¹Salleha Khalid, Ng Beng Kwang, Abdul Kadir Abdul Karim

¹Department of Obstetrics and Gynaecology, Universiti Sains Islam Malaysia

²Department of Obstetrics and Gynaecology, UKM Medical Centre

Introduction

With the advancement of reproductive technology, women are now able to conceive at a later age. In Malaysia, the mean menopausal age is at 50.7 year. While perimenopausal age can be defined as time around menopause. By enlarge many women reach perimenopause by mid forties. Perimenopause also refers to time during the body make natural transition to menopause by which the body is approaching the end of its reproductive years.

Fertility rate decreases with age. The chances of getting pregnant is 20% in any given month among women aged 30 years and below. However the chance drop to below 5% among women aged 40 years and above. Even if all fertility factors are at an optimal stage, the percentage of women who are infertile noted to be up to 87% by the age of 45 compared to only 7% among women aged 30 years and below.

Cause of age-related infertility

The cause is multifactorial. There is a demonstrated decrease in the number of eggs as women aging throughout their reproductive years. It is also important to add here that the risk of miscarriage increases with age. The miscarriage rate was approximately under 15% among women aged 35 and below while the rate increases to 29% among women aged 40. In addition to this, genetics disease are more common among children born to older mother. It is estimated that one in 60 live births children born to 40-year-old women is genetically abnormal.

The decrease in fertility and increase in miscarriages are due to the decrease in the quantity and quality of eggs among older women. Women are born with definite number of eggs. With age, the quantity and quality of eggs reduce making it more difficult to get pregnant. The increase risk of miscarriage is attributed to abnormalities associated with an aging egg. There is also increase risk of chromosomal abnormalities due to the unhealthy egg.

The challenge of conceiving among the advanced maternal age does not stop there. At such age group, women are more likely to have co-morbidity that may affect their fertility such as tubal diseases, uterine fibroids and endometriosis. In view of the above conditions, patient who are approaching forty and above, it is advisable for them to expedite assesment on their fertility status. Women in their mid 20s and 30s could go for unassisted reproduction up to one year prior to in depth assessment, for older women it is advisable for them to have fertility assessment after six month of trying to conceive. This is because further delay will seriously impair their chance in getting pregnant.

Assessment of Ovarian Reserve

In addition to the series of tests any women need to take to assess fertility status, older women will need to be assessed on their ovarian reserved. As woman are born with a definite number of eggs and the reserve will diminish with age, test for ovarian reserve will give an idea on the capacity for the ovary to provide eggs for fertilization resulting in pregnancy. With this information in hand, women will be advised on the best optimal treatment and at the same time they can be given a realistic expectations on their chance for a having a successful pregnancy.

Till this date, the best test available for assessing ovarian reserve include measurement of hormone Follicular Stimulating Hormone (FSH) on day 2- 3 or menses and serum Anti-mullerian Hormone (AMH) via blood test.  Serum FSH of less than 10 miu/ml indicate a good reproductive potential. Wherelse serum AMH of less than or equal to 5.4pmol/l is regarded of having a low ovarian reserve.  Alternatively, a transvaginal ultrasound to measure antral follicle count at early part of menstrual cycle can also be used to assess the ovarian reserve.  A total count of 15- 20 follicles from both ovaries are regarded to be good reserve. A total count of less than 10 follicles may indicate a low reserve.

Management and Treatment

With the above informations, treatment can be tailored according to their ovarian reserve. Those with good ovarian reserve could undergo ovarian stimulation during the in vitro fertilization (IVF) cycle. Those with a low reserve will be counselled on other options including having a natural cycle IVF, egg donation or adoption. In a natural cycle IVF, woman will have transvaginal ultrasound scan at early part of their cycle in order to detect the presence of any follicle. Should it be present, the follicle will be followed through the cycle and egg collection will be performed at a timely manner in order to proceed with IVF. The success rate for natural cycle is noted to be much lower to almost one fourth to one third of that conventional IVF cycle. This is primarily due to premature ovulation which lead the cycle need to be abandoned.

Egg donation happens when egg is collected from another woman after ovarian stimulation and then fertilised using the conventional IVF methods. The resulting embryo is then place back to the patient womb allowing her to carry until term.  Egg donation although is available, sparks debates especially when it comes to the question of who is the mother of the childconceived. Some cultures and religious beliefs are against egg donation. Islam does not permit egg donation as it cross the genetic lineage between generations.

It is also important to inform women that even if they manage to get pregnant they are at an increased risk of having pregnancy complications such as high blood pressure, diabetes in pregnancy, heart diseases, caesarean section and fetal abnormalities. Before conception, patient should undergo extensive medical screening and once preganancy is confirm, they should be referred to feto-maternal specialist for further management of high risk pregnancy associated with advance maternal age.

In the spirit of having reproductive freedom, a doctor must uphold ethical values which include beneficence and nonmaleficence. Beneficence is to provide benefits to the patients and nonmaleficence is to cause no harm. A doctor must weighs that  whether the benefits of motherhood and and childbearing outweigh the risk to the mother and child. Hence when assessing older patient for artificial reproductive techniques, a doctor should consider the right of the patient, their physical and mental health, their remaining life expectancy as well as financial and social support around them.

References

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