Delaying the decision to start a family is increasingly common in western societies for a number of reasons. These include the fact that many couples prefer to wait until establishing a stable relationship and financial security. In addition, there are increasing numbers of late and second marriages. In Ireland, house prices have increased so much that there is a need for both partners to work which may also add to the delay.
Despite what you might think from the contemporary magazines (and the older mothers with small children that feature within their pages), fertility (the ability to achieve a pregnancy) decreases with advancing age. The decline is gradual over the reproductive life span of the woman; it is particularly noticeable over the age of 30 and accelerates between 35 and 40 so that fertility is almost zero by the age 45. Bear this in mind when you next see some of the high profile older mums who feature regularly in celebrity magazines – they may well have been the recipient of donor eggs from a 22 year old college student.
The risk of miscarriage is also increased with age (e.g. the risk of miscarriage at age 25-29 years is 10% while the risk at age 40-44 is 34%). Furthermore, advanced maternal age is associated with an increased risk of congenital abnormalities in any resulting children.
Age and Infertility
Ageing of the ovaries is part of the normal ageing changes that affect all organs and tissues. Most women have about 300,000 eggs in their ovaries at puberty. For each egg that matures and is released (ovulated) during the menstrual cycle, at least 500 eggs do not mature and are absorbed by the body. By the time the woman reaches menopause (usually between 50-55 years) there are only several thousand eggs remaining. As a woman's age increases, the remaining eggs in her ovaries also age, making them less capable of fertilisation and successfully implanting.
Fertilisation in later age is associated with a higher risk of genetic abnormalities (i.e. chromosomal abnormalities). The risk of a chromosomal abnormality in a woman age 20 years is 1/500 while the risk in woman age 45 increases to 1/20.
Gynaecological problems such as pelvic infection, tubal damage, endometriosis, and fibroids also tend to increase with age. Sexual function is also decreased with ageing.
It's not just female fertility which is affected by age, but also men's - although to a much lesser degree. Age affects sperm and coital frequency. Advanced paternal age can increase the risk of autosomal dominant diseases such as Marfan’s syndrome, neurofibromatosis and achondroplasia. However, unlike women, there is no maximum age limit at which men are not capable of conceiving a child.
Tubal Disease and Infertility
Tubal factor infertility accounts for up to one quarter of all cases of infertility. This includes cases where both the fallopian tubes are blocked, or one is blocked, or one (or both) are scarred. It is usually caused by pelvic infection (e.g. pelvic inflammatory disease (PID) or appendicitis), by pelvic endometriosis, or by scar tissue that forms after pelvic surgery.
In cases of relatively minor tubal damage it can be difficult to be certain if it is solely responsible for the infertility – or simply an additional factor in addition to other significant contributing causes. From a practical point of view, the presumptive diagnosis is of tubal factor unless the degree of scarring is very minimal. In this event, and if no other cause of infertility is found, then a diagnosis of unexplained infertility may be warranted.
The diagnosis can be made in a number of ways. Your doctor may suggest a laparoscopy and hydrotubation. A camera is placed through your belly button (usually) to inspect the pelvis. This is especially useful if other features are present e.g. pain which might suggest endometriosis (often treated at the same time). Dye is passed through the tubes and patency (or blockage or swelling) confirmed. The most common cause of blocked tubes is infection (PID) of which the most common infection is chlamydia. About 70% of women who have blocked tubes have had a chlamydia infection although it is often silent and they will not have even been aware of it.
A less invasive test still carried out in some hospitals is called a hysterosalpingogram. It is a useful test but is being superseded in many parts of the world by HyCoSy or saline sonography. These do not require X-Ray technology but rather vaginal ultrasound (like you may have when being monitored for fertility treatment). HyCoSy uses a special contrast dye while the saline test uses sterile salty water (saline). These are much less invasive than the older tests and may themselves be overtaken by three-dimensional ultrasound in years to come.
Endometriosis is a condition that commonly affects women during their reproductive years. It occurs when endometrial cells, which are normally found only inside the womb, are found outside the uterine cavity. Some women with Endometriosis are without symptoms, but others suffer painful periods and pain during intercourse.
Endometriosis can appear as spots or patches called implants or as cysts on the ovaries and in severe cases can affect surrounding tissue causing adhesions or scar tissue. Unlike the lining of the uterus, endometrial tissue located outside the womb is trapped and does not have a way to leave the body. This can cause inflammation near the implants and if nerve tissue is affected, pelvic pain may result.
The diagnosis of Endometriosis cannot be made from symptoms alone as some women have no symptoms as there may be other reasons for pelvic pain.
Surgery or Laparoscopy is the only definitive way to diagnose endometriosis. Laparoscopy allows direct visualisation and ideally biopsy of areas suspected of being endometriosis. It is carried out by inserting a small telescope through an incision close to the naval.
Endometriosis can be managed quite simply and IVF is an appropriate treatment for associated infertility where other methods have failed.
During a laparoscopy, the surgeon can also clarify if the tubes are open. This is where liquid is flushed through the neck of the womb. This flushing with liquid is similar to Saline Infusion Hysterosonography which is carried out on all female patients pre-IVF at Sims.
Many women who have Endometriosis can conceive without any difficulty however some women do have difficulty getting pregnant. IVF is an appropriate treatment for infertility associated with Endometriosis where other methods have failed.
Ovulatory problems are the most common cause of female infertility and occur due to hormonal imbalance. This imbalance may arise either within the hypothalamus, the pituitary gland or in the ovaries. Common causes of these problems include stress, excess weight loss or weight gain, excessive production of prolactin (the hormone that stimulates milk production in the breasts) and polycystic ovarian disease.
About 20% of women have polycystic ovaries (PCO). Many women with PCO have normal menstrual cycles and actually do not have a problem conceiving. However, some women have small follicles on their ovaries which get stuck at a certain stage of development before they can get to the stage of producing an egg. This condition is known as polycystic ovarian syndrome (PCOS). PCOS is due to a hormonal imbalance, especially a raised LH, with irregular or absent periods. PCOS can very often be caused by a high glycaemic diet as many PCOS patients are also insulin resistant. It can also cause increased hair growth on the face and body and inevitably – difficulty conceiving.
Symptoms of PCOS in women include irregular or no periods, often heavy and prolonged when they do arrive. The patient may be prone to being overweight and often craves mid-meal snacks, is often tired and may also complain of pelvic pain.
Treatment usually involves a practical diet and if required, the use of drugs to correct the hormonal imbalance and to stimulate ovulation. If a woman is overweight then losing excess weight, exercising and changing to a low glycaemic diet may help to improve the hormone imbalance. Medication is used to increase sensitivity to insulin and the most widely used is Metformin. Alternatively, a laparoscopic polycystic ovarian drill, which involves putting a telescope into the tummy and inserting a needle into the ovary to disrupt it and trigger ovulation, may be performed.
Patients with PCOS are often successfully treated, though there can be the complication of either over or under stimulation of the ovaries, which has to be carefully managed by an experienced and reputable consultant.
What are fibroids?
Fibroids are benign swellings (also known as tumours) arising from the muscle of the womb. They are exceptionally common in women - indeed post-mortem studies show that most women will develop one or more during their lifetime. They are more common in black women or women who have had a child. There are often more than one and, thankfully, they rarely become malignant. They usually get bigger during a woman's reproductive life (especially during pregnancy) and smaller after the change of life, i.e. the menopause.
Where do they arise?
They arise in the outer, middle, or inner layers of the wall of the womb. Those that arise in the outside layer are known as subserous because they distend the serous membrane that covers the womb (which is called the peritoneum). These are the ones your gynaecologist will see at laparoscopy.
Those that arise in the middle of the womb are called intramural and may cause pain or heavy bleeding .Those that arise from the inner layers are called submucous because they stretch the inner mucous layer of the womb (called the endometrium). The specific problem with submucous fibroids is that they distort the normal contour of the cavity of the womb into which the embryo is trying to implant itself. This is clearly not advantageous to getting (or staying) pregnant so is associated with infertility or recurrent miscarriage. This is why we may suggest making the cavity more normal before proceeding with fertility treatment including IVF. However, if the distortion is minor, the risks associated with surgery (e.g. hemorrhage, infection, scarring in the womb, or rupture of the womb before or during labour) may not be worth incurring.
How are they identified?
While ultrasound is usually used to identify intramural fibroids (i.e. those in the wall of the womb), alternative methods are often used to establish whether the cavity of the womb is normal. These include hysteroscopy, hysterosalpingogram, saline sonography, or hycosy.
How are they treated?
No treatment is needed if they are not malignant or contributing to pain, bleeding, infertility, or recurrent miscarriage. Those on the outside
(subserous) or in substance of the muscle of the womb (intramural) are usually treated by laparotomy or laparoscopy. Those protruding into the cavity may be treated by laparotomy but ideally are treated by operative hysteroscopic resection as the latter has less risks associated with it.
If I have surgery and get pregnant, will I need a Cesarean Section (C/S)?
In most cases you will need a C/S although you would need to discuss this with your Obstetrician depending on what type of surgery you have had carried out.