Conception Challenges In The 40s: The Intersection Of Advanced Maternal Age And Perimenopause

Introduction

An increasing number of people assigned female at birth (AFAB) are now opting to have children at a later stage in life. This could be due to several reasons. Examples include:

• Wanting to achieve certain career goals
• Waiting for financial stability
• Simply being unable to find the right partner until recently 

Of course, deciding to conceive a child in your 40s comes with its own special challenges.

For people AFAB trying to conceive in their 40s, this time intersects with perimenopause. Perimenopause occurs 2-8 years before menopause when the body undergoes a series of hormonal changes. These hormonal changes can impact your mood, health and fertility.

The combination of advanced maternal age and perimenopause can be difficult to navigate. Issues in these areas often do not have easy answers. Education on these aspects is necessary now more than ever. It allows for appropriate expectations when considering any future family building. This article will help people AFAB in their 40s who are considering conception and those planning for this important life transition. It will allow them to gain a better understanding of their options.

Understanding advanced maternal age

Advanced maternal age or geriatric pregnancy is the medical terminology used to describe people AFAB above the age of 35 during pregnancy. Healthcare professionals have found that the biggest decline in fertility for people AFAB occurs in the mid to late 30s due to a decrease in egg quality. This does not mean people AFAB cannot conceive past their mid-30s. However, it may become more difficult and is associated with increased risks of:

• Miscarriage
• Down syndrome and other genetic disorders
• Stillbirth
• Preeclampsia
• Gestational diabetes
• Premature Birth
• Ectopic pregnancy

Currently, the average age for first-time birth parents in Europe is 30 years. When people AFAB are younger than 30, there is an approximately 85% chance that they will conceive within a year. This chance falls to 75% at age 30, 66% at age 35 and 44% at age.¹

Perimenopause and its impact on fertility

Perimenopause means ‘around menopause’ and refers to the period before menopause where people AFAB still have periods but start to experience some symptoms associated with menopause such as:

• Irregular periods 
• Periods that are heavier or lighter than usual
• Sleep problems
• Hot flashes and night sweats
• Mood swings
• Vaginal and bladder problems
• Changes in libido
• Loss of bone density
• Decreases in fertility

Specific conception challenges in the 40s

Egg quality and quantity

People AFAB are born with a fixed number of eggs in their ovaries from birth. As time goes by, and more menstrual cycles are completed, the number of eggs decreases over time. They go through a process of oocyte atresia, where immature eggs are broken down and reabsorbed.

Typically, at birth, people AFAB are born with 600,000 eggs. 60,000-160,000 eggs remain at 30, this steeply drops to 25,000 or fewer in the late 30s and less than 10,000 in the 40s.² There is also a decrease in egg quality as people AFAB age, where there is a higher likelihood of genetic mutations to be found in the available egg.

Hormonal fluctuations

During perimenopause, hormonal fluctuations become more pronounced. The changing levels of follicle-stimulating hormone (FSH), which is involved in the regulation of ovulation, can have effects on the cycle and cause disruption.

The body may not release an egg every month or the timing may be unpredictable. The increase in FSH can shorten the length of the follicular phase of the menstrual cycle. In perimenopausal people AFAB, the growth of the follicle for the subsequent cycle can already start before the end of the current one.

This type of cycle is associated with menstrual cycle irregularities that are associated with perimenopause.³ Due to the changes in the menstrual cycle length and irregularity, it can be difficult to identify when your fertile window is, which is a crucial part of conception.

Another two key reproductive hormones that fluctuate are oestrogen and progesterone.⁴ These play a role in preparing and maintaining the body for pregnancy. Oestrogen thickens the uterine lining while progesterone maintains it.

Both these hormones fluctuate during perimenopause. For example, when oestrogen is reduced, the uterine lining may not develop sufficiently for an egg. Reduced oestrogen is also associated with vaginal dryness which can cause discomfort during intercourse. Low progesterone on the other hand can lead to irregularities in the menstrual cycle.

Furthermore, it can lead to not being able to maintain the uterine lining and can therefore cause miscarriages. These hormonal shifts can disrupt ovulation, affect the uterine lining, and cause irregular menstrual cycles. All of these factors contribute to difficulties in achieving and maintaining a healthy pregnancy.

General health considerations

Your overall health plays a role in fertility. Conditions such as 

• Diabetes
• Thyroid disorders
• Obesity 

are more common as we age and have been shown to impact fertility. For example, diabetes can lead to hormonal imbalances, which can make it more difficult to conceive. If you suffer from any health conditions, it is important to work closely with a healthcare provider so they can discuss how the condition and medication may affect fertility.

It is crucial for people AFAB in their 40s who are trying to conceive to maintain a balanced and healthy lifestyle. This includes:

• Proper nutrition: a diet rich in whole foods, especially rich in omega-3 which has been shown to improve egg quality in women⁵
• Regular physical exercise before and during pregnancy can help maintain a healthy weight
• Managing stress: chronic stress can have negative effects on fertility but can be controlled with interventions such as yoga and meditation

It would also be a good idea for regular health check-ups to monitor any changes in reproductive and overall health and address these issues as soon as possible.

In vitro fertilisation (IVF) for conceiving

Natural IVF harnesses your body’s abilities to choose healthy eggs for ovulation. Instead of taking the normal medication, the egg your ovaries release naturally that cycle is used for in vitro fertilisation.

Mild IVF is similar to natural IVF. It works alongside the menstrual cycle of a person AFAB. However, there is some administration of stimulating drugs to collect 2-10 eggs. However, a lower dosage of the drugs is given and for a shorter duration compared to conventional IVF.

In conventional IVF, you receive a higher dosage of drugs that stimulate ovulation and cause your ovaries to produce multiple eggs. These eggs are then removed, and fertilised before being implanted back into the womb.

A 2022 study showed that people AFAB below the age of 30 who underwent IVF or embryo transfer had a 69.4% pregnancy rate. For the 30-34 year olds, this dropped to 52.6%. For people AFAB ages 35-39 it was 24.7% and in those between the ages of 40-43, the chances of pregnancy from these treatments was 9.4%.⁶ As demonstrated by these figures there is a steep drop in fertility rates using IVF after the age of 35 years old (yet conception is still possible).

Supportive therapies for IVF

IVF can be both physically and mentally demanding. Some therapies that have been shown to support IVF treatment include:

• Acupuncture
• Yoga
• Meditation
• Herbal supplements

Conclusion

Navigation conception in your 40s can be difficult and confusing. However, many people AFAB successfully conceive with the right information and support. Understanding how advanced maternal age intersects with perimenopause and the implications of this on fertility is crucial.

This can help people AFAB make informed decisions on their conception journey and set realistic expectations. Advancements in technology such as various forms of IVF and supporting therapies mean that people AFAB have more options than ever before.

During this period, maintaining good health and managing current conditions can improve the chances of conceiving. With careful planning and the right medical guidance, the goal of becoming a mother can still be within reach.

Summary

• Many people assigned female at birth (AFAB) choose to conceive in their 40s due to personal reasons
• Conception in people AFAB in their 40s comes with its own special challenges
• The combination of advanced maternal age (people AFAB over the age of 35 during pregnancy) and perimenopause (deregulation of the menstrual cycle and other symptoms before menopause) can make things difficult
• Advanced maternal age comes with the increased risk of several complications including miscarriage and stillbirth
• People AFAB in their 40s have reduced egg quality and quantity and suffer from hormonal fluctuations, both of which decrease fertility
• Additionally, health conditions such as diabetes and obesity are more common at advanced age and also impact fertility
• Living a healthy lifestyle with proper nutrition and regular physical exercise while managing stress improves the chances of conception
• Furthermore, treatments such as different forms of in vitro fertilisation (IVF) and supportive therapies for IVF also increase the likelihood of successful conception