April 8, 2020
Advanced maternal age is now a trending and critical social and clinical issue. Reasons for this increasing trend are due to the modern women preferring to postpone childbearing and marriage over their career goals, availability of highly effective contraceptive methods and misbelief among the general public that IVF can compensate the natural decline in fertility due to age factor. Higher proportion of couples these days are therefore dependent on assisted reproductive technologies to achieve a pregnancy.
Unlike men who can produce sperms throughout their lives, a woman is born which finite number of eggs in her ovaries , the completion of which marks the onset of her menopause.Initially in embryonic life this number is around 7 million, which decreases to 1million at birth ,and by puberty this decreases to around 3 lakhs due to a continuous physiological process called atresia & finally only 300-400 follicles are available to be used in entire reproductive span.
Thus women have a” Reproductive Life Span” during which her ovaries are active ,which starts at her puberty and ends at menopause. Most Indian women reach their menopause in their early 50’s.Age-related decrease in the quantity of eggs in the ovaries is called “ Diminished Ovarian Reserve” .However even young women may have reduced ovarian reserve due to smoking, family history of premature menopause or prior ovarian surgery or idiopathic also. This is referred as Premature Ovarian Failure / Early Menopause.
As women ages ,not only the quantity of eggs decrease, but also the quality of eggs gets declined as evident by less chances of becoming pregnant and more chances of having miscarriages. This is due to the increase in the number of chromosomally abnormal eggs as the woman ages.
Women are most fertile in in their 20’s .Chances of having a healthy pregnancy and live birth decreases as age advances, even with assisted reproductive technology. IVF is often discussed in the context of women above 35 years and as last resort. But like all things related to fertility ,your chances of getting pregnant with IVF are better, the younger you are. As IVF does not really fix the age of your eggs, so you have to think about it early.
IVF is most successful for the women in their 20’s and early 30’s .Success rates start steadily decreasing once she reaches her mid 30’s.
In 2014, a retrospective study was conducted in Department of Reproductive Medicine ,Singapore . Outcomes of 3412 fresh IVF cycles in terms of live birth rates and miscarriage rates were studied in relation to the age of the women. Live birth rates are highest in women aged less than 30 years- around 40%. In women aged 30 to 35 years ,it declined to 38%. Among women aged 36 to 40 years, the live birth rate decreased to 21%.It is at its lowest in women aged greater than 40 years, that is as less as 6%.
Miscarriage rates in women aged less than 30 years was found to be 15.1 percent, whereas the rate of miscarriage doubled to 30% among women aged 38 years .This rate increased to 47.7% among women aged 39 years. Among women aged 40 to 44 years, the miscarriage rate was as high as 55.3%.
Hence women aged less than 30 years have maximum healthy pregnancy rates in both natural and assisted conception methods. So choosing IVF at the right age ,but not as a last resort is very crucial for the successful outcome of IVF.
With current advancement in technologies & hormonal manipulation it’s possible to get pregnant even after menopause with donor eggs .
However pregnancy at advanced age can become risky for both mother and foetus, so the couple should be counselled for all the risks involved with advanced age pregnancy.
As per the guidelines of 2017 ICMR bill for assisted reproductive technology,the upper age limit for women to get pregnancy is 45 years and for men it is 50 years.
But according to the latest ART Bill 2020, the upper age limit for conception using assisted conception/IVF in India is 50 years for female and 55 years for male.
As per research success of IVF in terms of implantation rates, clinical pregnancy rates and live birth rates are at its best in women less than 30 years of age and the start decreasing as women crosses 35 years
Common complications during pregnancy in patients with advanced age are gestational diabetes, preeclampsia, increased cardiovascular morbidity of mother, increased miscarriage rates, premature delivery, low birth weight and chromosomal abnormalities in fetus.
Pre-existing comorbidities like diabetes, hypertension are also more common in women with advanced age which further complicate the pregnancy, if they plan it at a later age .
Couple are advised to opt for IVF timely if any one of them are diagnosed with the following conditions
• Poor egg reserve
• Problems with ovulation
• Low sperm counts
• Blocked fallopian tubes
• Genetic disease of mother or father
• Unexplained infertility
So , couple who have not conceived with natural or any other minor assisted reproductive techniques like IUI ,should not waste their precious time to opt for IVF as the last resort at an advanced age because success rate of IVF is majorly dependent on women’s age and is maximum when the woman’s age is less than 35 years.
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