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  • Title: Reproductive potential in the older woman.
    Author: Gindoff PR, Jewelewicz R.
    Journal: Fertil Steril; 1986 Dec; 46(6):989-1001. PubMed ID: 3536609.
    Abstract:
    There is a definite increase in the number of women bearing children in the 30- and 40-year-old age groups. The total number of women who are 35 to 40 years of age in the United States is projected to increase 42% and the percent births to this age group is projected to increase 37%. This is apparently because of a trend to postpone childbearing and first birth due to women's career priorities, advanced education, control over fertility, financial concerns, late and second marriages, and infertility. Associated with this is an increase in visits to the infertility specialist for older women who have an intrinsic decrease in fecundity with advancing age. Although, on the average, a woman will not experience menopause until about 50 years of age, her effective childbearing period may stop almost a decade earlier. A woman in her late 30s and, especially, early 40s is at some disadvantage in terms of conception delay, ability to carry a chromosomally normal fetus until term, and risk of trisomic conception. Certain endocrinologic parameters have been identified for the woman entering the transition to menopause. Biologic aging of the hypothalamic-pituitary-ovarian axis is intertwined with changes in the endocrine milieu of the perimenopause and preperimenopause. Despite a clear association of decreased fecundity in older women due to multiple biologic and social influences, so long as the individual has regular cycles and essentially normal endocrine parameters, she should be a candidate for an expedited infertility workup and ovulation induction, if not more aggressive treatment. Her obstetric profile is much improved, except for an increase in congenital anomalies and chromosomal defects. Chorionic villus biopsy study or amniocentesis is advised in all cases, regardless of therapy. This discussion and review of the literature of the reproductive potential in the older woman covers the following: the physiology of the transition to menopause, the endocrinology of the older woman; the aging of the female reproductive system; factors affecting the age at menopause; patterns of fertility in the older woman, the epidemiology of late fertility (levels and trends of late fertility and characters of birth order); biologic and social interactions in the determination of fertility in the older woman (factors affecting probability of conception and factors affecting the frequency of spontaneous abortion); genetics and maternal aging; obstetric implications of the older gravid woman; and the treatment of the older infertile woman. Experimental data from animal studies have implicated an aging process in the hypothalamic-pituitary-ovarian axis. The influence of this aging process on the intactness and functioning of ova and their genetic material and on the pattern of oocyte depletion and atresia chronologic, age is the main determinant. To advise an older woman about her reproductive capacity and potential, the physican needs to be aware of the natural endocrinologic history of menstrual physiology during these years, which coincide in many instances with the preperimenopause or the perimenopause. The prodromal period of failing ovarian function may cover 5-10 yars before the complete cessantion of menses at menopause. Even after menopause, there is some evidence of cyclic changes in the ovary. The peroid of reproductive potential cannot extend much beyond the menopause in humans due to progressive atresia and exhaustion of all oocytes. In an indefinite percentage of women, reproduction ceases up to several years before this time, either naturally or prematurely, which may result from age-related changes in the hypothalamic-pituitary axis. The potential for ovulation during the perimenopausal period is present, although reduced. No basis is know, other than clinical experience, for determining whether a given interval without menses is likely to represent permanent amenorrhea. Demographic studies have shown that there is a consistnt decline in fecundity with advancing age after 30-35 years. In many societies this fall in birthrate is due to deliberate fertility control by the use of contraception, abortion, or decreased frequency of sexual intercourse. Such factors can mask any interactions between biologic factors of the aging female reproductive system and other social factors that might otherwise detemine fertility during the later reproductive years. The risk of a trisomic birth remains the singel most outstanding problem for the older woman who does conceive successfully. Despite modern perinatal and neonatal care, several series continued to show a high fetal wastage from variety of causes. The probability of the older woman ovulating, conceiving, and having a normal child are compromised as the chronologic age of the individual approaches menopause.
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