Facing fertility at 40 and what to expect

An increasing number of women are having babies later in life, but many face an uphill battle to get pregnant, says Helen O’Callaghan.

SHE was 43. She’d never had a baby. “I want to try everything else before I try IVF,” she told her gynaecologist.

Recalling the hopeful 40-something, Dr Mary Wingfield, consultant gynaecologist in Holles Street and clinical director of Merrion Fertility Clinic, says: “She was already 43 — she’d missed the boat for IVF.”

Yet, trends seem good for women in their 40s hoping for motherhood. CSO figures show 4,202 women aged 40 and over had babies in 2015 — 988 for the first time. This was a slight rise on 2014 figures — 4,135 including 940 first-timers. 

“Births to first-time mums aged 40 and over have doubled in the last 10 years,” says Wingfield.

But births to women in their 40s still represent just 6% of total births in Ireland. 

“Certainly, you can get pregnant when you’re 40 but you’re much more likely to when you’re younger,” says Wingfield, citing a 1986 US study that looked at age of marriage and likelihood of having children. Only 6% of women marrying aged 20-25 remained childless compared to 64% of those marrying aged 40-44.

Today’s figures tell the same story, says Wingfield. 

“If women start trying for a baby at 30, they have a 75% chance of getting pregnant naturally after a year — at 40 they have a 44% chance.” 

And maybe that doesn’t sound too bad — except the rate of miscarriage also rises with maternal age. At 30-35, a woman’s miscarriage risk with any pregnancy is 15% — at 40-44, it’s 50%.

Wingfield believes the very fact of IVF can lull women into a false sense of security about their chances of motherhood. Yet IVF can’t make up in any total way for the loss of female fertility.

At Cork Fertility, Dr John Waterstone says the rate of IVF success for 40-something women depends on where they are in their 40s. 

“There’s a massive drop-off beyond age 42. The chance of a single treatment leading to a live birth is 42% for under-35s. It’s 38% for those aged 35-37, 26% for 38- to 40-year-olds and 16% for women aged 41-42. Beyond 42, it’s less than 5% — there’s a sudden decline down to a very low success rate.”

At Zita West Clinics, group practice manager Anita O’Neill says in five years of doing IVF only one 44-year-old has had a live birth through IVF using her own eggs.

“IVF is woefully unsuccessful at 44 using a woman’s own eggs,” says O’Neill, who runs clinics on alternate months in Dublin and Cork. 

“I often meet women who say ‘I’m 42 but everyone says I look 32. I’m actually fitter now than in my 30s — I’m eating better and going to the gym’. But it’s all about the egg — those eggs have been inside her body for 43 years. She might be ageing well but her ovaries aren’t.”

O’Neill says a 44-year-old has more chance of conceiving naturally than through IVF with her own eggs. She explains: “Around 90% of a 21-year-old’s eggs are normal. The reverse is true for a 41-year-old woman — 90% of her eggs are abnormal. 

"IVF stimulates the ovaries to push out as many eggs as possible — great if she’s younger and has loads of good eggs, not so great if she’s older.”

Mother Nature, however, may naturally select a dominant egg that’s healthy. 

O’Neill says there “isn’t a clinic on the planet” that hasn’t had a woman, 42 or 43 years old — who’s decided to move on after a number of failed IVFs — come back saying: ‘guess what? I’m pregnant naturally’.

O’Neill wishes celebrity mums having babies in their mid- to late-40s would divulge if these births result from egg donation. 

“I wish more women were open about this. Chances of having a baby at 44 with your own eggs is around 1% — with egg donation at that age, it’s around 60%.”

Consultant obstetrician and director of Infant Research Centre UCC, Dr Louise Kenny, says the numbers of women having babies in their late 30s/early 40s are going up year on year. At CUMH, 491 mums aged 40-plus gave birth in 2015, up from 432 in 2011. 

While fertility “does decline somewhat steeply after 40”, she says spontaneous pregnancy among women in their 40s is “not uncommon”.

When early-40s women come for pre-conceptual advice, Dr Kenny tells them three things: fertility isn’t as guaranteed as in their 30s; there’s higher risk of conceiving a baby with a chromosomal disorder like Down syndrome; and there’s greater risk of pregnancy complications (eg, pre-eclampsia, high blood pressure, smaller baby or developing gestational diabetes with all associated complications).

“Older women have been around for longer. They’re likely to have already picked up health-related problems like being overweight or having an endocrine or autoimmune disorder.”

Dr Kenny finds women in their 40s significantly underestimate the fertility problems they may encounter, yet overestimate risk of having a baby with Down syndrome. 

In fact, she says risk of having a baby with a chromosomal disorder isn’t as high as people think — at age 36, risk is one in 250; at 40 it’s one in 100; at 45, it’s one in 30. 

“They’re much more likely to struggle to conceive than they are to have a baby with problems or to encounter problems in pregnancy.”

Maternal age isn’t the biggest worry Dr Kenny has when giving pre-conceptual advice. 

“Risks increase, even for a [pregnant] mum in her 40s who’s fit, healthy and a marathon runner — but not as much as for a morbidly obese 20-year-old who’s a smoker. Obesity’s as big a problem as maternal age.”

The good news is if women in their 40s do conceive, their chances of having a good outcome are excellent. 

“I don’t have any major concern taking care of a fit, healthy, slim, non-smoking woman in her 40s who’s pregnant — there are very few issues for me to worry about.”

WHY women wait ’til their 40s to have a baby is multi-factorial. It’s rarely because they “want everything” — getting ahead in their career, the perfect house — says O’Neill. 

“For most, life has just got in the way. They only met their guy in their mid- to late-30s. Some have had major adversity because of the recession. I’ve had women say ‘I can’t afford to get pregnant right now — we’ve got a huge mortgage, he’s lost his job, mine’s precarious’ and I’m saying ‘yes, but you’re 40!’ 

"I’ve had other women, who’ve looked after elderly parents and suddenly they wake up and they’re 40.”

And there are women like Delia Pearlman, 43, who has two children from a previous relationship and now has a four-month-old, Lizzy Rose, with current partner, Liam. 

“We wondered if we were selfish having a baby at our age — Liam’s 47. Maybe we wouldn’t be as healthy when the child was growing up? But Liam had never had kids — having a child was important to him. 

"We knew we really wanted it so we just got on with it,” says Delia, who got pregnant with Lizzy Rose five months after suffering a miscarriage.

When trying to conceive, she attended Dun Laoghaire-based natural fertility specialist Jessica Bourke. Bourke (www.jessicabourke.com) has been in practice for 12 years and says 30% of clients are women in their 40s. 

They’re often “down in the dumps” when they first come, partly because their experience at fertility clinics has been “overwhelmingly negative”.

Bourke’s beginning to hear slightly better feedback now — “where the consultant says ‘well, we’ll see’ and doesn’t flat out dismiss their chances”.

O’NEILL also believes most doctors don’t judge women for waiting ’til their 40s. 

But women often find out in the same consultation that their eggs are so poor they’re close to menopause, their chances of conceiving are minuscule and their only chance is egg donation.

“The woman goes in hoping for some little drug or test that’ll help her conceive and in 10 minutes she gets information that wasn’t even on her horizon. 

"Doctors are busy but you can give honest information that comes across as brutal or you can do it with sensitivity,” says O’Neill.

Bourke has concerns about placing too high a focus on maternal age and the over-emphasis on ageing eggs, believing it leaves women feeling powerless.

“Eggs go through a four-month maturation process. During this time, a woman can influence the follicular fluid in which the egg’s suspended. 

"This fluid nourishes the egg — dictates its end game,” she says, citing antioxidants and folic acid, for example, as supportive of egg quality.

Dr Kenny had her babies in her 20s and says she’s unusual in her group of well-educated friends. 

“I have colleagues and friends in their late 30s and 40s who are trying. They won’t have to worry about being the [only] older mum at the school gate and — with 40 being the new 30 — they won’t have to worry about not seeing their grandkids.” 

Older mothers, she says, are “financially secure, have lived a little so they’re more mature, have a good outlook on life and make great parents”.

Delia Pearlman finds her body “almost re-energised” after having a baby at 42. 

“I feel like I’m more in my 30s because I have this young baby and I’m breastfeeding her. Fifteen years ago, I thought of 43 as old — when you get to this age you don’t think it’s that old.”

Dr Kenny would never try to talk any woman out of trying to get pregnant in her 40s. 

“If you have a baby-shaped hole in your life, it becomes a chasm in your 50s. I’m only ever positive and encouraging.”

  • Free pregnancy information meeting at Royal College of Physicians of Ireland, Thursday, March 9 (6-8pm). Expert speakers include Dr Mary Wingfield and Master of Rotunda Hospital Professor Fergal Malone; booking: rcpi.ie

‘We’d stopped trying on particular days’

Cait Barden with her son Frankie: ‘On my 42nd birthday, I was two days late and did a test. It told me I was pregnant. It was the most magical feeling I’ve ever had!’ Picture: Dave Meehan.

Dublin-based Cait Barden, aged 45, discovered she was pregnant on her 42nd birthday with son Frankie, now 2½.

“I’m married almost seven years. The first year, we didn’t really try for a baby – we’d had bereavement of a close family member and I was in a busy job.

"The second year, we really started trying. I assumed I’d have no problem getting pregnant. Then I realised I didn’t have a lot of time. By now I was 40 or 41.

“We went for tests. I had extremely low AMH [approximate quantity of remaining eggs] and was told it was highly unlikely I’d become pregnant either naturally or through IVF. I was devastated but only for a minute. My sister advised me not to go on the internet and I didn’t.

“I didn’t want to go the IVF route. I’ve always believed in looking at the whole as opposed to the bit. I went to an acupuncturist, herbalist, healer and for shiatsu. I went to fertility specialist Jessica Bourke who helped with nutrition and around stress. 

"I embarked on a whole self-care regime, looking at my regret over not trying to conceive earlier. I work in education and I changed jobs. I joined an amazing choir and sang my heart out. The womb represents creativity and I did a lot of visualisation around the womb.

“I allowed myself the budget I’d have spent on IVF to make myself really well. We bought a little camper van and we’d go off in that. I never gave up hope of a baby. 

"The month I got pregnant, we’d stopped trying on particular days and were intimate whenever we felt like it. I was in Clare, learning to surf, and I thought: ‘well, you know universe, if it’s not going to happen with a baby I’ll take up surfing’.

“There were challenges. Every month’s a disappointment once you start trying. I remember trying to do complicated saliva tests to check vitamin D, thinking ‘if we can’t do this, how will we have a child?’ There were simple things like should you give up coffee and then having coffee and feeling guilty.

“On my 42nd birthday, I was two days late and did a test. It told me I was pregnant. It was the most magical feeling I’ve ever had! I had no health problems during pregnancy, though I got tired in the last weeks. Frankie was born by C-section.

“Having a young child is tiring but everyone says that. I go to a kinesiologist every three months. I take vitamins, do yoga twice weekly, go for acupuncture.

"The one thing that was trying in the early days was having no support nearby. But you find your tribe; some of my friends, the same age, are in a similar situation.”


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