Forty-year-old Anju Sharma, a physiotherapist and chemistry teacher at Dwarka in Delhi, decided to have another child a year ago when her first-born celebrated her 12th birthday and wished she had a sibling to keep her company. “I realised her need and since I was fairly settled in life, decided to conceive again. I chose assisted reproduction methods instead of wasting time on natural conception which could have been iffy given the fact I was pushing 40. Today, I have twin girls,” she says. Meanwhile, in Mumbai, a 42-year-old birthed a naturally-conceived baby while a 48-year-old became a mother using her own eggs for IVF (in-vitro fertilisation, a process where eggs are fertilised by sperm outside the body and then implanted inside the uterus), just five days apart. “Traditionally, women choosing to have babies above 35 were considered to be in the advanced maternal age. But with egg freezing options, advancements guided by assisted reproductive technologies, more and more women are choosing to become mothers in their 40s. By that time they are settled in their life, having achieved a major part of their career goals which are sometimes unmet while choosing motherhood in earlier decades. They have fewer anxieties, are economically more empowered and confident, more mature and take a considered and informed call on the future of their child,” says Mumbai-based infertility specialist Dr Anjali Malpani, who guided the two women through their pregnancies. “There is a huge misconception that the uterus grows old. What most doctors don’t tell you is that a woman’s uterus stays as strong till her 70s,” adds Dr Malpani. Anju’s gynaecologist, Dr Neelam Suri, has been seeing more women in the 35-to-45 age bracket at her clinic at Apollo, Delhi, seeking motherhood after prioritising their personal milestones, emotional maturity and financial security. “With the right guidance and discipline, such pregnancies are having positive outcomes,” she says. Dr Anjana Singh, HOD, obstetrics and gynaecology, at Fortis, Noida, says that pregnant women over 40 now form 30 per cent of her patients. So clearly, Katrina Kaif announcing motherhood at 42 or comedienne Bharti Singh now announcing her second child at 41, are not exceptions but prove the rule. What are physical challenges for women choosing motherhood at 40? Dr Singh says the biggest challenge is the ovarian reserve or the number of healthy eggs remaining in a woman’s ovaries that have the potential to be released for fertilisation and pregnancy. “A woman is born with a finite number of eggs and both their quantity and quality decline over time. That’s why there’s a much reduced chance of natural conception of five per cent. If choosing IVF, the women may need donor eggs, usually harvested from a younger person. IVF can then result in multiple pregnancies," she elaborates. Since women over 40 usually enter the peri-menopausal stage when they undergo hormonal imbalances and disruptions, their bodies go through a change and may be more prone to developing certain conditions like hypertension, diabetes – particularly pregnancy-induced or gestational diabetes – IUGR (intrauterine growth retardation, babies are weaker and frail), pre-term births and preeclampsia (high blood pressure that damages other organs like the kidneys). “A woman planning a baby after 40 has to go through each stage of pregnancy with full knowledge and counselling before conception and more aggressive follow-ups to avoid complications. There are less chances of a normal vaginal delivery. Usually babies are delivered through Caesarean section surgery,” says Dr Singh. The other major challenge is the possibility of chromosomal abnormalities that may result in children being born with some conditions like Down’s syndrome. “When the baby is conceived naturally with her own eggs, this risk goes up. With donor eggs, frozen eggs and IVF, this possibility goes down,” says Dr Singh. Dr Malpani has quantified the risks. “The possibility of Down’s syndrome is one in 1,500 in your 20s, in your early 40s, it is one in 85, and above 45, it is one in 35. The risk of stillbirth is high. The chances of miscarriage go up to 30 per cent from 10 per cent in your 20s. A woman may develop placenta previa, where the placenta attaches itself close to the cervix, triggering bleeding. Sometimes the babies tend to be born heavy and big,” she says. Is natural conception possible at all? Dr Singh had a 40-plus woman present herself with PCOD (polycystic ovary disease), obesity and irregular ovulation and menstruation. She advised lifestyle changes, worked out a diet and exercise discipline which the patient adhered to strictly. “She lost weight gradually. One day, she came to me saying she had missed her periods for seven months, thinking her PCOD was acting up again. Tests showed she was six months pregnant. She had not made much of the movements in her uterus, thinking it was gas,” says Dr Singh. One of her patients conceived unexpectedly at 43 after trying out seven IVF cycles in different countries and adopting a son. “As the stress went out of her mind following the adoption, her body relaxed and was primed for natural conception,” she adds. Preparing the body for motherhood All three doctors root for pre-conception counselling and taking preparatory supplements like folic acid, iron and multivitamins. “Any pre-existing medical disorder, especially among those with a family history, has to be controlled before conception. Blood sugar has to be very well-controlled. Since such pregnancies tend to be high-risk, women need to be regular in their prenatal checkups, once every two weeks. Those intending to be mothers should amp up their physical activity gradually, beginning with yoga and regular walks. Those who are fitter and already used to more intense routines like running and swimming can do so till the first trimester but slow down in the later trimesters. Diet should be low-carb, low fat, high-protein with a lot of fruit and vegetables and up to three litres of fluids,” says Dr Singh. But uppermost is emotional well-being. Anju recalls she developed a positive outlook and focussed on the birth rather than what people said about her choice of late motherhood. “Every woman has to prepare for stigma. Besides, there is the pain of IVF protocols and egg retrieval. I gave up eating outside and had a lot of apples, pomegranate and coconut water. Still my twins came early, at the end of eight weeks, I had high BP and some bleeding before a C-section,” says Anju. Dr Malpani counsels 40-plus would-be mothers over a long time. “Even with their own eggs that can be harvested and extracted, the chances of IVF conception are less than five per cent as compared to 45 per cent for IVF done in younger ages. At this age, we can grow three or a maximum of four eggs instead of 10 or 11 in younger years,” she says. She focusses on improving the quality of eggs. “Before the IVF cycle, we give DHEA (Dehydroepiandrosterone, which is a steroid hormone precursor to boost estrogen) three months prior to conception. We even administer CoQ10 (antioxidant), Vitamin D3 (in cases of deficiency) and even low-dose aspirin in certain cases,” says Dr Malpani. Advanced age maternity is not to be looked at as an oddity. “Women are financially well-off and are not struggling at this stage to make a mark. They can manage spending on assistive help like maids and nurses and given the work-from-home options post-Covid, can actually devote more time to their children. “A 2017 study that analysed UK birth cohort data found that children born to mothers aged 35 or older had higher cognitive ability scores than those born to younger mothers. The shift was attributed to modern older mothers being more likely to be educated, less likely to smoke during pregnancy, and professionally established, suggesting socio-economic factors rather than biological age are key to smarter kids,” says Dr Malpani.
