A woman’s fertility declines as she gets older, however, maternal age is increasing. Obstetrician and gynaecologist Dorianne Spiteri tells Stephanie Fsadni about the potential consequences of late pregnancies but reassures her that most pregnancies over 35 years of age are possible and that most babies are healthy.

While it is common knowledge that it is more difficult to get pregnant the older you are, it is a fact that the maternal age is increasing. Data from the National Obstetrics Information System (NOIS) on maternal age at delivery shows that the percentage of mothers aged 35 to 39 years of age who gave birth in the first three-quarters of 2015 (full year results are not out yet) was 16 per cent compared to 10 per cent in the year 2000. In the same period, 36 per cent of those who gave birth were 30 to 34 years, while the number of mothers aged 40 to 44 was 2.6 per cent.

This increase in maternal age may be due to various factors, including the fact that women may be choosing to conceive later in life, possibly to pursue a career. However, a number of problems normally characterise the ability to achieve pregnancy over 35 years and one should weigh the risks.

“There is a noticeable decline in the fertility rate starting at 35 years to a level of about 10 per cent per month, compared to 25 per cent for women in their 20s and 15 per cent for women in their early 30s,” explains obstetrician and gynaecologist Dorianne SpiteriSpiteri.

“This is mainly due to the decline in the number of eggs that the woman produces and also an increase in genetically abnormal eggs.

“Moreover, there is more chance that these women would have suffered from some form of infection causing tubal damage or, in some cases, would have developed conditions like endometriosis or would have required surgical intervention.”

A woman’s ability to achieve pregnancy declines sharply when she reaches 40 .

“The fertility rate per month is only five per cent.  Even with interventions such as IVF/ICSI, which is the most successful infertility treatment available, the pregnancy rate is only 10 per cent per try. This is due to the greatly reduced numbers of normal eggs remaining in the ovaries.”

However, it does make a difference if one already has a child as the reproductive system would already have been “tried and tested”.

“So the chances of getting pregnant are higher but the age-related decline in fertility would still be a liability,” Spiteri says.

“Research suggests that if you effortlessly get pregnant once, it may be easy next time round, though it is unclear whether that is due to your natural fertility or lifestyle. Moreover, certain risks of a first pregnancy, such as the risk of pre-eclampsia, will be less.”

Apart from fertility issues, there may be other factors that may hinder a woman from getting pregnant as she grows older.

Getting pregnant late in life is not as bad as it may sound, even if complications may increase with age

“First and foremost, they fear that they will not manage to get pregnant and that if they do get pregnant, they might have an abnormal child,” Spiteri says.

Miscarriage, the chances of which increase drastically with age, and deliveries requiring caesarean section, are the main complications but there could be possible complications for   both mother and baby. These may include ectopic pregnancy (pregnancy outside the womb), multiple pregnancy, pregnancy-induced high-blood pressure and pre-eclampsia, deep vein thrombosis (blood clots), premature delivery and stillbirth. The baby is also at a higher risk of chromosomal abnormalities such as Down’s syndrome, the rate of which is one in 1,250 at 25 years compared to one in 100 at 40 years of age.

“This fear causes a lot of stress and anxiety, which impacts the chance of getting pregnant. However, most pregnancies over the age of 35 are possible and most babies are healthy,” Spiteri says.

“As specialists, we have to explain the risks involved but we can never take the decision for a patient if she should become pregnant or not.”

Medical conditions are another obstacle.

“Secondly, there could be medical conditions such as diabetes that can complicate the pregnancy and, consequently, the couple opts not to conceive in view of the high risk that the pregnancy would entail.”

“From a non-medical point of view, another reason could be the lifestyle. Some women would not be ready to change their lifestyle!”

Spiteri emphasises that it’s very important for women thinking of getting pregnant to do a preconception consultation, especially those over 35 years of age or those with medical conditions. This means discussing the possibility of getting pregnant with one’s gynaecologist so as to optimise any health issue.

“One should have a smear test if it has been a long time since one has had one and preferably do an ultrasound to look for fibroids and ovarian cysts. Also, one has to make sure they are immune against rubella and chicken pox and, if not, take the vaccine.

“Folic acid should be started at least two months before trying to conceive. It is also advisable to lose weight if one is overweight or obese as this would increase the risks further. Medications for various conditions might need to be stopped too.”

But how long should one to try to conceive before realising that she might be infertile? There are some guidelines, which depend on the woman’s age.

“For women in their 20s and early 30s, tests are usually started after one year of actively trying to get pregnant, unless there is a known clinical cause of infertility,” points out Spiteri.

“Over 35 years, a woman should consult a gynaecologist after only six months of trying and over 40 years of age, this should be done after three months. This is a bit contradictory as investigations start earlier for age groups where it takes longer to conceive. However, this is due to the lack of time from the natural decline of the eggs.”

A couple’s medical, gynaecological and sexual history may help identify possible problems. Fertility tests involve both the male and the female: the man does a semen analysis and the woman undergoes blood tests to check hormones, including Anti-Mullerian hormone (AHM) as well as a pelvic ultrasound.

However, each woman is different, and there are some limitations.

“The AMH, which is a test of ovarian reserve, cannot be done when the woman is on the pill, and gives an idea of the number of eggs a woman has in the ovaries. As women are born with all of their eggs and the egg pool declines with age, the results of the test are very much age-dependent. In Polycystic Ovarian Syndrome (PCOS), which is a condition commonly associated with difficulty getting pregnant there will be high levels of AMH.”

Fertility treatments currently available in Malta are medications (tablets and/or injections) to stimulate ovulation, artificial insemination, in-vitro fertilisation (IVF) and intra cytoplasmic sperm injection (ICSI).

The rate of success again depends on the age of the woman and on the cause of infertility, remarks Spiteri.

International figures quote the live birth rate for those women below 35 years undergoing IVF as 31 per cent and, for those over 42 years, less than five per cent. In the first three-quarters of 2015 in Malta, there were 61 mothers giving birth after artificial reproductive techniques (ART), which include ovulation stimulation, IVF and ICSI.

IVF is not suitable for all.

“There are certain situations where IVF is not advisable, for example, if the woman has a serious medical condition which puts her life at risk such as with certain heart conditions. Also, if you have certain deformities in the womb, ovarian tumours or cancer, then IVF shouldn’t be performed.”

Despite all the above-mentioned issues, Spiteri reassures that getting pregnant late in life is not as bad as it may sound, even if complications do increase with age.

“Women getting pregnant after 35 years of age are more likely to breastfeed, less likely to suffer from post-natal depression and their children do better at school than those born to young mothers,” she claims.

Spiteri also advices to take very good care of oneself once pregnant, including attending regular antenatal visits, eating healthy, staying active, reducing stress factors, gaining weight wisely and avoiding harmful substances such as alcohol and smoking.