Prof. Dr. Levent Şentürk

1. FERTILIY PROBLEMS
IN LATE
REPRODUCTIVE YEARS
Levent M. SENTURK, MD, Professor
Istanbul Universitesiy Cerrahpasa School of Medicine
Dept. of Ob&Gyn,
Division of Reproductive Endocrinology, IVF Unit
President, Turkish Society of Menopause and Osteoporosis
Elected Governing Board member, EMAS

2. • Advisory Board: Exeltis, TR
• Lecturer: Exeltis TR, Merck TR, Bayer TR
Personal Disclosure

4. Faddy MJ,1992
Decline in ovarian follicular reserve
Decline in ovarian follicular reserve

5. Broekmans FJ, 2009
Decrease in quantity and quality of follicles
Age

6. Natural fertility by age
Different populations
Menken J, 1986

7. Richardson MC, et al, 2014
Decline in ovarian follicular reserve

8. Richardson MC, et al, 2014
Decline in ovarian follicular reserve

9. Sauer MV, 2015
Percentage of aneuploidy relative to age
in biopsied human embryos

10. Percentage of cycles relative to age
with NO euploid embryos on biopsy
Sauer MV, 2015

11. Sauer MV, 2015
% 1987 2005
>30 11 26
>35 4 11

12. Sauer MV, 2015
“Menopausal mothers”
• An accelerated increase in births to older women,
especially in their 40s and 50s, occurred after 1990 in US
• Pregnant women
• “elderly”
• “advanced / very advanced maternal age (AMA)”

13. SART, 2014

14. SART, 2014

15. SART, 2014

16. SART, 2014

17. SART, 2014

19. Sauer MV, 2015
“How old is too old?”
• 50 y/o
• IVF
• Own oocytes
• Preterm
delivery
• C/S
• HT
• IDDM
• Preeclampsia

20. “How old is too old?”

21. “How old is too old?”

22. “How old is too old?”

23. “How old is too old?”

24. Sauer MV, 2015
Older gravity is always w/ high risk
• Obesity
• HT
• DM
• Maternal mortality: CVD, DM, placental abruption, and
complications from operative deliveries
>45 yrs
0.2% of
all gest.
2.0% of
all deaths

25. Sauer MV, 2015 (Schoen C, Rosen T, 2009)
Older gravity is always high risk!

26. Deatsman S, et al, 2016
Results
• Prospective IRB approved survey of women (n=94)
attending an OB/GYN clinic
• Ages ranged from 18 to 67
• ONLY 30.5% were aware fertility begins to decline at age
35, however this varied among groups depending on prior
hx of infertility or requiring fertility treatment.
• Nulliparous women were more unaware of the health risks
of pregnancy over age 35 (1.4% vs 13.6%, p=0.02).
• African American women were less likely to think obesity
(76% Caucasian vs 47.8% AA vs 66.7% other, P < 0.05) and older age (88%
Caucasian vs 60.9% AA vs 82.7% other, p=0.02) may affect fertility.
Age and Fertility: A Study on Patient Awareness

27. SOGC, Clinical Practice Guideline, 2011
Advanced Reproductive Age and Fertility
• Women in their 20s and 30s should be counselled about
the age- related risk of infertility when other reproductive
health issues, such as sexual health or contraception are
addressed as part of their primary well-woman care.
Reproductive-age women should be aware that natural
fertility and assisted reproductive technology success
(except with egg donation) is significantly lower for women
in their late 30s and 40s. (II-2A)
• Because of the decline in fertility and the increased time to
conception that occurs after the age of 35, women > 35
years of age should be referred for infertility work-up after
6 months of trying to conceive. (III-B)
CONCLUSION

28. SOGC, Clinical Practice Guideline, 2011
Advanced Reproductive Age and Fertility
• Ovarian reserve testing may be considered for women ≥ 35
years of age or for women less than 35 years of age with
risk factors for decreased ovarian reserve, such as a single
ovary, previous ovarian surgery, endometriosis, poor
response to follicle-stimulating hormone, previous
exposure to chemotherapy or radiation, or unexplained
infertility. (III-B)
• Ovarian reserve testing prior to assisted reproductive
technology treatment may be used for counselling but has
a poor predictive value for non-pregnancy and should be
used to exclude women from treatment only if levels are
significantly abnormal. (II-2A)
CONCLUSION

29. SOGC, Clinical Practice Guideline, 2011
Advanced Reproductive Age and Fertility
• Pregnancy rates for controlled ovarian hyperstimulation
are low for women > 40 years of age. Women > 40 should
consider IVF if they do not conceive within 1 to 2 cycles of
controlled ovarian hyperstimulation. (II-2B)
• The only effective treatment for ovarian aging is oocyte
donation. A woman with decreased ovarian reserve should
be offered oocyte donation as an option, as pregnancy
rates associated with this treatment are significantly higher
than those associated with controlled ovarian
hyperstimulation or in vitro fertilization with a woman's
own eggs. (II-2B)
CONCLUSION

30. SOGC, Clinical Practice Guideline, 2011
Advanced Reproductive Age and Fertility
• Women should be informed that the risk of spontaneous
pregnancy loss and chromosomal abnormalities increases
with age. Women should be counselled about and offered
appropriate prenatal screening once pregnancy is
established. (II-2A)
• Pre-conception counselling regarding the risks of
pregnancy with advanced maternal age, promotion of
optimal health and weight, and screening for concurrent
medical conditions such as hypertension and diabetes
should be considered for women > 40. (III-B)
CONCLUSION

31. SOGC, Clinical Practice Guideline, 2011
Advanced Reproductive Age and Fertility
• Advanced paternal age appears to be associated with an
increased risk of spontaneous abortion and increased
frequency of some autosomal dominant conditions, autism
spectrum disorders, and schizophrenia.
• Men > age 40 and their partners should be counselled
about these potential risks when they are seeking
pregnancy, although the risks remain small. (II-2 C)
CONCLUSION

32. Sauer MV, 2015
CONCLUSION
• Older mothers have unrealistic expectations that a baby
will solve problems in their life and serve as an
enhancement.
• The reality of childbearing for older mothers is different
from their younger counterparts and more complex.
• The pregnancy is often complicated, and more importantly
the dynamic of raising a family during retirement years is
challenging.
• Physical, psychological, financial, and social resources will
be consumed thoroughly as children are raised.
• Many patients of AMA are first-time mothers; they have
lived adult lives without children and now must undergo a
radical transformation in lifestyle to accommodate many
needs of a baby.

33. Levent M. SENTURK, MD, Professor
Istanbul Universitesiy Cerrahpasa School of Medicine
Dept. of Ob&Gyn,
Division of Reproductive Endocrinology, IVF Unit
President, Turkish Society of Menopause and Osteoporosis
Elected Governing Board member, EMAS
FERTILIY PROBLEMS
IN LATE
REPRODUCTIVE YEARS
Thank