Older and older women are at quickly increasing numbers requesting fertility care, - and infertility practice is largely failing them
By Lyka Mochizuki, MSc, until 2024 a former research associate at the Center for Human Reproduction (CHR) in New York City who is now is a Visiting Scientist at the CHR and can be contacted through the editorial office of The Reproductive Times, and by Norbert Gleicher, MD, Medical Director and Chief Scientist of the CHR. He can be contacted through The Reproductive Times or directly at either ngleicher@thechr.com or ngleicher@rockefeller.edu. This article was adopted from a prior publication in the CHR VOICE.
Completing our center’s 2024 data analysis of IVF cycle outcomes, we were, for the second year in a row, surprised by the results. Once again, in just one short year between 2023 and 2024, the CHR’s median patient age increased by a full year — from age 44 to age 45. What makes this such a remarkable result is not only the significant difference to the median age at other IVF clinics across the U.S. (which has remained stable at age 36 for years, according to SART and CDC reports), but also the fact that in the last two years, our center’s median age has increased by a full year each year, while the median age at other clinics across the country has remained the same. This discrepancy holds major clinical — and, even more importantly, societal and policy — relevance, which we will explore in more detail.
While it is clear that the CHR attracts a highly selected international patient clientele of older women, the apparent stability in the national IVF cycle age data is misleading. What it actually reflects is the longstanding reluctance of U.S. fertility clinics to treat infertile women using their own eggs after age 42, or at most, after age 43. After that age, most U.S. clinics essentially insist that patients use third-party donor eggs.
How IVF clinics expect to ever learn how to treat older women’s infertility without using donor eggs is difficult to understand. Yet, with the number of older patients continuing to increase, the current practice appears unsustainable.
A little bit of background
Birth rates around the world, except in Africa and certain other underdeveloped regions, are declining. In some highly developed countries, like Italy, Spain, South Korea, Japan, and even mainland China, the decline is reaching economically threatening levels. Recent headlines in the U.S. press have pointed out that the U.S. is also close to missing replacement levels. However, within this overall decline in birth rates, one unique finding may come as a surprise: Birth rates in older women are on the rise. More specifically, pregnancies and deliveries among women aged 45 to 49, and even above 50, have been significantly increasing. This trend in the oldest age group is almost exclusively the result of the growing use of donor-egg cycles.
FIGURE 1. Delayed childbirth, the principal reason why women who are having children are getting older
The principal reason why the U.S. and many other countries face such contradictory demographic trends is the fact that women are delaying childbirth. The later they start trying, the more likely it is that by that time, they will have developed a fertility problem. Figure 1 demonstrates the increase in age at first birth and, cumulatively, for all births.
As is apparent from the figure, first and cumulative births since 2017 follow parallel curves. However, these societal developments not only increase infertility problems — they also contribute to obstetrical and neonatal complications, as pregnancy-related issues increase with maternal age. Caring for older women during pregnancy is, therefore, increasingly becoming a subspecialty within perinatal medicine. In major institutions, this involves teams of obstetricians and physicians from various medical specialties, depending on the needs of individual patients (1).
Why, then, haven’t ages of U.S. patients undergoing IVF cycles significantly increased?
While everyone agrees that women are having babies at more advanced ages, and that infertility is therefore on the rise (though there are, of course, other contributing factors), how is it that the median age of women undergoing IVF cycles in the U.S. (i.e., using their own eggs) has not significantly changed over the years and has remained stable at around 36 years? The CDC reported an average patient age of 36.3 years for 2022, the most recent year for which data is available (2).
This, of course, stands in stark contrast to our center’s experience, especially over the last two years. In 2023, for the first time, our median patient age surpassed 44. And, even more remarkably, as we just discovered, in 2024 — in just one year — our median age rose to 45 years (see Figure 2).
FIGURE 2. Age distribution of the CHR’s IVF patients in 2024 *
Interestingly, and as a side note, this was also the second year in a row that the CHR improved ongoing pregnancy rates in this patient population. For several years, until 2023, the average ongoing clinical pregnancy rate in this group had been around 8%. In 2023, however, this rate increased to 10%, and in 2024, it further improved to 12%—a 33% increase in clinical pregnancy rates over two years. This is quite a remarkable accomplishment, considering the age of this patient population.
The very obvious age difference between the national U.S. and CHR patient age data raises the question: How can this discrepancy be explained? The answer is likely multifactorial, but one conclusion appears unavoidable: The CHR’s patient population undergoing autologous IVF cycles is radically different from the average U.S. patient population treated at almost 500 other U.S. IVF clinics.
For the CHR, this has, of course, not been a new discovery. As a “last resort center,” with over 90% of patients—unfortunately—consulting with the CHR only after having repeatedly failed elsewhere, often at several IVF clinics, it has been obvious that we are serving a much older and more adversely selected patient population than the overwhelming majority of U.S. IVF clinics. However, what was not obvious until very recently is that this difference in prognosis has grown with increasing velocity in recent years.
And there can be only one reason for this: Most U.S. IVF clinics—by now for decades—have simply refused to change their practice pattern of, rather automatically, advancing women above the age of 42 to 43 into third-party egg donation. There is simply no other explanation for the national median age of women undergoing autologous IVF cycles in the U.S. having hardly budged in so many years, despite the very obvious increase in the age of infertile women seeking infertility treatments. In parallel, the number of autologous IVF cycles after age 42-43 has remained minuscule. The annual CDC report, in fact, depicts only patients up to age 42 on its main page (2).
The CHR’s situation, on the other hand, is at the opposite extreme of the spectrum. As the relative percentage of patients above age 43 has been quickly growing, especially in the most recent years, the CHR has become known worldwide as one of the very few IVF centers where infertile women—even at more advanced ages—would still receive serious treatment attempts using their own eggs, offering surprisingly reasonable pregnancy and live birth chances. In 2023, we for the first time reached a 10% ongoing clinical pregnancy rate for women who produced at least one embryo in their cycle. The 2024 results will be available by April. The emphasis on the word “serious” in the previous sentence is intentional, because our experience with patients who underwent those rare autologous IVF cycles above ages 42-43 has shown that, in national outcome statistics, they almost uniformly received what we have come to call “alibi cycles.”
What we mean by this term is that many colleagues who, in principle, still believe that autologous IVF cycles above age 42-43 are mostly futile, may agree to such cycles only because of pressure from their patients. However, they often go through the motions unconsciously or consciously intending to prove to the patient that they were correct in recommending third-party egg donation. Patients then end up receiving the same kind of IVF cycles used for younger women, which, of course, makes little sense.
This brings us to another important question: Why is the IVF field still stuck on the notion that autologous IVF cycles above age 42-43 are not worth it? This notion is difficult to understand, especially since it has dictated practice for decades. In the very early days of IVF, practically all clinics—including the CHR in those days in Chicago—refused IVF treatments for patients over age 38 because pregnancy rates were abysmal under age 38 and essentially zero above age 38. Had the IVF field, at that point, decided to send every woman over age 38 into egg donation, one wonders where the field would be today.
The argument must therefore be made that the apparent lack of interest in pursuing autologous IVF cycles for women above ages 42-43 is self-defeating for IVF practice. Without trying, how would one ever learn?
Current third-party egg donation practices in this country (and in many other regions of the world where egg donation is allowed) make little sense. One must also ask what other motivations might be behind this seemingly unchanging practice.
Unfortunately, and unavoidably, any answer to these questions leads into the complex realities of the IVF business. Donor egg-recipient IVF cycles are by far the most profitable IVF cycles for clinics. They have also, with the establishment of frozen egg banks, become the most logistically simple cycles to manage. Last but not least, they also produce the highest immediate psychological satisfaction levels for both patients and treating physicians because they yield the highest pregnancy and live birth rates.
But this practice pattern also causes immense harm and pain to many patients who, for religious, moral, and/or ethical reasons, cannot pursue donor eggs or who simply are not ready to give up on their genetic motherhood. This sentiment is often expressed even more strongly by the male than the female partner.
Recognizing a patient’s almost absolute right to self-determination in medical decisions, it is difficult to understand how patients can be refused treatment if they desire to work with their own eggs or be given “alibi cycles” if they are not ready to give up on their eggs. That both of these practices are increasingly common is no longer deniable. The time, therefore, appears ripe to not only openly address this issue but also to encourage special research efforts aimed at improving autologous IVF cycle outcomes in women above age 42-43.
Unfortunately, Congress still excludes IVF from almost all federal research funding. IVF research is, therefore, entirely dependent on private funding sources. Considering the increasing value that other governments are now attributing to IVF births due to declining birth rates, it seems timely for the U.S. to begin supporting research aimed at improving IVF outcomes, which, since around 2010, have been moving in the opposite direction nationwide, for all age groups. However, no group deserves such governmental research support more than older infertile women.
Mr. President, we need your help!
References
1. Newman RA, Esakoff TF. Contemporary OBGYN.net. November/December 202418-21
2. CDC. 2022 Assisted Reproductive Technology (ART) Report. https://www.cdc.gov/art/php/national-summary/index.html