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IVF & fertility treatment for women over 40 – what are your chances?

Esther Marbán, MD
Gynecologist & Fertility Specialist , Clinica Tambre

Category:
Advanced Maternal Age, Donor Eggs, Embryo donation, IVF Abroad

IVF & FERTILITY TREATMENT FOR WOMEN OVER 40S-Tambre-500th
From this video you will find out:
  • What is the advanced maternal age definition, and is it more challenging for women over 40 to conceive naturally?
  • What are the potential consequences or risks associated with advanced maternal age for both the mother and the baby during pregnancy and childbirth?
  • What are the key factors influencing IVF success rates for women in this age group, and how their chances be maximized?
  • When is egg donation recommended for women over 40, and what are the benefits and potential challenges associated with this option?

IVF & fertility treatment for women over 40 – what are your chances?

During this milestone session, our 500th webinar, we’ve discussed IVF and fertility treatments for women over 40. Dr Esther Marban, Fertility Expert at Clinica Tambre, Spain, shared her invaluable insights and expertise on this crucial topic as well as answered the most interesting questions.

Understanding Advanced Maternal Age

Advanced Maternal Age is typically defined as getting pregnant at 35 years old or older. We know that at this age, older patients may have decreased egg quality and reduced ovarian reserve, and it all happens when age increases. Apart from that, we know that age may increase the chance of carrying a baby with chromosomal disorders, such as Down syndrome.

In addition, it’s also important to note that age is related to increased fetal risks, such as miscarriage, stillbirth, and abnormal growth, and maternal risks such as high blood pressure, diabetes, and premature birth. These risks are even higher in twin pregnancies, so that’s something that we should consider.

It’s also important to see how increased maternal age can have an impact on the chance of having healthy embryos. In this slide, you can see how maternal age affects the percentage of euploid (genetically normal) embryos we expect in the laboratory. It also has an effect on the miscarriage rate and live birth. You can see how live birth starts decreasing as the miscarriage rate increases and the number of euploid embryos also decreases.

Treatment options for Advanced Maternal Age

We mentioned that Advanced Maternal Age may have consequences, and now we are going to talk about the potential treatments and the different options we can offer to our patients. The first one, which is the most common one, is the in vitro fertilization (IVF) treatment. How does it work? Normally, the treatment starts by stimulating the ovaries using medication to encourage them to work as much as possible. In more than 90% of the treatments, we prefer using the ICSI (Intracytoplasmic Sperm Injection) technique, where a single sperm cell is injected into the cytoplasm of a mature egg. This technique helps ensure successful fertilization.

There are different stages of embryonic development. The first stage shows the signs of fertilization, and as the days progress, you can observe cell division and embryo quality. It’s important to perform single embryo transfer at the blastocyst stage to reduce the risks associated with multiple pregnancies. We always avoid transferring embryos on day two or day three, as the chances of successful implantation are higher with blastocysts.

If you’re considering adding pre-implantation genetic testing (PGT), it’s essential to understand that it may not be suitable for all patients. This discussion pertains to a particular group of patients: those facing advanced maternal age. In this group, there’s an elevated risk of non-implantation due to factors related to the embryos.

Egg Donation: a promising solution

When the initial stage of the treatment proves ineffective or a patient experiences multiple failed attempts, alternative options, such as egg donation, should be considered. The World Health Organization (WHO) defined egg donation as a fertility treatment designed for women unable to produce their own eggs or at high risk of transmitting genetic diseases.

The main indications for egg donation include premature ovarian failure, where the patient no longer menstruates, making egg donation the ideal solution. Additionally, many patients with failed IVF treatments, often linked to low-quality and low-quantity eggs, are primarily caused by age-related factors. Other cases may involve problems that pre-implantation genetic screening cannot diagnose, making egg donation a viable option.

The egg donation process comprises two key components: the donor’s contribution and the steps undertaken by the recipient patient. The donor undergoes ovarian stimulation, similar to that experienced by the patient. The selection of a suitable donor involves two steps, beginning with a consideration of general characteristics, followed by facial biometry using a computer program called Fenomatch.

It’s crucial to recognize that egg donation in Spain is always anonymous. Patients are unable to select specific donor characteristics, and both the donor and the recipient remain unknown to each other. The recipient patient prepares her uterus for the embryo transfer following the donor’s ovarian stimulation. Embryos are created in the laboratory, similar to traditional IVF, with the key distinction being the ovarian preparation by the patient to optimize her uterine conditions. After this preparation, the embryo transfer follows the same process as traditional IVF.

In terms of success rates, it’s crucial to understand the differences. While the implantation rate with the patient’s own eggs decreases with age, the egg donation treatment maintains a consistent pregnancy rate and implantation rate, regardless of age.

It’s essential to consider that although the implantation rate remains consistent with donor eggs, the associated pregnancy risks could increase with the patient’s age. Pregnancy in one’s 40s is different from pregnancy at almost 50, and age-related risks must be taken into account.

Concluding thoughts

The cumulative implantation rate increases as the patient undergoes more embryo transfers. In conclusion, a precise diagnosis and specific tests are essential for a correct assessment. While age is a contributing factor, it’s not the sole determinant, and other factors need examination. Both male and female factors should be evaluated. For advanced maternal-age patients, IVF combined with pre-implantation genetic testing can enhance the implantation rate, reduce miscarriage rates, and expedite the path to pregnancy. Egg donation may serve as a solution for many patients following previous failed attempts attributed to age, low ovarian reserve, or poor egg quality. In advanced maternal age cases, it’s advisable to opt for a selective single embryo transfer to minimize risks during pregnancy, especially in egg donation treatments.

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- Questions and Answers

I’m 49, about to do my 5th donor IVF cycle with the 3rd donor. The first cycle resulted in a chemical pregnancy. My BMI was over 30 for all cycles. The cycle will include an ERA test. Would you recommend a hysteroscopy at the same time as the ERA test? I am on medication for hypothyroidism and have one ovary and blocked fallopian tubes. I have gone through menopause but have been on progesterone for 3 months. Any advice you can give to increase the odds of success?

In this case, it’s a complicated scenario. A hysteroscopy or a three-dimensional scan to assess the uterine cavity is recommended in addition to the ERA test. Further tests such as endometrial and immunological assessments like ANA and APA should be considered. Egg donation may offer a solution, given the challenges faced in previous attempts. Consultation with an immunologist can help identify potential clotting or immune system factors. Checking sperm quality is essential, and pre-implantation genetic screening on embryos is an option to explore. After several failed attempts, comprehensive examinations are advisable.

None of the embryos were tested in my donor cycles. I have two 6BB embryos left. Would they be considered good to transfer?

Yes, 6BB embryos are of good quality. It is expected that at least one of them is healthy, as the chances of having healthy embryos with egg donors are generally high. However, embryo viability can only be confirmed by testing them.  

I would like to know about immunological treatments for elevated NK cells and cytotoxic cells. What is your opinion? Is it complementary to use them with Cyclosporin?

At our clinic, we don’t use Cyclosporin in these treatments. Our immunologist typically uses treatments like prednisone, hydroxychloroquine, and heparin. The choice of treatment depends on the specific case and the immunologist’s recommendation.  

I’m 45 and just did my 3rd IVF cycle with donor eggs, which all failed to implant. No PGT-A was done on any of the embryos. I have had children in the past and had comprehensive screening tests. My doctor doesn’t know why the embryos are not implanting. Would you recommend picking a new donor using a fresh cycle instead of frozen eggs?

The implantation rate with frozen eggs is similar to that of fresh eggs. Consider doing PGT-A on the embryos, especially given the previous failed attempts. Comprehensive uterine and immunological assessments are essential, but embryo testing is also crucial.

I’m 44, with an AMH of 0.07. My clinic is not advising IVF. Anything you can advise?

With an AMH of 0.07 and at the age of 44, the chances of success with IVF using your own eggs are not very high. You can try, but it’s important to understand the limitations. Considering alternative options like egg donation may be advisable.  

Is fresh embryo transfer better than frozen?

The pregnancy success rates with fresh and frozen embryos are nearly the same. At our clinic, we typically freeze embryos in advance, as it’s more convenient and the results are comparable.  

I’m 44, without health conditions and have an AMH of 0.216. My husband’s analysis came out good. My doctor recommends transferring at least 2 embryos on day 3. Is this a better approach?

Transferring embryos on day 3 does not provide enough information for embryo selection. It’s better to wait for two more days and transfer on day 5 at the blastocyst stage, which allows better embryo assessment. Consider comprehensive testing for a more informed decision.  

Do you have a genetic laboratory to provide PGT results for transferring on day 6?

It is possible to perform a biopsy on day five and transfer on day 6 (24-hour PGT). While this may not be the preferred choice due to the potential impact on the implantation window, it can be done if requested.  
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Endometrial factor and recurrent failures in IVF: diagnosis and treatment
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Authors
Esther Marbán, MD

Esther Marbán, MD

Dr Esther Marbán has been part of Clínica Tambre’s medical team since 2010. She is a gynaecologist specialized in Human Reproduction with a brilliant academic career. In fact, she obtained a special honourable mention in her Master’s Degree in Human Reproduction that she completed during 2009-2010 (organised jointly by the Spanish Fertility Society and the Faculty of Medicine of the Complutense University of Madrid). Dr Marbán is known for her restless and proactive personality and her innate talent for empathizing with people which she proves every day by working with patients.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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