How do you counsel patients about the realistic chances of IVF success over age 40?

Highlights

• IVF success after age 40 is primarily driven by both age, which correlates with egg quality, and individual ovarian reserve, which indicates egg quantity.
• Clinicians should use national data, prediction calculators, and age-based euploidy charts to provide personalized, data-driven estimates of a patient's success.
• Set realistic expectations by explaining that a significant percentage of embryos will be genetically abnormal, a reality that IVF technology cannot change.
• Inform patients that they may need to undergo multiple IVF cycles to obtain a single genetically normal embryo with a good chance of live birth.
• Consider recommending PGT to avoid transferring abnormal embryos, which can help determine more quickly if another IVF cycle is necessary.

Article

The Dual Impact of Age and Ovarian Reserve

When counseling patients over 40 about the prospects of in vitro fertilization (IVF), a nuanced conversation is required that balances population-level data with individual patient characteristics. All consulting experts agree that chronological age is a primary driver of success, but it is not the sole determinant. Dr. Randi Goldman begins by showing patients national SART data to establish a baseline understanding of average outcomes for their age group. However, she quickly pivots to the other crucial factor: ovarian reserve. As Dr. Goldman notes, while ovarian reserve generally declines with age, the two are not perfectly correlated. A patient's specific ovarian reserve markers, such as AMH, provide a more personalized prognosis, a point echoed by all contributors. The central tenet of counseling is to synthesize the powerful, unmodifiable impact of age on egg quality with the variable, individual factor of egg quantity.

"While ovarian reserve tends to decline with age, the two are not completely linked." Dr. Randi Goldman

Communicating the Reality of Oocyte Quality

A critical aspect of the consultation is explaining that IVF cannot reverse the age-related decline in oocyte quality. Dr. Molly Moravek emphasizes this point, noting that many patients are unaware of this limitation. She explains that since oocytes have been present since birth, they accumulate genetic changes over decades, leading to a higher rate of aneuploidy. By age 40, more than half of a woman's eggs are genetically abnormal, which can lead to implantation failure or miscarriage. As Dr. Moravek states, there is currently no test for egg quality, making age the best available proxy. This fundamental biological reality underpins the statistical challenges faced by patients in this age group and must be communicated clearly to manage expectations.

"Unfortunately, IVF cannot overcome this decline in quality, which many patients don't know." Dr. Molly Moravek

Personalizing Prognosis with Ovarian Reserve

While age sets the statistical backdrop for oocyte quality, ovarian reserve determines the number of opportunities a patient has to find a euploid embryo in a given cycle. This concept of "playing the odds" is a cornerstone of effective counseling. Dr. Goldman explains that a 40-year-old with a higher AMH is expected to have more eggs retrieved, which increases the likelihood of obtaining at least one genetically normal embryo compared to a peer with diminished ovarian reserve. Similarly, Dr. Dana McQueen uses the antral follicle count from an initial ultrasound to adjust expectations based on projected egg yield. Dr. Moravek uses the SART pregnancy calculator, which incorporates personal metrics like AMH and BMI, to provide a more tailored success estimate. This personalized approach moves the conversation beyond generic age-based statistics to a more specific discussion of the patient’s individual potential.

Setting Expectations for Multiple Cycles

A shared strategy among the experts is preparing patients for the high probability of needing more than one IVF cycle. Dr. McQueen provides a clear, data-driven framework for this discussion. She explains that on average, a 40-year-old woman yields 10 eggs, resulting in approximately one euploid embryo, as about 45% of embryos are euploid at this age. Given that a euploid embryo has about a 65% chance of live birth, she counsels that two IVF cycles are often needed to obtain two euploid embryos for a high cumulative chance of success. Dr. Moravek also prepares patients for multiple rounds, framing it as a necessary process to find the "one normal embryo" and celebrating if success comes sooner. To make statistics more tangible, she often uses an analogy: "At 42 years old, your chance of pregnancy with an untested embryo is probably less than 10%. That means if 10 women exactly like you... only one of them would probably get pregnant... It's like flipping a coin."

"Setting expectations early that it may take more than one cycle helps patients prepare mentally for the road ahead." Dr. Dana McQueen

The Role of PGT-A and Strategic Planning

The high rate of aneuploidy in this patient population brings the discussion of Preimplantation Genetic Testing for Aneuploidy (PGT-A) to the forefront. Dr. Moravek reports that she tends to recommend PGT-A for older patients to avoid the time, cost, and emotional toll of transferring non-viable embryos. This allows for a more efficient pathway, enabling a quicker transition to a subsequent retrieval cycle if no euploid embryos are identified. She uses tools like the Cooper Genomics euploid embryo graph to further illustrate the chances of success based on age and the number of embryos tested. This strategic approach, combined with frank discussions about the statistical realities and the potential need for persistence through multiple cycles, provides patients with the clear, authoritative, and realistic guidance necessary to navigate their treatment journey.