Over 35 and trying to conceive? The passing of years can mean reduced fertility. We discussed what challenges you may face and how to best address coming late to motherhood with Dr. Amos Grunebaum, medical director of the WebMD Fertility Center, as part of the 2003 Trying to Conceive (TTC) Online Conference, presented by WebMD in collaboration with RESOLVE: The National Infertility Association.
The opinions expressed herein are the guest’s alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Member question: Are the challenges associated with being over 35 preconception or post (whether you are 35 when you conceive or 34 and due after you turn 35)? Are the challenges a dramatic drop or gradual as the years pass after 35?
Grunebaum: Challenges are both pre and post conception. The eggs are just not as good as they were before, there are more ovulation issues, and the lining of the uterus is less competent to allow implantation of the fertilized egg.
In addition, even when the egg implants, there is an increased chance of a miscarriage and most is due to chromosome issues, which increase significantly after 35. And then there are medical problems like diabetes and hypertension, which in and by themselves increase early and late pregnancy complications.
Member question:
When a woman is over 35 and there is known male factor infertility issues how long should the couple wait to see the RE (reproductive endocrinologist)?
Grunebaum: My suggestion is to see the RE or a good ob-gyn as soon as you are thinking about TTC. Time is of essence, and seeing a doctor, getting examined, and maybe doing some tests will save you a lot of time later on.
Member question:
I am 33. Am I right in assuming that the issues grow over time and there is nothing magic about the age of 35?
Grunebaum: You are absolutely correct! It’s not an “all or nothing” issue. Things move slowly but steadily as you (and all of us) get older.
They do accelerate, though, around 40. That’s really for many women the outside time of fertility. Once that big 4-0 rolls around, fertility significantly decreases each year.
Member question: Is fertility in regards to age affected by the age of onset of menses — I mean does a “late developer” have more time later?
Grunebaum: That’s a very good question! This issue has been studied, and there are different opinions. Most that I can recall feel that it does not make a huge difference. You are your actual age, independent on whether you started ovulating at 9 or 14.
Member question: I am 43 with a high FSH, currently took estradiol to lower it and am now on Clomid. Are there any new and successful procedures for women with my problem?
Grunebaum: I surely hope you are seeing an infertility specialist, a reproductive endocrinologist. Many REs would like to make sure the indication for Clomid is correct, especially when the FSH is high. And it also really depends, to paraphrase our prior president, on ‘how high is high?’
Member: Thirty was the last reading.
Grunebaum: Thirty is considered high by most doctors, especially if it’s repeatedly that high on CD 3. That surely makes it very difficult getting pregnant.
Member question: What is usually prescribed after Clomid if your problem is not ovulating?
Grunebaum: Clomid is usually increased to about 150 mg/day to see if you ovulate or not. If the FSH is normal then most doctors usually give ‘injectables,’ both gonadotropins and HCG to stimulate the follicles and induce ovulation.
Member question: What are your thoughts on FSH levels under 10 and getting pregnant at 42?
Grunebaum: Your FSH levels surely indicate at least a good egg quality. That in and by itself should improve your chances of getting pregnant. A low FSH improves your chances, even at 42. Good luck!
Member question: Can working out for two hours a day, five days a week affect getting pregnant after 35?
Grunebaum: No. But it also depends on what you mean by working out. If you ovulate regularly, then the working out is not usually responsible for infertility issues.
When you have difficulties getting pregnant, and before you ask yourself if something is responsible for the problem, you should try finding out the real problem. If you are healthy and you work out but his sperm count is low then your exercise is not responsible for the infertility.
Member question: At RESOLVE we often get questions about diet and FSH, are there any known correlations between environmental factors, including diet, and FSH level?
Grunebaum: I am not sure what it is you are asking. But I am not aware of any specific studies that have shown a direct relationship between high FSH and diet. That does not mean that a diet should be unhealthy, but as far as specific diets are concerned, I am not aware that one diet is superior to the other.
Member: I think this person is asking is there anything we can do to “help” our FSH be at a correct level, like avoiding certain environmental factors, losing weight, improving our diet by adding “X”?
Grunebaum: Loosing weight and being at optimal weight is among the top recommendations I usually give. Being overweight increases ovulation problems, and being at the optimal weight (BMI of 20 to 25) is a good beginning. In addition, being overweight increases pregnancy problems once you get pregnant, so that should be another incentive for losing weight.
No smoking, no more than one to two cups of coffee a day, and no alcohol would be the next suggestions, in addition to regular exercise. You may also meet with a dietician and discuss your diet. Adjusting an individual diet is one of the most difficult things to do, because we all have different opinions of what is generally considered a ‘healthy’ balanced diet.
Member question: Is losing weight when TTC bad?
Grunebaum: No, it’s not bad, but being on an unbalanced diet may not be optimal. When you try losing weight you still need your good nutrition, just more balanced and often fewer calories. In addition regular exercise will help you lose weight and is unlikely to interfere with TTC.
Member question: The infertility challenge we face is recurrent pregnancy loss. Two pregnancies in the last year have ended at 9 weeks after a heartbeat was observed at seven weeks. I am 37 and both my husband and I have normal karyotypes. All the blood testing and hormone levels have been normal too. Are we to believe that we are prone to repetitive random miscarriages?
Grunebaum: Believe it or not, you have an excellent chance to have a normal baby after two losses. Even though it’s devastating losing two pregnancies in a row, most couples will be able to go on and have a normal pregnancy. In the meantime, your doctor can do some tests to see if any turn up abnormal. These tests may include tests to see if you have an autoimmune problem, look for infections, or check the shape of the uterus.
In addition, doing pathologic testing of the miscarriage and maybe looking at the chromosomes will help you answer what has been going on.
Member question:
What about a beta 3 integrin test of the uterine lining?
Grunebaum: I don’t know much about this specific test. I have heard of it, but it’s not commonly done and I am unsure about its value.
Member question: I will be 36 soon and have been TTC for over 3 years. I’ll be referred to a specialist after this cycle of Clomid if it didn’t work. What will the specialist likely want to do next?
Grunebaum:
The specialist will ask three questions:
What about your ovulation? Is it regular and is the egg quality OK?
What about his sperm, are there enough and in good shape?
What about your fallopian tubes, are they open and moving well?
Once these questions are answered, the RE can determine the next steps. One question: Do you know his sperm count and is it fine?
Member question: Already done sperm analysis. HSG and ovulation tests are fine too. Then what?
Grunebaum: Next is usually a laparoscopy to get a better idea about the fallopian tubes. Sometimes the tubes are open on HSG but there are problems seen on the laparoscopy.
Member question: How can you know if egg quality is OK?
Member question: What are the key variables that determine good egg quality? How are they measured? What is a “normal range?”
Grunebaum: The major test is usually your regular cycle and fertility chart. If both are normal then this is often a good indication of the egg quality. In addition, a CD 3 FSH that’s low and normal is also a great indicator of egg quality.
Member question:
If a woman has been diagnosed as being perimenopausal, what can be done to assist in achieving pregnancy?
Grunebaum: Perimenopausal usually means the FSH is too high. Sometimes IVF can make a difference. But many doctors feel that in peri and postmenopausal women the best chance of getting pregnant would be through an egg donor. Peri/postmenopausal means a woman’s eggs don’t work well. Getting an egg donor will usually improve a woman’s chance of getting pregnant.
Member question: My cousin has been TTC for several years. She is in her early 40s and I believe has had laparoscopy to assess fallopian tube damage. She has been on fertility drugs for a while, and I believe she has now gone through three rounds of IVF. Are there other steps she can take or should she just remain on the same course of action?
Grunebaum: IVF is usually the very last resort for many women, and beyond IVF the options usually depends on many different issues. They depend on the cause for her infertility and what the reasons are for the IVF not working. Unfortunately, women over 40 have a lower chance getting pregnant and though you said she is in her “early 40s” each year beyond 40 makes a big difference in the success rate. Women who are, for example, 40 have a better chance of getting pregnant, even with IVF, than women at 44 or 45.
Member question:
Do most IVF programs have age limits for patients?
Grunebaum: Yes, most IVF programs have some kind of age limits and there are many reasons for this. One of the reasons is that because older women have a lower chance getting pregnant it will worsen the program’s statistics if they take too many older women. But there are some programs specializing in women well over 40. You need to call around and find out who is more willing to take you.
Member question: if you have tried IVF before, is it dangerous to try it again? I’m scared because my wife is 36 now.
Grunebaum: I am not sure what you mean by “tried.” It all depends on the circumstances, how often it was done, what the outcome was, and also what the indication was. So it’s impossible to make a general statement about repeat IVF. Many women who have had it before can have IVF again.
Member question: I am a 36-year-old woman with PCOS and would like to know if my chances of conceiving are still very good. I would love to have a child but my insurance covers nothing for infertility expense and so the cost is an issue for me.
Grunebaum: PCOS comes in many different forms and severities. If you do ovulate now then you have a good chance getting pregnant. You should see your ob-gyn and discuss this issue. Most insurance companies will pay for at least the initial consultation with your ob-gyn. At that time you can get examined and find out how severe your PCOS is.
Moderator: PCOS = polycystic ovary syndrome.
Member question: I am 35 and have been TTC for 10 months. I think I may have a luteal phase defect. Should I see my ob-gyn first or head straight to a reproductive endocrinologist?
Grunebaum: I usually suggest to first see the ob-gyn before you start TTC. But at this point you can also see the RE. The RE is usually best trained to help you get pregnant faster.
Member question: My ob-gyn put me on Clomid even though I am ovulating. What will it do for me? I’m 37 right now. Shouldn’t I be doing something more drastic than just Clomid?
Grunebaum: It’s impossible for me to comment on the reasoning of your ob-gyn. I always suggest that you never take a medication without completely understanding the why. So your first step is to ask your ob-gyn. She knows you best and must explain, and if you don’t get a good enough answer, ask again. And if you still don’t get a good explanation, find another doctor who will explain it better. Or even better, see an RE. They should be best trained to provide you with infertility help.
Member question: I am 37 and suffered a miscarriage two months ago. I am ovulating. Is it true that a woman is more likely to conceive after a miscarriage? My doctor did a D&C.
Grunebaum: There is a very small increase in fertility for the first months after a miscarriage. But within months it returns back to where it was before. Good luck!
Moderator: Thanks to Dr. Amos Grunebaum, for answering our questions. For more information on fertility issues, be sure to explore all the TTC info here at WebMD, including our message boards and regular live chats with Dr. Amos. You can also explore the RESOLVE web site at www.resolve.org.
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