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Infertility Due To The Declining Age of The Woman and Treatment Options
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Infertility Due to the Declining Age of the Woman and Treatment Options
Woman’s age:
Today, most of the women postpone their desire to have a baby. Especially university graduates and working women would like to have a baby in their 30’s or 40’s. In western countries 20% of the women wait till they are over 35 to establish a family. Many social factors play a role in this decision: Having a carreer firstly, waiting for a healthy relationship, guaranteeing their lives economically or being sure that marriage is wanted. Conceiving and the probability to have a healthy pregnancy become difficult in later years, but this issue is not sufficiently explained.
Though the probability to conceive for women under the age 30 is nearly 20% a month, this ratio is only 5% for women over 40. This decrease is not only limited to conceiving via natural methods, but also is reflected in the success ratios of the test tube baby treatments; pregnancy ratios in treatments applied to women over 37 decreases dramatically. In addition, since the oocyte quality deteriorates in older mother candidates, the risk of having a child with chromosome abnormalities also increases. Therefore, women who can not conceive over the age of 37 should apply to the test tube baby centres without wasting time.
Changes in ovaries (Decrease in the ovary reserve)
For couples over 40, in addition to the problems leading to infertility, changes in the ovaries due to declining age also plays an important role.
The hormones released from the hypothalamus and the pituitary gland in the brain regulates ovulation and periodical menstruation. Hypothalamus stimulates the pituitary gland and has it release FSH (Folicule Stimulating Hormone) and LH (Luteinizing Hormone) which pass into the blood circulation and provide the development of oocytes in the ovaries and the releasing of the estrogen hormone.
There are approximately 300.000 primordial folicules (undeveloped oocyte) present in the ovaries of a young woman during adolescence. Every month, one oocyte develops through the cycle and becomes ready for fertilization. However, again every month, at least 500-1000 folicules are degenerated before completing their developments. When a woman approaches menopause (generally between the ages of 40-50), only a few thousand oocytes are left. Since these oocytes can not respond to FSH and LH sufficiently, the pituitary gland increases its FSH and LH levels to stimulate the ovaries more. Though the ovaries partially respond due to the increasing hormone levels, after a couple of years the ovaries can not respond at all, despite the increasing FSH and LH levels.
Increase in the FSH level in the blood at the 3rd day of menstruation shows that the respond of the ovaries to the stimulations of the pituitary gland has been decreased, that is to say, ovary reserve is diminished. This lack of response leads to the less amount of oocyte production. Due to the insufficient response of the ovaries to FSH and LH released from the pituitary gland, estrogen and progesterone levels produced by the ovaries also decrease later on. Therefore, the oocyte and hormone production by the ovaries decrease in the course of time. Irregular menstruation can be seen in woman reaching this period. The interval between the two menstruations shorthens first, and then begin to prolong. Sometimes no menstruation can be seen for 2-3 months. During the irregular menstruation, generally healthy oocyte development can not also be accomplished. Estrogen and progesteron hormones are necessary for the development of the womb layer (endometrium) of the uterus.
Number and quality of the oocytes
Since the number and the quality of oocytes decrease with age, their ability to be fertilized by sperm also decreases. And also even if the fertilization occurs, risks of genetic diseases of the embryo increase. For example, the risk of "Down syndrome" which is a chromosomal disease seen in the children of women giving birth in declining years increases. Even if an oocyte having chromosome disorder is fertilized, its chance to stay alive and develop decreases. Therefore, the probability of a miscarriage increases over the age of 40.
When embryos developed from the oocytes of women in ther 20’s-30’s are transferred to the uterus of a 40 year old woman (test tube baby with donor oocyte), pregnancy rates similar to young women occurs. If oocytes of a woman in declining age do not develop or she can not conceive with her own oocyte, then test tube baby application with a donor oocyte is recommended in countries in which this is legal. By this way, the problem of having undeveloped oocytes and the quality of the oocyte is overcome. This application is not legal in our country yet.
Declining age and the options of infertility treatment
FSH, LH and E2 levels, determined on the 2nd-3rd day of menstruation is very important. The levels of these hormones determine the response that the ovaries give during the treatment and the chance to conceive. Though it is known that probability to conceive is low in women over the age 40; the increase in FSH and LH levels on the 3rd day of menstruation expresses that this chance is diminished even more. After these results are evaluated, the patient should be provided with correct information and the treatment options should be discussed.
Genetic consultancy
Since babies of women over 37-40 have a high probability of chromosomal disorders, when they decide to have a baby, they should be provided with genetic consultancy by a gynecologist or a genetics specialist. "Amniosynthesis" must be recommended for these late pregnancies. If test tube baby application is decided to be provided for the patient, then they should be informed about pre-implantation genetic diagnosis (PGD). If normal embryos are selected and transferred with PGD application, then the patient would obtain many benefits from it.
Treatment methods and alternatives
After all necessary tests are conducted; couples should be given detailed information on the treatment methods and the rates of success. Some couples would like to adopt a child instead of receiving an infertility treatment or would like to receive test tube baby application with a donor oocyte.
In the infertility cases due to advanced age, patients should be evaluated carefully and the treatment schedule should be provided within the range of the simplest application, intra-uterine insemination and test tube baby application.
IVF with donor oocyte
The treatment methods for women in declining ages who had no success with various treatment methods before are limited. In these cases where the patient’s own oocytes can not be used; the method of using the oocyte of a younger woman can be selected. A woman diagnosed to undergo early menopause can only conceive like this. Chance to conceive is high with the test tube baby application, conducted with an oocyte taken from a young woman with healthy ovaries. The donor can either be known or not. Generally, donors having similar physical properties are selected. In this method, it should be noted that the baby will possess the genetic properties of the donor.
This method which can not be applied due to legal limitation in our country, has been successfully applied in some European countries like Belgium, England, Spain, also in Australia and USA. However, it is prohibited in some countries such as Germany, Switzerland due to legal, religious or ethical reasons, including Turkey. |
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