Most developed countries face similar population problems. The number of births is down and with increasing life expectancy, the proportion of the older, retired population is increasing. This leads to aging of the population that has significant economic consequences. Whereas decades ago it was rare for women to work full-time, today most women enjoy equal work benefits and many pursue professional careers. This leads to a delay in the first pregnancy and fewer overall pregnancies per couple. Trying to start a family at an older age is also associated with an increased need for infertility services. The average age of women undergoing fertility treatment is increasing and the proportion of cycles in which donor eggs must be used is also on the rise.
A woman’s fertility is significantly affected by her age. Several studies have shown that fertility rates decline with age.[1,2] This is partly the result of both the smaller follicle pool toward the end of the reproductive years and the increased incidence of genetic abnormalities in embryos that have a maternal (egg) origin.
This retrospective study assessed in vitro fertilization (IVF) success rates over a 5-year period from a single center with a large number of cycles.
The outcome of 2386 IVF cycles was analyzed. A total of 16% were cancelled before egg collection and 11% before embryo transfer. The risk for cancellation increased with age and exceeded 55% in women older than 45 years of age. The clinical pregnancy rate was 17.9% per embryo transfer and 13.4% per initiated cycle. Overall, 45% of the clinical pregnancies were lost, resulting in a 6.7% live birth rate per cycle started and 8.8% per embryo transfer. The miscarriage rate also increased with age; it was 67% for women older than 45 years of age. The live birth rate per embryo transfer was 12% at the age of 40 years, but it was only 2.8% at 43 years and around 1% at 44 and 45 years of age. The live birth rate was significantly lower in women older than 43 years compared with those younger than 43 years.
The fertility management of older, reproductive-age women is particularly challenging. Most of them have evidence for diminished ovarian reserve and therefore, stimulation itself may be a difficult task to manage. These women typically end up using high doses of gonadotropins and usually have only a few eggs. This limits the success of the fertility treatment; in addition, most of the embryos created during IVF are aneuploid, reducing the chances for implantation. Several clinics have reported poor pregnancy rates in the over 40-year-old population and only a very few successful cases have been reported in women aged 46 years and older.[4-6] Despite these data, the number of women older than 40 years of age who are using IVF is increasing and the average age of the women attending the clinics is increasing as well.
Poor ovarian reserve cannot be corrected, so we need to find other ways to help these couples achieve the desired pregnancy. All young women should be educated about the consequences of delaying childbearing by the primary physician, gynecologist, or other healthcare provider who sees the patient regularly. However, this issue is rarely discussed at the time of the annual visit and some women’s health practitioners look at fertility treatment as a sure solution for older women.
With recent advances in cryopreservation technology, elective egg banking — and in the future, ovarian tissue banking — may be options. However, these are controversial solutions. Women who delay childbearing until they have achieved a successful professional carrier are unlikely to have a large family at an older age. Most women will not be able to afford the fee for the procedure and long-term storage, and insurance companies are unlikely to cover these expenses. In addition, a pregnancy later in life carries more risks (hypertension, diabetes, preterm delivery, operative delivery, thrombosis, etc.) when compared with pregnancy at a younger age. From an individual’s point of view, egg banking with IVF at an older age may offer a solution but from a society’s point of view, it is not the answer.
For now the most effective management of infertility in older reproductive-age women is the use of donor eggs. The regulations differ from country to country, and the expenses are prohibitive — only a fraction of the women who actually need this technique can afford it.
Until more advanced techniques to increase fertility chances in older reproductive-age women become available, pregnancy will continue to be difficult for women who delay childbearing. Even with education and government programs to support childbearing in younger women, the many factors that enter into a woman’s decision about when to start a family will continue to influence the timing of pregnancy for many women. Society will have to find other ways to cope with the growing economic burden of our increasingly aging population.
Peter Kovacs, MD, PhD For original article, Click Here
J. Kyle Mathews, MD
Plano OB Gyn Associates
Plano Urogyenecolgy Associates