Being a mother after 40: reproduction options, pros and cons - Instituto Bernabeu

The delay of motherhood is a social phenomenon. More and more women choose to develop their life projects and postpone the moment of becoming mothers. A new model inspired by social, cultural and economic changes. The 40s are a time of plenitude for women, and motherhood after 40 is an increasingly common option. As a result, there are several reasons why motherhood is delayed: sometimes because it is not a priority when in the most fertile stages; or economic stability is sought; the right partner may not be found; the development of a professional career is put before having a child; or motherhood is sought again at a later age and in many cases because there is a new partner with whom we wish to become a mother again.

In the 21st century, a woman who reaches 40 years of age, feels more prepared and mature, has all information at hand, is physically and mentally strong and decides to take the road.

Which is the best biological age to be a mother?

Best personal moment is not always the best biological moment. It is a fact that fertility alters with age. There is a biological moment to be a mother that coincides less and less with the women’s decisions. It is between the ages of 25 and 30 when the body is best prepared for motherhood. While from the age of 35 the ovarian reserve (the eggs amount) decreases and also its quality, and after 40 is a drastic drop until menopause arrives. Therefore, it’s more difficult to get pregnant and the risk of abortion and abnormalities in the embryo is greater.

Organizations such as the World Health Organization (WHO) consider as a moderate risk factor motherhood above 35 years of age. Despite this, the delay of motherhood is a fact.

In Spain, the National Institute of Statistics (INE) set the Spanish women average age to have their first child in 2019 at 32.2 years. This places Spanish women next to Italians as the oldest European mothers. At international level, statistics establish an average age of 30.1 years to have the first child.

Fertility preservation to choose the right time to form a family

Therefore, an option to preserve fertility is the freezing of oocytes in the fertile stage. With this technique, the woman takes control of her reproductive life, being able to decide in the future the best moment for her to become a mother. In the reproduction consultation, many women regret not having known before that fertility has an expiration date and after the age of 35, achieving pregnancy with their own eggs is complicated.

Nowadays, sophisticated oocyte cryopreservation techniques offer a possibility which more and more young women who do not want to give up their reproductive project choose. And when the time comes, through an in vitro fertilization treatment -either with the partner’s sperm or with a sample from a donor bank-, the patient’s own eggs are used, and they keep the same quality and characteristics with which they were frozen. This way we avoid to turn to an egg donor and also suffering a miscarriage risk or chromosomal abnormalities in the foetus which is more frequent with the eggs of women of advanced age.

What reproduction options are there after 40?

Although it’s possible to become pregnant naturally, after 40 the pregnancy rate with own eggs is reduced to 5%, according to the Spanish Fertility Society (SEF). If an elderly mother wants to have a child, it’s advisable not to waste time. Reproductive medicine offers different alternatives and the main assisted reproduction technique at this stage is:

Depending on the ovarian reserve, the response to pharmacological stimulation, genetic markers and even the body mass index, different guidelines are carried out to optimize the result. At Instituto Bernabeu, from our low ovarian reserve unit, we rely on different strategies that are personalised, such as gentle stimulation and adjusted doses that try to obtain eggs of better quality, also double stimulation to obtain a greater number of eggs, the application of pharmacogenetics, etc.

It may happen that the woman is already in menopause, and therefore does not ovulate or the quality and / or number of oocytes is not enough, so she requires donation of gametes to achieve pregnancy. The main treatments are:

  • Egg donation (in vitro fertilization with the eggs of the most compatible donor).
  • Embryo adoption (adopting an already created vitrified embryo).
  • Double donation (generate and embryo with donated sperm and egg from the most compatible donors).

Avoid miscarriages and genetic anomalies: Embryo Preimplantation Genetic Diagnosis (PGD)

A significant fact is that an embryo has higher chances to have anomalies if the mother is over 40 and this might happen:

  • no implantation in uterus
  • miscarriage risk in the first gestation months or
  • is born with an anomaly

That is why it is advisable to carry out the Preimplantation Genetic Diagnosis or Test (PGD, also called PGT). PGD is performed on the embryo before is transferred to the mother’s uterus. It consists of an embryo analysis from a small biopsy to detect genetic and / or chromosomal abnormalities. Consequently, it allows the selection of healthy embryos, avoiding transferring abnormal embryos and therefore the birth of babies with different syndromes, as well as the emotional distress caused by an abortion.

Advantages of motherhood after 40

Delayed motherhood has its advantages. In this stage the woman is more mature and responsible. Pregnancy is desired, postpartum depression is less common and the mother has a lot of information regarding her personal and her future family care. In addition, she usually has a better economic and work situation that offers greater stability to educate her child. Children born to mothers over 40 have been shown to receive more emotional support and better education.

Disadvantages of motherhood after 40, what pregnancy risks are there?

However, the older the age, the risks to the pregnant woman and the foetus also increase. In addition to a decrease in eggs, the aging of the ovary and consequently of the oocytes, can lead to genetic defects in the embryo and a greater risk of suffering different pathologies during pregnancy and at birth:

  • Higher chances to suffer an spontaneous miscarriage.
  • There’s an increased risk of developing ectopic pregnancy
  • It is more common for the mother to have hypertension
  • Gestational diabetes
  • Preeclampsia
  • Thromboembolism
  • Thyroid problems
  • Abnormal placental insertions
  • Preterm birth is more common
  • Often delivery is by cesarean section
  • And there is an increased risk of postpartum haemorrhage

Gynaecological tests and follow-ups

For this reason, a pregnancy after 40 is considered a high-risk pregnancy. Gynaecological follow-ups must be more frequent and exhaustive to avoid or detect, as soon as possible, these pathologies that can alter the pregnancy development.

In this period, the pregnant woman can choose to perform prenatal diagnostic tests, which are helpful to know the baby’s risk to suffer chromosome alterations or ruling out congenital defects or malformations. The main tests are:

Non-invasive techniques

  • We have the fetal DNA test in maternal blood to detect the most common chromosomal abnormalities that can be identified through the mother’s blood sample. These are
    • trisomy, the presence of three copies of a chromosome instead of two
    • or monosomy, when one of the copies is missing
  • and microdeletion, when a small part of the chromosome is missing.

Most frequent chromosomal alterations that can be detected are:

  • Trisomy 21 or Down Syndrome
  • trisomy 18 or Edwards syndrome
  • also, trisomy 13 or Patau syndrome
  • and alterations in the sex chromosomes X and Y

Is possible to perform an extended test such as the one offered by Instituto Bernabeu that allows the analysis of the 22q11,2 deletion or diGeorge syndrome and the complete test that analyses the alterations of all 24 chromosomes together with microdeletions.

Invasive tests

  • Through amniocentesis, amniotic fluid is extracted from inside the placenta – the bag where the foetus is in. The puncture is performed with a very thin needle through the abdomen and cells are removed from the embryo that later will be analysed to locate the possible presence of chromosomal or genetic abnormalities and neuronal tube defects. It’s done between week 15 and 18.
  • Through chorionic or chorionic biopsy, tissue from the placenta is obtained for the study of foetal chromosomes, DNA or foetal enzymes. It is performed via abdomen or transcervical route. Its advantage over amniocentesis is that it can be performed at week 11 and 12.
  • Funiculocentesis or cordocentesis is the puncture and extraction of blood from the umbilical vein to detect congenital and blood anomalies. It is a rare method that must be performed by expert doctors. It is done from week 19-20. It makes it possible to quickly study the chromosomes and thus confirm possible infections or a serious foetus disease.

Pregnancy cares for mothers above 40

Healthy diet is key for pregnant women and should be taken seriously in late pregnancy.

  • Is advisable to follow a varied diet, rich in fruits and vegetables and foods with folic acid such as legumes, green leafy vegetables, nuts or cereals. At Instituto Bernabeu we have a specific endocrinology and nutrition unit during pregnancy.
  • Second, it is important to get some exercise, maintain a suitable weight and be active.
  • Finally, avoid harmful substances such as alcohol, tobacco, and excitements such as coffee. You should also stay away from chemicals that are present in everyday life such as cosmetics or products with chemical components.

Preconception gynaecological consultation to prepare for pregnancy

Pregnancy planning should begin with a preconception consultation. This recommendation becomes even more necessary when considering motherhood at an advanced age. Pregnancy above 40 is considered risky and requires stricter controls that should start with adequate prevention and preparation.

What will delivery be like if I get pregnant from the age of 40?

Age does not imply great differences when it comes to giving birth. Although from the age of 40, the risk of premature delivery is higher. Probabilities of delivery by cesarean section is also higher. The musculature of the uterus is less elastic and has less ability to contract. Hence, the gynaecologist may recommend inducing or provoking labour. Instruments such as forceps or suction cups are more commonly used because uterine contractions are often weaker and the baby needs to be assisted.

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