Bollywood actor Kareena Kapoor Khan announced her second pregnancy last week. As congratulations poured in, so did an observation: Khan, who is 39-year-old, is among the many women choosing to conceive later on in their lives, during what is known as the ‘advanced maternal age’.

There could be numerous reasons for this shift from the preferred 20s till some time ago to the late 30s today. To name a few, women are gaining agency over their bodies and lives; they are prioritising their financial and emotional stability, and they have better access to contraception.

Doctors take us through the biological processes and clarify misconceptions about late pregnancies.

The Basics of Fertility, and How It’s Linked to Age

To put it simply, women are born with a certain million eggs in their ovaries. As they age, the number, as well as the quality of these eggs, declines. The fewer the eggs in your ovaries, the lower your odds for conception.

Dr Madhu Goel, Associate Director, Obstetrics and Gynecology at Fortis LaFemme, Delhi, says,

Dr Sangeeta Anand, Infertility Specialist, Reproductive Medicine at Apollo Fertility, Bangalore, explains how this happens, “The number of follicles which are recruited from the resting pool to grow into a dominant follicle (which releases the egg) keeps on increasing till 35 years of age. There is an average of 30-40 follicles recruited daily before that. But after 35, the reserve pool starts declining drastically, bringing down the chances of pregnancy.”

“But it must be stressed that 35 is not the benchmark for all and experiences differ. We do see a lower reserve in women of ages 30 or 31, and for others, it could happen even later at around 38. So, 35 is not a fixed number,” she adds.

What Are the Risks and How Can They Be Managed?

The decline in the reserve pool is accompanied with a fall in the quality of the eggs, which can show itself in chromosomally abnormal fetuses, implantation failures in IVF, and higher chances of miscarriage.

These complications could get aggravated with health conditions like thyroid, hypertension, high blood pressure, diabetes and weight. But even though these risks exist, they can be monitored, detected and mitigated in time with the necessary tests and follow-ups.

Dr Goel tells FIT, “The pregnancy risks that are associated with different medical conditions also increase as the age advances. These could be hypertension, diabetes, blood pressure, among others.”

Dr Anand recommends that women in their late 30s should definitely get their BMI, thyroid and weight checked before conceiving, “The most important thing to monitor and keep in check before pregnancy is weight and obesity. Once pregnant, there is a higher risk of gestational diabetes-induced hypertension, which can lead to growth-restricted or preterm babies among these women,” she says.

If there is suspicion of a certain complication, the woman would be recommended a non-invasive test or amniocentesis. The latter is 100% accurate but carries the risk of miscarriage, so people usually opt for the former.

Even though the nuchal translucency scan and double marker test are non-negotiable for women of this age group, these evaluations are now part of routine screening for all pregnant women.

Alternative Methods of Contraception

If a couple hasn’t been able to conceive after trying naturally for a year, then they must visit the doctor for consultation - even if the woman is under the age of 35.

For women in their late 30s, doctors will recommend the future course of action based on their ovarian reserve, checked through the AMH blood test. “If it is lesser than required, we do not tell them to wait to conceive naturally. Since the reserve is an age-related decline, we can't let them exhaust it. Instead, we advise them alternative methods such as ovulation induction with timed intercourse, where women are put on oral medication, their follicle and egg growth is monitored, and they are told to have intercourse around the fertile period. This increases the chances of pregnancy by 10-12% in a month,” Dr Anand explains.

Even after this, doctors may advise the couple to try naturally for another month. If that doesn’t work either, the couple would finally be counselled for IVF.

However, it must be known that with age, there is a greater risk of implantation failures in IVF. For instance, a study published in The New England Journal of Medicine, found that among women who received artificial insemination, 74 percent of those under 31 years old were pregnant within a year. This decreased to 61 percent of among those between the ages of 31 to 34, and it further fell to 54 percent of women aged over 35.

Is Pregnancy in Your Late 30s Then Recommended?

Even though there is the possibility of age-related risks, they can all be managed with proper care and medical supervision. “Not everybody above 35 would have problems. Yes, the chances are a little higher, which is why we need to be more cautious for timely identification of the complications if they do come up,” says Dr Anand.

Dr Madhu Goel adds, “If you plan your pregnancy after the age of 35, you should be aware of the associated risks in terms of decreased fertility and pregnancy complications.”

“But apart from this extra caution and awareness, there is no difference in a healthy pregnant woman in her 20s and a healthy pregnant woman in her 30s,” she adds.

It all boils down to this: Despite the relatively higher risks, most women above 35 proceed with their pregnancies without any difficulties. It's important to be under medical supervision and manage your health.