Fertility for women over 40: what are my options?

Apart from the potential clotting and immune system factors that could also be affecting, the high antibodies against the thyroid can also play a role. We also try to have the TSH under control. So, having just antibodies is a risk factor for certain autoimmune diseases in the thyroid. But if the TSH is doing fine, we don’t add any treatment.

In terms of the polymorphisms she has, depending on the other factors, sometimes we need to add heparin or aspirin treatments. But in the end, the main factor in the other round is age. So, if that patient is able to get a healthy embryo, if possible, the chance of getting pregnant will increase.

Apart from the other immune system factors that should maybe be treated or at least discussed with the patient to decide what the impact is of those factors, the most important thing—which is the topic we are discussing today—is the age and the potential effect it might have in this patient.

So, in the end, if she’s able to get at least one good quality embryo—which is also important—and also a healthy embryo, her chance of getting pregnant will increase. Otherwise, even though she has the most accurate treatment for the immune system, things won’t work.

Let’s assume it is being nanograms. So, according to age, the chances of being successful with IVF treatment with the patient’s own eggs are almost zero. I would suggest at least discussing the option of egg donation. In this situation, 47 years and AMH—this is the indication.

It’s possible to try, but I would suggest, in this scenario, as we were saying before, having the embryos tested before any other step. As we explained in the presentation, the chance of having healthy embryos when we get older than 45 years old is quite reduced. So it’s quite likely that if the embryos weren’t tested, one of the most common reasons to have that early miscarriage could have been just the abnormalities the embryo might have.

So, is it possible to try? It’s possible to try, but we need to be realistic about what we might expect from the treatment. Same as the patient before—when we are 46, 47, or 45 years old—the realistic chances of having an ongoing pregnancy in that group are low. So we should also start discussing other options, such as egg donation.

According to Spanish law, before the treatment, we can’t provide information because it’s not allowed by law to choose the donor the patient wants to have. But once the patient is in treatment or pregnant, the basic information we always share with our patients is medically important information, such as age and blood type.

If the patient wants to have more information like general information such as skin colour, eye colour, hair colour, and race, this general data can be given to the patient. According to the law, donation is anonymous, so it’s not possible to provide any data that can let the patient recognize the donor. That information is what we can provide to the patients if they want to have it.

With stress, it’s very difficult to measure the impact it might have. It’s very difficult to do standard research. It’s really difficult to measure the effect it might have. Stress might affect many different parts of fertility, not only the quantity, but also the quality and the implantation. But to know exactly how deep that impact would be is very difficult to say. We know that it might have an impact, but we don’t know at which point and how deep that impact would be.

It depends on the kind of treatment the patient is receiving, as well as the age of the patient. Just the fact of transferring embryos doesn’t mean that there’s a failure of implantation. We also need to know what kind of embryos we are transferring—if the quality is good enough, if we are talking about blastocyst embryos. Depending on the situation, we can discuss if it could be a failure of implantation or not. Also, whether they have been previously tested or not. We need to know more about the case to give an opinion.

In the event of a triple pregnancy, it’s true that a multiple pregnancy, such as a triple pregnancy, has a high risk of prematurity. So if all the babies keep on developing, it’s very likely that the pregnancy ends much earlier than expected, and there are potential complications from prematurity.

To talk about early menopause, we refer to patients younger than 35 years old who no longer have periods. A patient who is 42 years old with AMH 0.5 has a normal ovarian reserve for that age. We can’t consider that patient menopausal if she’s still having regular periods, and it wouldn’t be early menopause because of age. In this group of patients, IVF can give good results, but we must consider what to expect from the technique. For a 42-year-old patient, if we do a biopsy of the embryos, we expect around 12–14% of healthy embryos. That’s related to age, not AMH. So, would it be possible to get pregnant with her own eggs? Yes, but we need to be realistic about the result.

That has, let’s say, scientifically proven that there could be any changes in terms of egg quality—I could say no. But it’s true that many supplements, like CoQ10, are supposed to have an impact on egg quality, and also inositol. So, it’s possible to take them, but we should know that the potential impact in terms of the quality is not so big. Of course, it’s good to take them—why not—and it might help, but it hasn’t been proven in all patients. And the impact is not very clear at this point.

If she’s not having periods anymore, IVF with her own eggs wouldn’t be possible because she’s in menopause. So it seems the ovaries are not working anymore.
In terms of the scar tissue, I don’t know if it means inside the uterus—maybe what we call Asherman syndrome, which is a pathology where there are scars in the cavity. Depending on how severe that syndrome is, sometimes some techniques can improve the result. But sometimes that pathology could be quite challenging, and it’s very difficult to help a patient get pregnant with that condition.

The patient added she’s 46 and asked about IVF with egg donation. With egg donation, it would be much better. But it would be important to check the uterus in the best way to know how likely it would be to get pregnant depending on the status.

It depends on what she means by “in her 50s,” and also depends on the country. In the States, for instance, the limit is normally 50 years old. Here, we don’t do treatment in patients older than 50. Not because of the results, but because of the risks of pregnancy and the potential complications that the patient might have when she gets pregnant in her 50s.

So, it depends on the country. In other countries, it could be an option, but in Spain, the maximum is 50.

Regarding the aneuploid embryos, according to Spanish law, it’s not possible to transfer them, so we exclude them.

Regarding poorly graded embryos, it depends. A blastocyst 5CC normally wouldn’t be implanted at any point. If it’s the only embryo a patient has with her own eggs, and she doesn’t want to do the genetic screening and wants to transfer it, of course, we can give her the opportunity. Generally speaking, with egg donation, we wouldn’t transfer that embryo for sure. With IVF, it depends on the condition, but I don’t remember transferring any embryo graded so low. It depends on the case.

It depends on the classification that the biologist does in the laboratory. If the embryos are rated CC, DD, or CD, those embryos are normally discarded. It depends on the quality. Also, if they do the PGT-A and the embryos have been classified as aneuploid, we always discard them.

We have not been using stem cells, but we are using plasma-rich platelet (PRP) in a certain group of patients. These are still experimental techniques and have to be performed in young patients. With stem cells, there is not much experience, and we are not using them. But with PRP, we are using it for young patients with really low ovarian reserve.

It is very difficult to restore the environment and conditions the ovaries had 10 years ago. Even though we try to stimulate the ovaries in the best way possible to get the best quality, we also need to be conscious about the impact of age. Sometimes it is very difficult to reverse that impact.

Normally below 35 years old with low reserve. That’s the criteria we normally follow.

We have done quite a good number of PRP infusions. Some patients had better response in the upcoming cycle, but in others, we didn’t find any difference.

That’s the reason we focus on younger patients—the ones without an age factor. It may be just oxidation in the ovaries, and we try to reverse that. But with older patients, we know the main factor is age, and reversing that is almost impossible.

If the embryo on day 6 has expanded and is of good quality, I would suggest transferring it. Many patients think that day 6 embryos do not have any chance of implantation. We indeed prefer day 5 embryos, but on many occasions, we transfer day 6 embryos, and the success rates are also good.

If we can choose between day 5 and day 6, I would say a good day 5 embryo is better. But if the embryos are not good enough on day 5, waiting one more day gives us the option of having an expanding blastocyst and transferring it, then it is still a good chance.