Advanced Maternal Age


Advance maternal age, a poorly worded term, refers to women who defer child bearing plans beyond the age of 35 at the time of delivery.  Women who delay childbearing are at increased risk of infertility and certain pregnancy complications. Providing information to all patients of child-bearing age about the obstetrical risks of advanced maternal age can help them make informed decisions about the timing of child-bearing.


Women should know that the probability of achieving a pregnancy begins to decline significantly at about age 32 and that coexisting medical disease and pregnancy complications become more common with advancing age. These complications include ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, some congenital anomalies, placenta previa, gestational diabetes, preeclampsia, and cesarean delivery. Such complications may, in turn, result in preterm birth. There is also an increased risk of perinatal mortality.


FERTILITY — This term refers to the ability of   a couple  to conceive.

Many experts suggest initiating a fertility evaluation after six months of unprotected intercourse without conception in women 35 to 40 years of age, and immediate evaluation in women over 40 years of age

The late reproductive stage is characterized by a transition from fertility, to subfertility, and finally sterility. Sterility due to age-related ovarian insufficiency can be difficult to diagnose in the absence of 12 months of amenorrhea because ovarian function oscillates during the late reproductive stage and the menopausal transition. FSH levels are not useful for predicting an older woman’s inability to conceive. However, a woman who has FSH levels >50 pg/mL on three occasions over six months with estradiol levels <20 pg/mL is highly likely to be sterile because of complete or near complete depletion of the ovarian follicle pool.



Expectant management of age-related infertility is an option for couples who do not desire medical intervention. Options for active intervention include controlled ovarian stimulation with intrauterine insemination (IUI), in vitro fertilization (IVF), and oocyte donation.


Controlled ovarian stimulation and intrauterine insemination — The negative effect of older age on success of controlled ovarian stimulation and IUI was illustrated in different studies.

  • In vitro fertilization — The success of IVF using fresh nondonor eggs is lower for women in their late 30s and early 40s than for women under 35 years of age. As her age increases, a woman's chance of progressing from the beginning of ART to pregnancy and live birth (using her own eggs) decreases.
  • Oocyte donation — Oocyte donation is an  effective option for women over age 40 who have diminished ovarian reserve/ The risk of chromosomal abnormality in offspring correlates with the age of the oocyte donor, whereas the risks of pregnancy complications, such as gestational diabetes and hypertension, are consistent with the age of the recipient. The success of egg donation does not significantly vary according to the recipient's age up to age 50, after which there may be a small decline due to lower rates of implantation.
  •  Cryopreservation to preserve fertility — For women who are approaching advanced reproductive age, but are not ready to become pregnant or are not in the position to have a child, options to preserve fertility, including embryo and oocyte cryopreservation, may be considered.




The following suggestions apply to women ≥35 years of age at the estimated date of delivery:

 The risk of fetal chromosomal abnormalities  based on maternal age should be reviewed. There are two approaches to identifying fetal aneuploidy: (1) invasive testing (amniocentesis, chorionic villus sampling), which is diagnostic, and (2) screening using the detection of abnormal ratios of free floating fetal chromosomes in the maternal blood. Women whose screening test suggests a high risk of aneuploidy could choose to undergo diagnostic invasive testing,

 Age and obesity are risk factors for development of  diabetes mellitus, as well as gestational diabetes.

 Given the increased risk of congenital anomalies in older women, we feel a detailed second trimester ultrasound examination to look for significant structural abnormalities.

 The clinician should discuss pregnancy complications that occur with increased frequency in older gravidae, such as spontaneous abortion, some congenital anomalies, placenta previa, gestational diabetes, preeclampsia, and cesarean delivery. Some of these complications may, in turn, result in preterm birth, so the implications of preterm birth should also be reviewed.

 The patient's risk for adverse outcome, including preterm delivery/low birth weight, intrauterine growth restriction, and stillbirth, should be assessed by considering not only her age, but also the presence or absence of concomitant risk factors such as hypertension, diabetes, obesity, low socioeconomic status, black race, and previous pregnancy complicated by growth restriction or preterm birth.




Dr. Pinky Ronen, M.D.

950 Threadneedle, Suite 282

Houston, Texas 77079

713-464-4444 phone

713-465-9718 fax




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