The reality of pregnancy over 40 - is it really safe?

When Natasha Stephens’ periods started to become irregular and she began to feel irritable, tired and bloated, she thought that, at 43, she was experiencing the first stages of menopause. 

In fact, Stephens, now 52, was pregnant with her second son, Sam, now a healthy, energetic seven-year-old. 

“He just came along,” she laughs. “It was definitely a surprise.” 

Stephens, who gave birth to her eldest son at 40, is part of a growing majority: since 2015, women over the age of 40 in England and Wales have had more babies than women under the age of 20. And every month, it seems, brings news of older women having children: in November 2023, broadcaster Victoria Coren Mitchell, 51, announced the birth of a second daughter, joining the ranks of other high-profile older mothers, from Naomi Campbell (in her 50s when both her children were born) to Rachel Weisz (48 when she had her second child). 

Such women make later-life motherhood seem both glamorous and easy. But the truth is, the longer you leave it, the more complicated having children gets, in almost every aspect. So what’s the reality of having a baby over 40?

First things first: your chances of conceiving naturally diminish the older you are – which makes Stephens’ unplanned and naturally conceived children fairly rare. “Your monthly chance of conceiving over the age of 40 is in the region of 5 per cent,” says Prof Adam Balen, a gynaecologist and former chair of the British Fertility Society. For a couple of this age, a year of trying will see a 35-40 per cent chance of getting pregnant “at best”. Meanwhile, adds Balen: “Natural conception is extremely uncommon over the age of 45.” This is thanks to declining egg rates: at birth, the normal female ovary contains about 1-2 million oocytes (eggs), but women don’t make new eggs and lose them every month during their menstrual cycle. Even at a woman’s peak fertility age – around 25 – chances of conception are only about one in four per month. This is a figure that declines as you get older, and over the age of 35, you’re considered to be of “advanced maternal age”. 

The numbers bear this out: a report produced in June 2023 by the Human Fertilisation and Embryology Authority (HFEA), the UK’s independent regulator of fertility treatment, found that IVF and donor insemination cycles increased by 10 per cent between 2019 and 2021. Meanwhile an HFEA report published in November 2022 found that among patients aged 40 and over undergoing IVF, donor eggs are often used. This is most common among women aged 45-50, who are three times as likely to use donor eggs – average IVF pregnancy rates were just 6 per cent for patients aged 43-50 using their own eggs. 

How to conceive over 40

So if you do want to conceive over 40, how do you improve your chances? “If you’re older and have anything in your history that might reduce your chances of pregnancy, seek advice early” advises Prof Alison Murdoch, a reproductive specialist and president of the British Fertility Society. In practice, that means if, for example, you’ve had an infection in your fallopian tubes, don’t leave it too long to find out if they’re blocked. If you’re a man, get your sperm count checked, which you may have to have done privately, but the test is fairly inexpensive at around £150-£160. 

General overall health is key (for both partners): eat a balanced diet, get enough sleep, exercise regularly, minimise alcohol, don’t smoke, and if you are overweight, tackle the problem. Balen has written a book on the topic with nutrition scientist Grace Dugdale, The Fertility Book: Your Definitive Guide to Achieving a Healthy Pregnancy, which takes a comprehensive view of all the genetic and lifestyle factors at play in trying to conceive, including diet advice. 

“A Mediterranean diet is helpful,” advises Balen, who also recommends taking a preconception multivitamin that should include folate. Men, he says, should avoid protein shakes or anabolic steroids. If low sperm count is contributing towards fertility issues, there are treatments available, including gonadotrophin hormones that stimulate the production of sperm.

Ultimately though, says Balen, “It’s all to do with the health of your eggs.” While the quality of sperm does start to decrease from the age of 40, the decline in fertility is slower for men, and “the [quality of the] egg is more important than the sperm”, says Balen. Here you’re down to nature, although “for older women, a supplement called Coenzyme Q10 can be good for the health of eggs”. Though there are no tests to determine whether you can conceive naturally, it is fairly straightforward to get an AMH (anti-Mullerian hormone) blood test done (it costs around £140 to do privately), which will give a strong indicator of ovarian reserve, or egg supply – a good starting point when looking at future options. Doctors can also carry out an ultrasound scan to look at ovarian reserve and identify anything like polycystic ovaries or fibroids in the uterus, which become more common in women as they age. 

Some women may talk about a late or midlife “fertility surge”, supposedly a brief burst of fertility approaching the menopause. This is something of a misnomer, however, says Balen. “There is an increased likelihood of having a twin pregnancy [later in life]”, he acknowledges, but this is due to changing hormone levels. As women age, production of the follicle-stimulating hormone (FSH) increases because the ovaries work less efficiently. Paradoxically, this can lead to the release of more than one egg, meaning the twin rate goes up. “But it’s not the case that fertility per se goes up,” warns Balen, who adds that seemingly surprising later-life pregnancy could be equally down to women taking their eye off the ball when it comes to contraception. 

What if I need IVF?

If your egg reserve turns out to be low, you may decide to explore the option of IVF. Again, there are various routes you can take, which basically come down to whether you use your own eggs – which involves stimulating the ovaries to produce eggs, gathering them, fertilising them outside the womb and then implanting an embryo – or go with a donor egg, where the fertilisation again happens outside the womb and an embryo is implanted. Later in life, the latter offers more options for success. One HFEA report found that the birth rate per embryo transferred for patients under 35 using their own eggs was 41 per cent, compared with just 6 per cent for patients aged 43 and above. By contrast, “For someone in their 40s who uses donated eggs from a 25-year-old, the risk to the baby would be that of a 25-year-old, not a 40-year-old,” explains Alison Murdoch.

It’s important to note, however, that IVF is not a guarantee of success. According to the NHS, the amount of treatments that resulted in a live birth for women using their own eggs was 11 per cent for those aged 40-42, 5 per cent at 43-44 and 4 per cent at over 44. 

Whatever you choose, it is also likely to cost you, as women can receive fertility treatment on the NHS (a postcode lottery as it is) only up to the age of 42 and only then based on the likelihood of success (many integrated care boards will only offer IVF to women under 40). It is wise to interrogate costs carefully at the outset: according to analysis carried out by Fertility Mapper, a review platform for fertility clinics, a standard course of IVF cost 50 per cent more than advertised at a quarter of private clinics, thanks to additional hidden costs such as blood tests and pregnancy scans.

What to expect during pregnancy

Once you are pregnant, how is the experience at 40 or above, compared with being younger? Natasha Stephens’ first pregnancy was “completely straightforward and blissful”. By the time it came to Sam, however, things had changed somewhat. “I didn’t fill out in the same way,” she recalls. “It wasn’t so easy and was more uncomfortable.” When she went for check-ups, doctors noticed her blood platelet count was low, giving her a longer clotting time, and became concerned that this might lead to complications. She was carefully monitored and when it was found that Sam was underweight, she was induced at 38 weeks. When Sam was born, he was 2.2 kilos [4.85lb], “like a scrawny little alien with giant eyes and sticks for arms and legs”. Stephens later discovered that she had a severe vitamin B12 deficiency, which may have contributed to Sam’s low birth weight.

Does a pregnancy over 40 have any more risks?

While being older doesn’t always mean a trickier pregnancy, there are associated risks. It’s harder to stay pregnant, for a start – particularly if you’re pregnant with your own eggs. “There is a higher rate of miscarriage when you’re older because of the age of the eggs,” says Murdoch. Pregnancy losses before 24 weeks (anything later is considered a stillbirth) are almost always caused by chromosomal problems with the embryo which, says Murdoch, is “nature’s way of dealing with any real problems”. 

Older women are also at higher risk of developing certain cardiovascular problems like high blood pressure – one of the reasons women over 40 are more likely to suffer with preeclampsia and gestational diabetes. There is also a higher chance of developing placenta previa, in which the placenta either partly or fully covers the cervix, which can increase the risk of premature labour and stillbirth.

It may all sound a little daunting but, says Dr Jeffrey Ahmed, a consultant gynaecologist at the Chelsea and Westminster Hospital (who last year delivered a 57-year-old mother’s baby perfectly and says that delivering a 40-year old’s is “a doddle” by comparison), it’s important to keep things in context. “Overall, the risk of everything goes up as you age, so take it all with a pinch of salt, especially if you’re fit and healthy. The overall majority of women who get pregnant at 40 will have a very healthy outcome.”

How does age affect labour and delivery? 

Longing for a home birth or to have your baby in a soothing pool? It might be wise to temper your expectations. Older mothers are more likely to end up having a Caesarean section or intervention of some sort during labour. The reason for this is probably because, with a greater focus on the potential risks, interventions are planned in advance. “Induction of labour is now routinely recommended for women of an advanced age,” warns Ahmed, who adds that the recommended gestation for older mothers now stands at between 39 and 40 weeks maximum. “A lot of institutions will also recommend monitoring of labour in a much more close way, with less accessibility to natural birthing techniques.” He is at pains to stress that the evidence for doing so is “weak”, and that options will vary according to where you are. At Chelsea and Westminster, for example, the average age of a first-time mother is 32, much higher than the majority of the country. Because doctors there are more familiar with older mothers, “we can have an open conversation about the options and risks”. 

Bringing up baby

At the end of the day, “It is right that women have babies when they want to have babies – the most important thing is that it’s a planned pregnancy,” says Murdoch. In modern society in the developed world, pregnancy is far less risky than it once was, and “the vast majority of babies are born perfectly healthy”. 

But, of course, the real hard work of parenthood only starts when you give birth – and bringing up kids in your 40s is likely to be a very different experience to doing it 10 years earlier. You also need to consider the number of babies you’d (ideally) like to have. “If you want a family of just one child, you’re probably OK to wait,” says Balen (although he only suggests waiting until your early 30s). If you want two or three, you’d be well advised to try and start earlier still. Meanwhile, says Murdoch, “Someone who’s had a baby at 35 and 37 and is then trying for a third in her 40s has a good chance of conceiving.” It’s having no underlying evidence of fertility that makes later pregnancy potentially problematic. 

“At 52, I’ve got a 7-year-old and a 12-year-old, and I feel my age sometimes,” admits Stephens. “Sometimes I wish I was 10 years younger because they’d get a different kind of energy from me.” But, she adds, “At the same time I notice some younger mothers, who maybe weren’t planning on getting pregnant, struggling a bit with being a mother and the level of sacrifice you have to make. I was very ready to make the sacrifice. I always feel grateful for their existence.”