Over 35 and trying to conceive? The passing of years can mean reduced fertility. And with the approach of menopause, the window of opportunity gets smaller. As part of National Infertility Awareness Week, WebMD joined with RESOLVE: The National Infertility Association, to host the Trying to Conceive Cyber Conference. Paul Gindoff, MD, joined us to discuss the special concerns of coming late to motherhood.
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The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome, Dr. Gindoff. Thanks for being our guest today.
Gindoff: Thank you, and it's a pleasure to be here.
Member: I am trying to conceive and I am 47 years old. Am I dreaming or what? I've been on 50 mg Clomid for five months now and nothing. I've done the blue ink test to see if I am blocked and I am not. My doctor tells me I am ovulating; had the test done there, too. So what's next? What am I doing wrong? It's not like I haven't had kids -- I have three.
Gindoff: Fertility does change with age and despite the excellent fertility you have had in the past, at age 47 the prognosis is quite different. It's highly unlikely to conceive now. The only option that would be recommended now is donor egg.
Member: I'm 37 and have had very regular cycles until about three months ago, coinciding with an elevated FSH level of 19.1 (up from 5.9 two months prior). I'm really worried now that I'm starting perimenopause.
Gindoff: I think that's a reasonable concern. FSH levels above 15 are associated with declining fertility. And it's reasonable to suspect that perimenopause may have begun, particularly if your age is around 40.
Member: Is it true that after 35, each month you only have a 10% chance of conceiving?
Gindoff: In general, the chance of conceiving is approximately 15-20% in women in their third decade of life. It does drop significantly after age 35.
Member: I'm 35. After five months of trying to conceive we got pregnant and then miscarried. It's been four more months of trying (BBT, CM, ovulation tests, etc.) but I'm still not pregnant. How long should we wait before we see a specialist?
Gindoff: Usually between 10 and 12 months would be a pretty good standard before seeking an evaluation for secondary infertility.
Member: Is there anything we can do to improve egg quality?
Gindoff: Egg quality is programmed and genetically imprinted. A person is born with her full compliment of eggs. Quality cannot be improved, but quality can be decreased by disease and environmental hazards.
Member: We have several over-35 members on the board who ovulate regularly. Are our treatments the same as for non-ovulatory women? And are the outcomes similar?
Gindoff: To answer this I would have to know specifics. Ovulation is one major factor in terms of fertility treatments. However, when you prognosticate for a couple, one has to be aware of all the parameters that affect fertility for both the male and female partner.
Gindoff: In general, the success for IVF is based on the age of the patient. And in this particular situation one has to be concerned about egg quality because of the PCOS disease. The male factor should not play into overall success as long as sperm injection is utilized.
Member: If you are over 40, does IVF work or should you stick with IUI?
Gindoff: Well, national medical societies involved in fertility treatments do recommend IVF as the first line of treatment in women over 40.
Member: What type of IVF stimulation and suppression protocol works best in your opinion for women with higher FSH (between 8 and 14)? Should the BCP be used prior to stimulants or avoided?
Gindoff: Again, the specific protocol would have to be custom-tailored to the particular details of the case. In general, I would recommend a short protocol over a long one for a patient with a poor prognosis, whether due to advanced age or elevated FSH.
Member: Does PCOS worsen year by year for women in their mid-30s? Does it become harder and harder to become pregnant with or without medications?
Gindoff: PCOS is an interesting problem in the sense that it can self-regulate. It can begin later in reproductive life or even early in reproductive life. It can last for years or actually correct itself. Many times after pregnancy the patient may slip back into a normal menstrual cycle. Age or time of PCOS should not influence prognosis.
Member: How many cycles of IUI, using the husband sperm wash and insemination procedure, is recommended before moving on to more intense ART?
Gindoff: Again, depending on specifics of the couple's problems (male and female factors) one would move to fertility drugs with insemination at this point or to IVF. It depends on the full range of female and male factors:
- Function of the fallopian tubes
- Morphology of the sperm
- FSH level of the female
- Age of the female partner
- Overall reproductive history of the couple
One must look at all these factors in order to recommend the correct next step. Only a qualified fertility specialist would be able to give the appropriate recommendation.
Moderator: So what I think you're saying overall here, is that each case is truly unique and no specific "guidelines" should be taken into consideration over your individual circumstances
Gindoff: To a certain extent. Age is an overriding issue, as are sperm quality and FSH levels. You have at least three major variables that are different in each couple.
Gindoff: This observation is rather unique and might suggest some immune problems. But concerning implantation and early miscarriage, it's pure speculation that there is any cause and effect.
Member: I am about to turn 34. I have been on birth control pills since I was 18. I probably won't try to conceive for at least two years. Is this a smart move? Is it too risky to wait? And if not, should I go off birth control now and be without them for the next two years until I try to conceive?
Gindoff: In general, the earlier one tries to start a family, the better the prognosis, since age impacts so significantly on fertility potential. However, planning a family must be timed appropriately for one's lifestyle and life goals, and balance in making that decision has to be up to the couple. One can use medical information to guide the couple in when to start a family, but ultimately that decision has so many factors that play in, it can't solely be based on that.
Member: Is there any reason a woman who has decided to go the donor-egg route should try alternative therapies to lower her FSH?
Gindoff: There are no treatments to lower FSH that would lead to successful pregnancy.
Member: What is the success rate of someone who is over 40, perimenopausal, and only will try naturally?
Gindoff: If the patient is truly perimenopausal the prognosis is poor and risky for miscarriage.
Member: I am trying to conceive for the first time at the ripe age of 48. My ob-gyn says it's possible. Any suggestions?
Gindoff: It is quite possible and highly successful if one uses donor eggs to conceive after the age of 45.
Member: I'm doing acupuncture and Chinese herbs in preparation for a fourth IVF. I'm almost 44 and we have no issues except egg age (FSH is 5). I got pregnant with two of the IVFs and miscarried early. One of the goals of the acupuncture and herbs seems to be changing my period length and volume and color and even cycle length (from 26 to 28 days) and smoothing my BBT curve! The color and volume have already gotten better (more like the past). What do you think of those goals and the potential of these changes?
Gindoff: Alternative medicine has a role in adjunct care. The problem that exists is we don't have controlled case studies or prospective data to evaluate efficacy of these adjuncts. Therefore, one must be cautious in recommending any of these modalities. In my experience, acupuncture is safe. However, Chinese herbs, depending on which they are, can have profound impact both negative and positive.
Member: What type of IVF stimulation and suppression protocol works best in your opinion for women 37 years of age with normal FSH, etc., but with PCOS?
Gindoff: With PCOS you have concern about egg quality. It's important to use a suppression protocol, accomplished by using GnRH analogs, birth control pills, or GnRH antagonists.
Member: Is it common for an older woman to use a donor egg from a younger relative such as a sister so the genes would be more similar to the woman's?
Gindoff: You can do that. We have done that where sisters donate eggs to each other. That's called directed donation. The majority of egg donation, though, is anonymous. Success rate, though, is determined by the age of the donor and her fertility history. Directed donation might or might not enhance fertility, depending on who the actual donor is.
Member: My sister got pregnant with her first baby at 37 and my aunt got pregnant with her third at the age of 49 without the use of donor eggs. Is late conception at all related to genetics?
Gindoff: We do know the onset of menopause is genetically related or inherited. So if your mother had an early menopause, you more likely will have an early menopause, too, and vice versa. Indirectly there may be a relationship, but it's not been published or evaluated.
Member: If I was tested for the TNP anticardilipin, Lupus anticoag and DRVVT and it was within the range (not positive), does this mean the immunity factor isn't an issue for me? Or, are there other immunity issues I could check out? I'm 42, and had four miscarriages.
Gindoff: Those are the most important; however, we have documented that many women have negative blood test results when they are not pregnant. Once they are pregnant, the antibodies become positive, so it's important to check these blood tests when you are pregnant. Baby aspirin is used for these patients.
Member: My wife and I are both 36 and have been trying to get pregnant for the last six to eight months with the help of a fertility calendar but have had no luck. We have an IVF appointment for next month. Could you talk briefly about some low-tech things we can try on our own?
Gindoff: I would keep the appointment. The time frame is correct, if you have tried for a reasonable time, which you have. The diagnostic tests need to be done. You need to find out the particulars between yourself and your wife as evaluated by fertility professional. Good luck to you.
Moderator: Thanks to Paul R. Gindoff, MD, for joining us this hour. For more information on conceiving later in life and other TTC issues, be sure to explore all the fertility info here at WebMD, including our message boards and live chats.
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