The document discusses reproductive aging and its impact on fertility. It notes that a woman's quantity and quality of eggs naturally declines with age starting in her mid-30s. While lifestyle factors like smoking can accelerate this decline, age remains the strongest predictor of egg quality and IVF success rates. The document reviews tests of ovarian reserve and treatments for advanced reproductive aging, concluding it's important to counsel patients on realistic expectations and consider alternatives like egg donation if natural conception is unlikely within 3-4 months.

1. How Old is Too Old? Age, Genetics and Reproduction Marcelle I. Cedars, M.D. Director, Division of Reproductive Endocrinology UCSF

7. Normal Biological Decline Gougeon, Maturitas, 30:137-142, 1998

8. Percent Increase in Birthrates CDC Vital and Health Statistics 2000 1976 1980 1985 1990 1995 35-39 30-34 40+ 15-19 25-29 20-24

10. Concurrent Loss in Quantity AND Quality

12. Abnormalities in oocytes increase with age

25. Antral follicle count AFC = 18 AFC= 4

31. FSH Predicts Quantity, but not Quality P=0.3 P=0.05 P=0.06 P=0.01

32. AFC Predicts Quantity and Quality p=0.014 p=0.048 p<0.001 p<0.001

33. Age is the Best Predictor of Quality IR = 28.4 IR = 15.9 p<0.001 PR = 28.7 PR = 46.7 p<0.001

34. Quantity and Quality IR 21.6% 22.6% P=0.78 IR  Poor Responders 38.9% 14.5% P = 0.001

35. Decreased AFC 10 20 30 40 AFC Age # Follicles Reproductive window

40. Estradiol Priming addition of luteal phase GnRH antagonist

42. Minimal Stimulation

43. Minimal Stimulation Stimulation Mild: closed Conventional: open

45. Androgen Pretreatment Balasch et al., 2006 Transdermal testosterone 2.5mg over 5 days

51. IVF – Pregnancy and Livebirth CDC 2004

55. Thank you for your attention