INTRODUCTION:

Pregnancy during menopause has always been a matter of concern as many women are now choosing to delay motherhood for a variety of personal and social reasons. One key factor for all women who are trying to conceive later in life is awareness about menopause, which is a natural part of the female ageing process that usually occurs between the ages of 45 and 55 years. The assumption that woman will no longer be able to get pregnant during menopause can be misleading. The advancement in reproductive technology made it possible for women to conceive even after they reach menopause. Even though it becomes easier for women to get pregnant whenever they wish to be but the risks of complications in pregnancy and delivery increase with a woman's age.^[1]

Menopause:

Menopause is defined as the time when the ovaries cease functioning and menstrual periods stop, marking the end of the reproductive years.

Menopause has two stages Perimenopause and Postmenopause.

Perimenopause which is also referred to as menopause transition is 3-5year period before menopause when estrogen and hormone levels begin to drop. A woman typically enters into perimenopause in late 40's and could begin to experience irregular menstrual cycles and symptoms such as:

· Mood changes—Irritability, depression, anxiety

· Hot flashes

· Night sweats

· Sleep disturbances-insomnia

· Elevated heart rate

· Vaginal dryness

· Urinary issues

There is still a chance that a woman could get pregnant during this time. As woman’s age advances, the egg reserve also start to decline and older eggs are more likely to have chromosomal abnormalities. Thus a woman have less chances of getting pregnant as she grow older but If a viable egg is released and fertilized, conception can occur

Postmenopause occur when a woman has not had a period for 12 months. Most women have menopause at 51 to 52 years of age. The transition from perimenopause to postmenopause can take 1-3 years. Once woman reaches this phase hormonal balance changes permanently. At this stage, ovulation will no longer occur and woman cannot conceive naturally.

Conception after menopause:

Assisted Reproductive Technologies:

After 40’s woman have only 3 or 4 percent chances of getting pregnant. Assisted reproductive technologies are most opted method for conception from which intrauterine insemination (IUI) or in vitro fertilization (IVF) are commonly used clinical modalities. In an IUI cycle, fertility medications are administered to start the growth of multiple eggs in the ovaries. When these eggs are ready to ovulate, the partner’s washed sperm is placed directly into a woman’s uterus. Whereas IVF includes removing the eggs and fertilizing them with the sperm in the lab and then implanting the resulting embryos to the uterus. Each treatment’s success depends upon woman’s age. The success rate of IUI is generally less than 5% per cycle after 40 years of age whereas the success rate is 10% for women ages 35 to 40. Success rate for IVF is more as compare to IUI that is 20% in women 40 and older. ^[2]

Egg Donation:

For older women especially over 42, who have faced failure with other therapies, Egg donation, which includes the use of eggs donated by another young and healthy woman, is highly successful. If the woman is over 40, chance of successful pregnancy is quite high with IVF using donor eggs. In an egg donation cycle, the woman receiving the donated eggs is referred to as the “recipient.” The recipient needs to undergo hormone therapy to prepare her uterus to receive the fertilized eggs (embryos). Once the eggs are obtained from the donor, they are fertilized in the laboratory with sperm from the recipient’s partner. After fertilization, the embryos are transferred to the recipient’s uterus. If any embryos are not transferred they can be frozen (cryopreserved) for a future cycle. Donor-egg IVF helps a woman to experience pregnancy, birth, and motherhood. Counseling is usually recommended so that all involved in a donor-egg agreement understand the ethical, legal, psychological, and social issues related to this procedure as the child born will not be genetically related to the recipient. Egg quality is associated with age and it is the main barrier to pregnancy in older women, this can be evident from the high success rate with egg donation.^[2]

Fertility Preservation Fertility preservation involves freezing of embryos after IVF or retrieving and freezing eggs for later use. Embryo freezing (cryopreservation) is well established modality for women who want to delay pregnancy till 40s. Egg freezing for preservation of fertility is a new technology that has high success rate but age also pose a barrier for women interested in using elective egg freezing. As the age of women undergoing egg freezing increases, the outcomes of assisted reproductive technology utilizing their frozen eggs become questionable because of other age related changes.^[2]

Pre-Implantation Genetic Screening:

Pre-implantation genetic testing is a used to detect genetic abnormalities in embryos created through in vitro fertilization (IVF) before pregnancy. Pre-implantation genetic diagnosis can be used if genetic parents (one or both) have a known genetic abnormality and testing is performed on an embryo to determine if it also carries a genetic abnormality. With pre-implantation genetic diagnosis (PGD), a small number of cells are removed from each embryo and genetically evaluated. Only the healthy embryos will be transferred to the uterus for implantation. This procedure will lead to improved successful pregnancy rates. Pre-implantation genetic testing provides an alternative to current post conception diagnostic procedures (ie, amniocentesis or chorionic villus sampling) and it save the parents from making difficult decision of pregnancy termination in case of unfavorable diagnosis^.[2]

Risk and Efficacy:

Women over 40s, those who have conceived following assisted reproductive techniques, using ovum donation and those who have conceived spontaneously, both have age in common but they differ in terms of risk. Women who have conceived with assisted reproductive technology underwent vigorous diagnostic testing therefore have less risk of genetic abnormalities as compare to women who conceived spontaneously. In addition these women are at higher risks of miscarriage, ectopic pregnancy, gestational diabetes, hypertension, antepartum hemorrhage, premature birth, C-section, and unexplained still birth^.[3][4]

Instead of medical complications there are many ethical and social issues related to postmenopausal motherhood.

It is believed that parenting a young child beyond the age of 40 can be both emotionally stressful and physically demanding. Similarly there are opinions that older women should not be treated with assisted reproductive technologies as advancing age would make it difficult for her to raise a child and there is possibility that child will lose mother in early years of life. This will emotionally and psychologically harm the child causing addition burden on family

In line to these objections to postmenopausal pregnancy, there are not enough evidences showing that older parents are lacking in physical and psychological stamina for raising children. In many societies children are usually raised by grandparents and parenting responsibilities are shared by family members.

As per the medical complications are concerned they can be managed by through pre-conception diagnosis and counseling. There is need for regular monitoring during antenatal, intra natal and postnatal period. Promptness is required to deal with any emergencies^{. [5]}

Ethics Committee of the American Society for Reproductive Medicine affirms that “it would be wrong to deny women the use of donated oocytes solely because of their age.” There fore Women who are willing to use, and able to access, donated eggs, or who have preserved their own eggs can enjoy the motherhood after menopause. However, the use of in vitro derived gametes is also an available option and it could significantly increase the number of women opting for postmenopausal motherhood.^[6]

REFERENCES:

1. Cadman Bethany. What you need to know about menopause and pregnancy [internet]. 2017 December [cited on 2019 November 24]; Available from URL: https://www.medicalnewstoday.com/articles/320228.php

2. American Society for Reproductive Medicine. Age and fertility, A guide for patients; 2012

3. Daniela Cutas, Anna Smajdor. Postmenopausal Motherhood Reloaded: Advanced Age and In Vitro Derived Gametes. Hypatia.2015 May; 30(2): 386–402.

4. Tower C. Pregnancy in peri- and postmenopausal women: challenges in management. Menopause Int. 2009 Dec; 15(4):165-168

5. Verma S, Agarwal K, Gandhi G. Pregnancy at 65, risks and complications. J Hum Reprod Sci. 2016; 9(2):119–120.

6. The Ethics Committee of the American Society for Reproductive Medicine. Oocyte Donation to Postmenopausal Women. Fertil Steril 2004; 82(Suppl 1): S254–5.

Received on 16.01.2020 Modified on 02.03.2020

Int. J. Nur. Edu. and Research. 2020; 8(3):394-396.

DOI: 10.5958/2454-2660.2020.00085.X