Two main fertility challenges women over 40 face are decreased oocyte quality and quantity. Age is the most significant predictor of oocyte quality. There is no reliable test aimed at evaluating a single oocyte quality in vivo or in vitro following oocyte retrieval or just prior to fertilization. On the other hand, there are good ovarian reserve tests aimed at estimating the residual follicular pool in aging women: AMH, AFC, and cycle day 2-4 FSH. Each have acceptable specificity for detecting diminished ovarian reserve. The majority of clinicians prefer AMH over AFC and FSH due to its technical simplicity, lower intra- and intercycle variability and increased prognostic value in the context of older women 43,44. Once stating a desire to conceive, women who are 40 or older should have an immediate comprehensive infertility evaluation that must include prompt ovarian reserve testing. Lifestyle changes including nutrition, vitamins, exercise, stress reduction and adequate sleep can only assist in the goal. Lastly, preparation, engagement and support of a team of professionals are essential to approach conceiving over the age of 40.

Women have healthy babies in their 40s and the number presenting to antenatal services is increasing steadily. The statistics around maternal morbidity in the 40s are troubling. The number of women who are trying to conceive in their 40s and ask for help has also been increasing. What is possible today is significantly better than 15 years ago.

We have brought together a stellar group of international experts who diligently describe the best current evidence and their practice of treating women 40 and over who are trying to conceive. The table of contents includes chapters on demographic trends, contemporary insights from reproductive biology, optimal patient management, and support systems using patient experience architecture. Additional chapters include best practices in nutritional and preconceptual counseling, the most successful ART protocols and strategies as well as the most recent data on egg donation using fresh and frozen oocytes. Also included are chapters addressing optimal management of each stage of pregnancy, neonatal and long-term outcomes of children, ways to optimize these outcomes, and a discussion about the ethics of reproduction and fertility treatment in the 40 plus group. Rounding this off are sections on the discussion of emerging new reproductive technologies, rethinking and redefining family planning, or “fertility planning” for the twenty-first century including the most recent data on ovarian reserve assessment.

Recently there has been an increase in age-related infertility, termed ‘reproductive aging’, in which both quantity and quality of oocytes decline. Various established ways to analyze oocyte quantity include assessing age, follicle stimulating hormone, antral follicle count, and anti-Mullerian hormone. Each test has strengths and weaknesses inherent to the test itself and there can be concern when the tests are discordant. Additionally, several algorithms have been proposed that assess multiple elements to predict live birth rates per transfer and most recently cumulative live birth rates per retrieval. Knowledge about fertility has been assessed in several survey-based studies. These surveys illustrate a limited understanding of the participants regarding the impact of age-related fertility decline and a lack of realistic expectations regarding the limitations of IVF or egg cryopreservation to preserve the age-related decline in fertility. Additionally, there are inconsistencies in whether women would choose to have ovarian reserve testing and whether this would alter management. Lastly, emotional response after receiving ovarian reserve testing is also highly variable. This encourages providers to have a conversation about potential ramifications of testing.