Dr Cathy Allen, Member of the Institute of Obstetricians and Gynaecologists
Consultant Obstetrician and Gynaecologist and Specialist in Reproductive Medicine, National Maternity Hospital and Merrion Fertility Clinic, Dublin
Changes in health, lifestyle and society have impacted greatly on human reproduction, particularly in females, over the past 50 years. But there is more we can do to help infertility.
2018 maternities, compared with with previous decades, show higher average age of first time mothers, smaller family sizes, increased case-complexity, more C-section deliveries, and better neonatal outcomes.
Fertility problems are more common than people realise
Despite developments in health and technology, the fundamental biology of reproduction remains unchanged. Patients are often surprised to learn how common fertility problems are (one in six couples), and how success rates of fertility treatments are more limited than realised.
Female age is still the biggest single determinant of ability to conceive, miscarriage and livebirth rates. The optimal biological time for fertility and maternity is in the 20s, with a clinically apparent ‘threshold’ for fertility problems seen in women over 35 years.
Older mothers are less likely to have straightforward pregnancies
Female fertility requires the availability of eggs from a finite stor, which diminishes in quantity and quality over time. The health of the reproductive tract can be affected by progressive conditions such as endometriosis and uterine fibroids. From a social perspective, better education and career opportunities can mean more financial security and personal readiness to raise a family. But delay incurs the possibility of negative age-related fecundity risks.
Infertility rarely makes headlines because we’re focusing on teens not getting pregnant
Infertility has a low profile in the wider picture of Irish healthcare and its resourcing. This may be because infertility has not traditionally received recognition for the morbidity it entails. Fertility is also a deeply private matter, so patient representation is not as forthcoming as for other disorders.
It is possible that the traditional focus on avoiding pregnancy in young adult years impedes public awareness of the potential for infertility in later adulthood. In any case, public awareness of fertility issues – although less than ideal – seems to improving. An old perception of stigma with infertility is being gradually dispelled by brave individuals sharing their personal stories.
IVF should be made more financially accessible
It is both heart-breaking and infuriating to witness the distress of infertility, which could be treated successfully, but this treatment is denied to those who cannot afford it. For example, for a woman who has lost both fallopian tubes to ectopic pregnancies, IVF offers a realistic chance of pregnancy. Or for an azoospermic man (no sperm in the ejaculate), a surgical sperm retrieval is an option. But unless these individuals have considerable disposable income, there is little hope. Such patients are not uncommon, but because of chronic inequity they remain the voiceless and the choice-less in modern Irish healthcare.