Fertility options for older women



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By Dr Champa Nelson
Director, Apeksha Fertility Care
Council Member, Menopause Society of Sri Lanka


Introduction


Many women now defer having a child until their later thirties or beyond. If these women then fail to conceive readily they become one of the most difficult problems in reproductive medicine today. As women become older they inevitably go through a phase of ovarian depletion. When superovulated these women produce few eggs, and are described as poor responders. Most but not all poor responders are to be found amongst older women.


Age and Fertility


Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. The biological basis of decline in fecundity with increasing women age appears to involve several factors. Germ cells in the female are not replenished during life, the number of oocytes and follicles is determined in utero and declines following an exponential curve from the second trimester to menopause, the quality of remaining oocytes diminishes with age, and the frequency of sexual intercourse often declines with age.


Although there is an apparent decrease in the frequency of sexual intercourse with advancing age, this does not fully account for the decline in female fertility. Another factor frequently unaddressed is the male’s age. Increased male age is associated with a decline in semen volume, sperm motility, and sperm morphology but not with sperm concentration. There appears to be some decline in male fertility with age, particularly over the age of 50, but the data is confounded by the age of the female partners. There is no absolute age at which men cannot father a child. Thus, fertility is more dependent on the age of the female than the male. The dominant factor is the declining number and quality of oocytes available in the older women.


Miscarriages are also more frequent as maternal age rises. The age-associated decline in female fecundity and increased rate of early pregnancy loss are largely attributed to abnormalities in the oocyte.


Evaluation


Formal evaluation of infertility is generally indicated in women attempting pregnancy who fails to conceive after a year or more of regular, unprotected intercourse. Older women should be evaluated earlier than a year.


These patients have already lost a significant part of their fertility potential due to diminished ovarian reserve. Intense diagnostic effort is not warranted in these patients, and rapid movement towards ART treatment is always encouraged to insure better outcome without wasting more valuable time. Success rates achieved with ART also decline as the age of the women increases.


Management


The National Institute for Health and Care Excellence (NICE) guidelines on IVF in United Kingdom, recommends women aged between 40 and 42 should be offered one cycle of IVF on the NHS under certain conditions.


The success rate of IVF depends on the age of the woman undergoing treatment as well as the cause of the infertility (if it’s known). Younger women are more likely to have healthier eggs, which increases the chances of success. IVF isn’t usually recommended for women above the age of 42 because the chances of a successful pregnancy are thought to be too low. Therefore egg donation becomes the only option for such women.


Egg donation is the process by which a woman provides one or several (usually 10-15) eggs (ova, oocytes) for purposes of assisted reproduction


A need for egg donation may arise for a number of reasons. Infertile couples may resort to acquiring eggs through egg donation when the female partner cannot have genetic children because she may not have eggs that can generate a viable pregnancy. This situation is often, but not always based on advanced reproductive age. Early onset of menopause which can occur in women as early as their 30’s can require a woman to use donor eggs to grow her family. Some women are born without ovaries or other reproductive organs. Sometimes a woman’s reproductive organs have been damaged due to disease or circumstances required her to have them surgically removed. Another indication would be a genetic disorder on part of the woman that can be circumvented by using eggs from another person. Many women have none of these issues, but continue to be unsuccessful using their own eggs.


Procedure


Egg donors once recruited, are screened. They consent prior to participation in the IVF process. Oral contraseptive pill is used to synchronize the donor’s cycle with the recipient’s. The egg donor undergoes IVF stimulation therapy, followed by the egg retrieval procedure. After retrieval, the ovaries are fertilized by the sperm of the male partner of the recipient couple, in the laboratory. After few days, the best resulting embryo(s) is/are placed in the uterus of the recipient, whose endometrium has been appropriately prepared for embryo transfer beforehand. The recipient is usually, the person who requested the service and then will carry and deliver the pregnancy and keep the baby.


Egg donation remains one of the ways of bringing the joy of parenthood to many couples who cannot conceive naturally. Although egg donation is the ideal treatment for older women, many ethical and social issues are associated with this treatment. These ethical, moral, legal and medical issues have been addressed time and time again, yet the debate goes on. Strict guidelines and protocols should be formulated and an authority appointed. Within the complexity of these issues efforts should be made to arrange thorough supervision on these programs in this country. All patients and their partners should be given a detailed explanation of the procedures involved and should have counseling on the moral, ethical and legal implications of egg donation.


 
 
 
 
 
 
 
 
 
 
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