More and more women are putting off having children, so there comes a time when many of them ask a gynecologist for help. In her practice at Primavera Medical Centre in Dubai, Dr Rosalie Sant, a member of the livehealthy.ae expert panel, deals with this issue all the time. We asked her what is going on with our fertility these days – and what we can do to help it along.
Are we leaving it too long before having children?
Yes, very much so. People don’t realize that even though they look younger, feel younger, are very healthy and behave much younger than their age, a woman’s complete reserve of eggs is in her ovaries at birth. If you are 44, so are your eggs. They have been exposed to everything your body has been exposed to; all the environmental toxins from the air we breathe, the food we eat, all the viruses and pathogens, all the stresses – everything that a woman of 44 might go through, and because of that, the quality of your eggs is very poor.
What role does lifestyle play?
There’s a vast range of normality with regard to the number of eggs we are born with. Some people are just born with fewer eggs than average. In some women, the rate of atresian or use is faster and we don’t understand why. That said, eggs diminish in quality and number irrespective of what we do, simply because we are growing older.
Some women think that if they’ve been on the contraceptive pill or been pregnant a few times they have “saved up” some eggs because they didn’t ovulate every month. But it doesn’t work like that; the eggs diminish steadily throughout our life at a rate that is difficult to influence substantially. Naturally, a healthy lifestyle with no diseases, loads of antioxidants and good stress management can slow the rate down somewhat. However, menopause will still happen around the age of 50 to 51 in most women and fertility will still start to decline significantly about 10 years before that, no matter what preservation techniques a woman may use.
What other factors play a role?
There is the issue of autoimmunity, where the body starts attacking the eggs as they are perceived as foreign bodies. This more commonly concerns the thyroid gland, like Hashimotos’s Thyroiditis, but it can also happen to the ovaries and the eggs within them. Autoimmune conditions have a genetic link as well as being affected by environmental factors and they are becoming more common.
In the case of thyroid autoimmune conditions, when we don’t produce enough thyroxine, it is easy to replace it by taking medicine. However, although it is possible to replace oestrogen if the ovaries are not producing enough of it, it is unfortunately impossible to replace eggs.
Secondly, the quality of the eggs is as important as how many of them there are, and that’s what we’re struggling to understand. Somebody may have a lot of eggs in their ovaries and respond very well when taking medicine to stimulate ovulation but then still find it difficult to get pregnant because the quality of her eggs is poor.
How much of a problem is this autoimmunity issue?
It seems to be becoming more of a problem. We don’t understand exactly why. We’re seeing women in their late 20s and early 30s who, for some reason, have a fertility age of a woman over 40. Sometimes, it runs in families; there would be someone in the family history whose periods stopped in their 40s, for example. Usually this would have been attributed to a shock or a stressful episode in the woman’s life, not realizing that there is an underlying predisposition that might run in the family.
However, nowadays we’re also seeing it in people who don’t have a family history and it seems to be more to do with an autoimmune condition. In fact, it has a very well-defined name now: Premature Ovarian Failure (POF). It’s always been around, but it seems to be happening more often.
Why is this happening?
As other autoimmune diseases are increasing, so is POF. Researchers don’t fully understand why, although lifestyle and environmental factors have been implicated. The good news is we can do a blood test called Anti-Müllerian Hormone (AMH) to find out if you could be at risk. This hormone reflects the number and quality of the egg reserves in our ovaries. It’s how we measure what we call the ‘fertility age’ of the individual.
I often encourage people to do this test, particularly if they have a family history of POF or they are planning on postponing conception. In addition, if POF has not completely set in, they can try to slow the process, or maybe even reverse it, by cleaning up their lives, going as green as possible, de-stressing and trying out some of the new strategies suggested by research. It’s amazing how the ovaries react. The AMH doesn’t improve, but at least the rate of deterioration may slow down. Even if this does not happen, it might improve the ovarian function at the present time. Why is that important? Because it gives an idea of how likely it is that the ovary is going to ovulate spontaneously or respond to fertility assistance and increase the chances of getting pregnant.
Has this become more of a problem over your 25-year career as an Obgyn?
Very much so, mostly because people are older when they’re trying to get pregnant nowadays. This means their eggs are older but also, time-related conditions that affect fertility – like polycystic ovary syndrome, endometriosis and adenomyosis, which scars the uterus and reduces its ability to incubate a pregnancy – have had time to get established. If you’ve got a certain mild condition, the older you are, the more ingrained in the body it’s going to become.
All these contributing factors add up and the result may be that achieving a pregnancy becomes difficult.
When you talk about age, what scenarios do you see in your office?
Well, it’s becoming unusual nowadays for a woman under 30 to even think about getting pregnant, especially here in Dubai. You ask a 32-year-old if they’re considering it and they say, ‘Absolutely not. I’m far too young for it. I’ve got so many other things to do with my life before I get pregnant.’ I recently had a 46-year-old come in asking about fertility, and she is definitely not the first. She said she had only just met someone that she wanted to get pregnant with – which is fair enough.
When someone comes to you at that point, what do you do?
Well of course you have to try and assess their fertility reserve by checking the AMH and their Follicle Stimulating Hormone (FSH), together with an ultrasound of their ovaries to check the antral count. (An antral follicle is a resting follicle and appears as a small fluid-filled sac which contains an immature egg.) You assess their situation to see if they may still, with treatment, have a small chance or not. To be honest, if they have a chance, they need to go to a very specialized fertility center. An ordinary fertility center would have very little to offer them other than a referral overseas for egg donation, as this would be the only way for them to get pregnant.
However, this situation has now become such a common worldwide problem that there are a few centers around the world, particularly in the US, which actually focus on trying to eke out those few healthy eggs that a 46 or 47-year-old woman might still have. They’re using stem cell therapy and other methods – all experimental at the moment, but that’s where we are.
What would your advice be for older women then?
If a 42-year-old woman came to me and said, ‘You know what? I’ve just got married but I don’t want to have a child just yet,’ my advice would always be to freeze her embryos, not her eggs. It’s too late to freeze eggs at 42. The quality of the eggs is poor and freezing and thawing eggs is very stressful on the eggs and they may not survive. However, an embryo – a fertilized egg – freezes and thaws much better. Naturally, there may be ethical issues about this which need to be considered. The alternative would be to change your life plans and get pregnant now.
Naturally, the above scenarios only work if you’re lucky enough to have the man of your dreams in your life.
What happens when you try to get pregnant with frozen eggs?
Egg freezing is best if it is done earlier in life; 35 seems to be the cut-off point, as the attrition rate is higher if the quality of the eggs is not optimal. The reason is that if the eggs are much older, the chances of their resulting in a pregnancy, and eventually a baby, diminish.
For example, you may have 20 eggs collected but only 12 to 14 of them are good to freeze. Then, when they are thawed, only 5 to 7 will survive. Of those, only 2 to 3 will fertilize. Will they implant and result in a pregnancy? Will the pregnancy result in a baby? That’s what we mean by attrition rate. The attrition rate is so high between the number of eggs you produce and the likelihood of ultimately having a baby. The percentage of women who will manage to have a baby from their frozen eggs is very small , especially if they were collected when the woman is older.
What about male fertility?
Well, I always say it takes two to tango! Some men are very willing to have a semen analysis to check the number and quality of their sperm and make sure that everything’s fine. Others, unfortunately, still are not so keen and they have to be put under a little bit of pressure to actually do it. It can be very emotional for men because they link it to their ‘manhood’ and they feel their masculinity is really threatened. But also, treatment is not very effective so it all makes for an emotionally loaded situation.
Male factor infertility has risen enormously in the past few years. We have often said that this is because of all the oestrogens (female hormones) that men are unwittingly consuming. We don’t know exactly if this is true. But there are a lot of men under a lot of stress, both emotional and from factors such as smoking, toxins and lifestyle.
The annoying thing is that, most of the time, there is something we can do to help a woman but there’s very little we can do for men. Most men will benefit from antioxidants unless, of course, they have a very specific problem where hormones or surgery may help. This reflects how important environmental factors are on fertility.
So men can also improve their fertility with lifestyle changes?
In men, it’s a completely different story to women. They are not born with their sperm. The sperm is formed from a cell that divides and eventually becomes a sperm after about two months of maturation. Therefore, sperm are very fresh. Antioxidants help the environment in which sperm are developing. So, age does not affect men like it does women. That said, stress of all kinds is cumulative, so they do need a healthy lifestyle too. However, too much exercise, especially in the heat, can be detrimental.
Dr Rosalie Sant
Dr Rosalie Sant is a consultant in obstetrics and gynecology at Primavera Medical Centre. She trained at the University of Malta and Queen's Medical Centre in Nottingham, UK, and later in Germany and Switzerland, where she undertook research in non-invasive pre-natal diagnoses. As part of earning her PhD at the University of Basel, Switzerland, her doctorate thesis won the Roche Prize of the year. She is a fellow of both the Royal College of Obstetrician & Gynecologists and the European Board and College of Obstetricians and Gynecologists. Dr Sant has a special interest in gynecological endocrinology, particularly menopause and polycystic ovarian syndrome, fertility, obstetrics, and minimally invasive surgeries.