IVF for women over 40 – Isn’t it just a matter of comparing IVF clinics based on their statistics? No. Different clinics have different patient groups and that feeds into their numbers. You are not comparing apples with apples. A clinic whose median patient age is 43 is going to have very different pregnancy rates to one whose median patient age is 35.
The published pregnancy statistics depend not only upon who you treat but how they are expressed. A lot of women who start fertility treatment do not make it to the finish on a first attempt. Yet pregnancy rates based upon a successful embryo transfer instead of cycle start are the norm. That is not what a 40 year old is interested in because women in their 40’s do not all get to the embryo transfer stage. A 40 year old is really interested in how many cycle starts resulted in live births at a particular clinic. The number is going to be lower and lower still if the median patient age is higher. That higher age patient group is her cohort.
So published rates of IVF clinics are really meaningless on their own if you cannot get information on the clinic’s median patient age and statistics for cycle starts.
Bigger is not necessarily better. It might mean the exact opposite for a 40 year old. A good clinic for a 30 year old is not necessarily a good clinic for a 40 year old.
Streamlining practices do achieve better efficiency and cost savings and even perhaps better pregnancy odds for the majority of the patients but this may not serve older patients. That depends upon whether care can be individualized because making exceptions is a costly business. It is the opposite of streamlining protocols. If individualized care is not done, meaning protocols are not adapted for the older patient, then you may find yourself being treated as if you were a decade younger and living up to your poor prognosis.
IVF for a 40 year old is a completely different story. 40 year olds are typically poor prognosis patients with very high FSH or very low AMH which typically means they are less likely to produce eggs and embryos. This means their treatment protocols need to be tailored to better their pregnancy chances.
In fact some IVF clinics worldwide will not treat you if you are 42 or 43 and so clinics may have little experience in treating women in the older age group. You do not want to be at a clinic which is only familiar with patients having far better pregnancy chances.
Test numbers are also different and relative to age. So an elevated FSH for a 30 something year old may be slightly challenging but for a forty year old it may be really ominous. You want care based upon test results that take account of your age. And while your doctor may be alive to the differences due to their training, other employees at the clinic may not be as aware because it is not something they routinely come across. That can matter. Often test results are left to others to convey to patients and crucial decisions as to next steps, such as how many embryos to implant, needs to be based upon individualized advice for the older patient.
So you want to do your treatment at a clinic which deals with the tip of the iceberg in terms of age and fertility severity. Those clinics are more likely to adapt their protocols and be very motivated to consider how protocols adopted universally for the general population fare in the poor prognosis group. They are more likely to scrutinize any new protocol which has only worked in a younger patient cohort because that is not their typical patient.
Ask what the median age at the clinic is? If it is low 30’s, high 30’s or early 40’s. Obviously you may not be lucky enough to have a clinic in your area that serves the oldest patient population but the older the better. Of course if your IVF clinic has an age limit, you may be forced to travel to get treatment.
You also do not want to be wasting your money. There will be a higher proportion of forty year old patients whose ovaries no longer respond to stimulation. They do not produce eggs and embryos. So you want to recognize this at the appropriate time and consider perhaps donor eggs earlier than might otherwise be canvassed at a clinic that serves younger patients. To this end, it is imperative to receive good counsel that you trust. Trust is earned by a clinician demonstrating their expertise in dealing with older patients.
Protocols are different for 40 year old patients. New research indicates the need for different protocols as compared to the standard protocols for younger patients[1]:
- The various test numbers are different and age relative. Most forty year olds are poor responders due to their age and have very high FSH and very low AMH. The same high or low numbers in a younger patient whilst challenging may not be as dire.
- The follicle growth in older women is slower and ovulation may occur earlier. Research has shown that a 40 year old may benefit from early triggers at smaller follicle diameters, namely 16 mm as opposed to the standard 20 to 22 mm[2]. This means the eggs are extracted earlier.
- Cell function declines with age. This includes egg cells. So clinics that cater to older patients often look at very early follicle growth, not just the final two weeks of follicle growth before ovulation but the four months prior, to improve pregnancy outcomes. Clinics sometimes prescribe coenzyme Q10 which is an important nutrient for the mitochondria to help recharge the egg cells to counteract unhealthy processes and produce hopefully better eggs. Clinics also sometimes prescribe dehydroepiandrosterone (DHEA), a hormone essential for the production of healthy eggs to produce better eggs. These medications introduce a preliminary step before the typical start of a standard IVF cycle. As a 40 year old’s prognosis is anything but standard, the more individualized the care the better.
- Add-on treatments such as pre-implantation genetic testing may not be appropriate unless specifically medically advised. It cannot be used routinely as a method of selecting out embryos because a 40 year old doesn’t have the luxury of selection. Only one or two embryos may be extracted let alone survive culture in the laboratory. You do not want to be taking away a 40 year old’s last chance of pregnancy with her own eggs if it could produce a healthy baby.
- The protocol for culturing the embryos is also important because the embryos of older women often do not survive to day 5. Whilst day five provides a natural way to self select embryos, older women are less likely to have a lot of embryos and ones that survive to day 5. A day 3 transfer allows the embryo to grow in the uterus before it implants as opposed to the laboratory.
As with all things IVF for women over 40, you need to be advised by your fertility doctor as to what protocol is best for you.
Protocols change all the time and none of the above is intended as medical advice. I am not a doctor. You should be advised by your fertility doctor. The purpose of the above is simply to highlight that IVF for a 40 year old is a different story as compared to a 30 year old. Of course medicine changes and protocols change but the underlying rationale that individualized care helps older patients is undeniable. This is the group most affected by delaying parenthood in the sense that their efforts to procreate are the most likely to fail. They do not have time to waste at clinics treating them as they do their younger patients because time is not on their side.
A forty year old’s first choice of clinic has a lot more riding on it. If a bad choice is made, then their chance of pregnancy with their own eggs may be foregone.
[1] I have extracted these protocols from my book “Making Babies in Your 40s”. These protocols are subject to change and you should be advised by your fertility doctor as to the best care for you given your age and personal circumstances.
[2] N. Santoro, B. Isaac, G. Neal-Perry, T. Adel, L. Weingart et al, Impaired folliculogenesis and ovulation in older reproductive aged women, J Clin Endocrinol Metab. 2003 Nov; 88 (11): 5502-9. N. Gleicher, A. Weghofer and D. Barad, “Defining ovarian reserve to better understand ovarian aging”, Reproductive biology and endocrinology, 7 February 2011, ; 9:23.
