In this session, Dr Adriàn Moreno, Gynaecologist, Specialist in Human Reproduction at Clínica Eugin, located in Barcelona, Spain has been discussing various IVF options for women of advanced maternal age, also, he had provided lots of useful advice on how to get a successful IVF after failed IVF attempts.
When we look at the analysis of the causes of the socio-demographic situation, which could have a strong impact on female fertility. As shown on the graph, there has been a postponement of childbirth during the last decades. In many countries, from the Czech Republic to Spain, and the United States, the age of motherhood has been postponed from, on average, 24 years old to 29 nowadays. This has a strong impact on fertility rates. For example, in Spain, giving birth at 40 is 2 times more frequent than 20 years ago. In 2018 at Eugin, almost 50% of IVF treatments were performed, and patients were over 40 years old, if we take into account, for example, when it comes to 36-year-olds and above, it was almost 75% of the treatments performed.
The current tests that can give you an idea of your ovarian reserve testing (ORT) and predict your prognosis are AMH Anti-Mullerian Hormone and Antral Follicle Count (AFC). They are only going to estimate the capacity of the ovary to produce eggs during ovarian stimulation, it’s not a marker of fertility. These markers are not going to tell you the capacity of this woman to get pregnant naturally, it’s about giving the idea of how many eggs we can expect to get after stimulation.
IVF over 40
In women over 40, IVF is more advised than IUI. It’s important to mention that in patients up to 42 years of age, it should not be encouraged to do more than 4 cycles. In one of the studies presented, patients younger than 35 years old had live birth close to 25%, when we look at the group of patients between 42-43, the success rates drop significantly, and after the age of 44, the chances diminish. Data from the Eugin group showed that from 200 patients who went ahead with IVF treatment and were over 43, only 11% had Beta HCG positive tests after the embryo transfer. This wasn’t a live birth rate or ongoing pregnancy, so there is also a risk of miscarriage during the first trimester. IVF may largely overcome infertility in younger women, but it doesn’t reverse the age-dependent decline in fertility.
For patients younger than 35 years old, doing up to 5 cycles increase the chances of success, the cumulative rate will still be reasonable, it will be around 63%, according to a study from 2009. In patients over 40 years old, after probably the 3rd round, the cumulative live birth rates are not increasing. To conclude, in the group of patients from 40 to 43 years old, it’s not advisable to perform more than 3 rounds of IVF because probably after the 4th, the result is going to be the same. Patients over 43, do not have a realistic chance of achieving a delivery with their own oocytes.
PGT-A in advanced maternal age
PGT-A is a tool that is used more and more often. It can be useful in the advanced maternal age group of patients to optimize or at least increase the chances for a successful IVF round. PGT-A helps to screen and then identify the euploid embryos. The aneuploid embryos will be discarded, and only genetically normal embryos will be transferred. The idea behind this is to reduce the time to pregnancy, avoid unnecessary transfers, and theoretically reduce the rates of miscarriage. To perform this technique, we need to culture the embryos until day 5 (blastocyst stage), and then a biopsy will be performed. A few cells from the embryo will be taken (from zona pellucida), and this embryo will be identified as normal or abnormal.
PGT-A should be applied to some specific patients that could have a higher benefit from it. It is recommended for patients who are older or over 38 years old, it was possible to retrieve a good number of eggs, probably more than 10, and in the end, it was possible to obtain at least 3 or more embryos on day 5.