Many women choose to delay childbearing until their 30's or 40's due to many factors including career, finances, or personal choice. Approximately 20 percent of women do not attempt pregnancy until age 35 or older. It is a fact that fertility decreases with age. While women under age 30 have approximately a 20 percent per month chance of conceiving, only 5 percent of women over age 40 will conceive. Although women continue to have regular menstrual cycles until the time around menopause, this does not mean that they are necessarily fertile. Ovarian function and egg quality decrease as women age resulting in fertility issues.

One of the main causes of decreased fertility and increased miscarriage risk is the increased risk of chromosomal abnormalities in eggs. This also results in an increased risk of miscarriage if a couple does conceive. A patient age 40 or older has up to a 50 percent risk of miscarriage. Genetic counseling is offered to women who conceive and will deliver at age 35 or older. Prenatal testing may be considered with amniocentesis or chorionic villus sampling to test for chromosomal abnormalities.

Women who conceive after age 35 are also at increased risk of complications in pregnancy including diabetes and high blood pressure. Pre-existing medical conditions may worsen in pregnancy and require special monitoring. Health problems should be treated prior to attempting pregnancy.

Patients should discuss these issues with their physician. An obstetrician/gynecologist will often initiate an infertility evaluation at 12 months of infertility, however, for older patients, this may be initiated after 6 months. If the presumed cause of infertility is age related, ovulation induction or IVF may be recommended. Even with infertility treatment, age affects the chance for pregnancy and this should be discussed with your physician.

Testing for Age Related Fertility
Several tests may be useful at determining a patient's fertility potential, also known as ovarian reserve.

Day 3 levels of FSH and Estradiol
Follicle stimulating hormone (FSH) is a hormone released from the brain that triggers egg development by the ovary. Estradiol is the hormone produced by the ovary as the egg develops. Patients with an elevated estradiol and/or FSH level on the third day of a menstrual cycle have poor pregnancy rates with both ovulation induction and in vitro fertilization.

Clomiphene Citrate Challenge Test (CCT)
The day 3 FSH and estradiol levels may be normal in patients with decreased ovarian reserve. The CCT is another test to more thoroughly evaluate fertility potential.

Clomiphene citrate is an oral medication given orally on menstrual days 5-9. Estradiol and FSH are measured on day 3 and day 10 of the cycle. Elevated blood levels of these hormones are associated with very low pregnancy rates with fertility treatment.

Response to Fertility Medications
The response to injectable high-dose fertility medications is another method for determining ovarian reserve. Patients with decreased ovarian reserve require larger amounts of medication to produce eggs and generally have lower pregnancy rates with ovulation induction and in vitro fertilization. Egg donation is an option for those patients who do not conceive with other therapies or have abnormal ovarian reserve testing. Egg donation involves using eggs donated by another woman. Patients may provide a donor (typically a sister or close friend) or an anonymous donor may be provided.