AGE AND FERTILITY
As a fertility specialist, my goal has always been to provide the best state-of-the art fertility care at the most affordable price for patients. Even patients who have health insurance are generally not covered for infertility treatment.
Our ultimate goal at Bronx Fertility and IVF is, of course, to help you become parents.
I have been blessed with the privilege of making thousands of couples become parents during my career.
Infertility is a condition, not a diagnosis. The first step in fertility care is to examine the underlying cause or causes that prevent a couple from conceiving. Once we have a diagnosis, we can consider possible treatment options to address that diagnosis.
As we go through the process together, I always make sure that the couple understands every step of the process, and that every test or procedure. At Bronx Fertility and IVF, I see to it that explaining test results to the couple is a learning opportunity for them. I take time to do the explanations myself, and do not delegate these discussions to any assistant.
Time and the woman’s age are crucial elements in infertility. A woman younger than 35 who fails to conceive after one year of unprotected intercourse should see a fertility specialist. A woman older than 35 should consult if she fails to conceive after six months of unprotected intercourse.
In general, women younger than 37 respond better to fertility treatment because studies have shown that after 37, the chances of even normally fertile women to conceive on their own decrease. Women have conceived spontaneously at older ages, of course, but they are happy exceptions, not the general rule.
Increasing age decreases the fertility potential and increases the miscarriage risk. These two effects are associated with the aging of the egg cells that a woman is born with, which therefore have her age. Older egg cells are more liable to chromosome abnormalities which can develop or worsen in the fertilized egg. They often result in abnormal embryos which nature does not allow to prosper, and the embryos simply do not develop. This is the cause of most spontaneous abortions. Some abnormal embryos which do continue to be viable may result in offspring with congenital defects like Down’s syndrome.
For all these reasons, women who suspect they may have a fertility problem should seek help as soon as possible. We offer this assistance at Bronx Fertility and IVF.
It is true that great advances in egg freezing have opened up a possibility for women to ‘beat the biologic clock’. But they are more likely to succeed if egg freezing is done before age 35.
Women who plan on delaying motherhood until they achieve certain career goals or pursue higher education should consider to freeze their eggs during their prime reproductive years. Freezing eggs after age 35 may not lead to optimal results.
FERTILITY EVALUATION AND THE SPERM PROBLEM
One-third of infertility cases are due to a female factor only ; another third due to a male factor only; and the final third, due to both female and male factors, including so-called unexplained infertility.
At Bronx Fertility and IVF, before I order any tests, I first review with the patient her medical and gynecologic history, including family history, and any gyn or fertility testing that she has already done. Likewise, with the male partner. It is always useful for me to have any available reports on such previous testing because they contribute objective data to the patient’s history.
Both partners are generally tested in the basic fertility work-up, unless they have had such testing done within the past six months and were shown to be normal. Abnormal results may need re-testing.
Basically, the male partner requires a semen analysis. Initial female evaluation includes baseline hormonal testing and a baseline pelvic ultrasound at the start of her natural cycle. An X-ray of the uterus and ovaries (called a hysterosalpingogram, HSG) is done after the period end but before Day 11 of the menstrual cycle.
At Bronx Fertility and IVF, we try to have the couple complete these basic tests within one menstrual cycle. If the patient has no medical or gynecological problems that require further diagnostic evaluation or treatment before she proceed to fertility treatment, the couple can start fertility treatment within a month after their initial testing.
Allow me to discuss the sperm problem ahead of possible treatment options, because this factor is often a primary concern with infertile couples.
Even if semen analysis shows problems with the sperm, the technique of intra-cytoplasmic sperm injection (ICSI) has made the sperm factor very ‘solvable’. In ICSI, which is done within an in-vitro fertilization (IVF) cycle, one sperm cell is directly injected into the egg cell in the laboratory, resulting in fertilization rates between 75-100%. Theoretically, the embryologist needs only as many sperm cells as there are eggs to be fertilized. As I always remind my patients at Bronx Fertility and IVF, it only takes one sperm to fertilize an egg.
Before ICSI, the man’s sperm count had to be at least 10 million sperm per cc of semen so that the IVF lab could concentrate enough moving sperm to surround the eggs retrieved from the patient with 250,000-500,000 sperm, by conventional fertilization. The fertilization rate was never as high as with ICSI. Obviously, the more eggs fertilize, the more embryos can result, which increases pregnancy chances.
For intra-uterine insemination (IUI), there have to be enough sperm cells for the lab to concentrate into the tiny volume of sperm preparation that is used to inseminate the female partner. In most labs, a minimum of 20 million sperm per cc of semen is required.
At Bronx Fertility and IVF, I emphasize that IUI is a realistic treatment option if the male partner has an adequate sperm count and t air sperm morphology (percent of sperm cells that have normal shapes) and both the woman’s tubes are open and healthy.
CAUSES OF INFERTILITY
Previously, we discussed the primary fertility factor in males, namely, the amount and quality of the sperm produced, assuming that the male has no erectile or ejaculatory problems which prevent the normal delivery of sperm into the female reproductive tract.
Genetic, hormonal, anatomic, or medical reasons (as a consequence of cancer treatment with chemotherapy and radiation, or of certain medications that affect sperm production) can cause poor sperm or no sperm at all.
These days, poor sperm quantity and quality can also be caused by lifestyle factors. Nicotine, marijuana, other recreational drugs, exposure to environmental toxins, and excessive use of hot tubs and saunas, are among the known causes for poor sperm.
Males who are younger than 40, who are found to have poor sperm and who may desire to have more than one child, are encouraged to see a fertility urologist for thorough evaluation and possible treatment of the underlying cause. But I tell my patients at Bronx Fertility and IVF, that attending to this problem will not and should not postpone fertility treatment itself because ICSI has made even the most severe sperm problem ‘solvable’.
Before ICSI, using donor sperm was the only alternative for couples in whom the male partner has no sperm or too little to make IUI or IVF possible. These days, donor sperm is considered primarily for the absolutely azoospermic male – who makes no sperm or only makes immature forms.
What about the woman? The main causes of female infertility, in patients without congenital anomalies of the reproductive tract, are 1) ovulatory dysfunction, 2) tubal blockage or disease; 3) pelvic factors (endometriosis, adhesions or scar tissue from previous pelvic surgery); 4) uterine fibroids that alter the architecture of the uterine cavity where the baby grows; and to a lesser extent, 5) cervical factors such as a cervical opening that is too tight, inadequate cervical mucus, and sperm antibodies found in the cervical mucus. We will discuss each of these factors after these introductory overviews.
At Bronx Fertility and IVF, I like to add that the main cause of infertility for too many women today is age – seeking fertility care after age 37 when the biological odds for pregnancy are less even with the best IVF treatment possible.
However, every patient is different, and some can indeed be exceptions to the rule of age as a limiting factor for fertility. That is why it is very important for every fertility patient to have ‘customized’ care tailored to her specific condition.
This includes close monitoring of her natural cycle or cycles before she proceeds to any fertility treatment, in order to determine her ovulation pattern: At the start of her period, her hormone levels and number of ovarian follicles seen on ultrasound. At midcycle, her peak estrogen production, the size of her dominant follicle, and when she ovulates. After ovulation, her progesterone level 3, 7, and 9 days afterwards.
For our patients at Bronx Fertility and IVF, If the patient has subsequent cycles before she starts treatment, the baseline hormones and ultrasound may be done every time she has a period. In older patients, this is helpful in order to commence treatment when the hormones and follicle numbers are optimal.
‘Close monitoring’ by frequent blood tests and ultrasound is a reality that a patient faces during her fertility care because this provides the doctor with objective data to make optimal diagnostic and treatment decisions.
WHEN IS THE OPTIMAL TIME FOR EGG FREEZING?
Current interest in egg freezing has also focused the attention of women interested in egg freezing on the relationship between fertility potential and a woman’s chronological age - which is the age of the remaining egg cells she has from the 400,000-500,000 she was born with.
Indeed, the relation between age and fertility potential is a significant factor that we underscore at Bronx Fertility and IVF, for a realistic look at pregnancy chances using any of the Assisted Reproductive Technologies (ART). It has not been appreciated enough by most women seeking fertility treatment, even well-educated ones.
A recent national online survey by the Fertility Centers of Illinois of women aged 25-45 who have not yet had children showed that
● Only 48% understood that there is an age-related decline in fertility and increase in chromosome abnormalities in older eggs which also contributes to increased pregnancy loss.
● 52% of those who were aged 35 or older said they would have made different life choices if they had known about the age-related decline in fertility.
A doctor writing for Medscape rightly suggested recently that gynecologists seeing young women for their annual gyn visits should find time before the patients reach 30 to have a discussion on age-related fertility decline, so they can be presented with the egg freezing option for fertility preservation and they can make their reproductive choices before they turn 35. At Bronx Fertility and IVF, I try to raise the awareness of my younger gyn patients on age-related fertility decline.
As you can see, a graph is worth a thousand words. The percentages given are for normally fertile women, so the infertility number would be even lower in women with infertility factors.
It took 30 years from the first reported birth in 1986 from IVF using frozen eggs t0 2007 when the freezing technique that was optimal for egg cells became reproducible in most IVF laboratories, and another five years before the American Society for Reproductive Medicine ruled in 2012 that egg freezing should no longer be considered an ‘experimental’ procedure. By 2015, more than 2,000 healthy babies had been born in the United States from frozen eggs.
The technology is there and now widely available, but as with infertility patients, chances for an eventual successful pregnancy and live birth using frozen eggs are best when the woman – and her eggs – is 35 or younger at the time she freezes her eggs.
The most compelling reason for egg freezing had always been medical – as an option for reproductive-age women diagnosed with cancer or other conditions that may require removal of their ovaries.
The relative simplicity and efficiency today of IVF for egg freezing have made it an option for women who have chosen to delay motherhood for career reasons or to pursue higher studies – a choice that has been referred to as ‘social’ egg freezing. But a 2015 paper in Reproductive Biomedicine Online confirmed findings in the USA and Europe that absence of the ‘right partner’ is the most common reason given by respondents to why they are considering this option.
Most of the highly-educated professional women who were surveyed said it was not their deliberate intention to delay childbearing, but that they want to become a mother in a supportive, long-term relationship which they do not currently have or see prospects for having soon.
They seem to be significantly committed to the conventional family structure and consider single parenthood with the use of donor sperm to be a last resort. Therefore, they see the cost and small risks associated with egg freezing as worth the price if they can ‘buy some biologic time’.
For more reason, we at Bronx Fertility and IVF encourage women who plan to freeze their eggs to do so before age 35. It is currently recommended that patients for egg-freezing should produce at least 15 mature oocytes for cryopreservation. Women older than 35 may need at least two IVF cycles to produce that many mature oocytes.
About sex selection
Determining the sex of an embryo is probably one of the simplest genetic tests done today in terms of technique. It is simpler than detecting aneuploidy – whether the embryo has more chromosomes or less than the normal number of chromosomes (22 chromosome pairs representing all the genetic features of an individual, and a pair of sex chromosomes – XY if male, XX if female), because only the sex chromosomes need to be identified.
However, that does not make the pre-testing technique necessary for all pre-implantation genetic testing (PGT) any less demanding as for more complicated genetic testing like trying to identify if the embryo has the gene mutation responsible for a heritable serious disease.
This pre-testing technique is embryo biopsy, in which, usually on the third day after egg retrieval, the IVF embryologist extracts one cell from each of the viable embryos resulting from IVF. These cells will then be tested in the genetics lab for aneuploidy, sex determination or detection of a known disease-causing gene mutation.
Patients doing ART at Bronx Fertility and IVF may be assured that the embryologists assigned to do embryo biopsies have high-complexity embrylogy skills gained from long years of experience, and that genetics testing is done by Genesis, one of the top genetic labs in the country.
Sex-determination is an important PGT before testing for many diseases which are linked to the X chromosome, like hemophilia, Duchenne muscular dystrophy and many syndromes resulting in serious neurologic and muscular deficits . A female must have two copies of the disease mutation in order to manifest the disease, while a male needs only one. Therefore, X-linked diseases are more common in males.
If a single copy of the mutation is detected by PGT for a specific X-linked disease in a male embryo, then the male embryo is not transferred. If a single copy of the mutation is found in a female embryo, the female embryo is transferred. If, however, the female embryo contains two copies of the mutation, it will not be transferred.
It was inevitable that sex determination through PGT was seen as a foolproof way to select embryos for transfer that have the sex desired by the parents. At Bronx Fertility and IVF, In Europe, many countries have laws that prohibit the use of PGT for ‘social’ sex selection.
Even China and India, the two most populous countries in the world prohibit social sex selection. Yet both countries already suffer from an unusually high male-to-female ratio in their populations (140 males to every 100 females in China, compared to 104:100 in the developed countries) because of the marked cultural preference for sons instead of daughters. Of course, this has serious consequences for their birth rate just a few decades from now – there will not be enough females to bear children for the number of available males.
In the USA, there are no laws against sex selection. The American Society for Reproductive Medicine which regulates fertility centers in the USA issued a recommendation in June 2015
that while it recognizes the ethical controversies connected with social sex selection, “practitioners offering assisted reproductive services are under no ethical obligation to provide or refuse to provide nonmedically indicated methods of sex selection”.
For this reason, the USA has become a destination for ‘fertility tourists’ from Canada, the UK and Australia where PGT for sex selection is legally allowed only for medical reasons.
Bronx Fertility and IVF is pleased it can offer sex selection through PGT at a cost
considerably below prices charged nationwide.