Advanced Maternal Age at 35: Accurate or Artifactual?

Traditionally, women aged 35 and over who become pregnant are referred to as AMA, or advanced maternal age. But is this a thing of the past?

Pregnant Mom Over 35
It's 12:01 AM on the eve of your 35th birthday. Poof! You're considered AMA, or advanced maternal age. The likelihood you will be able to conceive plummets, and your risk factors for pregnancy complications skyrocket. Right? Not so fast, say experts.


"It's not as if a switch is flipped," says Siobhan Dolan, M.D., medical advisor to the March of Dimes, ob-gyn and author of Healthy Mom, Healthy Baby: The Ultimate Pregnancy Guide. "The guidelines have changed. We're moving toward personalized risk assessment. There's no one size fits all answer."


That's right: age is, well, just a number when it comes to understanding a woman's risk factors during pregnancy. Increasingly, doctors are looking at the individual, and how her genetics, health history and current health status play a role.


Conception


It all starts with TTC.


"The number one factor is really health," says Kecia Gaither, M.D., maternal fetal medicine specialist and director of perinatal outreach at Montefiore Medical Center in New York City. "If nothing else is going on with her health, a woman's ability to conceive is the same after 35."


But Dr. Gaither still wants women to understand this simple biological fact: "As you get older, the number of eggs you have decreases."


"Fecundability, or the probability of achieving a pregnancy in one menstrual cycle, begins to decline significantly in the early 30s, with a more rapid decline a few years later at about 37 years," explains Margarita Mercado-Medina, M.D., a board-certified ob-gyn in South Nassau, N.Y.


She notes a large, well-designed study that looked at the probability of clinical pregnancy following intercourse on the most fertile cycle day in women of average fertility. In women aged 27 to 34 years, the probability was approximately 40 percent. In women 35 to 39 years, it was 30 percent.


Yes, ladies, there is some truth to the notion of the biological clock, especially around age 40.


"As we get closer to 40, the ticking becomes louder and by 45, it can be deafening," says Sheryl Ross, M.D., ob-gyn and women's health expert at Providence Saint John's Health Center in Santa Monica, Calif. "Fertility decreases by as much as 95 percent in women between 40 and 45 years of age."


Potential complications


As women age, the likelihood of having a multitude of medical conditions like hypertension and diabetes goes up, and that is why the risk of potential pregnancy complications increases. Dr. Mercado-Medina notes the risk for spontaneous abortion, ectopic pregnancy, preeclampsia, gestational diabetes, stillbirth, and chromosomal abnormalities like Down Syndrome all increase with age.


"At 35 years of age the risk of having a baby with chromosomal abnormalities is 1 in 204, at 37 years 1 in 130, at 39 1 in 81, and going as high as 1 in 39 at 42 years of maternal age," she says.


The good news is that health assessment, genetic screening, diagnostic and counseling options are more sophisticated than ever, allowing women to understand as much as possible about their health, and pregnancies.


Testing


It used to be that the risk of a woman at age 35 having a baby with Down syndrome equaled the risk of her suffering a miscarriage during amniocentesis. In fact, that is where the age of 35 being considered high risk originated from, according to Dr. Dolan. But now, using the guidance of ultrasound, the risk of miscarriage during an amnio is somewhere around 1 in 500, making that "magic age" obsolete.


"All women should be offered prenatal diagnosis, regardless of maternal age," says Dr. Dolan in keeping with recent ACOG recommendations.


Explains Dr. Ross, "Chorionic villa sampling (CVS) is done between 11 and 14 weeks, and amniocentesis is done between 16 and 18 weeks. Both these tests determine the chromosomes to know if the baby is genetically healthy."


The bottom line


"The age of 35 being a cutoff point is an artifact," states Dr. Dolan.


But not all doctors agree. Dr. Ross says, "The truth is advanced maternal age is over 35 years. If there are any reclassifications to be made it should be for those women over 40 years. I would call this group VAMA which would stand for very advanced maternal age."


Regardless of age, there is one thing that is not open for debate. A woman who maintains a healthy weight, takes a prenatal vitamin with folic acid, manages medical conditions, doesn't smoke, and keeps vaccinations up to date, has a better chance of conceiving a healthy baby, and having a healthy pregnancy.


And moms over 35, there are a few benefits to, ahem, your AMA, namely financial security, and as Dr. Ross says, "When it's your choice to get pregnant you are much more in control of the process and more prepared to become a parent."

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