Pregnancy in the 20’s

The total number of female eggs in women’s ovaries decreases with advanced reproductive age.Women in their twenties have a good chance of becoming pregnant as a result of a relatively greater number of eggs in their ovaries. Additionally, a larger percentage of those eggs are normal genetically. Since a woman is born with all of the eggs that they will have in their lifetime, the older she gets the fewer eggs are left. In addition, as women age the percentage of genetically normal eggs remaining decreases. This is why women have a decreasing fertility rate, increased miscarriage rate and increased chance of birth defects like Down syndrome as they age. The pregnancy rate per month of a woman in her 20’s is about 20-25%. Because of this, a woman should seek help with fertility if she has been unsuccessful trying to conceive after 12 months of actively trying. The spontaneous miscarriage rate is only about 5-10% and the incidence of a genetic abnormality like Down syndrome is about 1/1200. Women in their 20’s are probably much more likely to be physically active and should moderate exercise in the first and third trimesters of pregnancy. Certain types of exercise to avoid are those that excessively increase the heart rate or body temperature such as spinning, cause bouncing like running or certain types of aerobic classes, or risk loss of balance such as martial arts or aggressive tennis. Exercise that maximizes the use of multiple muscle groups and is aerobic are preferred such as swimming, walking and Pilates. At all ages women should avoid smoking, alcohol, caffeine and certain foods such as raw fish (sushi and sashimi) as well as fish which may contain significant amounts of heavy metals. Read more recommendations on our patient fact sheets by the ASRM.

Pregnancy in the early 30’s

Women in their thirties will experience a decline in their fertility such that the fertility rate per month is about 15%. Women should seek medical help after 9 months of actively trying to become pregnant. The risk of miscarriage at thirty is about 20%. It is important for all women contemplating pregnancy to start prenatal vitamins at least one month prior to starting to try to become pregnant since there is evidence that extra folic acid prior to pregnancy decrease the incidence of certain types of birth defects. There is also some data suggesting that there is benefit to taking extra omega 3 fatty acid supplements during pregnancy as well.

Pregnancy over Age 35 and Related Risks

A number of different problems characterize the ability to achieve pregnancy over 35. There is a noticeable decline in the fertility rate starting at age 35 to a level of about 10% per month. A woman seeking pregnancy over 35 should consult a fertility specialist after only 6 months of actively attempting to become pregnant. The pregnancy risk over 35 is higher as well as evidenced an increase in the miscarriage rate and the incidence of genetic abnormality in pregnancy. At 35, the miscarriage rate is 25% and the risk of Down syndrome becomes about 1/350. 35 is the age at which genetic testing in pregnancy is first recommended since the chance of picking up an abnormality is greater than the risk of the procedure used to find it.

Pregnancy over 40 and Related Risks

There is a sharp decline in a woman’s ability to achieve pregnancy over age forty. The fertility rate per month is only about 5% and even with in Vitro Fertilization (IVF), the most successful infertility treatment available, the pregnancy rate is only about 10% per try. This is due to the greatly reduced number of normal eggs remaining in the ovaries of a woman over forty. Therefore, women who desire a pregnancy over 40 should seek help after only 3 months of trying to become pregnant. Estimates from embryo biopsy reveal that at least 90% of a woman’s eggs are genetically abnormal when a woman is over 40. This is explains the increased pregnancy risk over 40. The miscarriage rate is 33% at age 40. Genetically abnormal pregnancies are more common as well with an incidence of 1/38 at age 40. For this reason, there are many women over 40 who choose to use an egg donor to become pregnant. Eggs from a woman in their early twenties are used along with their husbands sperm to create embryos that are much more likely to lead to successful pregnancy. Pregnancy rates of about 80% are common in most egg donation programs. This is the best way to increase the likelihood of pregnancy over 40. An additional benefit is that the pregnancies that result from these younger eggs also have the miscarriage and genetic abnormality rate of women in their twenties. Therefore, the risk of pregnancy over 40 is limited to those potential problems that could occur that have nothing to do with genetics. As women get older the risks of medical conditions complicating pregnancy increase. Complications of pregnancy that increase with age include elevated blood pressure, gestational diabetes, premature labor and bleeding disorders such as placental abruption.

Pregnancy over 45 and Related Risks

Pregnancy over 45 is a very difficult proposition. Women over 45 have less than a 1% chance of getting pregnant using their own eggs. This is because virtually all of their remaining eggs are genetically abnormal. Successful pregnancy over 45 is therefore nearly always the result of egg donation. Many high profile women who have become pregnant in their forties, especially after the age of 45 did so with the help of donor eggs. The pregnancy risk over 45 is also increased. In the unlikely event that a woman over 45 becomes pregnant with her own eggs, the pregnancy risk over 45 results in a miscarriage rate of at least 50% and the incidence of a genetically abnormal pregnancy of 1 in 12. There is also a significantly higher risk of maternal and fetal mortality with pregnancy over 45 compared to younger women. It is especially important to make sure that a woman’s body is able to tolerate the stresses that pregnancy places on it prior to becoming pregnant. This means that a woman should be checked for problems like high blood pressure, heart disease and diabetes before trying to become pregnant. It may seem that there are higher rates of multiple pregnancy in older women. This is due to the fact that older women are more likely to seek treatment for infertility and these treatments have high incidences of multiple pregnancy than natural conception, especially when donor eggs are used. The fact is that it is much harder to get pregnant with one baby as a woman ages. The chances of a multiple pregnancy are even less. Nearly every woman over the age of forty who delivers more than one baby did so with the help of an egg donor. 

We have just completed some additions to our IVF laboratory and embryo transfer suite which will further enhance the success that we have demonstrated as one of the premier laboratories in the country.  A high efficiency air filtration system has been installed in the room where the eggs and embryos are manipulated and stored making it a virtual “clean room”.  This system also decontaminates the air and removes any chemicals which may be present.  The resultant particle counts in this room are in the range of 200-300 ppcf.  The air which supplies the embryo transfer suite is now HEPA filtered and all carpeting has been removed which along with the installation of clean room ceiling tiles will result in a much lower particle count in this important area as well.  Finally, we have given everything a sleek, high-tech appearance which is more in line with the nature of the work that is performed there.  All in all we can say that the conditions in the lab and embryo transfer suite are the best that technology can offer and will make the environment that the eggs and embryos enjoy as near to that found in the human body as is possible.  We expect that this will be reflected in the IVF successes of our patients for many years to come.

We know that the process of IVF is inefficient since the number of babies born per embryo transferred is relatively low, especially with increasing age.  It is commonly believed that this is due to the large number of genetically abnormal eggs that we retrieve during an IVF cycle. Until recently, our desire to distinguish a genetically normal embryo from an abnormal one  has not been matched by our ability to do so accurately. PGD/PGS has now been around for 20 years. During most of that time, a technology called FISH (Fluorescent In Situ Hybridization) was used. Due to the technical limitations of this procedure, we were only able to test half (12) of the chromosomes at best. Because of this, the accumulated data showed that we really weren’t able to improve the efficiency of IVF from this procedure. That of course makes sense since any one of the other 12 chromosomes could be abnormal and we wouldn’t know it.  We probably transferred a lot of abnormal embryos thinking that they were normal when FISH was used.   For that reason, I was never very enthusiastic about using FISH except in a few select situations.

Recently a new procedure called CGH (Comparative Genomic Hybridization) has become available which allows us to obtain information about all 24 chromosomes. We have been using CGH since late 2009 with much more success than when we were using FISH. This procedure gives us complete genetic information from a single cell obtained from the embryo in question. The results are available within 48 hours so that the normal embryos can be transferred without having to freeze them.  We are finding a high rate of genetic abnormality in the embryos that are tested.  For example, for women under 35 years of age, only 40% of the embryos biopsied were normal.  For the 35-40 year olds, 18% were normal and over 40 years less than 1/10 are normal.  I am very excited about using CGH because it appears from the results so far, that in time the data will probably show that PGS does improve the efficiency of IVF for certain groups of patients, especially those who are over 35 years old. We have had a few couples who have requested PGS in their first IVF cycle even though they were less than 35 years old, just to avoid having to do repeated cycles. Time will tell if this approach makes sense but so far, all of those couples have been successful.

PGD, the testing of an embryo for the presence of an abnormal gene causing a specific disease, is now applicable to over 1000 different disorders.  Probably the most common disorders are Cystic Fibrosis, Hemophilia, Sickle Cell disease and Tay-Sachs but there are many more lesser known ones that we can test for as well.  PGD can be performed along with PGS for chromosome screening on the same single cell.

If you would like to know more, check out out website. I have recently updated the section about PGD/PGS to include a detailed explanation of how CGH works.

The treatment of infertility, especially when using in Vitro Fertilization, can be a difficult process. It is a process that can be conducted in many different ways, depending on the philosophy of the doctors responsible for determining the protocol that will be used. We have found after more than twenty years in the field, that the best approach is one that maximizes the chances of success in each individual, by taking into account the fact that each woman is different and should be treated that way.

The concept of individualized care is based on the fact that there is tremendous variation in the fertility potential among women. Fertility potential refers to the ability of an individual to get pregnant, which in terms of IVF success is defined by the number of genetically normal eggs present in the ovaries. Age alone is not a very good way of determining this fertility potential because women start life with varying numbers of eggs, and at any given time in their lives, an individual may have more or less than the average number left depending on how many she started with. We have seen women barely out of their twenties who have few eggs remaining and are functionally menopausal, and occasionally women in their mid-forties who have more than twenty eggs retrieved during in Vitro Fertilization. As a consequence, it makes little sense to treat all women with the same protocol or medication dosage if the goal is to maximize success.

The number of genetically normal eggs available varies from woman to woman and even in the same woman from month to month. It is important to take this into consideration when determining whether to start treatment in a given month and how to conduct this treatment. We use the number of follicles present in the ovaries, as determined by ultrasound on day 3 of a natural cycle, and the FSH and Estrogen levels on that same day to determine whether or not to start an IVF cycle. The number of follicles present correlates pretty well with the number of eggs that will be retrieved that month. The FSH level is an indication of how easy or difficult it will be to stimulate the follicles to grow. These both can vary month to month. Sometimes it is necessary to monitor a woman for several months before finding the right time to start an IVF cycle. This is especially important in older women who have fewer eggs to start with.