Medicosnext
Words by Dr Neha Homagai
The journey to pregnancy after 40 involves understanding the limitations of a woman’s egg reserve. As the number and quality decline, assisted reproductive technologies like IVF become essential for those aspiring to become mothers.
Pregnancy after 40 is not only possible but often requires advanced fertility treatments like IVF. Comprehensive evaluations of both partners, empathetic counselling, and informed choices can make this journey more accessible and successful.
If you’re a female and over 40 years of age, the chances are thoughts of menopause has crossed your mind. The advent of menopause brings with it a host of associated changes in the body, including the ability to get pregnant naturally. While several women are gradually making conscious decisions to go childless, it is worthwhile to know what to expect from your body at 40.
Women are born with a limited egg reserve
At the time of birth, ovaries are laden with over one million immature eggs. By the time puberty is reached, the number of eggs decrease and about only 300,000 remain. One egg matures every month in the ovary and is released during ovulation, and a number of eggs may also get destroyed. Starting mid-thirties, the rate of deterioration of eggs increases manifold, compromising their quality and quantity. Over 50% of the remaining eggs become genetically abnormal once women hit 40. With an already depleted pool of viable eggs, such aberrations make pregnancy difficult.
Egg reserve testing is a crucial step for women over 40 considering IVF. From hormone levels to sonography, evaluating the ovarian reserve guides the choice between self or donor eggs, paving the way for successful assisted reproduction.
Menopause is the cessation of the menstrual cycle in women due to a loss in the activity of the ovary. Monthly menstruation, thus, does not take place. Menopause primarily occurs between the ages of 45 to 55, with the average age being 51 years. It sets in with pre-menopause and perimenopause stages wherein regular or irregular menstruation still takes place, and are marked with certain hormonal changes. For instance, hormones oestrogen and progesterone go down, and there is a marked increase in the follicle stimulating hormone (FSH) and luteinising hormone (LH) – all tell-tale signs of menopause.
Pregnancy after 40 is possible
A normal pregnancy can be attained after the age of 40, however, the chance is limited due to the number of eggs available and their condition. For women who are unable to conceive naturally, but ardently aspire to become mothers, assisted reproductive technology (ART) is a boon. In vitro fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) are ART techniques used. Proper and empathetic counselling from the right specialists can help put aspiring parents’ minds at ease. Both the female and male partners are evaluated for their fertility, and the best treatment options are then explained.
What should you know?
- Egg Reserve Testing
For women over 40, egg reserve testing is imperative and based on the result, ART treatments are suggested. This test is done in two steps – through blood test and sonography. The levels of the hormones FSH and anti Mullerian hormone (AMH) are checked via the blood test. Typically, the AMH level should be in the range of 2.5 to 4 ng/mL, subject to the follicles available. A reading of less than 2 ng/mL of AMH in addition to high FSH levels suggest that the egg reserve is less. A sonography checks for the number of follicles present. If follicles are under 5mm in size (called antral or Graafian follicles) and are less than 5 in number per ovary, the reserve is again said to be small.
- Know about self vs donor eggs
The results of egg reserve testing can either relay the information that there are enough suitable eggs to carry out ART or that there are none. If the reserve is significant, the woman is administered hormonal injections for 10-12 days during which the eggs develop. They are collected by a method called ovum pickup, fertilised with the sperm of the husband, and the selected embryo is transferred into the uterus.
However, if the reserve is empty, or embryos fail to form, donor eggs may be used with the patient’s consent and required documentation. The remaining procedures are the same in both cases.
- Understand that there can be complications
The incidence of congenital genetic disorders in children is higher in pregnancies at later ages. It is, thus, important that embryos produced through IVF are checked for genetic anomalies through a process called pre-implantation genetic testing (or PGT). The embryo biopsy is taken and is karyotyped, that is, size and number of chromosomes are checked. This helps eliminate embryos exhibiting genetic make up for conditions like Down’s syndrome, Edward syndrome, Patau syndrome, and others.
Pregnancies after 40 are considered high risk since problems may arise in the mother during the term.
- Hyperemesis gravidarum: severe vomiting and nausea.
- Placenta previa: the placenta partially or completely covers the opening of the birth canal (cervix); this leads to bleeding during the latter part of pregnancy.
- Gestational diabetes: high levels of sugar during pregnancy.
- Pregnancy-induced hypertension (PIH): high blood pressure during pregnancy; can cause pre-eclampsia which can be fatal for both the mother and the child.
- Postpartum haemorrhage (PPH): heavy bleeding after delivery, causing a drop in blood pressure.
- Pregnancy after menopause
Pregnancy post-menopause can be achieved with ART interventions, albeit this not the norm and only done in rare cases. Hormonal tablets are given for two to three months to prepare the uterus (that had contracted due to menopause) and menstruation is allowed to resume. Due to the absence of one’s own eggs, only donor eggs are used in such a procedure. It must also be noted here that many countries have established an age upper limit for ART procedures beyond which they are illegal.
- But first, take care of yourself
After the age of 40, a number of diseases may ail women such as diabetes, hypertension, thyroid, and obesity. These must be checked by respective physicians and endocrinologists, and brought under control before coming in for IVF treatment. A balanced diet and regular exercise helps and must be incorporated into the daily schedule. A healthy pregnancy can only begin by first ensuring a healthy self.
