More women are starting or expanding their families later in life. As a result, fertility treatment after 40 has become increasingly common.

Pregnancy after 40 is certainly possible, both naturally and through IVF. However, age has a major effect on reproductive biology, and realistic counselling is particularly important.

Why Does Female Fertility Decline?

Women are born with their lifetime supply of eggs.

Over time, both the number of eggs remaining and the proportion capable of producing a chromosomally healthy embryo decline.

This is why female age is one of the strongest predictors of reproductive success.

The decline becomes particularly important during the late 30s and early 40s.

Egg Number Versus Egg Quality

These two concepts are often confused.

AMH and antral follicle count mainly help estimate egg quantity and expected response to stimulation.

Age provides much more information about the expected quality of eggs.

A woman can therefore have a reasonable AMH at 42 but still experience age-related changes in egg quality.

Conversely, a younger woman may have low AMH but still have comparatively favourable egg quality.

Why Does IVF Success Decline After 40?

IVF can help overcome several fertility barriers, but it cannot completely reverse ovarian ageing.

During IVF, eggs are collected and fertilised to create embryos.

However, as maternal age increases, a greater proportion of embryos may have chromosome abnormalities.

This can lead to:

• Failure of fertilisation or embryo development
• Failure of implantation
• Miscarriage
• Reduced live-birth rates

This is why obtaining an embryo does not necessarily mean that embryo will result in a baby.

Should You Try Naturally First?

That depends on age and circumstances.

At 25 or 30, trying naturally for a period before investigation is usually reasonable when there are no obvious fertility problems.

After 40, time becomes more important.

If you are over 40 and wish to become pregnant, an early fertility assessment can be appropriate rather than automatically waiting six or 12 months.

What Tests May Be Helpful?

Assessment may include:

• Pelvic ultrasound
• Antral follicle count
• AMH
• Menstrual and ovulation history
• Semen analysis
• Assessment of the uterus
• Fallopian tube assessment when appropriate
• Relevant preconception investigations

The objective is to identify potentially treatable fertility factors and determine whether IVF is appropriate.

Can Higher IVF Medication Doses Overcome Age?

Not completely.

Increasing stimulation medication may influence the number of follicles recruited in some circumstances, but medication cannot make the ovaries produce unlimited eggs.

More importantly, increasing the medication dose cannot make an older egg biologically younger.

IVF protocols therefore need to be individualised.

What About Embryo Genetic Testing?

Preimplantation genetic testing for aneuploidy, commonly called PGT-A, examines cells sampled from a blastocyst to assess chromosome number.

It may provide useful information in selected circumstances, particularly where multiple blastocysts are available.

However, PGT-A is not a treatment that improves the underlying quality of eggs.

It also does not guarantee pregnancy or a healthy baby.

Whether PGT-A is appropriate should be discussed individually, including its potential benefits, limitations, costs and the number of embryos likely to be available for testing.

Can Supplements Improve Egg Quality?

Many products are promoted as ways to improve egg quality.

Good nutrition, regular exercise, avoiding smoking and optimising general health are sensible before pregnancy.

However, patients should be cautious of claims that a supplement can reverse reproductive ageing.

No supplement has been established as capable of making a 42-year-old egg biologically equivalent to a 30-year-old egg.

Is Donor-Egg IVF an Option?

For some women, particularly when repeated treatment using their own eggs has been unsuccessful, donor eggs may provide another pathway to pregnancy.

Success with donor eggs is influenced strongly by the age and reproductive characteristics of the egg donor rather than solely by the age of the recipient.

This is a significant personal decision requiring appropriate counselling and medical guidance.

Pregnancy Health After 40

Fertility is only part of the discussion.

Pregnancy at older maternal ages is associated with increased risks of certain pregnancy complications.

Preconception health assessment is therefore valuable.

Optimising blood pressure, weight, diabetes risk, medications and other medical conditions before pregnancy can improve overall pregnancy care.

The Take-Home Message

IVF after 40 is possible, but expectations should be realistic.

Age influences both the number and, particularly, the chromosome competence of available eggs.

An early fertility assessment can help determine ovarian reserve, identify additional fertility factors and clarify treatment options.

The aim should not be to promise success but to provide accurate information so that you can make timely decisions about the options available to you.