So tonight I’ve been asked to speak on the topic of the older the better and, of course,
as a fertility specialist, I’ll be talking more from the fertility perspective. I’ll
just acknowledge that I’m representing both Repromed and Flinders Fertility and the Flinders
University tonight. Now, I’m going to divide my talk into two parts. The first five or
so slides I’m going to give a bit of background on why fertility diminishes as you get older
and then I’m going to address the issues that Maria faces.
So, look, this trend of having children later and later in life has really been existing
for a number of years now. Ever since the early 70s throughout the Western world, there’s
been an advance in the average age of women. When I was a baby, the average age of a mother
was 23 and it’s now approaching 31 years. And interestingly, within the professional
class, so the women who have tertiary education, one in four women will still not have had
a child by the time they’re 45 years of age. Now, half of that is because they elect
not to have children. Not everyone wants a child. But in the other half, it is an involuntary
choice. Now, why are couples or women delaying having kids later and later in life? I think
this is probably pretty obvious. There’s an element of a career. I mean, certainly
having children can stymie the career a little bit and women are wanting to advance their
career, which is entirely natural. There’s an element of, you know, having a double income,
no kids, high disposal income. That’s fun. You get to travel a lot and children certainly
can be time-consuming – I know that, having four of them. I have a lot of women say to
me “Oh look, I can’t get my husband or my partner to commit.” Commitment phobia
seems to be quite prevalent amongst the male population. And then finally we have Lisa
Curry and others who, you know, front page of the New Idea, “My IVF Baby a 51”. It
gives this perception – there’s a perception out there of you can leave it until very late
and if it doesn’t happen naturally, well you’ve always got that parachute called
IVF. And I guess that’s true if you’re willing to go to donated eggs. But it isn’t
true that you’re going to have success at 51 using your own eggs. And that’s where
the majority of these stories… they don’t point out that it’s donor egg. So when does
fertility decline naturally? It’s actually quite a difficult question to answer from
a scientific perspective because there are lots of variables here. I mean there’s obviously
the male factor, whether she’s got open tubes, ovulates and also simple things like
coital frequency. You know, the older a woman gets, the longer the relationship, the reduction
in coital frequency. So this particular study from the New England Journal looked at getting
rid of those confounding factors. It was a study from France where they looked at donor
insemination. So all the men had no sperm, the husbands had no sperm. They used top quality
donor sperm and all these women were known to have open tubes and to ovulate. And you
can see that fertility is pretty good up until 30, but from then on, it starts to decline.
So the evidence suggests that fertility is pretty good up until 30 and then it starts
to spiral downwards. Another way of looking at this natural fertility is a population
called the Hutterites. These are a religious sect that lives in north-western United States
in Canada and they’re interesting because they get married very early, they never use
contraception and they live in a communal setting where everyone’s cared for equally.
So there’s no financial disincentive to have kids. So they’re a good natural model
of fertility. And the average Hutterite woman has ten kids. Sounds like fun. And the incidence
of infertility is very low – 1.8%. You know, in our community it’s 15%. So very few women
can’t have kids in this population. And you’ll see from the graph on the right that
looking at this, the fertility starts to drop even from the mid-20s. So, you know, we’re
not meant to be reproducing in our 40s. That’s not the natural process. What’s also interesting
is that average age of a Hutterite woman, who has been previously fertile, to have her
last child is 41. So half of women who’ve never had a fertility issue before will stop
having kids at 41 because they’re run out of good quality eggs. And that’s an important
point. There’s been lots of studies around the world that have looked at this. There’s
various populations that don’t use contraception and the average age where the woman has her
last child is about 40 or 41. So there’s a ten year disconnect between when fertility
runs out and when menopause occurs. And this is a very important point. Most people think
that while they’re still getting a period, they’ve still got eggs and they’re still
fertile and the reality is that’s not the case. Even a lot of doctors believe this.
Now, why does fertility reduce with age? Well, this graph on the left shows you that it’s
an egg issue, not a uterus problem. So this data from the US looking at IVF success rates.
Now, if you look at the top line, that’s the success rate according to the maternal
age when you’re using young donor eggs. So like a woman of 50 still has the same pregnancy
rate as a woman of 25 if you use eggs from a 22 year old donor. Yet if we use her own
eggs, you can see how precipitous the drop-off is. So it’s suggesting it’s not the uterus
that’s aging, it’s the ovary. And the problem is depicted on that right picture
there. This is the mytotic spindle. The mytotic genetic division process. At ovulation, the
chromosomes are separated and that process breaks down as you get older and, as a result,
you have any increase in genetic abnormality in the embryo and a decline in fertility.
So the graph on the left shows that we all know that miscarriage risk skyrockets as we
get older and the fertility drops. The table on the left shows the risk of having a live
birth child with Down Syndrome at various ages. And you can see at Maria’s age of
45, that’s a 1 in 30 risk if she doesn’t have any screening or select a termination.
So that’s quite a scary risk.
So I just want to point out that IVF, unfortunately, is not a perfect cure for this age-related
infertility if you exclude donor egg. And the reason for that is twofold. First of all,
as a woman gets older, the proportion of embryos that are abnormal increases. So this graph
on the left is a study that looked at 15,000 embryos and they found that by the time a
woman hit 42, 90% of her embryos were genetically abnormal, 90%. So you’ve only got a 1 in
10 chance of making a normal one. And when you compare that also with the problem of,
as you get older, the number of eggs that we retrieve in IVF declines, it’s a double-whammy.
So not only do you have less eggs to play with, but more of them are abnormal. And,
of course, that means success rates plummet.
So how do we deal with a problem like Maria? I thought there were a few issues to raise
with this. The first one is should we do anything with this lady? She’s only been trying for
six months. The medical definition of infertility is 12 months. Now, there are a few GPs out
there who will say she’s not been trying long enough, just keep on trying. Now, I would
say this boat is about to sail. In fact, it probably already has sailed, and I think I
would say any woman who is 40 plus, we have to be quite aggressive in our investigation
and management. So I would say yes we do have to jump in with treatment and I think even
though IVF is not a fantastic treatment, I still think it has some value. And I’ll
touch on that in a sec. Now, this graph on the left depicts the pregnancy rates IVF throughout
Australia and New Zealand a couple of years ago, the last report. And you’ll see that
the chance of having a live birth in a woman of 45 is 2%. Okay, so it’s pretty dismal.
And you might say “Well how can we justify using public money on a fertility treatment
where there’s a 2% chance of success?” And what I would say is I think IVF, even
if it’s not successful, still has some therapeutic value. Because I can say to a lady in my room,
look 45, I’ve had only a dozen pregnancies in 15 years of IVF practice and it’s not
looking good, but they always think that it doesn’t apply to them. It doesn’t apply
to me, I’m healthy, I go to the gym three times a week. And until you actually give
the maximal dose stimulation and show that their eggs are not good quality or the embryos
are not good quality, they don’t understand that. So even if they don’t get pregnant,
they actually get to see this, and that’s quite good for closure. And not only does
it give them an opportunity to say “Look, I tried, I did my best, I can’t move forward,
I’m just going to give that up, I’m not going to have any more treatment”, but it
also gives them the opportunity to move to donor egg, which Emma’s going to talk about.
So, you know, and until they’ve given it a go themselves, very few women will be happy
to move directly to donor egg. It’s just the reality. And I would say, look, is it
a reproductive justice that a woman of 45 years of age who has paid taxes for 25 years
should be given the opportunity, at least one cycle of IVF, to give it a go. You know,
she hasn’t had children, you know, costing the government money for school and such.
I think we owe her that much. I don’t think we owe her 15 cycles of futile IVF, but I
think we at least owe her one go and see how she goes.
The last bit here is the risk. We have to consider another individual in this equation,
and that is the child. Is it ethical to treat a 45 year old where the risk of a live birth,
if she doesn’t terminate, is 1 in 30 of Down Syndrome? It’s a reasonable question.
It depends on, I guess, what her position is on termination of pregnancy and screening.
But I would say we do have the options of pre-implantation, genetic screening where
we can actually test the genetics of the embryo before putting it back. We have the Harmony
test etc. We have some options. But it needs to be considered in the equation.
My final slide. How do we reduce the number of Marias? I think this is really the critical
question here. Unfortunately, I think the boat probably has sailed for Maria. But how
do we stop there being lots of women at 45 looking to have their first child? I think
we acknowledge that women are not going back into the kitchen and becoming housewives again
and having children at 23. That’s not going to happen again. Women want to have a career.
We have to look at other options. Some of those options might be things like egg freezing,
egg banking, when they’re young so they can us those eggs later; it might be to look
at more flexible work conditions so it’s easier to have children and have a career
when you’re younger and then, finally, an area close to my heart is the egg timer. This
is where we screen women in their early 30s to see what their ovarian reserve is. And
I find that it gets back to this issue – a lot of women think it won’t happen to them
because they’re healthy, mum had three kids etc. Until you test them and show that their
result, their egg count is low for their age, they’re not willing to make that decision
to have kids. Sometimes having that hard information that they’re in the 10%, the lowest 10%,
in egg count will help them get across the line and make that decision. So I think it’s
got to be a multi-faceted approach.
So is older better? Are women like wine – they get better with age? I’m nervous in this
audience, I must say, to give the answer to this. Look, I think from a reproductive perspective,
unfortunately, women do not age well. Biology is not politically correct. We are ideally
meant to have our children in our 20s and maybe early 30s and I think we have to recognise
that and look at other solutions to this particular problem. Thank you very much.