For many women, the years leading up to menopause bring new questions around fertility. Periods can become irregular, symptoms shift, and it’s not always clear what this means for your chances of conceiving. At the same time, life circumstances may mean you’re only now considering pregnancy or wanting clarity about your options.

To shed light on this important topic, we’re delighted to feature Dr Rebecca Mackenzie-Proctor, Fertility Specialist, Gynaecologist, and Obstetrician. Rebecca trained in New Zealand, where our paths first crossed, and she is now based in Melbourne working with Life Fertility Clinic Melbourne.

Rebecca brings a wealth of expertise in fertility care — and answers some of the most common questions women ask about perimenopause and their fertility.

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What happens to fertility as women enter perimenopause?

Fertility declines because both the number of eggs (ovarian reserve) and the quality of eggs fall with age. Cycles become increasingly irregular as follicular recruitment becomes inconsistent, and the risk of releasing a chromosomally abnormal (aneuploid) egg rises sharply. This is the main driver of reduced conception rates and higher miscarriage risk in the 40s.

Markers such as anti-Müllerian hormone (AMH), antral follicle count (AFC), and early follicular FSH can help estimate ovarian response to stimulation, but they do not reliably predict natural fertility.

Miscarriage risk increases significantly with age — population data show approximately 53 % of pregnancies at ≥45 years miscarry. According to the Australasian Menopause Society, the chance of spontaneous live birth at ages 45–49 is <2 per 1,000 (<0.2 %). Fertility does not cease suddenly, but the probability of natural conception becomes extremely low.

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If your periods are irregular, does that mean you can’t conceive?

Not entirely. Perimenopause is associated with erratic ovulation rather than its complete absence. Pregnancy is still possible until true menopause (defined as 12 months without periods after age 50, or 24 months if under 50).

For those not wishing to conceive, effective contraception is recommended throughout perimenopause. For those hoping to become pregnant, timed intercourse can help, though standard ovulation kits are less reliable due to fluctuating basal LH levels. Ovulation is more accurately confirmed with a mid-luteal serum progesterone test.

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What are the realistic chances of pregnancy in the mid-40s, and how do doctors assess this?

The chance of live birth in the mid-40s (ages 43–45) is very low (when using your own eggs), while miscarriage risk is also high (>50 % by age 45).

The Fertility Society of Australia and New Zealand collects and publishes success data via ANZARD (Australia and New Zealand Assisted Reproduction Database), which generally shows steep declines in live births with advancing maternal age.

Clinicians assess likely success by considering:

• Chronological age — the strongest predictor
• Ovarian reserve testing (AMH, AFC, FSH) — useful for ART planning, not natural conception
• Excluding other factors (partner’s semen analysis, uterine/tubal evaluation)
• Optional genetic testing (PGT-A) in IVF to avoid transferring aneuploid embryos

Because age is the major limiting factor, the yield of good embryos is often the rate-limiting step. Many Australian clinics counsel strongly on egg donation if a woman is over a certain age threshold and expect low success with own eggs.

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For women considering assisted reproductive technology (ART) during perimenopause, what does the process involve?

In Australia and New Zealand, the typical path is:

1. Initial evaluation (ovarian reserve, semen, uterine/tubal imaging, hormonal and medical work-up)
2. Stimulation IVF cycle (ovarian stimulation + egg retrieval + fertilisation + embryo culture)
   • In perimenopausal women, the ovarian response is often poor, yielding few eggs/embryos
   • Many embryos may be aneuploid
3. Embryo testing/selection (some clinics offer PGT-A in an attempt to avoid transferring abnormal embryos)
4. Embryo transfer(s)
5. Luteal support / pregnancy follow-up

If the yield of viable embryos from one cycle is insufficient or outcomes are poor, many Australian/NZ clinics recommend donor-egg IVF (using eggs from younger donors) because that markedly improves success rates.

International registry outcomes with own eggs at 43–44 report ~5 % live birth per embryo transferred. With donor eggs (usually from women <35), live birth rates are commonly ≥30 % per embryo transferred and largely independent of recipient age. For this reason, many clinics recommend donor-egg IVF at advanced maternal ages.

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Are there other options women should be aware of (egg donation, embryo donation, preservation earlier in life)?

Yes. Donor-egg IVF offers the highest success in the mid-40s because outcomes track the donor’s age, not the recipient’s; UK data show >30 % live birth per embryo transferred with donor eggs in women 43–50. Embryo donation is another pathway with similar principles plus genetic-carrier screening and counselling. For those earlier in their reproductive years, planned (elective) oocyte cryopreservation can meaningfully preserve options — ASRM supports it with frank counselling about age, numbers of oocytes likely needed, and costs/limits.

In the Australasian setting:

• Donor-egg IVF: The most established way for women in later reproductive years to achieve pregnancy. Because the embryo’s genetic material comes from the donor, success rates correspond more with donor age than recipient age.
• Embryo donation: Less commonly used, but similar in principle, with donated embryos often from other couples who have completed their family.
• Elective oocyte cryopreservation (egg freezing): This can be offered earlier in a woman’s reproductive life (for example in her late 20s or 30s) as a form of “insurance.”

Note: In Australia, public funding or subsidisation for egg freezing is limited; many people access it privately. The same is largely true in NZ (private ART clinics). Clinics must provide detailed counselling about efficacy, limitations, and cost.

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How should women balance conversations about fertility and menopause — can both be managed at the same time?

Yes — dual-track care helps. If you’re actively trying to conceive, we prioritise fertility-safe strategies for vasomotor symptoms (sleep, CBT, and evidence-based non-hormonal options). Menopausal hormone therapy (MHT) with oestrogen and progesterone may be beneficial, as some preparations are not contraceptive and ovulation can still occur.

If you’re not trying to conceive, combined hormonal contraception or a levonorgestrel IUD can control bleeding, ease symptoms, and provide contraception until menopause; we can transition to standard MHT when appropriate.

In Australia, the Australasian Menopause Society guidelines recommend contraception until 12 months after the final menstrual period if over age 50, or 24 months if below age 50.

Management is individualised, reviewing cardiovascular/breast risk and symptom burden at each step.

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Key Takeaways

• Fertility declines steeply but does not disappear until menopause is complete.
• Pregnancy is still possible naturally, and assisted reproductive options exist — but outcomes vary by age and ovarian reserve.
• Early, honest discussions with a fertility specialist help clarify what’s realistic and safe.

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About Dr Rebecca Mackenzie-Proctor

Rebecca is a Fertility Specialist, Gynaecologist, and Obstetrician based in Melbourne, Australia. She works with Life Fertility Clinic Melbourne and is passionate about helping women understand their reproductive options at every age and stage. You can follow her professional updates on Instagram at @dr.rebecca.mac.

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References

1. Australasian Menopause Society. Contraception in perimenopause: practice points. 2023. Available from: https://www.menopause.org.au
2. National Perinatal Epidemiology and Statistics Unit (NPESU). Australia and New Zealand Assisted Reproduction Database (ANZARD) Report 2023. UNSW Sydney: NPESU; 2024. Available from: https://www.unsw.edu.au/research/npesu
3. Deeks AA, Zoungas S, Teede HJ. Risk perception, fertility and menopause management: a focus on midlife women. Med J Aust. 2009; 190(3):136-140.
4. Steiner AZ et al. Association between biomarkers of ovarian reserve and infertility among older women of reproductive age. JAMA. 2017; 318(14):1367-1376.
5. Nybo Andersen AM et al. Maternal age and fetal loss: population-based register linkage study. BMJ. 2000; 320(7251):1708-1712.
6. Hammarberg K et al. Development of an online resource for women considering oocyte cryopreservation: stakeholder involvement and usability testing. Hum Reprod Open. 2019; 2019(4):hoz027.
7. American Society for Reproductive Medicine (ASRM) Practice Committee. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2020; 114(6):1151-1157.
8. Human Fertilisation and Embryology Authority (HFEA). Fertility treatment 2022: trends and figures. London: HFEA; 2023. Available from: https://www.hfea.gov.uk
9. Maheshwari A, Hamilton M, Bhattacharya S. Effect of female age on the diagnostic categories of infertility. Hum Reprod. 2008; 23(3):538-542.
10. Teede H et al. Menopause: an evidence review and clinical practice guideline. Aust Fam Physician. 2022; 51(8):593-602.