“FORTY
IS THE NEW
THIRTY,” RIGHT?
by MARGO R. FLUKER, MD, FRCSC
Co-director, Genesis Fertility Centre
It’s a sign of our times: fit, healthy, fabulous-looking women
in their forties and even in their fifties. And some of them
are pushing baby strollers. How do they do it? The baby part,
I mean.
REALITY CHECK
The average age of a woman giving birth in Canada is now 30
years, and has been rising steadily for decades. Almost one in
five births occur in women 35 years or older. That is nearly
four times more frequently than a generation ago.
Women today have access to options that their mothers and
grandmothers didn’t have. We can control our fertility. We
have access to effective, reversible forms of birth control. We
can delay childbearing to pursue educational and career
goals. However, this comes with a price in terms of our fertility. The pronounced age-related decline in fertility means that
most women lose their ability to become pregnant in their
early to mid-forties. This is often the stage where we start to
feel settled financially, socially and emotionally. For many of
us, the “right” time to start focusing on having a family is the
same time that our fertility is ending.
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Creating Families • FALL / AUTOMNE 2008
AGE MATTERS
As women, we’re born with a limited number of eggs, and
we spend them. We spend some of them every single
month, from the time we’re born until the time we go
through the menopause, typically in our early fifties.
Our ovaries constantly select follicles (the tiny fluid-filled
sacs that contain immature eggs) out of the resting stage.
In our teens and twenties, a few dozen immature eggs may
start to grow each month in order for one to mature and
ovulate. In contrast, in our early forties, only a few eggs
remain to start growing each month. The eggs that don’t
ovulate in a given month will disintegrate. This process
continues even when we’re pregnant or on the birth control pill. It is inevitable and irreversible. Fertility specialists
refer to the eggs that remain in our ovaries as our “ovarian
reserve.” The progressive, yearly decrease in the number
of eggs is known as the “age-related decline in ovarian
reserve.”
Although each woman is slightly different, we can’t slow
the process down, and there are no medications that will
let us put the process on “pause” to save eggs for later.
There are, however, many factors
that will speed up ovarian aging, such as:
• cigarette smoking
• chemotherapy
• radiation to the pelvis
• extensive ovarian surgery
• family history of early menopause
• diagnosis of premature ovarian failure
(1% of women under 40 years)
Most of these are not under our direct control, with one
exception – cigarette smoking.
QUALITY VERSUS QUANTITY
The age-related decline in ovarian reserve usually involves
a steady decrease in both the number and quality of the
eggs that remain in our ovaries. It is estimated that a 38year-old woman has only 10% of her eggs remaining.
From that point onward, the progressive yearly decline in
a woman’s fertility will start to become one of the biggest
factors in her ability to conceive.
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SO, HOW OLD ARE MY EGGS, ANYWAY?
The easy answer is that our eggs are as old as we are. No
matter how well we’ve taken care of ourselves, we never
get any younger, and neither do our eggs.
However, some women’s egg quality or egg quantity
declines much earlier than expected. This is a difficult
problem to assess because we can’t actually see the eggs to
evaluate them, except during a cycle of in vitro fertilization (IVF).
Figure 1. Pregnancy and Miscarriage vs. Age in Healthy and Fertile Women
Once we’re in our forties, only a few eggs can start to grow
each month. Those remaining eggs are of lower quality
than in our teens and twenties. It is harder to get them to
ovulate, to fertilize, to implant and to grow normally. This
translates into lower pregnancy rates, higher miscarriage
rates, and a higher risk of chromosomal abnormalities in
the few babies that are born to mothers at this age.
Fertility specialists worry about declining
ovarian reserve in the following situations:
• a high FSH level (follicle stimulating hormone)
on menstrual cycle day 3
• a low antral follicle count on ultrasound
(the follicles that have been selected in a
given month, see figure 3)
• low numbers of follicles developing
in response to injectable fertility medications
• IVF cycle that produces few eggs, or low quality
eggs or embryos
At some point, fertility medications become ineffective,
because the ovaries can no longer select more than one
egg at a time, or because the quality is too low.
TOP TEN MISCONCEPTIONS
ABOUT AGE AND INFERTILITY
40 is the new 30.
Everyone says I look great for my age.
I know lots of women who got pregnant in their 40s.
I can’t be infertile. I had a baby 5 years ago.
I come from a very fertile family. My grandmother
had her 9th child when she was 45.
I’ve been on the birth control pill for years, so I’ve
been saving my eggs
I exercise regularly and I take good care of myself.
When I decide to get pregnant, I know it will happen.
I had a miscarriage 2 years ago, when I was 43, so I
know I can get pregnant. There must be something
wrong with my uterus that prevents me from staying
pregnant.
If _________ did it, so can I. (fill in the name of your
favorite 40+ pregnant movie star)
I’m too young to go through the menopause.
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Creating Families • FALL / AUTOMNE 2008
Figure 2. Predicted FSH Levels on Menstrual Cycle Day-3 Versus Age
Day 3 FSH level. FSH levels rise progressively in the last
decade prior to menopause (see Figure 2). Depending on
the individual lab and fertility clinic, levels greater than
10-12 IU/L usually indicate decreased ovarian reserve.
FSH levels can fluctuate markedly from one month to the
next, so one normal level does not guarantee a normal
ovarian reserve. In contrast, one abnormal level is usually
a sign of decreased ovarian reserve. Once FSH levels are
consistently above 12-15 IU/L, the peri-menopausal stage
is usually approaching.
Antral follicle count. This is not a regular pelvic ultrasound from a local ultrasound facility looking for an
abnormality in your uterus or ovaries. Instead, it’s a vaginal ultrasound done by a fertility specialist. The goal is to
count the number of immature (antral) follicles that have
been selected out of the resting stage that month.
This test helps your fertility specialist predict whether your
ovaries will respond to the injectable fertility medications
that are used in an IVF cycle. As a rough rule, perhaps
half of the antral follicles will grow in response to the
injectable medications. However, each mature follicle
won’t necessarily contain an egg. For example, 10 antral
follicles in one ovary might produce five growing follicles,
from which four eggs might be available for IVF.
WILL USING FERTILITY DRUGS
MAKE ME RUN OUT OF EGGS FASTER?
Good question. Thankfully, the answer is no. In a normal
menstrual cycle, our ovaries pick several eggs out of the
resting stage, but only one will be chosen to ovulate. The
rest will disintegrate and be reabsorbed. With fertility
medications, we try to encourage several of those immature eggs to grow. We’re actually making better use of the
ones that were recruited, rather than letting so many disintegrate.
Figure 3. Antral Follicle Count
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However, the number of eggs recruited will
depend on how many remain in the ovaries.
The older we are, the lower the number of
eggs that can begin growing each month, and
the fewer that will respond to fertility medications (see Figure 3).
THE GUILT TRIP
“Why didn’t someone tell me?”
“If only I’d known …”
“Why don’t they teach girls about
this in high school?”
Comments like these are heard all too often in
an infertility specialist’s office. None of us can
turn the clock back, but we can be proactive
about seeking treatment, and about spreading
the message. Each of us can help to raise
awareness about age and infertility by talking
about it to friends, relatives and co-workers.
ADVICE FROM A FERTILITY EXPERT
If you’re trying to conceive, be proactive. See
your family physician or gynecologist to talk
about your general health, your risk factors for
infertility, and how long you should try before
you start to undergo infertility testing.
Early testing and/or referral to a fertility specialist may be appropriate if you or your partner have any of the following infertility risk
factors:
• Irregular or absent periods
• History of IUCD use (especially if
it was removed for pain or bleeding)
• History of endometriosis
• History of ovarian or tubal surgery,
or extensive abdominal/pelvic surgery
• History of pelvic or genital infection
(either partner)
• History of sexually transmitted disease
(either partner)
• History of prostate infection (male)
• History of undescended testicles
or bilateral hernia repairs in
childhood (male)
• History of vasectomy or tubal ligation
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Creating Families • FALL / AUTOMNE 2008
The easy answer is
that our eggs are as old
as we are. No matter
how well we’ve taken
care of ourselves,
we never get any
younger, and neither
do our eggs.
If you don’t have any risk factors for
infertility, these are some general
guidelines for when to start
infertility testing:
• Women under 35 years:
after 12 months of trying
• Women 35-39 years:
after 6-12 months of trying
• Women over 39 years:
after 3-6 months of trying
• Women or men with a history
of infertility risk factors: start
testing sooner
and antral follicle count) can help to
identify women with reduced ovarian
reserve. In such cases, the ovaries are
unlikely to produce a reasonable
number of eggs, and those women
are unlikely to be successful with procedures such as IVF.
If you’re over 40, or find that you
have limited ovarian reserve, ask
yourself (and your partner) if you are
willing to consider alternatives, such
as donor eggs, adoption
and child-free living.
A FEW GOOD EGGS …
Egg donation is a variation of IVF for
women who have difficulty achieving
a healthy pregnancy with their own
eggs. You may be a candidate for egg
donation if you:
• have low ovarian reserve
• have gone through
an early menopause
• have had your ovaries removed
• have not had good egg
or embryo quality during
previous IVF attempts
WHAT CAN TECHNOLOGY DO?
Advanced technologies such as IVF
are the final treatment option when
all other simpler efforts have been
unsuccessful. Although complex and
expensive, these treatments usually
offer the best chance of pregnancy.
However, the success of IVF depends
on stimulating a woman’s ovaries to
produce several eggs at a time. From
those, a few top quality embryos are
chosen to replace in her uterus.
Ovarian reserve testing (day 3 FSH
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The woman who donates her eggs must be a healthy
young woman (usually under 35 years) who undergoes
extensive screening for medical, genetic and infectious
disorders. After using injectable fertility medications, several eggs would likely be taken from her ovaries, and then
fertilized using your partner’s sperm (or a donor sperm
sample).
REMEMBER …
For some women, the diagnosis of decreasing ovarian
reserve finally provides some answers for previously “unexplained” infertility. However, it’s also devastating news
that often aggravates the sadness and grief they already
feel from their struggle with infertility. Feelings of anger,
denial, guilt and loneliness are common.
To be a recipient of donor eggs, you must have a normal
uterus, and be healthy enough to expect that you could
safely carry a pregnancy (usually under 51 years). One or
two top quality embryos would typically be replaced in
your uterus. Depending on the stage and quality of the
embryos, most fertility programs anticipate delivery rates
of 50% or more in such circumstances.
• Remember that you’re not alone in this journey,
although it may feel like it sometimes. Infertility affects
about one in six couples overall, and at least half of all
women over 40 who are trying to conceive.
• Remember to be proactive about seeking evaluation
and treatment, and about spreading the message to
others about the effects of age and infertility.
• Remember that the age-related decline in fertility is
the factor that infertility specialists may not be able
to overcome. Although it’s not easy to move beyond
the dream of having your own genetic children, other
options are available, including donor eggs, adoption
and child-free living. Being infertile doesn’t mean that
you can’t be a parent in some way.
Figure 4. Livebirth Rates in IVF Cycles Using a Woman’s Own
Eggs Versus Donor Eggs (US-IVF Registry, 2005)
In Canada, we can only accept altruistic, or volunteer
donors. These are friends or family members who are not
being paid for their participation, and with whom you are
comfortable sharing this experience. Some women find it
necessary or preferable to search for an anonymous
donor, a woman who is recruited, screened and paid by a
fertility clinic, often in the US. This adds to the cost and
complexity of the process, but may make egg donation
available to women who don’t know a suitable volunteer
donor.
These are not easy choices to make, and not ones to make
alone. In addition to your personal support network, the
doctors, nurses and counselors at fertility clinics will help
you examine these issues.
• Lastly, remember to seek support from your partner,
your friends and family, the various members of your
health care team, the network of professional infertility
counselors, and support groups such as IAAC. We are
here to help.
About the author
Dr. Margo Fluker is the co-founder and co-director
of Genesis Fertility Centre in Vancouver. She has
published dozens of research papers, textbook
chapters and national guidelines in the areas of
reproductive endocrinology and infertility, premature
ovarian failure, and age-related infertility. While
nurturing Genesis through its growth into one of
Canada’s largest and most successful IVF programs,
she has also taken responsibility for the Centre’s
donor egg program. She is passionate about her work
at the clinic, adventure travel, and any activities that
take her outdoors.
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