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Chapter 14b
The Older Woman

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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This is why the older woman presents a number of unusual personal problems. For one, most women can hear their own biologic clock ticking away loudly, and don't like being reminded about the fact that their age can be a limiting factor in their fertility. Moreover, many of these women are busy executives pursuing a career. They are very used to being successful, and find it difficult to come to terms with their biologic frailty. Because of all the media hype , they expect the assisted reproductive technologies to provide them with a quick answer . However, few reports emphasise that pregnancy rates in older women, even with IVF, are only half of what they are with younger women - so that typically, a woman who is more than 40 years of age has a less than 10 % chance of having a live birth in an IVF cycle. Older women also find it much more difficult to get social support. Society can be both sexist and ageist, and most people feel it is "unnatural" for an older women to want to try to get pregnant.

The major problem for the older woman is that time is at a premium ! She simply cannot afford to waste her precious time on ineffective treatments; and it is better for her to move on to IVF sooner rather than later !

Older women present doctors with many challenging problems. For one, they usually respond poorly to ovarian stimulation, and pregnancy rates with treatment are lower. They also have an increased risk of having a miscarriage - and in women over 41 years of age, this risk can be as much as 50% ! Moreover, as a woman ages, she has an increased risk of having medical problems in her pregnancy , because of preexisting medical problems such as diabetes and hypertension.

An especially thorny issue is the increased risk of birth defects because of aging eggs. As eggs get older, they have an increased risk of harbouring chromosomal errors, and this increases the risk of the baby having a chromosomal error, such as trisomy 21 ( Down syndrome). Most clinics will offer prenatal diagnosis ( such as chorion villus sampling, and amniocentesis ) to these women to screen for birth defects during pregnancy - but since some of these procedures increase the risk of a miscarriage, the couple often find themselves on the horns of a dilemma - and it is hard for them to decide whether to do the test or not to.

What is the oldest age at which an infertility specialist should accept a woman for treatment ? Is there a particular age at which a woman should be denied treatment ? If so, then why ? and what should this age be ? and who should decide ? " Menopausal mums" have grabbed much media attention, and have raised a number of controversies - which still remain unresolved.

Much research is going on to try to increase the pregnancy rates after IVF in older women. One high tech option is to screen the embryos for aneuploidy ( an abnormality in chromosomal number) using FISH ( fluorescent in situ hybridisation) for preimplantation genetic diagnosis, a technique in which embryos are biopsied and their chromosomes analysed using probes. If only chromosomally normal , healthy embryos are transferred back, then researchers feel that embryo implantation rates and pregnancy rates will be higher. Another option is assisted zona hatching, using chemicals or a laser, to create an opening in the zona ( shell ) of the embryo. Scientists feel that this technique can allow the embryo to " hatch " and thus escape from the zone and implant into the uterine lining more easily. However, the clinical benefit of these procedures is still unclear.

For older woman with a persistently poor ovarian response, many options have been explored to try to improve the number of eggs produced. This includes using supplemental growth hormone ; and the newer recombinant gonadotropins.. However, the results of these have been disappointing, and the fact remains that we do not have an effective method of helping poor ovarian responders.

A very effective option for older woman whose own eggs do not grow well is that of using donor eggs or donor embryos. However, this is obviously a very sensitive emotional issue, and each couple needs to make their own decision. While using donor eggs and embryos does dramatically improve pregnancy rates, it is often an option many couples find hard to come to terms with. It is also becoming increasingly difficult to find suitable egg donors. While egg donation has become commercialised in USA, this has raised a lot of hue and cry, because critics feel that young women are being enticed to "sell their eggs". Finding altruistic egg donors is an uphill task for most women, because they are often very reluctant to ask for help , since this would involve telling others about their problem. Support groups like NEEDS ( National Egg and Embryo Donation Society) in the UK have been very helpful in motivating voluntary egg donors by creating public awareness of the need for healthy young women to donate their eggs. Clinics have also adopted various approaches to help resolve this problem . Some large clinics run successful anonymous egg donation programs; others use known egg donors ( either paid or unpaid); and others encourage their patients to share their supernumerary eggs ( often for a financial consideration) with other patients.

An exciting option for the future may be that of egg banking . A lot of research is being focussed on developing more efficient methods to cryopreserve and store eggs. If this becomes clinically practicable, then it may become possible to freeze a woman's eggs or ovarian tissue when she is young, and store these for her in liquid nitrogen at -196 C, so that she can use her own "young" eggs in the future, whenever she decides to start her family !

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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