Dr. Amanda Adeleye asked...

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

5 contributors

Highlights

It is essential to counsel patients that both age (the primary determinant of egg quality) and individual ovarian reserve drive IVF success rates.
Set expectations early that women over 40 may need to undergo multiple IVF cycles to achieve a live birth from a euploid embryo.
Use objective data tools, like the SART pregnancy calculator, to provide patients with personalized and realistic predictions of their success over several cycles.
For older patients, consider recommending PGT to avoid wasting time and money by transferring genetically abnormal embryos before starting another IVF cycle.
To simplify statistics, explain that at age 42, the chance of success is under 10%, meaning one in ten similar women might get pregnant.

Expert Insights

The Foundational Counseling Conversation

When counseling patients over age 40 about their prospects with in vitro fertilization (IVF), establishing realistic expectations from the outset is a universally shared priority among reproductive endocrinologists. Dr. Randi Goldman states that this early, open communication is key to helping patients make informed choices. The core of this conversation rests on two distinct but interconnected factors: maternal age, the primary driver of egg quality, and ovarian reserve, which determines egg quantity. While age is the most significant prognostic factor, Dr. Goldman notes that it is not the only measure. She emphasizes the importance of evaluating the patient holistically, as age and ovarian reserve are not always perfectly correlated; a 40-year-old may present with a high, normal, or low anti-Müllerian hormone (AMH) level, which directly impacts the treatment strategy and prognosis.

"Age definitely matters. It's one of the driving factors in IVF success, but it's not the only measure." Dr. Randi Goldman

The Unmodifiable Impact of Age on Oocyte Quality

A crucial point of clarification for patients is that IVF technology cannot reverse the age-related decline in egg quality. Dr. Molly Moravek explains that this decline is largely due to an increase in genetic abnormalities within the oocytes. She counsels patients that because women are born with all their eggs, these cells are subject to decades of aging, which can lead to genetic changes incompatible with a viable pregnancy. By age 40, Dr. Moravek notes that more than half of a woman's eggs are likely to be abnormal. This biological reality translates directly to embryo quality. Dr. Dana McQueen provides a complementary statistic, informing patients that at age 40, only about 45% of embryos created are expected to be euploid (genetically normal). This high rate of aneuploidy is the primary reason for lower success rates and higher miscarriage rates in this patient population.

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

Ovarian Reserve and the "Numbers Game"

While age dictates the quality of the eggs, ovarian reserve dictates the quantity that can be retrieved in a single IVF cycle. This becomes the central strategic element in treatment. As Dr. Moravek frames it for patients, treatment becomes a "numbers game." A patient with a higher ovarian reserve is expected to yield more eggs, which in turn creates more embryos for evaluation. This higher volume increases the statistical probability of obtaining at least one genetically normal embryo, even if the overall percentage of normal embryos is low. Conversely, Dr. Goldman explains that a 40-year-old with diminished ovarian reserve will likely retrieve fewer eggs, resulting in fewer embryos and a lower chance of finding a euploid one in a given cycle. After an initial ultrasound, Dr. McQueen adjusts patient expectations based on their antral follicle count, providing a more personalized prognosis beyond age-based averages.

Grounding the Discussion with Objective Data

To move the conversation from abstract concepts to concrete probabilities, experts rely on a variety of data-driven tools. Multiple physicians, including Drs. Goldman, Moravek, and Amanda Adeleye, use national data from the Society for Assisted Reproductive Technology (SART) to show patients the average outcomes for their age group. For a more individualized forecast, Drs. Moravek and Adeleye input the patient's specific characteristics into the SART Patient Predictor together with the patient. Dr. Adeleye also refers to academic literature, such as Jason Franasiak’s paper on aneuploidy, to give patients a clear sense of the proportion of embryos likely to be euploid. Similarly, Dr. Moravek uses a Cooper Genomics graph that illustrates the chances of obtaining at least one euploid embryo based on the patient's age and the number of embryos biopsied.

Preparing Patients for the IVF Journey

Synthesizing the data on age and ovarian reserve, the counseling culminates in preparing the patient for the practical and emotional realities of the treatment journey, which often involves multiple cycles. Dr. McQueen provides a clear heuristic: at age 40, women retrieve an average of 10 eggs, which leads to an average of one euploid embryo. Since a euploid embryo has approximately a 65% chance of live birth, she counsels patients that two IVF cycles may be required to obtain two euploid embryos and achieve a high probability of one live birth. Dr. Moravek reinforces this, advising patients to mentally prepare for multiple rounds while hoping for success in the first. To make statistics more tangible, she might say, "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 came to this clinic... only one of them would probably get pregnant." She also frequently recommends preimplantation genetic testing (PGT-A) for this population to avoid the time and expense of transferring aneuploid embryos and to move more quickly to a subsequent retrieval cycle if no normal embryos are found.