Our society has evolved and many women are pursuing advanced educations and career advancement – and delaying childbearing as a result. However, in general women should be more knowledgeable about the impact of delaying childbearing on fertility potential.

Fertility specialists know this is a problem. We commonly see women in their late 30s and early 40s that are very bright and well-educated who are surprised and very disappointed when told that it may be very difficult (or impossible) to get pregnant and have a baby using their own eggs.

I like to use a “garden” analogy when discussing infertility with patients. The uterine lining is the “garden”  and the embryos are the “plants”. As women age, the garden is rarely the problem – the plant is often the problem. This is why using donor eggs is so successful regardless of the age of the recipient woman.

When an “older” woman switches to using “young” donor eggs, she is much more likely to end up with a high quality “plant”. The ability of the uterus to accept implantation of embryos does not decline significantly with aging (the older garden is receptive).

Sometimes when in vitro fertilization (IVF) is not successful, women ask about using a surrogate to carry their embryos – hoping that would solve the problem. However, it is not an effective solution. We would be switching from her uterus (which is not defective) to using another woman’s equally receptive uterus. There is no point in it.

However, switching to higher-quality eggs from a younger woman is more likely to result in successful pregnancy outcome. If the problem is in the “plant” then we can switch the “seed” and expect a better chance for success. But switching the “garden” doesn’t help because that was not the problem.

So what should women and their primary care doctors do regarding aging and fertility issues?

Women that might want kids (or more kids) in the future should:

• Educate themselves regarding fertility and female age
• Ask their doctors to test their egg supply as they get into their 30′s

Tests of the egg supply are referred to as “ovarian reserve” tests.

Blood tests for ovarian reserve

• Day 3 FSH, LH and estradiol
• AMH, anti-mullerian hormone

Ultrasound tests for ovarian reserve

• Antral follicle counts
• Ovarian volume

However, regardless of the ovarian reserve, female age is a very important consideration.

Conclusions:

• Many women want to have kids – but delay it too long
• Our society is not educating women well about aging and fertility
• Women should learn about declining fertility potential – and be tested for it

In a perfect world:

• Women would be well educated about fertility and aging
• Early screening for ovarian reserve should be done by the OB/GYN, or other MD
• Then women can make well-informed choices about delaying childbearing
• Society should better accommodate childbearing during educational and early workforce years

Related links:

Age and fertility

Fertility after 40

IVF and age

Testing for egg supply – ovarian reserve

Egg donation
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Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

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• A recent report on the average age at first childbirth from the CDC’s National Center for Health Statistics showed that as of 2006, women in the US waited an average of 3.6 years longer to have their first baby, as compared to 1970.

• There is not enough discussion in our society about the effect of age on fertility.

• Women’s liberation is a good thing and women have made very significant advances over the past 40 years. Many women are pursuing advanced education and careers.

• However, there is a potential “disconnect” involved. Women are waiting longer to have children – but many are not educated about what that delay can do to their fertility.

These days, many couples try to have their first child when the woman is in her mid-to-late 30s. Some will get pregnant easily, and others end up needing fertility treatments. It is not uncommon for me to see a couple with the woman in her early or mid-40s who say that they had no idea that getting pregnant would be a problem. These are educated and intelligent people. Maybe they were not exposed to the right information about fertility and aging – or maybe they never paid attention to it.

• As the American Society for Reproductive Medicine has pointed out: “As women delay childbearing, there is now an unrealistic expectation that medical science can undo the effects of aging”.

• We try our to overcome the effects of age with advanced treatments such as in vitro fertilization. But IVF success rates decline significantly with advancing female age.

What causes fertility to drop with age?

• Success with fertility treatment using the woman’s own eggs is closely tied to her age.
• When using donor eggs, the recipient woman’s age is not important. It is then the egg donor’s age that matters.
• This tells us that the age of the egg is important and the age of the uterus is not.
• Because of declining egg quality, chances for successful pregnancy begin dropping in the early 30′s and usually drop faster in the mid-30′s (by about 36-37).
• For many women there is little or no fertility potential left by about age 40, and very few women over 43 are fertile.

Even with aggressive fertility treatment (such as IVF) success rates are very low by the mid-40′s. In 2006, the national average for live birth success rate in women over age 44 using their own eggs was less than 1% per attempt (CDC data). Miscarriage rates also increase significantly with advancing age.

Both the fertility decline and the increase in miscarriages are largely due to increased rates of chromosome abnormalities in eggs as women age. Research has shown that a structure called the meiotic spindle in the microscopic eggs in the ovaries becomes damaged with aging. The spindle is involved in organizing pairs of chromosomes for proper division into 2 sets during maturation of the egg. An abnormal spindle can cause disordered chromosome arrangements in the mature egg – and therefore in the embryo.

Can we test the quality or quantity of eggs in a woman?

Since we know that the issue causing fertility problems as women age is declining egg quality, it would help to have a test to check how good a woman’s eggs are. Unfortunately, there is not a good test for egg quality. A woman’s age is the best “test” for quality.

There are screening tests for “ovarian reserve”. However, these are tests of quantity rather than quality. Ovarian reserve tests include:

• Day 3 FSH and AMH levels – blood tests
• Ovarian antral follicle counts – determined by ultrasound.

Conclusions

• “Society” and the medical field should do a better job educating women about declining fertility with advancing age.

• If women are making a conscious choice to delay childbearing and understand the fertility implications – then at least they make a conscious choice.

• However, if they go to their doctor annually for a checkup – at some point (early to mid-30′s) there need to be discussions about declining fertility potential.

More information:

Age and Fertility

PGD – preimplantation genetic diagnosis (or PGS) – does it help to test the chromosomes of IVF embryos?

In Vitro Fertilization

Egg Donation

Richard Sherbahn, MD is a fertility doctor practicing in the Chicago, Illinois area. Connect with me on Google+

Mail | Web | Google+ | More Posts