Homologous assisted fertilization: no miracle when the problem is the woman’s age.
This is an uncomfortable article, one of those that could demoralize you in your research.
If you prefer to seek pregnancy without thinking about the implications related to your age, and the possibilities calculated on the basis of currently available data, do not read it. Stop here.
As is known, the age at which the couple seeks their first pregnancy has risen a lot in the last few decades. Based on Istat data published in 2018, in Italy the average age of women at childbirth is around 32 years old, a number that places us second in Europe after Spain, and which is, alas, constantly increasing. We also have a “record” for the number of children per woman: Italy ranks among the countries with the lowest fertility (1.26 children).
Fewer children and always later.
If you think about it there is a certain logic. If you decide to have a child late, the second child will have a hard time arriving precisely because the woman’s age can make pregnancy difficult by natural means (and not only).
There is also a threshold that many underestimate and that is 36 years of age . Year plus year minus.
Why do they keep telling us that after I’m 36, a woman’s fertility starts to decline?
Because it has been seen that as a woman ages, her oocytes, once fertilized, give rise to a progressively higher and higher number of embryos with an altered chromosomal arrangement ( aneuploidy ) . Most of the time these embryos lead to a spontaneous termination of pregnancy with abortions in the first weeks (see figure below which relates the age of the woman and the risk of abortion), other times they continue in a pregnancy of a fetus with compatible trisomies with life as 21 (Down syndrome), 13 or 18. Without forgetting that the more the years go by the fewer oocytes are obtained from the stimulations during an assisted reproduction treatment.
Although PMA (medically assisted procreation) has made great strides in recent decades, the tools available against the biological limits imposed by increasing age are very few.
Homologous assisted fertilization (that is, which uses the couple’s gametes, oocytes and sperm), whether it is first, second or third level, is the solution of excellence when there are fertility problems related to tubal closure, quality problems or number of sperm, problems of anovularity of the woman, hormonal, cervical or vaginal problems. But when pregnancy doesn’t come because of the woman’s age, she can’t work miracles.
In this case, where the limit is represented by the woman’s age, pre-implantation diagnosis can help, which can reduce the research time, or heterologous fertilization (gamete donation).
What can we understand from these images?
The study was conducted by evaluating more than 15,000 genetic screenings on embryos obtained in assisted fertilization cycles. The data collected showed that, with increasing age of the woman, the percentage of embryos that have alterations in the number of chromosomes increases considerably
This translates into a higher probability of more or less early abortions or a failed implantation.
How can PMA help in these cases? Simply by reducing what is defined as the ” time to pregnancy “, that is by selecting with the pre-implantation diagnosis the embryos with a normal chromosomal arrangement (euploid), thus reducing the rate of spontaneous abortions. In short, the concept is this: stimulations are performed, in vitro fertilization of the oocytes is collected, pre-implantation diagnosis is performed on the blastocysts obtained and only those with a normal chromosome are transferred. In this way miscarriages decrease considerably and the time to be able to get pregnant is reduced. The alternative remains heterologous fertilization .
It is interesting to note in the following figure how increasing age not only determines an increase in aneuploidies but also an increase in the percentage of embryos that have more than one aueuploidy chromosome: from a 48-49 woman we obtain 100% of embryos that have three or more errors in the number of their chromosomes.
Beware of illusions
When you are over 40 years old and come from a series of consecutive abortions, if you have excluded the known causes with the exams available to the couple, the motivation is probably to be found in age.
All this must be taken into consideration when deciding to embark on an assisted fertilization process.
How are the success rates based on age to be taken into account.
We know, for example, that in Veneto it is possible to resort to PMA under the NHS regime up to a woman’s 50 years of age. But do you know how many homologous treatments are successful after the age of 45? Practically 0 (zero) . How come you can do the same under the ticket regime? Simply for political choices.
Private centers, on the other hand, often (and rightly so) refuse to offer fertilization treatments with the woman’s oocytes to a woman over 45 (they would lower the success rates of their treatments and this is not good for the centre’s marketing), and directly suggest the ‘heterologous.
Not all women, or couples in general, are able to accept heterologous fertilization with oocyte donation even if in recent years it has become the preferential route after the age of 44-45, to avoid a series of abortions or implantation failures, which from a psychological and physical point of view (without thinking about the economic issue), they are really difficult to sustain, especially for the woman who undergoes hormonal stimulation that is anything but pleasant.
Why, then, do we read about famous people who have children at the age of 45-50?
Almost always the children she had at this age were born from gamete donation, or even from embryo donation, other times the woman uses oocytes that she had frozen when she was younger. Natural pregnancies over the age of 45 are very infrequent.
Can the heterologist be done in Italy? Yes, even in public centers that are equipped in this sense, the oocytes are in most cases purchased from Spain.
As far as pre-implantation diagnosis is concerned, there are very few public centers that carry it out (Arco in the province of Trento for example) unlike private ones where it is becoming an increasingly used method even if it has a considerable cost which adds to that of treatment.
Bibliographical references
Franasiak JM, Forman EJ, Hong KH, Werner MD, Upham KM, >Treff NR , The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening. Fertil Steril 2014;101(3):656–663.e1.
Anne-Marie Nybo Andersen, Jan Wohlfahrt, Peter Christens, Jørn Olsen, Mads Melbye, Maternal age and fetal loss: population based register linkage study. BMJ Vol 320 24 June 2000
REPORT OF THE MINISTER OF HEALTH TO THE PARLIAMENT ON THE IMPLEMENTATION OF THE LAW CONTAINING RULES ON MEDICALLY ASSISTED REPROCREATION (LAW 19 FEBRUARY 2004, N. 40, ARTICLE 15) – Activities in 2016 medically assisted procreation centers.
Kathryn Barlow is an OB/GYN doctor, which is the medical specialty that deals with the care of women's reproductive health, including pregnancy and childbirth.
Obstetricians provide care to women during pregnancy, labor, and delivery, while gynecologists focus on the health of the female reproductive system, including the ovaries, uterus, vagina, and breasts. OB/GYN doctors are trained to provide medical and surgical care for a wide range of conditions related to women's reproductive health.