There has been a complete paradigm shift in obstetrical
care for women in the 21st century. As more women
are seeking advanced reproductive techniques to assist
in achieving a pregnancy, the ceiling of reproduction
has been lifted such that almost any healthy women
in her forties and fifties can successfully mother
a child. In fact in a recent study, we reviewed the
pregnancies of 77 postmenopausal women with an average
age of 53 years who underwent an in-vitro fertilization
procedure with the assistance of egg donation (RJP,
Boostanfar et al., Journal of the American Medical
Association 2002; 288: 2320-2323).
This
10 year study is the largest series in the world's
scientific literature of reported pregnancy outcomes
among women in their sixth decade of life. This data
base will likely serve as a counseling tool to guide
physicians and patients to know what to expect in
their fifties. Although outcomes have been extremely
favorable, there are serious medical conditions that
can evolve or become exacerbated during pregnancy.
Therefore, it has become imperative to understand
the physiological changes during this time period
and to be prepared and watchful of possible complications.
A
proportion of women in their early forties are successful
in becoming pregnant with their own eggs spontaneously,
many others are able to conceive in cooperation with
an egg donor. Although the likelihood of becoming
pregnant is significantly higher with an egg donor,
pregnancy course and birth outcomes are extremely
similar whether a woman is able to conceive with her
own eggs or with an egg donor. That is, whether or
not the pregnancy is a result of a natural conception,
a conception with her own eggs and assistance from
advanced reproductive techniques like in-vitro fertilization
or with the assistance of egg donation, she is likely
to have similar risks and outcomes throughout the
duration of her pregnancy. The most notable risk factor
is not how the pregnancy was conceived but perhaps
the age in which a woman achieves a pregnancy.
Pressing
the boundaries of reproduction in women of advanced
reproductive age can be complicated by underlying
medical conditions that are undiagnosed. Such factors
like a decrease in the reserve of the cardiovascular
system and the diminished ability to adapt to physical
stress that both may accompany advancing age may combine
to increase risks to the mother and the baby. Some
authors have suggested that advanced maternal age,
defined as greater than age 35 by some authors and
greater than age 40 by others, is associated with
an increased risk of poor pregnancy outcome (Lehman
et al., American Journal of Obstetrics and Gynecology
1987; 157: 738-742). These reports may be confounded
by inconsistencies in prenatal care, preexisting medical
conditions and access to appropriate health care.
In contrast, when women of advanced maternal age were
followed and delivered in a sophisticated, high risk
care medical center, no increase in adverse outcome
was noted (Kirz et al. American Journal of Obstetrics
and Gynecology 1985; 152: 7-12).
All
in all, women in their forties and fifties should
expect to have some mild increase in pregnancy related
issues. However, carefully selected and monitored
women should anticipate a successful result. We recommend
that all women in this age group see a Reproductive
Endocrinologist for a history and physical exam. She
should also undergo an EKG, a chest X-Ray, mammogram,
PAP smear and blood work as part of her preconceptional
evaluation.
When
the assessment is completed, women can be counseled
suitably as to what their potential risks can be.
Appropriately screened, healthy women in their fifties,
who carry a singleton pregnancy, can expect their
gestation to go practically full term and deliver
babies that are approximately the same weight as their
counterparts half their age (RJP, Boostanfar et al.,
Journal of the American Medical Association 2002;
288: 2320-2323). Nevertheless, they are also approximately
three times more likely to deliver by cesarean section,
three to ten times more likely to experience pregnancy
induced hypertension and two to five times more likely
to encounter diabetes compared to younger women. Although,
there does not appear to be any medical reason for
excluding these women from attempting to become pregnant
on the basis of age alone, it is recommended they
seek the attention of a Reproductive Endocrinologist
that is aware of these complexities, in order that
they may be thoroughly screened and deemed to be an
appropriate candidate so that she may experience a
favorable outcome.
Finally,
the careful, deliberate and judicious transfer of
embryos should be taken into consideration among patients
undergoing an egg donation cycle. Because of the significantly
higher implantation rates of donor eggs and embryos,
couples attempting to conceive with the assistance
of an egg donor are at a particularly high risk of
multiple gestations. Moreover, it has become exceedingly
evident that multiple gestations may, in turn, further
complicate the course of a pregnancy.
Those
complications include higher rates of morning sickness,
preterm labor and preterm birth and increased rates
of pregnancy induced hypertension or toxemia. The
introduction of modern extended embryo culture, pre-implantation
genetic diagnosis and blastocyst transfer have resulted
in a conscientious and concerted effort to increase
pregnancy and implantation rates, while simultaneously
minimizing the number of embryos transferred to one
or two per cycle in a realistic attempt to reduce
the number of high order multiple pregnancies. It
is of critical importance to choose infertility centers
and subsequently obstetricians with both significant
clinical and laboratory expertise in this domain of
reproductive medicine.
When
the assessment is completed, women can be counseled
suitably as to what their potential risks can be. Appropriately
screened, healthy women in their fifties, who carry
a singleton pregnancy, can expect their gestation to
go practically full term and deliver babies that are
approximately the same weight as their counterparts
half their age (RJP, Boostanfar et al., Journal of the
American Medical Association 2002; 288: 2320-2323).
Nevertheless, they are also approximately three times
more likely to deliver by cesarean section, three to
ten times more likely to experience pregnancy induced
hypertension and two to five times more likely to encounter
diabetes compared to younger women. Although, there
does not appear to be any medical reason for excluding
these women from attempting to become pregnant on the
basis of age alone, it is recommended they seek the
attention of a Reproductive Endocrinologist that is
aware of these complexities, in order that they may
be thoroughly screened and deemed to be an appropriate
candidate so that she may experience a favorable outcome.
Finally,
the careful, deliberate and judicious transfer of embryos
should be taken into consideration among patients undergoing
an egg donation cycle. Because of the significantly
higher implantation rates of donor eggs and embryos,
couples attempting to conceive with the assistance of
an egg donor are at a particularly high risk of multiple
gestations. Moreover, it has become exceedingly evident
that multiple gestations may, in turn, further complicate
the course of a pregnancy.
Those
complications include higher rates of morning sickness,
preterm labor and preterm birth and increased rates
of pregnancy induced hypertension or toxemia. The introduction
of modern extended embryo culture, pre-implantation
genetic diagnosis and blastocyst transfer have resulted
in a conscientious and concerted effort to increase
pregnancy and implantation rates, while simultaneously
minimizing the number of embryos transferred to one
or two per cycle in a realistic attempt to reduce the
number of high order multiple pregnancies. It is of
critical importance to choose infertility centers and
subsequently obstetricians with both significant clinical
and laboratory expertise in this domain of reproductive
medicine. Extensive information on infertility at the Huntington site.
