Pregnancy after 40 years: the answers of Professor François Olivennes

By 2018, 2,000 women over 45 will be mothers. While they deserve special attention because of the risks to the mother and the child, late pregnancies are well controlled by doctors.

A child after 40 years, is it reasonable? It is no longer an exceptional phenomenon, the average age of pregnancy is approaching 30 years in our country. More and more women are tempted: nearly 40,000 a year against less than 10,000 20 years ago. There will even be 2,000 women over the age of 45 who will be mothers in 2018. What is the path to getting this pregnancy? What are the physical risks for both the mother and the child?
Responses with Professor François Olivennes, obstetrician and specialist in infertility treatments.
WhyDoctor: In your practice, how old was the oldest woman at the time of delivery?Prof. François Olivennes When I was an intern, I received a 64-year-old pregnant woman; it was a spontaneous pregnancy that did not develop favorably in a postmenopausal woman. There are very late natural pregnancies, but it is extremely rare, and since the existence of oocyte donation, which allows to use a young oocyte, I think the record is 71 years in India, which my opinion is atrocious.
What is the reasonable age not to be exceeded?Prof. François Olivennes : In our practice of medical assistance to procreation, with the oocytes of the woman, we go up to 43-44 years, and if we use the oocyte donation, I consider that until 46-47 years , it's reasonable. I'm not going beyond 50, even though I had applications at 54 years old. In the United States, getting pregnant after age 50 is not a problem.
Is not it normal that this age becomes higher and higher?Prof. François Olivennes : It is striking that the life expectancy of women, 150 years ago, was 50 years old. She could finally have children around the end of her life. Today, this life expectancy has been almost doubled, but the duration of fertility has not changed. And the problem is there: today, a 40-year-old woman who can not have children has not even reached half of her life expectancy; she finds it perfectly unfair. But its fertility, from 38-40 years, is low.
"The woman is born with a stock of oocytes that is constituted when the fetus is 3 months old. "Why is fertility low? Is it because the woman has fewer eggs, eggs, available?Prof. François Olivennes : There is a huge difference between the man and the woman. The man makes spermatozoa all his life, until his death. The woman is born with a stock that is constituted when the fetus is 3 months old.
When she is 40, her eggs are 40 years old. They are less numerous, and especially aging, even if it is shocking to say. There are also external causes: some chemotherapies can destroy the ovaries. Tobacco is an oocyte poison, women who smoke are menopausal 2 to 3 years earlier on average than those who do not smoke.

What is the number that expresses it?
Prof. François Olivennes
: According to a French epidemiologist, Léridon, showed that a 40 year old woman who has no problem, in one year she has about 35-45% chance of being pregnant. The problem is that women who fail to do so are turning to us specialists, but we do not succeed either because the techniques of assisted procreation work poorly after 40 years. It is a delusion to believe that an IVF will work if you do not succeed. The success curve of an IVF follows that of chances of spontaneously having a child. It is thought that over 40 years infertility treatments work in 30% of cases.
Can we count the number of eggs?Prof. François Olivennes : Absolutely. Today, for the past 5 to 10 years, this evaluation has been greatly improved with ultrasound. A trained sonographer with a good machine can count, not the follicles of the whole stock, but the follicles that, every month, leave the stock to cycle. There are about twenty follicles that come out every month when we are young, and five when we are 40 years old. There is only one who will become ovulatory and mature. Another way to evaluate this stock is the blood level of anti-Mullerian hormone (AMH) discovered 5 years ago. It gives an idea of ​​what is called the ovarian reserve and therefore the fertility of the woman.
Does the father's age count for the success of a pregnancy?Prof. François Olivennes : The father's age comes into play, both in the chances of success of in vitro fertilization, and in the risk of malformation and chromosomal disease, but this is out of all proportion to the influence of age of the woman which is the determining factor of fertility.
In recent years, however, it has been mostly men who have seen sperm altered by pesticides and endocrine disruptors.
"Beyond age 45, a woman enters an area where pregnancy is dangerous."Is there an age limit for the mother, medically, to have a child?Prof. François Olivennes : There is no age limit, but beyond 45, a woman enters an area where pregnancy is dangerous, at risk. The risk is not 100%, fortunately, but complications can occur in 20 or 30% of cases. After this age, women are warned. Above 45 years of age, the most common use is for oocyte donation. This egg is given by a young woman, it is fertilized with the husband of the woman of 45 years and we get an embryo that is placed in the uterus of this woman.
Can you take refuge behind the Fa when a slightly older woman consults you?Prof. François Olivennes : There is no Law because the Bioethics Law mentioned "of childbearing age". This summer, the Biomedicine Agency has set up a working group and would like to regulate the age of care in France. This was because they were attacked by a 62-year-old man whose wife needed to go abroad to do IVF. He had following a problem freeze his sperm. The ABM said no, you are too old. The man has won his case. We are not immune to the revision of the Act to have an age limit of care.
"A woman who wants to have a child after age 43 must have a cardiological check-up before any pregnancy. "What are the risks for the mother? More difficult deliveries ...Prof. François Olivennes : It is thought that over 40 years, but especially beyond 43, 44, 45 years, there are more vascular complications, high blood pressure, more diabetes and premature deliveries; there are also more complications of the delivery itself, cesarean section.
There are very few studies because they are not collected but we know very well that the older the age, the more the risks of complications increase. What is important is that there are not 100% complications. A woman who is 20% risk of major hypertension has a 80% chance that her pregnancy is going well.
It is very important, however, that a woman who wants to have a child over 43, 44 years old undergo a cardiological check-up before any pregnancy. I think a 45-year-old woman who is hypertensive, has heart problems and wants to have a baby, is at a high risk. Well followed, at 40, you can have a pregnancy that goes very well. She has about a half chance of being pregnant naturally, without the help of IVF.

What is the main risk for the mother?
Prof. François Olivennes
: It is especially high blood pressure that carries risks: for the child, with small birth weights and retro-placental hematoma that can cause the death of the baby; for the mother also with strokes and embolisms.
It is very important for a woman who wants to have a child over 43, 44 years old to have a cardiological assessment before any pregnancy. I think a 45-year-old woman who is hypertensive, has heart problems and wants to have a baby, is at a high risk. Well followed, at 40, you can have a pregnancy that goes very well. She has about a half chance of being pregnant naturally, without the help of IVF.
How does the natural chance of pregnancy decrease?Prof. François Olivennes : At 36, 37, the fertility of women begins to decline. At 40, it decreases sharply, and at 42, very clearly. A 30-year-old woman is 80% more likely to have a baby, and at age 40 she has only 40 to 45%.

But there is a huge variation from one woman to another. If you take the extreme, at menopause, there is no possibility at all; physiologically, it occurs between 40 and 60 years. There are menopausal women at 40, others are at 60. As infertility occurs 10 years before menopause, we can imagine that there are infertile women from 30 years, and others may have a baby at 47, 48 or 49 years.
Is the risk of trisomy 21 for a child born to a 40 year old mother real?Prof. François Olivennes : Absolutely. This risk is 2.3% at the age of 40, while it is 10 times lower in a younger woman. You should know that there is a screening test for trisomy that is close to perfection, but as for any screening, we can get through. It consists of a blood test, with the determination of certain markers, as well as a measurement of the thickness of the baby's neck by an ultrasound performed at the end of the first trimester. When these examinations suggest that there is a high risk of trisomy, an amniocentesis was performed which consisted of removing a needle of amniotic fluid with a needle and analyzing it. But amniocentesis carries a risk of 0.5% miscarriage. The approach is now to take a blood test from the mother that will detect fetal cells circulating in the maternal blood. With this new method, amniocentesis is no longer necessary.
After 40 years, when should a woman go to see an infertility specialist like you?Prof. François Olivennes : After six months, having a regular sex life. Because we must remember that to have a pregnancy, you have to make love. If we do it once a week, we have a 15% chance of having a child after one year, if we make love every day, this rate rises to 80%, when all is well.
The woman being fertile one day a month, we can also use small ovulation tests available in pharmacies, unfortunately not reimbursed, but very effective. It must also be known that obesity and smoking reduce fertility. Tobacco is very toxic for fertility, smokers are menopausal 2 or 3 years before those who do not smoke.
What to do if there is no pregnancy after six months?Prof. François Olivennes If the woman is 40 years old, you have to take a classic assessment. Check that the sperm is normal, that the woman's tubes are normal, and the most important point, check the ovarian reserve. How do her ovaries work at 40? Is she in the bracket of 40-year-old women who are lucky enough to have ovaries quite well, or on the contrary, very badly, or, which is the most common case, in the middle both, that is to say with a drop in fertility, but not crippling.
Then the simplest is to do ovarian stimulation, because a normal cycle is a single follicle that ovulates. With stimulation, we will have 2 or 3, we will multiply the chances by 2 or 3. It stimulates with hormones in injection, which can cause water retention or a little fat. We will monitor the stimulation, and when we will detect that this is the ideal period, if the sperm is normal, we will advise them to have scheduled reports; it's not very romantic, but effective.
If there is a small sperm problem, we can move to the next phase which is insemination in addition to stimulation. We will take the best spermatozoa and we will drop them directly into the uterus. If the ovaries work well and if all these simpler treatments have failed, we can go to in vitro fertilization, where we will take the woman's oocytes, take the sperm of the man, put them together, get embryos, then put them back into the womb of the woman.
"The results of IVF are 30 years of 40% of pregnancies and 40 years, only 15%. "Does in vitro fertilization give good results?Prof. François Olivennes : In vitro fertilization works well, but not for 40-year-old women, that's the problem. Today, the public tends to say to himself: "No problem, I'm waiting 40 years, and there, if it's not right, I'll do an IVF". But the results of IVF are 30 years of 40% of pregnancies and 40 years, only 15%. Because IVF can not answer the problem of quality of oocytes.

Older egg reacts less well to stimulation?
Prof. François Olivennes: No, an older egg exposes many more chromosomal abnormalities in the embryo. This has been proven for 4-5 years since there are countries that have the right to make complete analysis of all chromosomes of the embryo. At around 43 years of age there may be around 90% of embryos that are abnormally chromosomally. What has also been shown is that even when you put a normal embryo to a uterus, not even one out of two survives. There are other factors that interfere with the embryo. The embryo is the key to success.
When that does not work, there is the egg donation. Do you recommend it?Prof. François Olivennes : I am in favor of egg donation. Because when a woman is 40 years old without children, what are her solutions if IVF does not work? For a couple whose wife is over 40 and who can not procreate, I tell them that they have three solutions: to live without children, to adopt a child, to donate oocytes that will allow the lady to wear pregnancy and to the gentleman to be the genetic father. For a couple who is already in a process of assisted procreation I think they accept quite easily the egg donation. I see a lot of oocyte donations, in my office I do between 60 and 100 in France but not in France. In France it is legal but there is no donor because the gift must be free, sacrosanct principle of medicine in France.

In addition, women freeze their eggs more and more, thinking that later the process of procreation will be more complicated, what do you say to a young woman who consults you?
Prof. François Olivennes
: I tell them it's a good idea, I do not understand that France is one of the last countries in the world. I do not prescribe stimulation because one is not allowed to prescribe for a social security reimbursement. I do not believe that everyone is doing it because a very tough circular from the department was issued two years ago. The women go to Spain and Belgium. I do not know the conservation costs, the technique costs 4,000 euros.

How long does it take since the meter is running? For example, for a 40-year-old woman who consults you, when do you plan a pregnancy? ?
Prof. François Olivennes
: Studies make it possible to calculate the cumulative pregnancy rate: between 3 and 6 trials, the curve reaches a ceiling. After 3-4 stimulations if one has not obtained a pregnancy, it is very rarely obtained. 3-4 simple stimulations with reports, 3-4 stimulations with semination and 3-4 stimulations with FIV are carried out, so it takes about 1 year and a half. If that does not work, you have to move on to something else.

What are you doing during this time, are you moving towards a healthier life?
Prof. François Olivennes
Yes, since toxins have important effects, but this is an area where science is in its infancy. You can not answer a woman who wonders what she can eat to increase her chances of getting pregnant. On the other hand, she must avoid tobacco, alcohol, cannabis, stress.

(Article made from the transcription of the Jeudis de la Formation program with Dr. Jean-François Lemoine)