because you do not actually have infertility at the time you are making the request to store eggs for later use, you will understand that this will not be available to you through the NHS.  You will need to be referred to an Assisted Conception Unit where the treatment can be considered in the private sector.

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