For a variety of reasons, women are postponing starting, or growing, their family; so it’s not uncommon to find women trying to get pregnant at 40 – or older! For many years, most patients were not referred for fertility assistance until after they had tried to conceive for a full calendar year. Since we know that the number of healthy eggs that a woman has declines with aging, this recommendation has now changed. Women are encouraged to seek assistance after trying for 6 months if they are over the age of 35; if they are over the age of 40, we recommend immediate evaluation by a fertility specialist, as every month is important.
Treating women trying to get pregnant at 40 (or older)
Given the decline in fertility with aging, additional research has been performed to identify the most efficient and effective way for women over age 40 to conceive since each month is so crucial. The standard starting recommendation for treatment would be the administration of fertility medications to assist with ovulation followed by intrauterine insemination (“IUI”) using the partner’s sperm or donor sperm. If a woman does not conceive after 3-6 months using this treatment, then the recommendation would be to move to in-vitro fertilization (“IVF”), which involves placing the egg and sperm together in the laboratory followed by a transfer of the resulting embryos into the woman’s uterus. IVF is known to have higher success rates but is more time-consuming, costly and involves the female partner undergoing a procedure to extract the eggs. Therefore, we routinely did not recommend starting with this treatment in the past.
Forty and Over Treatment Trial
However, a study released in 2014 specifically addressed the best way to treat women who are 40 years and older and reaching the years of decreased reproductive potential. This study, called the Forty and Over Treatment Trial (FORT-T), evaluated women aged 40 years and older and assigned them to 3 treatment groups: immediate treatment with IVF, treatment with an oral pill to induce ovulation followed by IUI, or treatment with injectable medications to induce ovulation followed by IUI. For those patients who did not get pregnant after 2 cycles of IUI, they were switched to IVF for their subsequent cycles. The investigators evaluated the pregnancy rates from each of the groups. The results were very interesting and have changed the way that we think about treating women who are 40 and older.
In the group of patients taking an oral medication and doing IUI, 22% became pregnant and 16% gave birth. For the group of patients taking injectable medications and doing IUI, 17% became pregnant and 14% gave birth. But for the patients that went straight to IVF treatment, 49% became pregnant and 31% gave birth. Because of this higher pregnancy rate in the IVF group, these patients underwent 36% fewer total cycles than the couples who started treatment with insemination. On average, the patients in the IVF group conceived after 2 cycles, whereas those patients who began with insemination underwent 3-4 cycles in total. Furthermore, 84% of the babies born in the study were the result of IVF in the end.
This study tells us that in women over the age of 40, it may make more sense to move to IVF as quickly as possible, as the majority of pregnancies were conceived using this technology and women conceived quicker using this fast track approach to IVF. Clearly, IVF is not appropriate for all women and there are considerable financial differences between the treatment types. But if you are considering conceiving and are over the age of 40, now is the time to see a fertility specialist if you have yet to do so. Depending on your situation, treatment options can be tailored to your individual needs and circumstances. We encourage you to call today to set up a consultation!
Original post May 15, 2015
Updated August 19, 2021