How should prognosis be explained to women above 40 years?

[Tier B for figures; framing partially verified] Start from what ESHRE (2026) establishes: female age is a predictor of live birth (strong), while AMH and AFC predict ovarian response but are explicitly not recommended for predicting pregnancy or live birth (strong). A woman over 40 with a reassuring AMH should not be given a correspondingly reassuring prognosis, and this happens often. Principles for the conversation: Give cumulative rather than per-cycle figures where possible, and state the denominator — per cycle started rather than per transfer, since cycles yielding no transferable embryo are exactly what rises with age. Use your own unit's age-banded data. National or published averages will not reflect your population. Distinguish the chance of an embryo from the chance of a live birth. Many women over 40 will complete stimulation and retrieval without a transferable euploid embryo, and being told this in advance is materially different from discovering it. Discuss the number of cycles likely required, and set a point at which the plan would be reconsidered — before starting, not after the third failure. Raise donor oocytes as an option early enough that it is a considered choice rather than a last resort. Deferring it until everything else has failed is common and does not serve the patient. On PGT-A specifically: ASRM (2026) states it has not been shown to reduce time to pregnancy or increase live birth rate versus expectant management, though in women over 40 with a proven aneuploid miscarriage it is reasonable to discuss using shared decision-making. Reviewer: no specific success percentages are quoted here deliberately. If you publish age-banded figures, cite your own.