Amid Wave of Late Births, Israeli Doctors Chart New Tests for Women Over 45 Undergoing IVF

Committee proposes guidelines to assess health risks for growing number of older pregnant women

The rise in the number of women over age 45 giving birth has led physicians associations to recommend a battery of new tests for such women, in an effort to reduce pregnancy and birth complications.

The new instructions, formulated by a joint committee of the Israeli Fertility Association and the Israel Society of Maternal Fetal Medicine, are aimed primarily at women undergoing in vitro fertilization using donated ova. Such treatments are covered by the national health insurance program up to age 54, but until now, there have been no official instructions as to what prior tests should be run on older women.

The proposed instructions, written by a group of senior doctors from Hadassah and Poriya hospitals, could still undergo changes, as they have not yet been approved by the Israel Society of Obstetrics and Gynecology. As they stand now, however, they state that any woman over age 45 who wants to undergo in vitro fertilization must first undergo various physical and gynecological exams to assess the risk of pregnancy. These tests will focus on risk factors related to medical problems that are more common in older women, such as high blood pressure, obesity and diabetes.

According to a national survey conducted by the Health Ministry in 2003-04, the proportion of people with high blood pressure rises from 4.5 percent among those aged 35-44 to 17.3 percent among those aged 45-54. The obesity rate rises from 13.2 to 17.8 percent, and the proportion of diabetics from 1.6 to 4.9 percent.

"These diseases are liable to have a significant effect both on the development of the fetus and on the health of the pregnant woman, and they also raise the risk rate of cesarean operations for older women, a rate that's already very high at over 70 percent," the new instructions say.

Among the tests they recommend before approving in vitro fertilization for older women are an EKG, a profile of fats in the blood, blood tests to measure sugar levels, kidney function, liver function and thyroid function, and tests to rule out breast or cervical cancer. Gynecologists can also ask the woman's family physician for an assessment of her overall health.

For women over 50, the instructions add additional tests, such as a stress test to measure heart function and an early detection test for colon cancer. If the woman has any existing health problems (such as high blood pressure or obesity ), they recommend a comprehensive medical assessment involving her gynecologist, the doctor treating the problem and a fertility expert before approving the in vitro fertilization.

Once an older woman had become pregnant, she should be monitored regularly at a clinic for high-risk pregnancies, the instructions say. This includes doing an ultrasound at an earlier stage than usual due to the high risk of multiple embryos.

The instructions also recommend taking the age of the egg donor into account when assessing the risk of Down syndrome.

In 2010, 548 Israelis age 45 or older gave birth, accounting for 3 percent of all births, according to the Central Bureau of Statistics. That number represents an increase of 83 percent compared to a decade earlier. Most of these women were Jews (88.5 percent ) from the center of the country (46 percent ).

The mortality rate among all Israeli women giving birth is currently six per 100,000. There is general agreement among gynecologists that pregnancy and birth are riskier for older women, but there is no agreement on how much riskier.

A study done by Tel Aviv University in 2009 found that 43 is the age at which most women need an egg donation. A study published in the "New England Journal of Medicine" that same year found that in vitro fertilization has a success rate (after six rounds ) of 86 percent for women up to age 35, 78 percent for women age 35-38, 67 percent at ages 38-40 and 42 percent over age 40.

The oldest woman ever to give birth in Israel, in 2004, was 64 years old. She became pregnant via an egg donation and in vitro fertilization - though Sheba Medical Center in Tel Hashomer, where she gave birth, said its policy is not to perform in vitro fertilizations on women that old, because of the dangers of pregnancy and birth at that age.