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Question 52. Are there age or other restrictions on who should do IVF?

Posted Jun 30 2011 2:25pm
You know, Dear Reader, when I started in practice over 15 years ago I used to get the "you're too young to be my doctor." Now, not so much. Growing older is a fact of life. I personally find it very disturbing that the medical students that I teach at GWU were born in the 80s or even in the 90s (some Doogie Howser types). Unfortunately, the aging process is difficult to fight against. Some patients are now considering freezing eggs for future use, but this process has limitations and usually the patients seeking to freeze eggs probably should have done it 10 years ago but at that time they didn't think that they would need to freeze eggs for future use....

Fertility treatment success rates are age dependent and stimulated cycle IVF pregnancies in patients over 43 years old are very uncommon and usually limited to those patients who are still excellent responders to stimulation in spite of being on the other side of 40... FSH/IUI can be considered in patients with patent fallopian tubes and good sperm but what about the rest of the patients?

More recently we have used Natural Cycle IVF as an option for those patients unwilling to consider adoption or donor egg IVF. Some of these patients have succeeded including a 47 year old who had previously failed 4 stimulated cycle IVF attempts. We believe that patients should be offered the chance to pursue Natural Cycle IVF in such situations, although we are very clear in our expectations. We anticipate that rarely patients will have success. Those who fail to conceive still seem very appreciative that they were given a chance.

Imagine if Oncologists refused to treat cancer patients with a poor prognosis because it would hurt their statistics? I know that infertility and cancer are very different but both carry huge emotional and psychological costs.

So here is today's Question of the Day from 100 Questions and Answers about Infertility. An excellent book, according to my parents (see below), even though it was not written by any alumni of Tufts University or Tufts School of Medicine!

52. Are there age or other restrictions on who should do IVF?

Age restrictions for IVF vary from clinic to clinic. In general, women older than age 40 have a markedly lower chance for a live birth compared with women younger than 40 years old. Age is probably the most important factor influencing the outcome of an IVF cycle. Many clinics will not treat patients older than age 42, and some malpractice carriers dictate that physicians not perform IVF on patients older than 43 years old with their own eggs because of the poor IVF delivery rates related to advancing age.

A woman’s chances for successful stimulated IVF can also be predicted by measurement of her FSH and estradiol levels on cycle day 3. Elevations in either hormone are associated with poor IVF success rates, so many clinics impose additional restrictions once the FSH or estradiol levels are known to be elevated. The clomiphene citrate challenge test (CCCT) is another means by which to assess ovarian reserve and predict IVF success. Older women, those with elevated FSH levels on cycle day 3, and those with elevated estradiol levels may consider IVF with donor eggs or adoption.

Natural Cycle IVF has emerged as another treatment alternative for patients with diminished ovarian reserve. Remember that tests of ovarian reserve predict a patient’s response to fertility medications but no test exists to predict the presence or absence of a healthy egg in a given patient. The only true means to determine the presence of a healthy egg is that of delivering a healthy child – that proves that the patient had at least one good egg! Interestingly, the oldest woman to successfully conceive and deliver a healthy baby with her own egg using IVF was a patient who underwent Natural Cycle IVF and delivered at age 49.

Rebecca commentsAt over 40 years of age, I was fortunate that I had an RE that saw beyond my chronological age and aggressively worked with my husband and me to achieve a pregnancy and live birth using my own eggs. Our third and successful IVF resulted in boy/girl twins from eggs retrieved the day before my 42nd birthday. That said, our family building journey (two IUIs, three IVFs) was not an easy process, nor an inexpensive undertaking. It took an immeasurable amount of commitment on the parts of my husband and me; it was a journey best faced as a strong, unified team. We suffered heartbreaking losses and cycle failures. With each setback we had to regroup, reassess, reevaluate our finances, and discuss our options with our RE. We moved through the medical intervention 'process' gaining an understanding that we took a great deal of emotional and financial risk with every cycle. As we tried to establish realistic expectations from each cycle, we also tried to define the time point or cycle number where we might move on and explore different treatment or family building options. We had a firm belief that it was absurd to bring a child into a family situation that was emotionally and/or financially exhausted. Each patient must face making their own family building decisions, but it is important to consider all the issues (emotional, medical and financial) and enter into discussions with your RE (early and often!), when making decisions to move forward with IVF at advanced maternal age.
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