The Washington Post declared on the 16th of March, 1978 that “The Clock Is Ticking for the Career Woman”. I believe it’s ticking for all women. It’s heard everywhere and is just getting louder and louder. Women are born with their life’s store of 1-2 million eggs. These eggs gradually decline in number and accumulate genetic mutations and abnormalities as they age. With the result, an overwhelming cause of infertility in older women is the rise in abnormal chromosomes (genetic material) in their limited number of eggs. And that is impossible to treat. Even in prime fertile years, about half of all eggs have chromosomal abnormalities. The percentage of eggs with genetic problems just increases with age. Earlier, women were conceiving in their teens and twenties, when age-related abnormalities with the egg were not evident. However, in this modern era, women are delaying child birth until their thirties and forties, which has lead to the discovery of adverse effects of advanced maternal age on egg function and fertility and opened a can of worms. Though advanced reproductive age is defined over and above 40 years, we must remember that Caucasians age differently than us, at least as far as reproductive aging is concerned. The chances of spontaneous pregnancy plummet after the age of 35 years in view of diminished egg number and poor quality. At the age of 40, there is only a 5% chance of becoming pregnant spontaneously. There is also an increase in pregnancy wastage and miscarriages with advancing age. The scenario becomes exceedingly difficult for the fertility specialist to treat. While uterine aging can be compensated for by hormonal means, the egg quality and quantity are beyond any cure right now. There is a possibility of egg donation in older women which offers pregnancy rates of more than 40% but moral, social and most importantly, religious issues pose a problem especially in our society.
The widespread belief that male fertility is totally invulnerable to time is simply false. In men, aging affects sperm quality, making it difficult to achieve a pregnancy. If in good shape, the male can produce healthy sperm until 60 years of age before the sperm count begins to go down in number and quality.
It is a good idea to have a baby at a younger age. If one is unable to have a child earlier in life, measures can be taken to seek early treatment where prognosis and chances of having success are much higher rather than embark on a rather gloomy journey later on. The kind of treatment would depend on a number of factors including age, the cause & duration of infertility, and previous infertility treatments. Not everybody needs assisted reproduction and In Vitro Fertilization (IVF), but those who do, must do it in time rather than wait for age to catch up. In 2015, the Society for Assisted Reproductive Technology (SART), USA reported that 48.7 percent of embryo transfers using self eggs in women under 35 resulted in live births. For women 35-37, almost 38 percent resulted in live births; for women 38-40, 24 percent did, while only 12 percent of embryo transfers in women 41-42 resulted in a baby. Over age 42 only 3.7 percent had a baby. These are very important statistics that say it all.
Since many infertile couples and more importantly, their families are still averse to the idea of IVF, I would like to explain exactly how it works. During an IVF cycle, the woman is given hormonal/gonadotropin injections daily, which stimulate the ovaries to produce many eggs and this process is serially monitored by ultrasound and hormonal tests. Once the follicles (fluid filled sacs containing the eggs) reach a mature size of above 18 mm, a final maturation trigger injection is administered which leads to final development and maturation of the eggs. Just before those eggs would otherwise be ovulated, they are taken out under mild anesthesia in an operation theatre by ultrasound guidance using a narrow needle through the vaginal wall. There is no pain since this procedure is carried out under anaesthesia. Once the eggs are taken out, they are handed over to the embryologist who then fertilizes them using the husband’s/partner’s sperm. The sperm can either be mixed with the eggs to allow normal fertilization (conventional IVF) or by injecting one sperm into each mature egg (Intracytoplasmic Sperm Injection).
The fertilized eggs, now embryos, are allowed to grow and develop in culture media for typically 3 to 5 days in an incubator. Then, generally one or two best looking embryos are carefully and gently transferred into the womb of the mother under ultrasound guidance. This is the process of embryo transfer. The pregnancy test is then performed 2 weeks after the embryo transfer. The pregnancy rates in the best-case scenarios and younger patients are between 40 and 50%. As a result, majority of patients require a 2nd and often, a 3rd attempt with IVF to finally get pregnant.
Age matters for spontaneous conceptions and more importantly, is the most important prognostic factor for fertility treatment.
More women are delaying childbearing while they pursue a career, gain financial stability and seek an appropriate partner and more commonly in our scenario, wait for magic & miracles to happen after marriage. If IVF is indicated, ‘wait and watch’ policy will only make sure that they run out of their eggs. A lot of time is wasted before women in need of IVF finally reach a fertility specialist. A couple must be evaluated and tested for causes of infertility if they are not able to achieve a pregnancy within one year of staying together. The evaluation should be done earlier, say at 6 months, in case a woman is older. This saves a lot of precious time and eggs. In our scenario, the time taken to seek treatment from the right person is hopelessly long. The success story of IVF is astounding but we are still talking about a success rate not crossing 50%. The sad news is that the majority of patients never reach us, or reach very late, do not return for treatment after the diagnostic tests, drop out of treatment, or are lost to follow up after a failed IVF.
Since fertility declines drastically with age and we as doctors and you as patients are turning a deaf ear to the loudly-ticking fertility clock, there is a concern that more women will end up permanently and unintentionally childless. Couples must seek fertility treatment early and doctors must treat right and refer early. Why put off till tomorrow what can and should be done today!!
Dr Sabahat Rasool is Consultant, Govt LD Hospital, Srinagar
sabahatrasool@yahoo.co.in