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How old is too old for my IVF treatment?

Dr Ernesto Boshch, M.D., PH.D.
Medical Director
Dr Dimitrios Dovas, MD, DFFP
Obstetrician-Gynaecologist & Clinical Director
Dr Kristýna Frühaufová, PhD.
Head Physician , Gynem Fertility Clinic

Category:
Advanced Maternal Age

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From this video you will find out:
  • What are the age limits for IVF treatment in Spain, Greece and The Czech Republic and are there any restrictions on using donor eggs and sperm at a certain age?
  • How do age limits for IVF treatment vary based on factors such as ovarian reserve?
  • What factors should be considered when balancing patient wishes, realistic expectations, and success rates in IVF treatment decisions?

How old is too old for my IVF treatment?

It’s a continuing trend that women, with and without fertility treatment, are having their first child later and later in life. It’s only natural to ask the question as to whether there might be physical limitations.

During this event 3 Fertility Experts shared their own experience, discussed available options and limitations as well as answered patients’ questions.

The panel of experts included:

Dr Ernesto Bosch, PhD – Medical Director of IVI Valencia, Spain
Dr Dimitrios Dovas – Medical Director of New Life Greece
Dr Kristýna Frühaufová, PhD – Head Physician of GYNEM Fertility Clinic, The Czech Republic

The event was hosted by: Professor Alan Thornhill, Fertility Expert & Coach, Founder of The Fertility Guy

- Questions and Answers

Can you please explain in simple terms why the chance of getting pregnant for a woman decreases dramatically with age?

Dr Ernesto Bosch, IVI Valencia: The main reason why pregnancy rates are going down dramatically with age is due to the viability of the eggs. We know that as the woman gets older, the probability of producing an oocyte, an egg able to develop a viable embryo, goes down. This happens steadily after the age of 30 to 35, but much more sharply after 37 or 38 years old. We see at those ages that the probability of fertilization goes down, the probability of a fertilized embryo becoming a good quality blastocyst goes down, and, the probability of a blastocyst being viable, which means being chromosomally normal, goes dramatically down. We see in our donors who are younger than 30 that for every 3 eggs, we have a good quality blastocyst with normal genetic charts, and at the age of 40, we need 10 eggs to have 1 of those, and at the age of 43 or 44, you would need 20 to 25 eggs or even more to have one of those. That’s the main reason.

What sort of metrics and conditions would you consider that we should be talking about rather than age? What kind of things can we measure in a woman aside from age?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: Age is the most important factor, unfortunately, that we have to take into account when we want to make some assumptions about the IVF outcome. Several factors related to fertility, such as the AMH level, which is the strongest predictor of the ovarian response to the simulation of the pool of the oocytes or ovarian capacity overall, or the AFC, basically correspond, but those will just give us some idea about the possible response to the stimulation of the patients, but it doesn’t give us the full picture about the possible embryo quality. We use some other methods, such as the ultrasound, and the hormonal profile itself, but this is like to wrap up the whole image, to wrap up the idea about the patient, but other than that, there’s not much that you can investigate in terms of female fertility. Age is what matters in the IVF success.

Dr Ernesto Bosch, IVI Valencia: The probability of a pregnancy is a function of how many eggs you get and what’s the probability of each to provide a normal embryo. A function of AMH, which tells you how many eggs you can get, and age, which tells you what is the probability of each of the eggs being normal, would be a more precise figure if you want, and you say, “Okay, a patient with a 40-year-old and a probability of producing 5 eggs have X chances of having an embryo,” and then a patient of 43 but with 10 eggs have maybe a higher or lower chance. It would depend on the number of eggs that you can get and then the property of each of these eggs to be normal.

Are there some treatment medications or preparations to help older women when using their own eggs? 

Dr Dimitrios Dovas, New Life Greece: What is very important is to look at the combination of factors, meaning if said even at the age of 45, very common but she may produce 15 eggs, she’s got a reasonable chance of having a healthy egg that will lead towards a genetically healthy embryo. That has a low chance of aneuploidy at advanced stages, means that it’s virtually impossible to have normal embryos, this by increased risk of miscarriage. At this stage, I have to say that as medical professionals, we need to be very careful in order to counsel our patients correctly and protect them from unnecessary treatments or interventions. I wish we could rejuvenate the ovaries, but we’re not quite there. So we need to be very clear: yes, the woman could be lucky even in her late 40s and have this 1 egg that will lead towards a good embryo, but it’s extremely unlikely to happen.

Usually, the way forward for women of advanced reproductive age – I’m talking about very advanced reproductive age over 43, 44, and the low reserve – is donor eggs. What we should remember, though, is that the performance of egg donation is very high irrespective of the woman’s age group, so we don’t see huge differences in the performance if the woman is 43 or 46. What is important, though, is what are the circumstances under which a woman will become pregnant because you understand the woman’s body, the human body cannot support a pregnancy the way it does in the 20s when a woman is mid-40. We need to be very careful in order to protect our patients from unnecessary interventions, provide them with options, provide them with the figures, and help them make an informed decision themselves.

I’m 55, have I got any chance?  What are my options?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: Well, the first thing that I would like to address is the different legal frameworks for IVF in each country. So, for example, in the Czech Republic, 55 years of age is over the legal limit, so we cannot treat this patient. The upper age limit for the Czech Republic is 49 years of age, so that’s for using one’s own eggs or any kind of treatment. So it doesn’t matter what kind of gametes we use, 49 is the upper age limit. As I said, there are different legal frameworks within the EU or the world, so this is something that patients should look into concerning IVF treatment.

Speaking of IVF with her eggs, from the biological point of view, as we said, fertility dramatically drops after the age of 40, and then there’s a bigger decline even after the age of 42. So biologically, it is almost impossible to conceive this late. Also, it’s quite rare that a woman of the age of 55 hasn’t gone through menopause yet. So to conceive naturally or with IVF with her own eggs, I think it’s almost impossible, and the donor option depends on what’s available in different countries.

Dr Dimitrios Dovas, New Life Greece: It’s a very difficult question because we shouldn’t be judgmental about what we believe is moral and correct. Maybe it’s not the way other people think about it. Here in Greece, the law changed recently, and now it’s allowed to offer fertility treatments up to the female age of 54. I think probably it’s a little bit too much. But traditionally, in most countries, fertility treatments were allowed up to the age of natural menopause, which is 50 or 50 and a half. I think this makes much more sense. But again, we need to look at the individual woman. We may have very fit and healthy women at the age of 50, but at the same time, we have women with a lot of comorbidities in their late 30s or early 40s with hypertension, diabetes, etc. So we need to individualize, and it’s not just the age factor.

Dr Ernesto Bosch, IVI Valencia: In Spain, there is not strictly speaking a legal limit, but still, the Spanish Society for Fertility would not support any treatment above 50, even up to 52, more or less. Regarding the specific types of treatments, IUI above 40 has very little chance of working if it’s a woman without infertility. If it’s a single woman, it may still have a chance until 40, but not more than that. When speaking about IVF with one’s own eggs, our highest age pregnancy achieved after so many years and so many patients has been 46. We never managed to have a viable pregnancy, live birth with one’s own eggs, on a patient 47 or more. So this is our recommendation. We still have patients aged 47 who want to try and see if they are the first ones, but we always tell them, “You would be the first after 35 years and thousands and thousands of patients.”

Regarding egg donation, above 45, we do a very strict selection of patients that can be treated because what data shows us is that if you look at the risk of complications, above 45, they get significantly higher. We’re talking about pre-birth, postpartum hemorrhage, and gestational diabetes, all these complications increase dramatically or significantly after 45. But still, when you adjust for singleton pregnancies for patients with good health conditions, then the risk of complications is not that dramatic. It does not increase significantly. If you have a healthy woman with no diabetes, no hypertension, no obesity, no uterine pathology, and she has a completely normal uterus, then she goes for a single embryo transfer. You can still treat her up to 52, you can treat her with reasonable chances of success and with reasonable safety. You have to be very strict with the health conditions of the patient.

I am 50, and I heard about the 3-DNA embryo via spindle transfer. Would this option be an alternative to using an egg donor? What’s your opinion on this pretty advanced technique that isn’t available in all countries and all clinics?

Dr Dimitrios Dovas, New Life Greece: I have to say, we’re living in interesting times because our patients often come with a Medline review, but I wish the data they have were always up to date. When we have women of advanced age, the problem lies within the nucleus and the chromosome, so correcting the cytoplasm does marginally make a difference. Indeed, this type of treatment means a lot for women who have issues with mitochondrial disease, which means issues with the cytoplasm. In such cases, we can use the nucleus, the chromosome, so the baby will be biologically the woman’s, transferred to the cytoplasm of a younger patient to avoid the disease, boosting the performance.

There was a huge thing about it 8 to 10 years ago in the US, I think. At some point, this new method even received the first prize during ASRM Congress. It involved the condition where we perform mix to inject the sperm within the egg, and we inject mitochondria as well, obtained from the woman’s series, to enrich with mitochondria and energy. The egg and subsequently the embryo perform better. However, it didn’t work; actually, the company went bankrupt. So, the answer is that this is a very good method in very specific circumstances that we’re trying to avoid the specific disease, but it does not improve the chances of success in women of that age group.

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I would like to emphasize that these methods are still experimental, so there’s no widespread use. I agree with Dr. Dovas’s statement that there is a specific, fairly small percentage of patients for whom these methods might be suitable. However, there is no broad indication in the realm of female fertility aging that suggests this is the right approach, or that we have reached a level of advancement to support it. Dr Ernesto Bosch, IVI Valencia: I would say that those of us working on this for several years have seen some very promising technologies, starting from Cytoplasmic transfer up in the year 2000 and to PRP injections now, etc. All of them have been very promising at the beginning, as some pregnancies happen, right? When numbers become large, and the population involved becomes much wider, unfortunately, nothing has shown yet to be efficient enough to become something applicable in routine practice.

These technologies are still in an experimental situation, under research, and we don’t have yet good scientific evidence enough to support their use in daily practice.

Dr Dimitrios Dovas, New Life Greece: We have a huge responsibility to protect our patients from untested methods because those people are very vulnerable. It is us who need to step up and say that this is not proven to work, you shouldn’t do this, rather than giving them false hopes.

Should we recommend genetic testing  all embryos for women aged 44 and older, or even as young as 38 or 40? Even if only one embryo is obtained, what’s the rationale for testing?

Dr Ernesto Bosch, IVI Valencia: Definitely, at 44, the answer is yes. Even at 40, the answer would be yes. But at 44, the probability that the embryo is abnormal is at least 85%. This means that in 85% of cases, the embryo transferred is abnormal. A normal embryo has only 3  outcomes: it may not implant, it may result in a miscarriage, or if it implants successfully, it will likely be diagnosed with abnormalities during prenatal testing. At 40, the probability of the embryo being normal is around 65% to 70%. Therefore, I would still recommend testing. Between 38 and 40, we can be a bit more flexible, but that depends on the patient’s background.

If it’s a first attempt with no history of infertility or miscarriages, we could discuss it because the probability of a normal embryo ranges from 50% to 65%. While there may be room for transferring without preimplantation genetic testing (PGT), it’s always a recommendation, not a mandate. If a 44-year-old patient only has one embryo and wishes to transfer it without analysis, she has the right to do so. However, in such cases, we ask patients to sign a specific informed consent form acknowledging the risks involved. Thank you very much. Since this treatment is quite common, I’d like to hear from everyone on this.

Dr Dimitrios Dovas, New Life Greece: I think the question is how we balance the risk versus the benefit. The benefit, as Ernesto mentioned, is that you avoid unnecessary transfers and spare people from the emotional roller coaster of high chances of being unsuccessful. On the other hand, the benefit of avoiding testing if you have just one embryo is that theoretically, you avoid the risk of damaging this embryo during the biopsy process. The risk is very small, in single digits, less than 5%, so it depends on the lab’s expertise performing the biopsy. Imagine, though, how important it is if the only embryo available is biopsied, the diagnosis comes back as normal, and then you discover it hasn’t survived the biopsy process. It’s not very common, but it depends on the lab’s performance and the lab’s key performance indicators.

Another consideration is the policy on intermediate-stage embryos because we do not always get a clear answer when we test an embryo. We have those so-called Mosaic embryos, in which case, based on the level of mosaicism, we can suppose how likely this embryo is to be healthy. Here at our clinic, we always individualize the approach. Genetic testing does carry additional costs, but performing an unnecessary embryo transfer is costly as well. We provide the figures regarding our performance, the risk of embryo damage during biopsy, and the percentage of mosaicism we encounter. We also consider the patient’s emotional state and her journey so far because some women feel that they owe it to themselves to have an embryo transfer. We quote figures, as Ernesto mentioned earlier, and decide on an individual basis. Generally, our recommendation is to test even if the numbers are small.

Dr Kristýna Frühaufová, GYNEM Fertility Clinic:  In the Czech Republic, PGT-A is  partially funded with an age limit. There’s some difficulty understanding the funding of IVF because IVF cycles are reimbursed up to the age of 39. However, PGT-A is reimbursed up to the age of 49. Patients over 40 have to pay for the IVF cycle itself, but PGT-A testing is covered by insurance companies.

Generally, I would say that we need to individualize in these cases because there’s no general answer. You have to look at the patient’s history to see if she has any previous miscarriages. For example, in that case, I would do the PGT-A testing even if I had only 1 blastocyst to avoid a miscarriage. But overall, if she’s going through her first cycle, then I would consider the preference of the patients. I wouldn’t push them to do the PGT-A testing and make the final decision based on the final number of blastocysts that are suitable for biopsy.

Dr Dimitrios Dovas, New Life Greece: I think one of the reasons that confuses this discussion is because sometimes  in the old days of PGT-A, the genetic labs were charging per bunch of embryos. So either you had one embryo available for testing or four, you were charged the same. So we used to bank embryos to reach this golden number of four and send all of them for testing in order to reduce the cost. But nowadays, the cost is per embryo, so it doesn’t make much sense to batch the embryos because the healthy one may be the first one to biopsy.

Are there medications that older patients can take to improve their chances? What do you think about DHEA?

Dr Dimitrios Dovas, New Life Greece:  First of all, following a healthy lifestyle significantly improves the performance. I’m not talking only about the number or even the quality of the eggs, but also how prepared the woman’s body is to support the pregnancy. Regarding the vitamins and supplements, I think that somebody who’s on a balanced diet and avoids excessive alcohol smoking, or even caffeine doesn’t need to be supplemented. But now and then, studies come up. In the last few years, there’s been a huge discussion about the vitamin D and its effect on the quality. It seems that there is some room there, but again, like I said before many times, we need to be very, very careful. I mean, I see couples coming here for treatment. Each one of them spends about $300 to $400 per month just for supplements. At some point, we need to be reasonable about what is needed and what is not.

Regarding androgens, thses are precursors of the steroid hormones that are produced in a woman’s body. So theoretically, this could be helpful, but I think there’s some evidence showing that the naturally produced sex hormones are more important. The supplementation is debatable if it is of any help.

Traditionally, women who produce a large number of eggs are women with polycystic ovarian disease who have raised levels of androgen. So the concept was that probably it is helpful. I’m not convinced that it would make sense for a woman over the age of 43, or 44 to be for a few months on androgen supplementation or other supplements in order to become much more fit and delay the treatment because the age factor is much more important. But yes, definitely, we need to make sure that we prepare a body to support a pregnancy, so we need to look at all those conditions.

Dr Ernesto Bosch, IVI Valencia: Regarding lifestyle, the only factors that have been shown to have an impact are smoking and obesity. As far as avoiding that, everything else is quite blurry. We can assume that alcoholism, of course, would be a problem, but I have never seen an alcoholic patient. Smoking and obesity are there, so once you’re there, keeping a balance is okay. All the supplementations that are sold out there, all these add-ons, have shown not to have any impact. Even androgens were promising, but large studies have not shown a benefit and were particularly important for poor responders.

Melatonin, coQ10, selenium, zinc, everything, nothing has shown to work. We don’t know how they interact with each other. As Dr Dovas said, patients are taking a lot of things, all of them meant to be positive, none of them shown to have an effect. However, we still don’t know how they interact with each other and what’s the real impact on the body. When you look at pregnancy rates, there are no differences.

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I would just point out that this huge business with hope, all these add-ons in IVF, so that’s something that we should be rational about. And as you said, there’s nothing that has been proven to have any effect in the large studies, and these are the supplements. It’s not real medication, so there’s no regulation behind that. Even the doses may vary in the various products. That’s one thing.

Another thing that I would like to say is that we have to keep in mind that all lifestyle has a cumulative effect on the quality of the egg. When a woman is 40, we might be dealing with the damage that she has done when she was in her 20s or 30s. There’s no way to reverse the time, and since there’s no oogenesis, women don’t produce any new eggs, they are born with a certain amount of eggs they’re just running out of time, and we accumulate the damage over.

I am 46 and I have about 7-8 eggs. Most clinics are suggesting egg donors rather than using my own eggs. What should I do?

Dr Ernesto Bosch, IVI Valencia: Well, of course, you can try. You need to keep in mind that it is likely we would not get a normal embryo from that cohort. Still, 7, 8, I guess it means antral follicles. With 7, or 8 follicles at the end, you can have 4, or 5 eggs, and if they’re good quality, you may have some blastocysts there. The probability of that blastocyst to be normal is very low. But you can try. I mean, it’s legal, it’s not dangerous, so you can try.

The recommendation of egg donation is just looking for the probability of success and therefore the number of attempts that you’re going to have, the number of procedures that you’re going to undergo. If it’s positive, if it’s not. So, when you’re being recommended egg donation, it’s because you’re being recommended the most efficient treatment at your age. But this does not mean that you cannot try, of course.

Would you say that it’s better to do a day 5 transfer or freeze than a day 3 for an older patient?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I would generally say that depends on the number of embryos that you have. For example, you have a patient that is of advanced age and she’s a low responder, so you are lucky to obtain 2 good-quality oocytes and you end up with 1 being fertilized. In that case, you don’t necessarily have to do the blastocyst transfer, so you can do a day 3. The blastocyst transfer itself is a tool to pick the best quality embryo if you want to do a fresh transfer or if you want to proceed with PGT -A testing, then to see if you have blastocysts of good quality to perform the PGT-A. It’s kind of a selective tool , but if you have a low number of embryos, then you don’t necessarily have to do the blastocyst transfer.

Dr Ernesto Bosch, IVI Valencia: We always do blastocyst transfer even if we have 1 embryo unless the patient doesn’t want to. But you indeed need very specific and good conditions in the lab to implement that quality. At the end of the day, the question was if the blastulation rate is higher in the uterus or in vitro, right? Well, a blastulation does not happen in the uterus, right? It happens in the tube. You need to provide a lab with the specific conditions, and oxygen pressure, for example, is something very, very important, at that point, a part of many other conditions.

Sometimes if you have 1 embryo, transferring day 3 or transferring blastocyst doesn’t make any difference in terms of pregnancy rate per cycle. You would make it per transfer, in case that does not make it to blastocyst.

We have had IVF using our own eggs and sperm. It wasn’t successful. We were told the embryo wasn’t growing, so we’re thinking of doing egg donation, and our own gametes on the same cycle. Can this be successful?

Dr Dimitrios Dovas, New Life Greece:  Well, no, mixing embryos and performing mixed transfers doesn’t make any sense, and obviously, it’s illegal for many reasons. I can see that this woman, if I’m not mistaken, is 37 years old, so I don’t know how many rounds she had so far and how many eggs she can produce. If she hasn’t got a very long and unsuccessful history of treatments, probably the way forward is to use your own eggs unless there’s a long history of failures, combined with a very low ovarian reserve, meaning a high risk of cancellation, a small number of embryos to choose from, in which case, going for donation would make sense. But with the data I have, probably I wouldn’t go straight for donation, and definitely, I wouldn’t perform a split cycle, a mixed transfer.

I had this question asked many times by women mid-40s, or late 40s if they could have a mixed transfer with 2 embryos, 1 from their own eggs and one from the donor’s eggs because they would feel psychologically much better. Imagine if this woman becomes pregnant during the early stages of pregnancy, how we’re going to assess and screen her regarding the risk of chromosomal abnormalities if we use her age group as an indicator, this woman should have invasive testing, which carries its own risks during pregnancy, whereas if she’s become pregnant with a donor, which is most likely the case, she’s not going to have to go through this invasive clearing.

It’s not just an ethical condition, it’s also practical because it may raise a lot of complications during the actual pregnancy. Y

How fast can AMH drop within a year? If you’re at a certain age, how quickly do you need to act proactively, do things because you’re worried about your fertility dropping massively?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: Well, this is a very difficult question to address. If you have only one value of AMH at the age of 41, there is no general indicator saying how dramatically the AMH will drop.

Still, using AMH as a predictor of the age of menopause is a bit tricky because it doesn’t correlate. For example, saying that you have a lower AMH, which means that you might be at the risk of pre-term menopause, doesn’t always apply. So, you would have to do various checks to see the drop in the levels, and those checks should be done, of course, assuming that the AMH should be stable within all the phases of a cycle.

We know that technically, this is not true. Even if you do two samplings on the same day, you might end up with different results. They won’t be dramatically different, but they will differ. You should do the testing under the same conditions, preferably in the same phase of a cycle and the same lab, using the same machine because different machines may bring, dramatically different results.

What are your thoughts on a natural modified IVF for someone who’s nearly 45 with low AMH and low AFC?

Dr Ernesto Bosch, IVI Valencia: If ovarian reserve is really low, then it’s an option. If ovarian stimulation is not going to help you produce more than 1 egg, then the natural modified cycle is an option. Indeed, in that type of patient, we don’t use high doses of gonadotropins because they cannot work. I mean, they don’t have receptors, they don’t have follicles where to act, so it doesn’t make any sense. And we use very, very low doses of gonadotropins on those patients. But even if the patient has only 1 follicle, a natural cycle or modified natural cycle can be an option.

Dr Dimitrios Dovas, New Life Greece: No, I agree, but the thing is that those women have a huge risk of cancellation, so they need to be warned because, like we said in the beginning, the combination of quality and number is of huge importance. So if you end up having very small numbers, just 1 egg, things are really difficult.

Is PRP ovarian regeneration proven to help, and do you recommend it to any patients particularly those of advanced age?

Dr Dimitrios Dovas, New Life Greece: I have to say that the evidence is very limited. There are a few studies that show some improvement, but I don’t think that they’re adequately powered. This means that the results may not be as significant as they look. Ovarian rejuvenation means that you cannot improve the quality of the eggs; it’s genetically determined.

Can you improve the number of the eggs? I doubt if this is the case. I have come across cases where some improvement in the hormonal profile was observed, but I don’t know if that was just a random thing or not. Here in Greece, it’s a hot topic because some of the studies have been performed here, and many clinics offer it.

 I’m very skeptical about it because it’s not only the fact that you don’t get a lot of improvement, if any, but also you increase the risk of, for example, inducing an abscess when you infuse the ovary with solutions. Theoretically, there are growth factors within this part of the plasma that is platelet-free, but I’m not convinced that the evidence is there that this should be a mainstream treatment for women with a low ovarian reserve. Maybe there are other ways of rejuvenation; for example, I feel strongly about the stem cell studies that have been performed.

Dr Ernesto Bosch, IVI Valencia: We’ve been using PRP intra-follicle injections, but I’m very skeptical yet about the results, honestly.

I am 43, AMH of 12, using donor sperm. I had 3 rounds of IVF and one IUI round, I had 4AB embryo, which resulted in a chemical pregnancy, in the first round, no implantation in the second one, and 5AA, good quality blastocysts, but no implantation. I did endometrial testing, and a small infection has been discovered. Should I do more IUIs rather than IVFs with less medication?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I assume that you had PGT-A testing done, the embryo was a 5AA. Your AMH is quite high for your age group. That means you have a chance to obtain some eggs with the IVF stimulation, so using the IVF and the PGT-A testing gives you far better chances than the IUI. As we said, the success of IUI in women after the age of 40 is really limited. It’s below 5%. I would even say, it’s below 1% from our experience. I would say that IVF is more likely to lead to a successful pregnancy in this case.

Is performing both PGT-A and PGT-M more dangerous for the embryo? (I have Alport syndrome, I am almost 42 and I would like to have both performed if I have one or more embryos).

Dr Ernesto Bosch, IVI Valencia: What you have to do on the embryo is the same. It’s the biopsy of the trophectoderm, and then you will work on the cells, so the embryo will not suffer more because you’re adding the PGT-A in this case.

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I would just comment on that because we do it automatically in our country because all the PGT-M tests are done around the PGT-A as well. As we said, we want a euploid healthy embryo. You don’t want the disease-free aneuploid embryo to transfer.

Dr Ernesto Bosch, IVI Valencia: You are also almost 42. I mean, if you’re 37, 38, or older, the probability of an aneuploidy is higher than the probability of carrying the mutation, which is 50%.

Dr Dimitrios Dovas, New Life Greece: It’s also very important to identify the genetics of this particular case of Aort because it has different variations. If it is recessive, or dominant, I think the majority are X-linked, so they need to test the parents and identify exactly the mutation and the type of the disease we’re talking about before they proceed.

Can you get donor eggs and donor sperm in Spain at the age of 42? Are you still able to use them?

Dr Ernesto Bosch, IVI Valencia: Yes, of course. It has to be anonymous by law, but definitely, you can.

How old is too old for IVF and donor eggs?

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: It’s more an ethical question, and the answer is difficult because, as we know, the biology applies to all women, but some are lucky enough to have better ovarian reserve and can produce more eggs with the IVF stimulation, which gives a better chance to obtain 1 good quality blastocyst that would lead to a successful pregnancy. That’s one of the points.

The other point is to have a healthy woman to carry on the pregnancy and have a chance to give birth to a healthy child in the end. Those are the two points that should be most important to us as clinicians. I don’t want to put any upper age limit to that because some women might be on the verge of their ovarian reserve by the age of 39, and some might still have a good chance by the age of 42 or 43. Biologically, the upper age limit would be 44-45ish.

Dr Ernesto Bosch, IVI Valencia: If we’re talking about own eggs and provided that the patient still has ovarian reserve to respond to IVF stimulation, no matter if it’s a low number of eggs, my answer would be that 45 would be the limit. As mentioned before, we have had some pregnancies, but just a handful of them at 46. So let’s say 45-46 would be the limit. In the Czech Republic, they’re doing it until 49, but, well, that would be the limit.

If we speak about donor eggs, if the patient is healthy in terms of her general condition, I think that we can go pretty safely up to the age of 52. In the US, it’s quite frequent to go up to 55, so probably in that frame would be the limit.

Dr Dimitrios Dovas, New Life Greece:  I agree. It’s a matter of looking at the age factor and also the ovarian reserve. Usually, the age of 45, I think, is the maximum. But there’s hope out there. I will share with you a story. I had this 47-year-old woman who developed 1 blastocyst, medium quality. She opted against testing, and I said, “I don’t even know if this blastocyst has a 1% chance of being successful.” And she answered to me, “Well, 1 is better than none. Let’s do it.”

She has her own baby now. But this is the exception because, for this successful woman, there are hundreds, if not thousands of women who will not become successful. We must provide the data and help people make informed decisions.

There was a paper published by ASRM called futile treatment, meaning we are not going to treat you in simple terms. The percentage was 4% of a chance that it is going to work. What can you say about this?

Dr Dimitrios Dovas, New Life Greece: My experience has shown that it is not 4% or any figure will make sense as long as you explain adequately to the patient what they should expect, this is going to be their choice.

Dr Kristýna Frühaufová, GYNEM Fertility Clinic: I would just comment that you have to talk to the patient and see their preferences, and they have to make their decision based on some real data. You have to take into consideration what is their wish. I would say that a 4% cut-off sounds reasonable, but for some patients, it might be too low, for someone, it’s okay, it’s quite high, so let’s go ahead. You have to provide them with some perspective that has to be realistic and not give them false hope.

Dr Dimitrios Dovas, New Life Greece: If it is in a private setting and the people make all their own decisions, again, it’s a totally different thing compared to the National Health System reimbursing the treatment because, for them, it’s not cost-effective. But we have to respect our patients’ views and wishes.

Dr Ernesto Bosch, IVI Valencia: I think this is also very much determined if this is a private or public setting. Because in a public setting, you need to play with a cost-benefit case in terms of the budget that you have. Definitely, one or four or five or maybe eight would not really justify a treatment, right? Then it gets more difficult when this is a private setting, and then the patient has much more freedom to make a decision, right? Because she’s paying for the treatment. But still, you have to be very clear.

As Dimitrios was saying before when you tell the patient this is 4%, this is her 4%. This means 96% of failure, how can you tell her not to do it? You can recommend her, but I would say that you cannot neglect to do it.

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Authors
Dr Ernesto Boshch, M.D., PH.D.

Dr Ernesto Boshch, M.D., PH.D.

Dr Ernesto Bosch serves as the Director of IVI Valencia clinic. Dr Bosch was born in Philadelphia, USA, he graduated from the University of Valencia Medical School in 1992. Following that, he completed his Residency in Obstetrics and Gynaecology at Hospital La Fe, Valencia, from 1993 to 1997. Dr Bosch underwent training in Human Reproduction at the Hospital of the University of Pennsylvania in 1997. In 1999, he earned his doctoral degree with a thesis on the influence of LH on oocyte quality, receiving a "cum laude" qualification from the University of Valencia. He joined the Human Reproduction Unit of the Instituto Valenciano de Infertilidad (IVI) in January 2000. Additionally, in 2008, he obtained a Master's Degree in Research on Health Sciences from the Autonomous University of Barcelona.
Dr Dimitrios Dovas, MD, DFFP

Dr Dimitrios Dovas, MD, DFFP

Dr Dimitrios Dovas, MD, DFFP is an Obstetrician-Gynaecologist, Infertility Specialist, Clinical Director of the Newlife IVF Greece clinic and is responsible for all international patients. He graduated from the Medical School of Aristotle University of Thessaloniki (AUTH). He specialized in Obstetrics and Gynaecology in England. He obtained the Diploma in Family Planning from the London Royal College of Obstetricians and Gynaecogists. He participated in the training of medical students and midwives. He completed his residency in Obstetrics and Gynaecology at the 2nd Obs & Gynae Clinic of AUTH. He is a member of the European Society of Human Reproduction and Embryology (ESHRE) and the American Society of Reproductive Medicine (ASRM), has lectured in many international conferences, and published a large number of articles in scientific journals. Dr Dovas serves on international advisory boards for the pharmaceutical industry.
Dr Kristýna Frühaufová, PhD.

Dr Kristýna Frühaufová, PhD.

Dr Kristýna Frühaufová, PhD serves as the Head Physician at GYNEM Fertility Clinic. She was born in Prague, she graduated from the 1st Faculty of Medicine of Charles University in 2005. Dr Frühaufová obtained certification in Gynaecology and Obstetrics in 2012 and defended her dissertation in experimental surgery in 2014. She has worked at the Gynaecology and Obstetrics Department of Hradec Králové Faculty Hospital and later in Prague. Since 2013, her focus has been exclusively on assisted reproduction. In 2022, she received certification in Reproductive Medicine. Dr Frühaufová has authored and co-authored numerous domestic and internationally acclaimed publications. She actively participates in Czech and international conferences and is deeply engaged in oncofertility research. She is known for her personalized approach to patient care and, in her leisure time, enjoys spending time with her family and pursuing her favorite sports: running, cycling, yoga, and skiing. She speaks German, English, French and Czech.
Event Moderator
Professor Alan Thornhill

Professor Alan Thornhill

Professor Alan Thornhill is a fertility expert with over 25 years of experience and more than 100 scientific publications in IVF. Specifically, he’s a clinical scientist (specialising in embryology and genetics). Uniquely, he’s worked in IVF and diagnostic laboratories, research, clinical and business management, and even with the UK’s fertility regulator. Working in US and UK-based IVF clinics and consulting globally, he’s been involved in the IVF journeys of thousands of couples (both professionally and personally). He’s helped and advised patients, friends and strangers with issues including low sperm count, sperm and egg donation, genetic testing, surrogacy, treatment overseas and more. He currently works in the biotech industry, and his personal mission is to provide his unique brand of fertility coaching to people in need of help.
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