Treatment of the unfulfilled desire for children in women over 40 years old: Not too little, not too much

The unfulfilled desire for children in patient couples with a woman 40 years of age or more is mainly due to a factor concerning the oocytes. Only every tenth oocyte has the chance of a live birth. The spontaneous conception perspectives over long observational time periods are high and reach 30-50% for a 40-year-old woman; however, after six unsuccessful cycles at the latest affected couples benefit from assisted reproductive techniques (ART) with an increased chance of pregnancy and live birth. The chances then increase by at least 10% and the time to pregnancy (TTP) is shorter in an uninterrupted series of treatment cycles. These advantages are achieved with on average only five oocytes per follicle puncture and the anti-Mullerian hormone (AMH) level should exceed 1.4 ng/ml. A double embryo transfer (DET) could be approved as the chances of success are doubled. In contrast, intrauterine inseminations in monofollicular cycles do not increase the perspectives of a pregnancy compared to the perspectives of spontaneous conception and should therefore only be offered in cases of cohabitation problems. Before any reproductive medicine measures, the costs and the mental and physical emotional burdens of treatment should also be taken into account; however, if severe sterility factors are present only ART can provide a certain chance of pregnancy.