| There has been a complete paradigm shift in | | | | center, no increase in adverse outcome was noted |
| obstetrical care for women in the 21st Century. As | | | | (Kirz et al. American Journal of Obstetrics and |
| more women are seeking advanced reproductive | | | | Gynecology 1985; 152: 7-12). |
| techniques to assist inachieving a pregnancy, the | | | | All in all, women in their forties and fifties should |
| ceiling of reproduction has been lifted such that | | | | expect to have some mild increase in pregnancy |
| almost any healthy women in her forties and fifties | | | | related issues. However, carefully selected and |
| can successfully mother a child. | | | | monitored women should anticipate a successful |
| In a recent study, we reviewed the pregnancies of | | | | result. We recommend that all women in this age |
| 77 postmenopausal women with an average age of | | | | group see a Reproductive Endocrinologist for a |
| 53 years who underwent an in-vitro fertilization | | | | history and physical exam. She should also undergo |
| procedure with the assistance of egg donation (RJP, | | | | an EKG, a chest X-Ray, mammogram, PAP smear |
| Boostanfar et al., Journal of the American Medical | | | | and blood work as part of herpreconception |
| Association 2002; 288: 2320-2323). This 10-year study | | | | evaluation. When the assessment is completed, |
| is the largest series in the world's scientific literature | | | | women can be counseled suitably as to what their |
| of reported pregnancy outcomes among women in | | | | potential risks may be. Appropriately screened, |
| their sixth decade of life. | | | | healthy women in their fifties, who carry a singleton |
| This database will likely serve as a counseling tool to | | | | pregnancy, can expect theirgestation to go practically |
| guide physicians and patients to know what to | | | | full term and deliver babies that are approximately |
| expect in their fifties. Although outcomes have been | | | | the same weight as their counterparts half their age |
| extremely favorable,there are serious medical | | | | (RJP, Boostanfar et al., Journal of the American |
| conditions that can evolve or become exacerbated | | | | Medical Association 2002; 288: 2320-2323). |
| during pregnancy. Therefore, it has become | | | | Nevertheless, these women are also approximately |
| imperative to understand the physiological changes | | | | three times more likely to deliver by cesarean |
| during this time period and to be prepared and | | | | section, three to ten times more likely to experience |
| watchful of possiblecomplications. | | | | pregnancy induced hypertension and two to five |
| A proportion of women in their early forties are | | | | times more likely to encounter diabetes compared |
| successful in becoming pregnant with their own eggs | | | | toyounger women. Although there does not appear |
| spontaneously, many others are able to conceive in | | | | to be any medical reason for excluding these women |
| cooperation with anegg donor. Although the likelihood | | | | from attempting to become pregnant on the basis of |
| of becoming pregnant is significantly higher with an | | | | age alone, it is recommended they seek the |
| egg donor, pregnancy course and birth outcomes are | | | | attention of a Reproductive Endocrinologist who |
| extremely similar whether a woman is able to | | | | isaware of these complexities, in order that they |
| conceive with her own eggs or with an egg donor. | | | | may be thoroughly screened and deemed as an |
| That is, whether or not the pregnancy is a result of | | | | appropriate candidate to experience a favorable |
| a natural conception, a conception with her own eggs | | | | outcome. |
| and assistance from advanced reproductive | | | | Finally, the careful, deliberate and judicious transfer of |
| techniques like in-vitro fertilization or with the | | | | embryos should be taken into consideration among |
| assistance of egg donation, she is likely to have | | | | patients undergoing an egg donation cycle. Because |
| similar risks and outcomes throughout the duration of | | | | of thesignificantly higher implantation rates of donor |
| her pregnancy. The most notable risk factor is not | | | | eggs and embryos, couples attempting to conceive |
| how the pregnancy was conceived but perhaps the | | | | with the assistance of an egg donor are at a |
| age in which a woman achieves a pregnancy. | | | | particularly high risk of multiplegestations. Moreover, it |
| Pressing the boundaries of reproduction in women of | | | | has become exceedingly evident that multiple |
| advanced reproductive age can be complicated by | | | | gestations may,in turn, further complicate the course |
| underlying medical conditions that are undiagnosed. | | | | of a pregnancy. Those complications include higher |
| Such factors, like adecrease in the reserve of the | | | | rates of morning sickness, preterm labor and preterm |
| cardiovascular system and the diminished ability to | | | | birth and increased rates of pregnancy induced |
| adapt to physical stress both may accompany | | | | hypertension or toxemia. |
| advancing age and may combine to increaserisks to | | | | The introduction of modern extended embryo |
| the mother and the baby. Some authors have | | | | culture, pre-implantation genetic diagnosis and |
| suggested that advanced maternal age, defined as | | | | blastocyst transfer have resulted in a conscientious |
| greater than age 35 by some authors and greater | | | | and concerted effort to increasepregnancy and |
| than age 40 by others, is associated with an | | | | implantation rates, while simultaneously minimizing the |
| increased risk of poor pregnancy outcome (Lehman | | | | number of embryos transferred to one or two per |
| etal., American Journal of Obstetrics and Gynecology | | | | cycle in a realistic attempt to reduce the numberof |
| 1987; 157: 738-742). | | | | high order multiple pregnancies. It is of critical |
| These reports may be confounded by inconsistencies | | | | importance to choose infertility centers, and |
| in prenatal care, preexisting medical conditions and | | | | subsequently obstetricians, with both significant clinical |
| access to appropriate health care. In contrast, when | | | | and laboratoryexpertise in this domain of |
| women of advanced maternalage were followed and | | | | reproductive medicine. |
| delivered in a sophisticated, high risk care medical | | | | |