Age-related decline in fertility.

A progressive decline in fecundity with advancing age is a reality, attributed primarily to the detrimental impact of various aging processes on female gametes. Despite medical advances that have dramatically prolonged the female life span, declining numbers and deteriorating quality of oocytes, and an increasing incidence of meiotic errors and aneuploidy of gametes and embryos, reduce clinical pregnancy rates and escalate pregnancy wastage. Increased fetal aneuploidies in ongoing pregnancies and an increased predisposition to obstetric morbidities further contribute to the diminishing reproductive successes associated with advancing age. The age of male partners, despite the decline in semen parameters and sexual performance with aging, does not appear to have a major impact on the eventual fertility of the aging couple. The contributions of age-related impaired sexuality and ejaculatory problems, although slight albeit significant, to declining fertility in the aging should be appreciated in appropriate cases. With the realization of the age-related detriment on fertility potential and the limitations of available therapeutic interventions, management of subfecundity in women beyond their mid-30s should be approached aggressively. Success of ovulation induction with clomiphine citrate or gonadotropins is marginal in women aged older than 40 years; a case can be made to proceed directly with ART in women in this age group, especially when there is coexisting male factor or pelvic disease. Except for the use of donor oocytes, the outcome of various therapeutic interventions to optimize reproductive performance in women aged older than 44 years remains dismal. A broader application of PGD techniques may contribute to improved live birth rates in reproductively aging women. The greater likelihood of obstetric complications in pregnancies resulting from donor oocytes and an increased prevalence of age-related medical problems complicating pregnancy should prompt a thorough medical evaluation before proceeding with ART.