Fertility in women over 40

Decline in fertility has become a real problem in today's world. Gender differences in terms of ambitions and aspirations are blurring. Nature has been a little unfair with the fairer sex in the department of fertility. The eggs that a woman is born with slowly deplete with age, the better quality eggs first. So as the age advances, the egg reserve gets lower and the quality of eggs that are present in the reserve declines too. Whats worse is that sometimes the so called biological clock may be faster than usual!

Many women are aware of the vagaries of the biological clock, but there is still a large section of women who remain blissfully ignorant. When they do find out, they are left with limited options, many times with no acceptable options! 

In a lady in her forties, Intrauterine Insemination (IUI) should be used only if the ovarian reserve (assessed using Antral follicle count and AMH) is reasonable, there is no associated male factor infertility and the duration of infertility is short. The IUI trial should be short and should be upgraded to IVF if unsuccessful. In case the duration of infertility is longer and/or there is an associated male factor infertility, the couple should be counselled to opt for IVF immediately. If the ovarian reserve is low or if the lady is >43yrs old, the recommended option would be IVF using donor eggs. 

There is always a way......

When to call it quits with IUI?

Intrauterine Insemination or IUI in short is often the first line of treatment for infertility. The main advantages when compared to IVF, are that it is cheaper, doesn't involve daily injections and lesser stress levels. It is possible to get this treatment at your routine gynaecologist whereas IVF may only be done at an infertility specialist's clinic. Changing the treating doctor is usually disconcerting to most couples as it involves risks and having to build up rapport with a hitherto unknown person and talking about something so sensitive as fertility.

In my opinion, at least in India, too many people are reluctant to call it quits with IUI. As per studies done, the pregnancy chances with IUI plateau within 3-6 cycles. As such the recommendation is to restrict the number of cycles to 6 in couples with unexplained infertility. IUI works best in unexplained infertility, couples with psycho-sexual problems and when the cause of infertility is PCOS. Couples where there are other contributing factors to infertility especially if the woman is older than 35 years, should be reviewed after three cycles of IUI. Further IUI cycles should ideally be under the supervision of infertility specialist and that too after a thorough counselling.