Friday 20 October 2017

Key factors you need to consider before IVF according to leading Irish experts

Two of Ireland's leading fertility experts, consultant gynaecologist Bart Kuczera, and consultant obstetrician Dr Hans Arce explain the peak age for women to get pregnant - and why factors like semen quality, lifestyle and weight are so vital when considering IVF

A woman's eggs are quite normal until she reaches her mid-thirties
A woman's eggs are quite normal until she reaches her mid-thirties
Smoking affects the quality of a woman's eggs
Stressed

If, says consultant gynaecologist Bart Kuczera, he was asked to list the three most important factors in fertility, his response would be simple:

"Age, age and age!"

A woman's eggs are quite normal until she reaches her mid-thirties, he explains - the incidence of pregnancy with people in that age group is simple. One in five healthy women become pregnant within a month of trying.

"After that it starts to decline. It's hard to predict how an ovary will age, but by age 40 only about one in 20 women will get pregnant in a month of trying."

IVF and artificial insemination concept. Woman is injecting hormones to belly with syringe.
IVF and artificial insemination concept. Woman is injecting hormones to belly with syringe.

By age 42 even the effectiveness of IVF is minimal, he warns:

"The main problem for young couples in Ireland today is that they're simply not trying to become pregnant during the peak fertility period, from the twenties to the early 30s."

Put it this way, explains Dr Hans Arce, obstetrician gynaecologist and consultant in fertility at the SIMS IVF clinic in Dublin:

"We're animals. Nature meant us to live to about 35 years of age, so in a way, we're trying to have children at an age when we should actually be dead!"

Smoking affects the quality of a woman's eggs
Smoking affects the quality of a woman's eggs

As a woman ages, he explains both the quality and quantity of her eggs start to deteriorate - which is where the problems start.

"We should all have 46 chromosomes, 23 each from the mother's egg and 23 from the sperm, but with advancing age comes an imbalance, so that the number of chromosomes in the egg; either too few or too many.

"That's why someone's fertility drops with age, and why the risk of miscarriage increases with age and also why there's a higher risk of certain chromosomal diseases such as Down Syndrome."

A woman's fertility starts to drop at 35, falls further at 38 and plummets at 40, why is why, he explains, that success rates with IVF also drop with age.

A good alternative for the older woman is egg donation - and SIMS clinics offer a No Travel Egg Donation programme: "I always call egg donation the Plan B," says Dr Arce.

"If you cannot get pregnant with your own egg, a donor egg can bring fantastic results.

"If, for example, you use a 24-year-old donor, the egg quality is excellent."

"The donor egg option offers ageing women an excellent choice and it's the best chance of any treatment I can offer.

"In SIMS we do it this way. The husband freezes his sperm in our clinic and we then send the frozen sperm abroad.

"We stimulate the chosen donor, get the donor's egg which is then fertilised by the husband's sperm.

"We freeze the embryo which is then flown back to Ireland, where it is transferred to the patient's womb at one of our clinics in Dublin or Cork."

* Smoking - Studies show that smoking affects both the motility of the fallopian tubes and the quality of a woman's eggs, says Dr Arce:

"We find that women who smoke a lot tend to miscarry more. It tends to take them longer to get pregnant naturally or through IVF. There is a higher risk of ectopic pregnancy, which is pregnancy outside the womb."

* Drop in Semen Quality - There has been a drop in semen quality over the years, Dr Arce points out.

"We believe this has to do with certain environmental contaminants," he says, adding that while there is no firm evidence as yet, there is growing concern about the possibility:

"There seems to be an impact from certain contaminants in very industrialised cities which can act as false oestrogen and reduce the quality of the sperm.

"These can be substances coming from plastics, or parabens and from technology. The World Health Organisation has progressively lowered the minimum standard of semen quality to adjust to our new reality."

* Polycystic Ovarian Syndrome - This is an endocrine system disorder where there is an imbalance in certain hormones. This in turn is intimately associated with insulin resistance, explains Dr Arce.

If a woman is overweight or obese, there is a higher risk of this problem - and the more overweight the woman is, the higher the risk of insulin resistance. This in turn leads to irregular periods.

This condition also means the presence of more male hormone in the woman's system, which results in acne and facial hair or hirsutism.

This hormonal imbalance causes a deterioration in egg quality.

"However studies show that a drop of between 5pc and 10pc in the woman's weight results in improved ovulatory cycles in many women and also improved change of IVF success."

The condition can be temporarily treated with oral medication so that the problem is temporarily resolved to allow the women to become pregnant, says Dr Kuczera:

"It is a metabolic disorder which can be treated but not cured."

* Obesity - Obesity is an issue because it can increase the risk of miscarriage and lower the quality of the egg, Dr Arce explains.

* Endometriosis - Endometriosis affects about 10pc of women of child-bearing age. It occurs when the endometrium (the mucus membrane that lines the inside of the womb) grows outside the womb, usually in the fallopian tubes and the ovaries, causing inflammation.

"This inflammation can cause a malfunction in the fallopian tubes for example, or a blocking of the fallopian tubes and the inflammatory process can kill off eggs in the ovary, thus reducing the overall number of eggs in the woman's egg stores," Dr Arce explains.

"This inflammatory process also apparently affects egg quality because these eggs are growing in an ovary affected by inflammation."

A woman can become pregnant with endometriosis but having it does affect your chances of becoming pregnant.

If the condition is severe, and the fallopian tubes are damaged, explains Dr Kuczera, the best option for some women is IVF to bypass the affected tubes.

However, he emphasises, you can get pregnant with endometriosis :

"Some women with endometriosis present later in life and after several children, which means that mild cases are not necessarily an important factor in fertility."

* Sexual Abuse - Following sexual abuse some victims, Dr Kuczera says, find they are unable to have a normal sex life, and cannot become pregnant:"We have women coming for treatment to literally have sperm injected because they cannot engage in normal intercourse. This is a new phenomenon that we are seeing at The Beacon."

Treatment he says, usually takes the form of Artificial Insemination (IUI) under general anaesthetic or a single run of IVF:

"These women would be healthy, probably fertile young women in their twenties and thirties, most of whom come in to see us with their male partners."

Stress - Everyday stress does not affect fertility, believes Dr Arce: "When people believe that stress affects results, they will find a way to blame themselves.

"It doesn't affect results but it does make people miserable and depressed, and we are never at our best when we are miserable and depressed. So we need to stop asking people when they are going to have children! The majority of people walk into see me crying. It is happening on a daily basis and it is terrible - it really increases peoples' stress levels and makes them depressed."

Studies on IVF have, he points out, demonstrated that there is no difference in results between people who are stressed or not stressed - only extreme stress, such that as in war situations, can result in reduced ovulation as a protective measure.

* The Thyroid Gland - Autoimmune issues, such as thyroid problems which target the endocrine system, can affect the quality of the egg, the sperm and the hormonal environment in which the fertilisation process is taking place, resulting in problems with fertilisation, implantation and maintenance of pregnancy.

Women experiencing difficulty in conceiving must be screened for thyroid issues because thyroid malfunction can affect female fertility.

* Alcohol - Research shows that moderate drinking may not directly affect fertility though it does affect pregnancy, says Dr Arce. However, he points out, the NICE protocol which is very strict and evidence-based advises that women trying to become pregnant should not drink more than one unit of alcohol a day.

Overconsumption of alcohol can also affect the quality of semen, a man's potency and reduce the amount of sexual intercourse that takes place within a relationship - all of which, he points out, can affect a couple's chances of becoming pregnant.

* Pelvic Inflammatory Disease - This is a sexually transmitted infection in which bacteria infect the fallopian tubes causing them to become blocked, says Dr Arce.

"This used to be the most common cause of infection but has been overtaken by ageing."

Although PID can damage the ovary, says Dr Kuczera, extreme PID cases are very rare today as the condition is treated by antibiotics and in most cases is cured before it does significant damage.

The law and donors

* The Children and Family Relationships Act 2015 set out to place Donor-Assisted Human Reproduction (DAHR) on a statutory footing in Ireland for the first time.

* Under the act all sperm and egg donors would be required to provide their name, place and date of birth, nationality, place and date of donation and contact details on a special register. Also under the act, donor-conceived children would then have access to their entry on this register once they reach the age of 18.

* However the parts of the act which regulate donor anonymity in this way have not yet been enacted and the special register has not yet been established. A government spokesperson said the special register will be established and the other requirements of the act will be implemented later this year.

* "At the moment we are in a situation where we can use both anonymous donors and identifiable donors as we are awaiting the enactment of the parts of the legislation which relate to this area. We are currently actively encouraging our clients to go the identifiable donor route," said a spokesman for one of Ireland's top fertility clinics.

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