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Janet Jackson Delays Tour to Start Family: How Old is too Old for IVF?

by Dr. Geoffrey Sher on April 7, 2016

More and more women are deciding, based upon personal preference and professional necessity, to postpone having a family to a later age. In fact, very recently Janet Jackson (49Y) was in the news stating that she was cancelling her tour to prepare for treatment needed to have a baby. This event prompted me to write this article on IVF in women of a more advanced age

The truth is that hardly a day goes by when I am not asked the question of, “How old is too old to do IVF?” The standard answer for women under 43Y, provided that they have an adequate number of eggs (ovarian reserve), IVF with own eggs is definitely an option. After 43y the percentage chance that an IVF cycle (where the woman uses her own eggs) will result in a live birth, declines to the single digit range and after age 45Y it falls to well under 5% per cycle, making the use of an egg donor, the only rational choice.

Any decision of when/ whether a woman’s age should affect a medical decision on whether or not to proceed to IVF, should also take into consideration the following:

1) The increasing incidence of pregnancy complications with advancing age

2) The risk to the baby of poor intrauterine development and premature birth, both with their respective risks

3) Ethical factors, such as age and its effect on projected life span, as well as the physical, emotional and financial ability to provide for the needs of the child.

BUT it is not as simple as that! I will never forget a couple that travelled from Munich, Germany to consult with me regarding IVF with Egg Donation about 20 years ago. The lady, who will here be referred to as (JS) was 53 years of age and her husband (PL) was 44. At that time, we had a general policy not treat women over 50 years of age. When I informed her of this, she became very agitated. She responded that she was in perfect health, while her husband suffered from moderately severe hypertension and type 2 diabetes. She asserted that had the ages been reversed, (i.e. if she were 44Y and he 53Y) we would never have rejected them. She went on to insist that the ruling amounted to sexual discrimination….and you know what? She was right! I suggested that the couple personally present their argument to our Ethics Advisory Board…which they did. The board authorized me to perform IVF with egg donation. I did so and subsequently transferred two embryos to PL’s uterus. She conceived and gave normal vaginal birth (at full term) to two healthy girls. I have since heard regularly from this couple, receiving family photographs, virtually every year, and the two girls are now both in college. Sadly, PL passed away about 3 years ago and JS very recently got remarried. The new family is thriving.

Any woman, regardless of age, given access to “competent” eggs/embryos, whether own egg or donor-derived, who has a receptive uterus (her own, or that of a gestational carrier), is capable of achieving motherhood through IVF. This ability is of course predicated upon the patient having access to a full spectrum of options.

Herewith, a few basic considerations:

  1. Access to at least one “competent” embryo. It is a fact that as women advance beyond their mid-thirties, both the number and chromosomal integrity of their eggs, will inevitably decline. At age 30Y about 1:2 are chromosomally numerically normal (euploid) and “competent”, upon fertilization to implant in the uterus and propagate healthy babies. By age 40Y about 1:6 eggs are euploid and by the 42nd year, only about 1:10 will be “competent”. By the time the woman reaches age 45, only about 1: 25 harvested eggs will be euploid

Simultaneously, as the woman reaches her 40’s, the number of eggs remaining in her ovaries, (her ovarian reserve) will start to decline. This diminishing ovarian reserve (DOR) will be reflected in her basal blood FSH level rising progressively, and her blood antimullerian hormone (AMH) level dropping. What this means is that the woman’s pregnancy potential drastically declines as she emerges from her 30’s into her 40’s.

The combination of age-related egg “competency” and ovarian reserve is referred to as the “biological clock.” By the time the average woman reaches 43y, both of these component parts of the “biological clock” will usually have declined substantially, such that after 43 years of age, she would be best advised to preferentially choose egg donation. The transfer of a single advanced embryo (blastocyst) to the uterus of a 43 year old woman, will likely yield less than a 10% chance of a baby. Conversely, a similar looking blastocyst found through chromosomal testing or PGS (using next generation Gene sequencing or NGS) to be euploid and “competent” could allow the same woman a 40-50% chance of a live birth. It thus follows that for women with such declining fertility potential, NGS embryo testing with “banking” (stockpiling) of several embryos over multiple IVF cycles will at the time of transfer to the uterus, dramatically improve the odds of success. 

  1. A receptive uterus: For an embryo to propagate a viable pregnancy the uterus needs to be anatomically normal, its endometrial lining needs to develop normally in response to estrogen, and any underlying immunologic implantation dysfunction must be identified and corrected. Conditions such as uterine fibroids and adenomyosis are more prevalent in older women. And post-menopausal women who are estrogen depleted will find their uteri shrinking and the endometrial lining becoming ever less responsive to estrogen. It is important in such cases to prescribe estrogen hormone replacement therapy for 2-3 months, prior to performing embryo transfer.
  2. A healthy parturient, who is capable of carrying a baby to term. The Hippocratic Oath demands that physicians knowingly never put patients in harms way. Since pregnancy is inevitably associated with increasing maternal risk as the woman ages, it is important prior to embarking on fertility treatment in such cases, to perform a thorough physical examination and a barrage of tests that include, (but are not limited to) EKG, chest x-ray, blood chemistry (BUN, electrolytes, creatinine, liver enzymes, lipid profile, glucose etc..), mammogram, and PAP smear.
  3. A medical and laboratory team with the necessary experience/expertise, and with ready access to the most advanced options such as:
  •  Egg Donation
  • Gestational Surrogacy
  • Donor sperm (if needed)
  • Genetic embryo selection (using PGS)
  • Gestational surrogacy.

When it comes to a “cut off” for IVF eligibility, age is an important consideration, and the risk/benefit of any particular course of treatment needs to be critically addressed with patients but there can, in my opinion, not be any hard and fast rule. In the final analysis, each case must be considered on its own merit. As physicians, we have the responsibility of providing patients with information needed to make a decision without imposing our will upon them.

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  • CR - June 14, 2017 reply

    Dear Dr Sher
    I know that at 48 (nearly 49) going for IVF with my own eggs is really frowned upon but I cannot use donor eggs so this is my only last hope. This will be my 5th and last attempt. I had blood taken in the UK – my Gonadotropin levels taken on day 4 after my last period – FSH = 7.9, LH = 9.6 and Oestradiol level = 816. I was told that I was not menopausal. My Thyroid is 1.5 – I take Levothyroxine 50mcg per day. This month I have started an IVF cycle and started medication on day 2 – Tamoxifen 20mg once daily, Doxycycline 100mg twice daily, Prednisolone 5mg once daily, Folic Acid 5mg once daily and Melatonin 3mg once daily. Today is day 5 taking the medication and I have also had a scan today – and there is only 1 follicle in the right ovary 2.5cm x 1.5cm. The max endometrium thickening was 0.2cm. The uterus delinates normally and no ascites present. I would be really grateful for your opinion as to what you think of this. I am having another scan tomorrow evening and would like to know your opinion about increasing my stims as the Tamoxifen info states the dose can be changed to 40mg or 80mg. Of course I will go by my consultant but I would really like a second opinion. In the past one of my ovaries has responded better than the other (I have had ivf 4 times in the past – all have produced 2-4 very good quality blastocysts which have been implanted each time – one cycle ended in miscarriage, others nothing. I am concerned that this month I have chosen to do this cycle that my body is going with the less responsive ovary. Your opinion would be very much appreciated.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 15, 2017 reply

    Hi CR,

    I wish I could mbe optimistic but regardless of approach, using own eggs at 48 will almost certainly fail. You absolutely need to use an egg donor. Anything else would be a travesty.

    When you do try you will also have to face the fact that with hypothyroidism you could have an immunologic implANTATION DYSFUNCTION (SEE BELOW).

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
    • The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • IVF Egg Donation: A Comprehensive Overview

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

  • dalya - April 18, 2016 reply

    On my ivf .. they told me that most if my eggs were dark and fragile when doing icsi on them..
    Is this a quality issue?!
    Why they were dark and fragile?! Is it my age or the protocol?!or is it the high dose of the fsh injuctions?
    What should be done to avoid this condition and dose it affect sucess rate?!

    Iam 32 years old .. have text book PCOS..
    Was on long protocol with gonal-f 225 for 14 datys then hcg shot trigger on the 15th day.
    Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - April 18, 2016 reply

    At 32y with PCOS, the selection of the protocol for ovarian stimulation is pivotal. Women with PCOS do have a tendency to hyperstimulate and require a very strategic and individualized approach to ovarian stimulation otherwise egg quality can be adversely affected.

    My approach is consistently to have my patients who are at risk of developing OHSS, launch their ovarian stimulation, coming off a monophasic birth control pill (BCP). The last few days on the BCP is accompanied by the addition of Lupron. Thereupon the BCP is stopped and Lupron therapy is continued. After 3-7 days menstruation usually ensues, at which point the dosage of Lupron is reduced and low dosage FSHr (Follistim/Gonal-F/Puregon) -dominant ovarian stimulation is commenced. Lupron and gonadotropins are then continued together. This approach is referred to as the “Long Pituitary Down-regulation protocol” Use of the BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen (mainly testosterone) release (too much ovarian testosterone is harmful to egg development). Seventy five (75) units of LH/hCG (Luveris/Menopur) is added from the 3rd day of gonadotropin stimulation. Starting on the 7th day of ovarian stimulation with gonadotropins, I start watching daily for the # and size of follicles developing and for the rise in blood [E2]. If there are > 25 follicles, the patient becomes a candidate for “prolonged coasting” I keep stimulating with gonadotropins (regardless of the [E2]) until: a) 50% of all follicles reach 14mm and b) the [E2] reaches 2500pg/ml. At that point, gonadotropin stimulation is discontinued abruptly while daily Lupron injections continue. Thereupon I follow the daily blood [E2] without doing further US examinations. The [E2] will almost invariably continue to rise. I carefully plot the rise in [E2] (regardless of how high it goes). Usually, within 1-3 days it will plateau and then start to decline. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer the 10,000U hCGu (Novarel/Pregnyl/Profasi) “trigger” or 500mcg of hCGr (Ovidrel) and then schedule an egg retrieval for 36h later. ICSI is a MUST because “coasted” eggs usually have few or no surrounding cumulus cells and eggs without a cumulus layer will not readily fertilize on their own. All fertilized eggs are cultured to the blastocyst (up to 6 days) whereupon I transfer up to two into the uterus, or vitrify all expanded blastocysts for subsequent dispensation at the directive of the patient. In some cases the embryos are biopsied for PGS testing prior to being cryostored. Subsequent frozen embryo transfers are conducted as per the wishes of the patients.

    It is important to point out that the success of this “prolonged coasting” approach depends on precise timing of the initiation and the conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.

    Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.

    Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
    • The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

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