It’s no secret that many women today are looking at starting motherhood later. The opportunity to study and establish a career means that financial independence has become the cornerstone, before even considering starting a family. Research by the US Centers for Disease Control and Prevention (released in 2016) found that the average age of first-time moms is 26, with the percentage of women having their first babies between 30 and 34 increasing to 21% (up from 16.5% in 2000).
Dr Johannes van Waart, an obstetrician and gynaecologist at Wijnland Clinic in the Western Cape comments that the average age South African women become moms is between 33 and 36. However, with increased maternal age comes an increased risk of infertility with about a quarter of the South African population affected.
Dr Nicholas Clark, a gynaecologist who works at Medfem Clinic in Johannesburg, adds that one in six couples struggle with infertility in the US, while in developing countries, this number is one in four. About 9% of the global population have fertility issues.
“Statistics are against women who don’t want children at a previously accepted time. Society might have changed, but not fertility. Your fertility carries on irrespective,” concurs Dr Merwyn Jacobson, reproductive medicine specialist from Vitalab Clinic in Johannesburg. He says this social perspective of wanting to establish a career and experience life before motherhood is to be encouraged. “But your body may not fit into your plans.”
Much like you want to secure your financial wellbeing, so you can secure your fertility. “Make the decision to set aside your baby-making material for later years. Treat your reproduction the same way you would your finances,” adds Dr Jacobson.
It’s not as easy as simply identifying your potential fertility blockers. “The problem is that you generally don’t know you have a problem until you start trying to fall pregnant,” adds Dr Joanne Pottow, a gynaecologist and obstetrician at Medfem Clinic. She says it’s important to protect your fertility by understanding the processes and factors that can affect it.
One of the biggest factors, explains Dr Jacobson, is quality and quantity of your egg reserves. Simply put, you are born with a certain number of healthy eggs, and these decrease at a relatively rapid rate as you mature. Your body reaches peak fertility in your early to mid-20s. At this time, you only have 70% of the egg reserves you were born with. By the time you reach 35, these reserves are at about 30 000 to 35 000. This may sound like a lot – surely you only need one healthy egg – but not all eggs are created equal and at this age, only a third of your egg supply (about 10 000) are considered to be healthy and viable.
“The number of eggs at any one point in time is called the ovarian reserve,” explains Dr Pottow. “A woman’s age, while not the optimal predictor, can be used as an indicator of her biological clock.” Doctors can use a combination of blood tests and ultrasound to determine your ovarian reserve. “The ovarian volume (the size of the ovary) as well as the antral follicle count are both determined using ultrasound. Blood tests include the follicle stimulating hormone and oestrogen level on day two or three of the menstrual cycle, as well as the anti-mullerian hormone level.
Your ovarian reserve can be affected by ovarian surgery, autoimmune disorders, and cancer treatments such as chemotherapy or radiation. The treatment of endometriosis of the ovary, namely the removal of an endometrioma or benign ovarian cysts, or an oophorectomy (removal of a whole ovary) will also cause a reduction, explains Dr Pottow.
Lifestyle and fertility
Everything in moderation, and a healthy lifestyle, goes a long way to protecting future fertility, says Dr Jacobson.
Dr Clarke adds that fertility can be compromised in those who are either underweight or obese.
Smoking can also be a factor. “Studies showed that menopause occurs, on average, one to four years earlier in smoking women, compared to non-smoking women,” he says.
Exercise is encouraged for wellbeing and stress management, but excessive exercise can affect your menstrual cycle – some studies have found that more than seven hours of formal exercise per week can be detrimental to your fertility.You may think that a supplement will help guard your future fertility. But as Dr Van Waart cautions, “No supplement can protect fertility at present. Patients should also refrain from ‘over-vitaminising’, as too many vitamins can be harmful.”
Freezing your eggs
The experts agree that the best way to guard your fertility is to harvest and freeze your eggs – the sooner the better. Today’s technology means that frozen eggs are as good as, if not better than, fresh – allowing your 40-year-old self to use your 27-year-old biological eggs. This is called social freezing or vitrification – a service that, in the past, was only available for medical purposes, such as ahead of undergoing cancer treatment. However, it’s now growing in popularity for those who may not be ready to start a family, or may not be in a steady relationship. Think of it as temporarily freezing your biological clock.
Egg freezing allows the eggs to be rapidly cooled so they are preserved without the formation of ice crystals, resulting in improved pregnancy rates. The process involves the woman undergoing an extensive consultation. Tests are performed to determine the current ovarian reserve, as well as to predict the possible egg yield from an egg-freezing cycle. This will help determine the optimal stimulation protocol (through fertility medications), which will aim to maximise the healthy egg numbers. These frozen eggs are then stored indefinitely. When the woman needs them, they can be thawed, fertilised and transferred to her uterus as embryos.
The important thing, says Dr Jacobson, is that this is a security measure – you may find that you naturally fall pregnant. However, there is a chance that you may not. And much like saving for a rainy day, or taking out a life policy, freezing your eggs aims to protect your future fertility and increase your chances of motherhood.
Success rates differ from clinic to clinic, and process to process. There are a number of places that offer egg freezing and storage, so do your research first. Dr Jacobson recommends that you visit your chosen clinic and ask questions, such as what their pregnancy success rate with frozen eggs is. “A reputable clinic will give you statistics and will happily go through the protocol with you.”
The average cost of freezing your eggs is R30 000, with an estimated further R13 000 for fertility medication to stimulate the ovaries. The average cost of egg storage is R1 200 per year. This may differ slightly from clinic to clinic.
As Dr Jacobson shares, “Ultimately, you should look after your fertility like you would your health or your finances. Make arrangements for the ‘what if?’ scenario, and have a back-up plan.”
According to Wjinland Fertility:
- The earlier you freeze your eggs the better. However, for the best chance of success, you should be 35 years or younger.
- About 12 to 20 eggs should be frozen in order to have an 85% chance of a successful pregnancy. The egg survival rate after thawing in a good clinic is usually greater than 95%.
- More than 2 000 babies have been born worldwide from cryopreserved eggs.
How does contraception affect fertility?
The type of birth control you use will determine your return to fertility. Dr Van Waart explains that the contraceptive pill takes about 48 hours or so to work out of your system, while the Mirena, an intrauterine contraceptive device, will delay fertility for a month or two. Intramuscular contraceptive injections might mean that fertility takes three to nine months to return.
What about men?
Age does not affect a man’s fertility as much as it does a woman’s. While a man’s fertility does gradually decline from the age of 40, most men can still father children into their 50s and beyond. However, lifestyle factors such as smoking, excessive exercise, testosterone injections and some performance-enhancing supplements, can affect sperm quality. A healthy lifestyle is, of course, first prize. Male fertility also has a strong genetic component, so early testing is not a bad idea – particularly for couples that plan on waiting before starting a family.