Fast Track or Wait? Fertility Treatment Over 40 Explained - The FORT-T Study Illuminated

They say life begins at 40—but what about fertility?
 In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down the real numbers, treatment options, and emotional journey of trying to conceive after 40.

We take a deep dive into the groundbreaking FORT-T trial and how it flipped the script on fertility treatment for women over 40—proving that for many, IVF isn’t the last resort, it’s the smart first step.
You’ll also learn:
✔ The truth about natural pregnancy chances after 40
✔ IUI success rates and when to move on
✔ How IVF and embryo testing can change the odds
✔ Why your egg quality—not just quantity—is the real challenge

Whether you're over 40, supporting someone who is, or just want to understand the data, this episode will give you the facts and strategies to navigate this complex journey with clarity and hope.

💡 PLUS: Join us for a special Sperm Meets Egg Live Show this Wednesday, May 14th at 6 PM Arizona time, where we’ll be joined by Tasha Jennings, ND—Fertility Naturopath, Nutritionist, and host of the Conceive Baby Podcast.
We’ll explore integrative approaches to fertility over 40, including nutrition, supplements, and emotional wellbeing.
Catch the show live on our Sperm Meets Egg YouTube channel, or watch the recording anytime at www.SpermMeetsEgg.com.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we talk about fertility over 40. How, the for T trial changed the game. I'm Dr. Mark Amols and this is Taco About Fertility Tuesday. They say Life begins after 40, but when it comes to fertility, does the clock run out or can science and a little hope keep it ticking? Today, on Talk About Fertility Tuesday, we're going to dive into the world of fertility over 40. The real numbers, the treatment options and emotional journey that comes with it. Whether you're thinking about iui, ivf, which is trying naturally, this episode is for you. And thats because if you're over 40 and trying to conceive, the for T study might be the most important thing you never heard of. It didn't just shake up the world of fertility, it rewrote the book. So in 2010, a group of fertility doctors asked a bold question. Should we stop wasting time on IUIS for women over 40 and just go straight to IVF? Two major studies change how we treat women based on age. The first study was the FAST trial. This study looked at women under 40 and what they found was skipping FSH IUI and going straight to IVF after Clomid IUI save time, money without hurting your outcomes. To truly understand this, you have to understand that what we used to do was we have someone start with very simple treatment like Clomid or letrozole and do IUIs. And when that didn't work, then you would start trying to do injectable IUIs. And we know that injectable IUIs do have higher pregnancy rates and higher multiple rates. And so the thought was if one didn't work, you go to the next one and you keep stepping up. But what the study found wasn't what they thought they were going to find. In reality, if they didn't get pregnant with clomid or fer IUIs, adding on the injectables didn't really improve their chances, meaning their outcomes. And it cost them more time and more money. And so after that study, that's kind of where we talk about three IUIs and if you're not pregnant, moving on to the next thing, which is IVF. And so few clinics will do 6, 8, 9 IUIs anymore because these studies showed it was a waste of time and didn't really improve your outcomes. After this came the Fort T trial. That's, the word fort f o r t T. And this focused on women between about 38 and 42. And what did they find? Well, they found that starting with IVF up front gave the best chance for pregnancy and live birth and the shortest time to success. In fact, those who went straight to IVF had nearly doubled the success rate compared to those starting with iui. What this study did most was it challenged the old stepwise approach of starting with IUI treatment and then moving on to IVF. This is why today we tell women over 40 that IVF might be the smart first step, not the last resort. This doesn't mean IUIs may not work for people who are over 40. It just means for most patients over 40, spending the time doing IUIs will lose them time and not improve their outcomes versus going straight to IVF. So let's Zoom out a little bit and talk about why the 14T trial was even needed. That all comes down to biology. As women mature, there are several things that happen. One of them is that the egg quantity goes down, meaning as you get older, you have fewer eggs. But when you take medications to make those follicles grow, you make fewer of them. Additionally, even though you may make fewer eggs, one of the things that also happens is that there's a higher ratio of abnormal eggs, meaning chromosomal problems that occur. And so the aniploidy risk goes up. This is one of the reasons why the miscarriage rate rises after age 40. So let's start with the facts. At 25 years of age, the chance of conceiving each month is about 25%. By age 40, it drops to less than 5% per cycle. And by age 43, we're talking about 1 to 2%. Then that's not to say pregnancy is, impossible. It's possible it does happen, but the odds are not in your favor. And the reason why is because egg quantity is only part of the equation. The bigger culprit is, as we talked about the quality. And as we age, the rate of chromosomal abnormalities, what we call aneemloidy skyrocket. This is why the miscarriage risk at age 40 is about 35 to 40%. And by age 44, over 50% risk of a miscarriage. Actually. Remember a patient once told me, but I still feel 30 on the inside. Why cant my achesgs keep up? And thats a perfect way to frame it. Your body might feel young, but your ovaries are following a different calendar. The point is, women over 40 are challenged by both a quantity issue and a quality issue. Now, you may be lucky. You may be one of those women who can make way more eggs than your peers. But quality is age dependent. It doesn't matter how Good. Your ovarian reserve is the quality of the eggs is going to be based off your age. And that will be similar between people. I've seen personally professional athletes with low ovarian reserve. It's unfair, but it's a reality. Your ovarian egg health is not correlated to your actual health. So let's talk IUI, or what we call intrauterine insemination. For women over 40, the IUI success rate drops to about 4 to 7% per IUI cycle. Even if we add in medications like gonadotropins, the number barely moves. And like I said earlier, yes, some women will get lucky, but most won't. By the time you hit 3, 4 IUIs, you may have only about a 15 to 20% cumulative chance at best of getting pregnant with an IUI. And I've seen these patients at other clinics. They'll do six IUIs before moving on to IVF. And then when I meet them, they say to me, I just wish someone would have told me sooner that I was playing such bad odds, I would have jumped to IVF sooner. The key point here is II is still an option. It is an option for you, but for many women over 40, the data tells us it's time to move the IVF sooner. Now, I'm a big fan of IUIs, and I do believe with aggressive IUIs it is possible to get pregnant. But for most women, it is better sometimes to go straight to IVF after age 40. Now, if you're someone who just wants one child, I don't think it's unreasonable to try an IUI, one or two. But if you're someone who wants more than one child, absolutely. Jump straight to IVF if you're over 40. So this is where it gets a little tricky. So you would think from what I said, IVF is the answer. And, yeah, things get very hopeful, but they also get a little bit complicated. Per IVF cycle, the live birth rate at age 41 to 42 is about 13% over age 42. And now we're closer to under 5%. But here's where modern IVF has changed the game. PGT testing. With PGTA testing, we can test the embryos and find the ones that are chromosomally normal. We call these euoid embryos. And the success rate per transfer can now jump to over 60% even at age 42. As I'discussed before, it doesn't make your embryos better. It just helps you find the embryos that are better and can get you pregnant faster. Because you're able to get to the best embryos first. Now, I'm not going to pretend that IVF is always going to be the answer. For some people who can only make two or three eggs, it may not be cost effective to do IVF and maybe IUIs may be better for you. But in general, if you're someone who can make a, decent amount of eggs and you were over age 40, there is evidence that jumping the IVF first makes more sense than actually trying to do IUIS first. And for some women, when their own eggs no longer offer that chance, donor eggs can be the reset button, giving success rates similar to women in their 20s. Now, of course, the decision isn't just medical. It'emotional financial and deeply personal. The road over 40 can feel rushed, but remember, being informed lets you plan rather than react. If you are 40 and youe thinking about Conceiving, talk to your doctor about ovarian reserve testing. Talk to them about your partner's sperm quality and about what makes sense for you. Not what worked for your best friend or your neighbor, but find out in your situation what might be the best for you. The study may give you clues of what might be the best thing, but its always customized to each person. In the end, there's no one size fits all. But there are better strategies for your age and your story. So what did we learn today? Well, what we learned is several studies changed the way we practice medicine. Instead of using a stepwise approach and taking a long time to get the IVF, we've learned that even women under 40 shouldn't keep doing IUIS over and over and over. But after several failed IUIs, they should move on to IVF. For women over 40, that time is precious, but hope is still on the table. And so IUI might be worth a short attempt, but IVF is where the numbers start to climb, especially with embryo testing. So m if you're over 40 and you feel overwhelmed, that's normal. This is a marathon, not a sprint. But sometimes knowing when the sprint can make all the difference. And what the 14T trial showed is that sprinting to IVF right away makes more sense than wasting time doing IUIs for most patients, not all. That's why it's important to talk to your doctor and determine your plan. Hopefully this podcast was helpful for you. Or maybe you know someone who may be dealing with this and may benefit from this podcast. If they do tell them about us, give us a five star review on your favorite medium. If you're left wondering what else can I do to boost my chances over 40? Well, we got you covered this week on our live show Spermeats Egg. We're joined by Tasha Jennings. She's a naturopathic doctor in Melbourne and is a fertility naturopath in nutritionist who has spent over 15 years helping proactive women enhance their fertility, balance and nutrition and prepare for healthy pregnancies and babies. She's also a host of a podcast called Conceive Baby Podcast. On our show, we'll be discussing integrative approaches such as nutrition, emotional health and you'll get to hear some of her inspiring success stories. So join us live this Wednesday, May 14th at AH 6pm Arizona time on sperm Meats Egg. If you can't find out one of our social media channels, you can check out Spermeats Egg YouTube channel where you'll be playing live or you can watch it later on a recorded session. As always, I greatly appreciate everyone listens this podcast again. It's because of you why I do this. If you have a topic you'd like me to cover, please send it to tbft@newirectionfertility.com comm that's tbft like taco about fertility Tuesday@newirectionffertility.com and most of all, keep coming back. I look forward to talking to you next week on TALKAC about Fertility Tuesday.