Ep 310: How to Conceive After 40

 Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, they are joined by Ravi Agarwal, MD, from Reproductive Science Center of the San Francisco Bay Area in San Ramon. In this episode, they discussed the unique fertility challenges for women over 40 trying to conceive. Challenges include changes in egg number and egg quality that can affect their chances of conception and carrying a pregnancy. The hosts and their guest discuss how age impacts fertility, how testing guides treatment decisions, and why a personalized approach is essential. During this episode, the docs answered the following questions: What are the biggest fertility challenges women face after age 40? Women over 40 commonly experience both a decreased number of eggs and declining egg quality. As eggs age, they are more likely to have genetic abnormalities, which can make conception more difficult and increase the risk of miscarriage. Why does egg quality decline with age? Egg quality declines due to age-related genetic changes. A higher percentage of eggs become chromosomally abnormal over time, making it harder to achieve a healthy pregnancy. What fertility testing is recommended for women over 40? Testing often includes: AMH (Anti-Müllerian Hormone) to estimate ovarian reserve. Antral follicle count via ultrasound to assess how many eggs are present in the ovaries. These tests help predict treatment response and guide next steps. Can having more eggs help offset poor egg quality? In some women over 40, a higher egg number may partially compensate for reduced egg quality, increasing the likelihood of finding a genetically healthy egg. Do all women over 40 need IVF? No. Not every woman over 40 requires IVF. Some women can conceive without treatment, some are good IVF candidates, and others may not benefit from IVF at all. How do doctors decide which treatment is best after age 40? Treatment decisions are individualized and based on age, egg reserve, egg quality, medical history, and personal goals. This podcast was sponsored by U.S. Fertility. 

Transcript

Susan Hudson (00:01)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Susan Hudson MD (00:22)

Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here with my vibrant and vivacious co-host, Dr. Carrie Bedient from Fertility Center of Las Vegas and Dr. Abby Eblen from Nashville Fertility Center.

Abby  Eblen, MD (00:39)

Hi everybody.

Susan Hudson MD (00:40)

And we are so excited today we have Dr. Ravi Agarwal from RSC Bay at the San Ramon office who's joining us today. We are so excited to have you.

Ravi Agarwal (00:49)

Thanks for having me.

Carrie Bedient MD (00:53)

You were telling us now that you're back in the San Francisco area that you get to go hiking and spend time outside and especially close to Yosemite. We need to know all of the tips and tricks that we need to get through Yosemite in one piece? I think the last time I was there was probably about four or five years ago and it was gorgeous. But what's, what are your favorite places to go there?

Do you free solo El Capitan or what do you like to do when you're out?

Abby  Eblen, MD (01:18)

sounds scary.

Ravi Agarwal (01:20)

Well, it's funny that you mentioned that. Free-soloing is not even a possibility. I am terrified of heights. Even thinking about the movie, I'm getting sweaty palms right now. ⁓ Yeah, rock climbing and I aren't a thing. I did most of my training elsewhere, moved back to the Bay Area, so I'm happy to be closer to home. And because I haven't...been to Yosemite a long time and actually just was there a couple months ago. I think one thing to keep in mind is that that fear of heights is not just exclusive to free soloing El Capitan. It can also apply on a very routine hike, which I unfortunately learned the hard way. Yosemite Falls is a very, it's a hard hike, the views at the end are beautiful. And I allocated about four hours to get up and about two and a half hours to get back down. took me seven hours to get up because I was clutching the wall for dear life because my fear of heights was kicking in also. Yeah. And what I thought were just looking at the trail map didn't seem like these big drop offs were these big drop offs on the side. It's a lot, it's already a very strenuous hike.

Abby  Eblen, MD (02:13)

wow.

wow. Yeah, me too. I would that be scare me to death.

Ravi Agarwal (02:29)

Very physically taxing, but when your heart rate is going even higher because you are having a very minor panic attack on the side. I didn't factor that into my time and snack and calorie consumption planning. Just one piece of advice that that could be, might not have been a problem for people before, but it can be a problem a little bit later in life, unfortunately.

Abby  Eblen, MD (02:47)

So clearly one of your characteristics is perseverance, because I think if I'd gotten about halfway in and realized that I had like this much room to walk in, I would have turned around and gone back, I think.

Ravi Agarwal (02:55)

It's probably half perseverance and half just competitiveness where I saw people that were twice my age just bounding past me on the trail and I said I am not going to be shown up by them and I just kept going. It was both spectrums. I think I was getting passed by, people much older than me but also I was being passed by some groups of school kids also.

It was just being rubbed in my face from both sides that I was being very inadequate and I needed to make it up to the top. So I just kept going and I think I might've cried. I shed a tear of happiness when I made it to the top. And it was actually very fortuitous. When I made it to the I met a guy who is actually also from the Santa Ramon area. And it just happened very coincidentally that he lives about a block from my office. So we started chatting.

And he basically said, not many people know this, but there's actually another vista point a little bit. It's just a mile and a half higher, but the views of there are even more spectacular. You have to come with me. I, again, so I think we learned a maybe perseverance. I am competitive and I am also very much, I succumb to peer pressure very easily. Those are my three thoughts. I was like, yeah, sure.

Abby  Eblen, MD (04:09)

We know you really well, Ravi, and we just started talking to you. We know your deep inner secrets. ⁓

Ravi Agarwal (04:12)

I know. Yeah, exactly. Just bled a little out So what I thought was the end of my anxiety attack of scaling trails, I got another mile and a half up to the top. The views were much better from that that guy's defense.

Abby  Eblen, MD (04:23)

Wow.

So one last question, was it easier coming back now since you knew what you were up against or was it harder coming back? You're like, no, I've got seven more hours to go back.

Ravi Agarwal (04:35)

It was definitely easier knowing I've done it before, but I think when you were going uphill, I probably am coming across as the biggest baby of all time in retrospect, as I'm saying, I'm giving these stories. But when you're going up the hill, your perspective is just up. But then when you're coming back down, even though it's a little bit, maybe a little bit less physically taxing, you're just very aware of how high you are. So I think that added a little, so both were equally stressful.

Carrie Bedient MD (05:00)

Now, do you wear any kind of biometrics on you? Like, were you able to track your heart rate through an Apple Watch or an Oura Ring or one of those things as you were going through it?

Ravi Agarwal (05:08)

Yes, think it I did have my I have a little Garmin that tracked my my heart rate and I think the entire time it was saying that your heart rate seems dangerously high do we need to alert the paramedics or something because this is abnormal. I think it's it's funny too because you you track all those metrics and you you post it to Strava or one of the one of the the apps and it tracks the distance, it tracks heart rate and all those metrics, but I don't think real metric is how many years of, yeah, the terror, the panic, how many years of life it actually removed from my life expectancy as opposed to adding to it. I think those were the vital statistics that unfortunately went untracked from that hike.

Carrie Bedient MD (05:45)

Yeah.

Well, we're very glad that you survived to tell the tale and to come hang out with us. And even if you never go higher than two feet off the ground at Yosemite again, you know, the story.

Abby  Eblen, MD (06:04)

Yeah, it's a great story.

Ravi Agarwal (06:05)

yeah, think I'll settle for just watching documentaries about everything related to Yosemite now and just enjoying it all from the valley floor going forward. think that is now my...

Carrie Bedient MD (06:15)

Yeah. Yeah. Although I hear what you say about Free Solo. That does induce anxiety attacks, even if you don't have a fear of heights. It's a fabulous documentary, but my god.

Ravi Agarwal (06:27)

Yeah, yeah, more power to him. Everyone has their own strengths and I'm very okay with that not being one of mine.

Susan Hudson MD (06:35)

I have a fear of heights as well and it's gotten worse and worse as I've gotten older. And it's just so funny because there's things I want to do and there's a lot of things I can make it up there. And it's not like I'm scared of like being a plane or anything like that. I just don't like that perspective. And I think one of the funniest videos I've seen recently on social media was this lady who was at the Cliffs of Dover and she got on her belly and like shimmied to the edge. So she was laying down, but so she could look over and I was like, this is a woman after my own heart.

Ravi Agarwal (07:08)

That’s funny. I will say the last, I lesson learned was, you're never too old to get a new fear of heights. Lesson number two is you need to have a good photographer who can, maybe compensate for that. So I did this hike by myself and I was at the top and I would not even dare go near the edge, even if I was on all, crawling like that, like that woman.

I was a very safe 10, 15 feet away from the edge and I wanted someone to take a picture of me with the view. And I was hoping that they would at least make it seem like I was close to the edge, that I wasn't as big of a, scaredy cat as I was. But they made sure to include my entire lower body, the entire distance from where I was standing to the actual cliff. And then like other people who actually were brave enough to go to the edge and like included them in the background.

Was very aware of where I was standing relative to him. And yeah, he did me very dirty. And when I learned the two, just kinda like tell the guy, very clear instructions, please make me look much more brave and confident than I really am in this, than this picture implies. One lesson I learned on this trip. Yeah.

Susan Hudson MD (08:13)

That's awesome. That's awesome. Well, let's go into a question for today. Our question today is, hello. Thank you for the podcast. It has really helped me understand the IVF process. Thank you for listening. I'm about to have my second FET and I'm wondering if I should include Lovenox slash klexane or not. Either the short 20 days or full 10 weeks. She's 34 trying to conceive for 2.5 years.

One chemical after hysteroscopy in May and second chemical in August after full medicated FET with the euploid embryo. I'm in the process of Zoladex treatment for two months prior and plan to add doxycycline into a fully medicated cycle in January. We did the full RPL workup and nothing came back as an issue. Tested negative for APLA clotting blood tests, so no reason, but my clinic said this HAS protocol plus treatment for potential endometriosis. Any advice or things to consider would be helpful. Thanks.

Abby  Eblen, MD (09:15)

So she's tested negative for clotting disorders, but they want to give her Lovenox anyway, basically.

Susan Hudson MD (09:20)

What are y'all's thoughts?

Abby  Eblen, MD (09:20)

So there's really no data to support that. mean, certainly over the years, I'll admit I've done that before, but I'm less likely to do it now. I think there's less side effects from Lovenox maybe than heparin that we used to use, but I still don't think there's good data to really support that. And Lovenox can be, if you were in a car accident and the paramedics didn't know you were on Lovenox and you got hit, I you could have a brain bleed, you could have bleeding into your lungs. I mean, it's a big time drug.

I generally would not recommend that for somebody who doesn't really have a clotting disorder just because it's pretty hardcore and it could really, I could result in significant complications.

Susan Hudson MD (09:57)

What do you think, Ravi?

Ravi Agarwal (09:58)

Yeah, I agree. I with everything that Abby said, that there's no real data to support using it, empirically when all the tests are negative. can understand the sentiment to try something new when you've had a failed FET and I can't remember if it was a biochemical or a miscarriage after a previous one. I think that there a lot more other that are safer and maybe more effective than Lovenox that I would turn to first just to in an effort to maybe get a better outcome. And I think a good compromise is instead of Lovenox, you can always think about adding aspirin. It's still giving a little bit of the blood thinning anticoagulant properties. Also, the data doesn't really support that. But I think a lot of the sentiment that we have in this field is that aspirin, even if it has a marginal benefit for improving pregnancy rates, it definitely can reduce the risk of any complications down the road in the pregnancy, such as preeclampsia, gestational hypertension. If that's going to be added at around the 10 to 12 week mark anyway, we might as well just add a little bit earlier and see if we can get any benefit from it in the actual IVF, FET cycle as well.

Susan Hudson MD (11:02)

Carrie, what do you think?

Carrie Bedient MD (11:03)

I think the longer term Gossarellan implant, the Zolodex that she's taking, I think that's a very reasonable place to start. There's a lot of people who have good implantation after that. She didn't really mention one way or the other, at least not that I heard about a definitive diagnosis of endometriosis, but that...that's something that has far fewer overall health implications for the short term, just two months that she would be using it or less compared to Lovenox and can potentially be beneficial. So I think that that's worth trying. It's unlikely to hurt anything and may help. And also the benefit, even if this next transfer doesn't work, the benefit will continue on even if she's not taking it two months, two months, two months before every FET because that's not really recommended either. We don't want you on this all the time. We want you on it enough to have an impact and then get off and keep going with the other medication. I don't know that I would rush to anticoagulation either. I love the idea of aspirin.

Susan Hudson MD (11:57)

Absolutely. I think we've all seen things where you think everything is safe until it ends up not being. And part of what our job is, is to make sure you don't get in any of those bad situations and in the absence of good solid data. And there's not even much wishy washy data other than just people's experience to say that, you being on the anticoagulation such as lovenox for such a long period because realistically we're signing you up for almost a year of lovenox. You've got your whole pregnancy and sometimes six months postpartum depending on what's happening. And also understand just because we put you on something doesn't mean that once you get discharged from your REI that they're going to continue, your OB-GYN is going to continue that treatment because they may also say that there really isn't enough evidence to have the benefits outweigh those risks.

Susan Hudson (12:58)

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Susan Hudson MD (14:02)

All right, so today we are going to talk about something that comes across our door every single day, and that is women over 40 wanting to achieve pregnancy and dealing with challenges of infertility. So, Ravi, why don't we start off talking about why are we even worried about the chances of somebody getting pregnant over 40? Isn't 40 like the new 30.

Ravi Agarwal (14:31)

Yeah, I gonna say that I've done a lot of my training in Los Angeles. I'm very familiar with all the cosmetic treatments that can make, forty year-old look maybe even 20 these days. But, unfortunately, as we all know that the ovaries are not immune to the biological clock and it gets harder to get pregnant when you are even in your late 30s, early 40s, as I'm sure we'll talk about. think this is a scenario that we're all dealing with a lot more commonly now as women are very rightfully so choosing to have children later in life. They're their family building journey because of career or just they're finding partners later or whatever the situation may be. I think that this is a very relevant topic and something that a lot of our patients are facing.

And I think, the two things that we preach to our patients in terms of why it becomes difficult is not just diminishing egg quantity, but egg quality as well. I think women are born with all the eggs that they're going to have. And as those eggs get older, they just don't work as well. They're less likely to turn into pregnancies and even more, hard to overcome if those pregnancies are more likely to be unhealthy, abnormal in some way that just ripe for any sort of complication like a miscarriage or anything like that.

Abby  Eblen, MD (15:47)

Ravi, if someone asks you, do you think there's really a big difference in people who exercise all the time and take supplements and eat well? Does that make a difference, you think, in terms of egg quality or egg number?

Ravi Agarwal (15:58)

I think it's hard to say regarding egg quality. I think we know that the best metric for egg quality is age, unfortunately. While I don't think that, unfortunately, eating well and exercising can improve or really harm your egg quality one way the other, definitely can improve your chance of getting pregnant. I think we all know that being healthy, being a normal weight, having a healthy diet can optimize ovarian function in general, hormone production, all of which are also important to getting pregnant. I think it's definitely, even if not from an egg quality perspective, definitely something that all women should try to prioritize because it definitely can have all sorts of benefits.

Carrie Bedient MD (16:35)

What's the magic reason behind age 40 or age 35, somewhere in there? What's the trigger why that is the magical age when everyone starts to get their panties in a twist about trying to conceive? Why is it that age? Why is it not 39 in six months or 41 in a quarter or those? What magical thing happens on your 40th birthday that just all of a sudden you fall off that cliff.

Ravi Agarwal (17:06)

Yeah, well I think it's a little bit of our doing because I think we have labeled women over 35 trying to get pregnant as geriatric. Even though that's not true, it's a little bit of a, we brought this upon ourselves as to why, patients get very rightfully so stressed after turning 35. But I think it really just goes back to egg quality. I think the most important...job of the egg is to incorporate both the DNA of the egg and the DNA of the sperm and bring them together into an embryo that has a full complement of chromosomes and DNA. And unfortunately, as that egg gets older, that the machinery that's responsible for that process just gets more error prone and more likely to lead to embryos that either don't turn into pregnancies at all or end up being abnormal and turning into a miscarriage.

My patients are subjected to a very thorough PowerPoint, unnecessarily feel like a biology professor when I'm in a consult sometimes. But there's a curve that basically plots the percentage of embryos that are abnormal based on women's age. And you really do start to see a decline at 35. And then it's substantially lower in terms of percent of those embryos that are normal when you start to get to 40.

And I think one important thing I really want to emphasize that doesn't just affect getting pregnant naturally, this abnormal embryo issue, but also getting pregnant through any sort of fertility treatment, even IVF. I'm sure we've all had the consultation where a 42 year old comes into our office and they say, we've been trying and, we're finally here to bite the bullet and do IVF and get pregnant that way. But unfortunately, IVF doesn't.

Abby  Eblen, MD (18:40)

We're ready to start our family now.

Ravi Agarwal (18:43)

Yeah, exactly.

We're here, we're here, the hard part is done because we're in the office and now we'd like to order our baby by Christmas. But it doesn't work that way. Where IVF doesn't work for everyone, and then it just becomes statistically even harder in your 40s.

Susan Hudson MD (18:58)

Now, if somebody is out there listening or watching us on YouTube and they've been having unprotected intercourse, which for our definitions means you have been trying whether you were intentional about it or not, how long do you recommend somebody who once they're in their 40s, how long should they try until they reach out to a reproductive endocrinologist?

Ravi Agarwal (19:23)

I think they should reach out right away. I think that the first misconception we talked about is IVF works for everyone. I don't want patients to think that that's a completely fail-proof fallback plan for them. There a lot of markers that we have, a lot of tools that we can use to help predict how successful IVF is going to be to you. I think just at least getting some sort of evaluation in terms of where those markers are and some baseline assessment of your fertility. And I think if you have an issue that we know can cause problems getting pregnant, your cycles are irregular or you have some medical condition that might make getting pregnant difficult, like a thyroid disorder or some sort of other hormone abnormality or PCOS, or if your partner has a low sperm count, then it's better to just be more proactive and seek a doctor out initially as opposed to struggling when you know you're just gonna be hitting your head against a wall.

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Susan Hudson MD (20:44)

Does intended family size play into your counseling in women who are in their 40s who are trying to conceive?

Ravi Agarwal (20:51)

Yeah, absolutely. I think it's a delicate balance. We always like to give women an opportunity to get pregnant naturally. Not everyone that comes into our office can slap with the label, like this is an IVF patient. It's not like a scarlet letter that we assign. But I think that that's part of the counseling for sure. We're thinking about maybe freezing embryos to use right away for baby number one or even just freezing embryos and then try naturally and keep that embryo for baby number two. I think this is all definitely a very nuanced conversation. Going back to what I was saying previously about all of this really being dependent on what your remaining egg quantity is, what those ovarian markers are, like your AMH level, your follicle count, all those dictate whether these are even options for you or not, whether you are gonna make enough embryos to store away for the future for baby number two, whether you even get an embryo for baby number one. I think it's again, it's really important to have that baseline fertility and see, A, can you try on your own? Do you have the luxury of time before your success with IVF is really gonna drop? And B, what your expected success with IVF could be and what opportunities you have based on that.

Abby  Eblen, MD (21:59)

What kinds of testing would you do on a patient that's say 40 or 41 that's listening and she's not sure if she wants to do IVF or not, what kinds of things would you do testing wise on she and her partner to kind of determine which route they should go?

Ravi Agarwal (22:11)

One more thing we need to be mindful of is not just helping older women get pregnant, but also making sure it's a safe pregnancy for them as well. Part of the testing is making sure that they are fit to get pregnant, going to have a low risk, healthy pregnancy, and then all the fertility testing on top of that. In my practice, we do a pretty comprehensive just general health.

We check your blood count. We check your thyroid hormone. We check for pre-diabetes. We check for common conditions. We check your blood pressure at your initial visit to make sure that there are no chronic medical conditions that aren't being optimized or any hidden medical conditions that could be a problem when getting pregnant or when you are pregnant. And on the same vein, sometimes we'll even have patients not just see us, but even see a high-risk OB doctor if we are concerned from their age alone or from any medical conditions to see if any other treatments or testing is warranted before trying to get pregnant. But from a fertility perspective alone, I think that the two biggest of how successfully with IVF is some basic ovarian function testing. Checking that AMH, checking what's called the follicle stimulating hormone, both of which are blood tests and…what's called an antral follicle count or doing an ultrasound where we can see how many follicles you basically have in your ovaries which is a good indirect measure of your remaining egg count as well.

Susan Hudson MD (23:35)

When we're sitting here talking about women in their 40s and we're talking about this cliff because that's been the news recently about this cliff that happens with fertility. And we think of it happening at 35 because of the advanced maternal age, geriatric pregnancy type thing. Now, the reality though is when we have somebody who comes into our office and they're 40, 41, we're mildly anxious.

We're nervous, we wanna be aggressive, we wanna push things. But the reality is there is a cliff and that cliff is getting very steep once someone's getting into that 42, 43 age range. And most of us are probably sweating bullets when somebody comes in who's 44, 45. Would that be a fair assessment?

Ravi Agarwal (24:05)

Yes, absolutely.

Susan Hudson MD (24:30)

Why do we have that difference in our anxiety in just those couple of years?

Ravi Agarwal (24:35)

All of us can agree that there are workable, overcomeable problems or roadblocks in a patient's fertility and IVF journey. And there are some that are really hard to overcome. One that's very hard to overcome is a very low egg quantity. I think quality you can work with, quality you can sometimes overcome with quantity.

Even if a lower percentage of each egg that you have has a lower relative chance of turning into a baby, if you have a good quantity of eggs, then you're still going to get there. But if we know quality is inevitably going downhill, but then the quantity is really low, then that's a very difficult problem to solve. That's when we just assume in women who are 42, 43, 44, is that their quantity is very, very low.

Susan Hudson MD (25:21)

Is there a point where you tell patients that, we really don't think that you have a good chance of being able to conceive using your own eggs?

Ravi Agarwal (25:29)

So we typically think after your 46th birthday, at least with any sort of fertility treatment, the benefits are very much outweighed by the risks of any treatment. That's when we say that probably trying to get pregnant, at least with IVF with your own eggs, is not a good idea.

Carrie Bedient MD (25:47)

What about just being pregnant itself? I have a lot of patients who come in and say, oh, I'm thinking about getting a surrogate because I am older. And older can mean anything from in their late 30s to anywhere in their 40s to beyond.

At what point would you say, yeah, that's a very valid concern versus, no, you maybe don't need to go quite that far just yet?

Ravi Agarwal (26:10)

That's a delicate balance. Cause we obviously want to, this has been, this is something that our patients have wanted for so long and we want them to give them the opportunity, but like you were saying earlier, that we have to sometimes prevent our patients from doing these treatments that are going to, or just anything in general that could be potentially harmful for them in the future.

That's when we lean on our high-risk OB colleagues and we have that consultation with them. And to be honest, I recommend that for most of our patients who are over 40, 41, just because again, it can't hurt to know what those risks are, even if you were at very low risk for any of that happening. But I think their expertise and their experience is really invaluable in saying like, this is a good idea or this is an unsafe idea.

Abby  Eblen, MD (26:53)

What are some of the conditions that you would just say without seeing the high risk OB being like, this is just not a great idea for you to carry pregnancy because you have X, Y or Z. What are some of those things that you that really worry you a lot?

Ravi Agarwal (27:05)

There's some sort of a very profound cardiopulmonary issue, so some sort of heart defect, heart problem, lung disease, one that doesn't leave you fit to all the physiologic changes of pregnancy.

Another big one that's sometimes overlooked is just having a poor obstetric history. You had a horrible complication in a previous pregnancy, like you had a terrible postpartum hemorrhage, or you had preeclampsia at 22 weeks and were unbedred for in the hospital for eight weeks. I think that's another big one where you kind of tempted fate once and had a very unsuccessful or very stressful pregnancy. And maybe we shouldn't try that again.

Susan Hudson MD (27:46)

I'm curious amongst all of us, do your clinics have certain ages where you don't treat using autologous, meaning a woman's own eggs? And do you have an age at which you don't do embryo transfers into them? Now they can use a gestational carrier maybe, an age related, we won't transfer beyond this age.

Abby  Eblen, MD (28:08)

Which your's Carrie?

Carrie Bedient MD (28:09)

For our clinic using a gestational carrier, it's if you have turned 52 or beyond between 52 and 55, we'll use a GC beyond 55. We typically do not. There's a combined age that we're looking at for both partners that is similar to what the adoption agencies use. For using autologous eggs, we don't have a hard and fast cutoff. And part of the reason for that is because not everyone is created equal. If you say we're going to not do this after age 46, there will be some 42 year olds where you're like, you really shouldn't do this because your AMH is undetectable, your follicle counts one, and we have a very low likelihood. And then we'll also have some people who come in who are perhaps older, where the likelihood of us getting anything is extraordinarily low, but they just cannot get their head around using egg donation until they have tried at least once with their own eggs.

What I find myself doing is just hammering home minimum of three times before we'll say, you can potentially go ahead with your own and just saying, and making them actually, OK, do you understand that the likelihood of this working is well under 1 % and that even if I take your numbers and I quadruple what they are and I take four or five times what the likely success rate is, we're still not going to top out past 1%.

And I'm just incredibly straightforward about it. Never try and be, the goal is not to be rude or mean or anything. It's just, and I will say explicitly, this is extremely expensive, financially, emotionally, physically, and mentally. And if we're gonna do this, you need to know that we are doing this in some cases as a closure cycle, not because we think it's actually gonna work, and these are what the risks are. By the time somebody's 44, 45, we are pretty deep into that discussion and sometimes it starts earlier depending on what their success rates are. What about you guys?

Abby  Eblen, MD (29:59)

We typically set the number at about age 45 and we really just did a policy about this. We used to sort of be the same way, let everybody have a chance. But we just saw that there was really no benefit after 45. And you could argue that they're going through a surgical procedure and, risks are very low, sometimes things happen. We just felt like we needed to set a limit. So we set the limit up to through age 45. And I think our limit for embryo transfer is age 53, I believe is our limit. And that just has to do with physical risk as you get older.

Susan Hudson MD (30:28)

Yeah, ours for using your own eggs is 47th birthday. And then for embryo transfer, we will transfer, I believe up until your 56th birthday, but anybody who is 45 or older has to have a cardiac evaluation. One thing I'd like to emphasize is that realize that pregnancy is literally the most dangerous thing that most women are going to experience in their lives.

When different clinics have different limits, it's because sometimes bad things happen. We're a couple of generations away from where maternal mortality was a very common occurrence. But the thing is, it still happens. It still happens.

It's scary. I think it's one of those things that we think about being a historical thing, but when it does happen, it's absolutely terrible. And despite best medical care, not every time is it going to turn into healthy mom and healthy baby. Ravi, what kind of guidelines do you guys have?

Ravi Agarwal (31:34)

Pretty similar, we typically don't allow patients to do IVF with autologous eggs after their 46th birthday. And ⁓ we will not do embryo transfers either with a patient's own embryo or a donor egg, donor embryo after their 52nd birthday. So pretty similar.

To your point, Susan, I think we've all had bad outcomes. And I think it's really important for patients to know that we're not trying to be withholding and preventing patients from doing this treatment. We just really want to keep them safe, but also we want them to achieve their goal faster. And I think we all know that the success with donor egg is really, really high, even in women in their late 40s, early 50s.

And trying just cycle after cycle with your own eggs that we know just has a low risk of success is just going to put a big hole in your bank account, but also delay eventually having a kid for six months, 12 months. And sometimes making that step earlier, even if it's a big pill to swallow, is ultimately going to align with your family goals a lot better and a lot more quickly.

Susan Hudson MD (32:39)

I have one question divided into two parts. Two things that we hear all the time and I'd like to know your responses are number one, my mother, auntie, sister, relative, got pregnant at 48 years old and da da da da. Does that make you feel better or are you just kind of like, okay, that's great information? 

Ravi Agarwal (33:06)

Yeah, well, Alex Honnold can climb El Capitan without a rope and I can barely make it up a hike without having a panic attack. I think everyone is unfortunately different and that some of this is a little bit of getting pregnant and a little bit of fertility is genetic, but a lot of it is just luck and chance and a lot of stuff that's out of our control and...fertility is not inherited, so I don't think that you can use that as a marker. And you, again, you can't rest on those laurels of like, it worked out for her, it's definitely going to work out for me.

Susan Hudson MD (33:37)

And what about the statement of, name your favorite celebrity, got pregnant at 50 blank. Why can't it happen to me?

Ravi Agarwal (33:42)

Yeah, think it's a double-edged sword. I think they're all the success stories, but they're also a lot of not just, quote unquote, regular women, but celebrities who are probably also struggling with infertility who really don't bring it up. just like with anything, it's really easy for some people, but it also can be very difficult and very challenging. I think for every, I forget which of the Kardashians got pregnant at 50.

But there's a Jennifer Aniston who's struggling with her own fertility issues. And I'm glad that she was very vocal about it just to present the other perspective of herself.

Carrie Bedient MD (34:18)

Well, there's always the component of it of, there's you as the public, we don't know the entire story. We don't know who did use a donor egg or who was able to freeze eggs when she was 30 and use them a decade or two later. And those things are important. And the other portion of this is statistical. What are the odds that someone who is an international superstar worth a billion dollars and is a recognizable face on every street corner in the country, also was the one in, in some cases, literally a million, who was able to get pregnant at 50 with a healthy child that didn't have Down syndrome, that didn't miscarry, that didn't have, insert all of these really dire impacts. The stats are not really in favor, and there's always gonna be someone who's the one in the billion. But really, what are the odds that that happened and happened multiple times in our generation?

Susan Hudson MD (35:11)

Exactly. Really take what you see in the media with a grain of salt and realize that what is being presented is probably part of the story, but you may not have all of the story because it's not as sensational. It's still a beautiful, wonderful miracle, but it's it doesn't get as many headlines.

All right, well, any more thoughts about getting pregnant or struggling with infertility in our 40s?

Abby  Eblen, MD (35:40)

I think you should make the leap and go see your doctor because sometimes I think people are worried that there's no way they're going to get pregnant and other times people are overly optimistic about how likely their chance of pregnancy is. If nothing else, just take that leap and go see your doctor, go see a fertility doctor so that you can really find out for you what we think your chances really are.

Carrie Bedient MD (36:00)

And when you're doing it, even if you're not actively trying, but you think it's on your radar screen for the next year or two, it's something that's well worth. We will never get mad at you for having the conversation with us and for getting some of the basic testing. Even if it's just an AMH follicle count and day three FSH level, it's worth having that information. It's worth having these discussions early because they may apply differently for you than they would for your best girlfriend, neighbor, sisters, daughters, monkeys, uncles, cousins, whatever. So go have a conversation early because you want the information that's tailored to you.

Ravi Agarwal (36:32)

Yeah. And one more thing to add is that seeing your doctor doesn't commit you to treatment at all. Information is power in this whole thing. But even getting started with treatment can take two, three months. Sometimes there's testing that we have to do. There's, a lot of red tape with insurance and getting medications. And then we have to wait for a specific point in your menstrual cycle to be able to start treatment. It's not just snapping your fingers and starting a cycle, sometimes it can take a couple of months even to get that ball rolling and you're continuing to well, you're more than welcome to keep trying in that time. You can always just put irons in both fires and keep trying on your own, but plan for IVF if it doesn't work out.

Carrie Bedient MD (37:08)

Similarly, we'll never get mad at you for calling with a spontaneously positive pregnancy test, so you're pretty good.

Abby  Eblen, MD (37:13)

Yeah, that's even better.

Ravi Agarwal (37:13)

If I could. We won't get mad at you, will we try to take credit for it? Absolutely.

Carrie Bedient MD (37:19)

Absolutely, yeah, yeah. I'm actually sitting in a chair right now that was previously my office that is well known for getting people pregnant without any diagnostic testing or any treatment or anything like that. So, yeah, my chairs have taken lots of comfort or lots of credit for that.

Susan Hudson MD (37:35)

Good stuff. stuff. Well, Ravi, thank you so much for joining us today. Again, we had Dr. Ravi Agarwal from RSC Bay, San Ramon. And to our audience, thank you so much for listening and subscribe to Apple Podcasts to have next Tuesday's episode pop up automatically for you. Also be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Abby  Eblen, MD (38:00)

Visit us on fertilitydocsuncensored.com to submit specific questions you have and sign up for our email list. Check out our new book, the IVF Blueprint, at all major sellers including Amazon, Barnes & Noble, and bookshop.org.

Carrie Bedient MD (38:14)

Check out Instagram and TikTok for quick hits of fertility tips between our weekly episodes. And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. So subscribe, sign up for emails, and we will talk to you soon. Bye!

Abby  Eblen, MD (38:27)

Bye.