Business Times - 18 Apr 2009
Making babies: age a critical issue
The quality of a woman's eggs deteriorates with age and this is something science can do nothing about. By Cheah Ui-Hoon
THERE have been great advances in fertility treatment in the past five to 10 years - such as advances in hormone treatment, microsurgery, and assisted reproductive techniques.
The 'bad' news is that there are just some things that doctors can't do yet to change the human physiology when it comes to the female reproductive system.
The number of eggs that a woman has, for example, explains Dr Diego Ezcurra, the global scientific director of Merck Serono, which specialises in fertility drugs. Women are born with a certain number of 'eggs' or oocytes and their quality starts declining rapidly after the woman turns 35. 'Which is why the average age of women who go for fertility treatments are 32 to 42,' he says.
And for now, there's nothing that medical science can do to halt the deterioration of these eggs. Dr Ezcurra likens the situation to a cook having the best equipment and tools to bake a cake, but if the eggs or the dough are bad, then the cake's just not going to happen.
'I can be the best chef in the world, but I can't do magic tricks,' he adds. 'The thing is, with age a woman undergoes many hormonal changes in her body, so this affects the eggs and their quality as well,' he points out.
The age of the female - and the male as well - remains critical when it comes to having babies, says the fertility expert. And women the world over are delaying maternity for their careers, or for other reasons, he says, which is giving rise to infertility.
Infertility is defined by the World Health Organisation as the inability of a couple to conceive or bring a pregnancy to term. A couple is determined to be suffering from infertility if they are 35 years of age and older, and unable to achieve pregnancy after six months of regular unprotected intercourse, or after a year if the couple is younger than 35 years of age.
At least 10 to 15 per cent of couples worldwide (or about 70 million) are infertile. There is an estimated 15 to 20 per cent of couples in Singapore who are infertile, with only half of these couples seeking medical advice for their situation. Advances in the field include improvements to the drugs utilised for stimulation of the ovaries, laboratory equipment, new technologies, improved culture media and quality control, but 'the kitchen and the chef aren't enough, the quality of the eggs are critical to produce a tasty cake', Dr Ezcurra says.
There are still too many variables when it comes to assisted reproductive techniques. It can depend on the patient - her response to stimulation, genetics and infertility profile; the doctor's diagnosis, experience and treatment applied; the drugs and devices for controlled ovarian stimulation (COS); the retrieval process of the egg; the embryologist's experience; the laboratory facilities and technologies utilised; the transfer technique and so on.
The drugs utilised for the stimulation cannot be a variable and companies like Merck Serono are minimising the variables by coming up with the New Generation (Fill by Mas) Gonal-f prefilled pen, which is an easy-to-use, effective and reliable device for the self-administration of a hormonal treatment for controlled ovarian stimulation - which plays a major role in the whole cycle.
But even then, there still remains a lot of variables which affect fertility treatment, says Dr Ezcurra. 'The more control you have over the variables, the better the outcome,' he adds.
At the end, fertility treatment is a system of controlled variables, he says. 'But women do need to be aware that 35 years old is the cut-off age for their eggs quality. Delaying pregnancy is a major cause of infertility still, and after this age the possibiliteis of achieving a baby severely decline' he stresses.
Only 1 in 10 fibroid cases affects fertility
DELAYED conception and fewer births have contributed to an increase in the number of women with fibroids. However, the higher number can also be attributed to early detection due to annual health screenings, which more women go for these days.
Fibroids - overgrown muscle fibres of the womb that are mostly non-cancerous - affect as many as one in four women, says Adjunct Associate Professor Bernard Chern, head and senior consultant at KK Women's and Children's Hospital's Minimally Invasive Surgery unit. 'Many don't have symptoms and aren't aware of fibroid growth until they go for a screening,' he says.
Some women do experience problems, such as heavy bleeding during their periods. And some fibroids may affect fertility. However, only about 10 per cent of fibroid cases contribute to the inability to conceive. 'It depends on where the fibroids are,' says Dr Chern. 'They can be located inside the womb cavity, which is called a sub-mucous fibroid, or in the muscle wall (intra-mural), or on the surface of the womb (sub-serous).'
The sub-mucous fibroid within the womb is the main one that can present a problem for women trying to be pregnant, he says. If it grows too big, then it will 'compete' for space. 'So that's the main one for which doctors recommend removal.'
But ultimately, removal boils down to size, number and location. 'The intramural fibroid is generally harmless but if it gets too big then it will distort the uterus or obstruct the fallopian tubes,' says Dr Chern. 'That's when it requires removal. Otherwise, if it's small, then sometimes the patient doesn't have to have it removed.'
The good news is that minimally invasive surgery (MIS) techniques are increasingly being used to remove fibroids. Laparascopy is used to remove sub-serous and intramural fibroids, whereas sub-mucous fibroids are removed via hysteroscopy. This procedure is very similar to the resection (part removal) of the male prostate gland through the urethra.
In general, the keyhole approach is suitable for fibroids that are fewer in number and smaller in size. However, fibroids up to 15cm have also been removed via laparoscopy. 'Despite that, only half of our fibroid removal surgery is done by MIS, due to the number and size factor,' says Dr Chern, adding that the other half are removed by open surgery.
Still, handling 50 per cent of fibroid cases with MIS is a huge leap - from a mere 7 per cent in 1993. In 2004, 28 per cent of fibroid removals were done by MIS, and the percentage almost doubled to 46 per cent by 2007. 'There are two reasons for this. Women are detecting fibroids earlier, thanks to health screening,' says the doctor. 'Also, patients are more discerning these days. They are requesting MIS because they're aware there is such a procedure that will result in less pain and faster healing.'
Ultimately, fibroids are more troublesome than they are dangerous - the risk of malignancy is low. Even for fibroids affecting fertility, it's mainly those in the womb. 'Women can opt not to do anything with their fibroids if they're asymptomatic or if they're not fast-growing,' Dr Chern advises.