Knocked Up Podcast - Fertility and Peri/Menopause Part 2
From embryo banking to donor eggs, discover what fertility treatment can truly offer women in their 40s.
In part 2 of our fertility and perimenopause series, CREI Fertility Specialist Dr Raelia Lew takes us through the treatment pathways available for women in their 40s who are trying to conceive. We discuss embryo banking, PGT testing, IVF and donor eggs.
Dr Raelia explains why proactive planning can make a difference, the role of sperm health, and what to consider when deciding between treatments. This episode is an honest and informative conversation about the realities of fertility in your 40s, and the options that can still lead to parenthood.
TRANSCRIPT
Jordi Morrison: Hello and welcome to Knocked Up, the podcast about fertility and women's health. You are joined as always by me, Jordi Morrison, and Dr. Raelia Lew, CREI Fertility Specialist. Today's episode is part two of fertility and perimenopause.
If someone is in their 40s, struggling to conceive, and they've come to see you, possibly after the six-month mark, possibly longer, what are the treatment options available?
Dr. Raelia Lew: So the treatment options that are available are the same regardless of the age of the patient, but my likely recommendations are going to be influenced by the age of the patient and their stage of life, how many children that they are seeking help to have. Is this their first baby? Would they ideally love to have more than one? Do we have the potential to try and help them do that or do we have to, in realistic terms, focus on the here and now. They'll be different for different people.
If I have a patient trying to have their first baby at 38 plus and they would love to have more than one child, the first word that's going to come out of my mouth is embryo banking and the second word is going to be PGT testing. So embryo banking is a concept where we in IVF have the facility to freeze embryos for the future. And that's really important for women, particularly when they're at a stage of reproductive life where they can still make normal embryos, but that is the exception to the rule. And that I can predict that in a few years time, they will no longer have that option or opportunity. And so what we are able to do is through IVF, which can be very difficult, but if there's a will, this is a very good strategy, to pause plans for immediate pregnancy and do IVF cycles with an embryo freeze agenda so that we can put embryos away for the future. We know that one in two genetically tested normal embryos will translate to a birth. And so we want to bank two to three embryos per child desired. And we want to do that now. And that may be months of treatment. It is unlikely to be one IVF cycle.
One of the reasons I say to patients to come earlier when they need help rather than wait longer is for every IVF cycle that I do to help a patient at 35, I will need to do two at 37. And for every IVF cycle that we do at 37, we're going to need to do two at 39. So people who are older need more treatment because they can't get as many eggs in a cycle and the egg quality is poorer. So the chance of finding a good embryo is lower. Coming earlier and being proactive is very helpful to reduce the number of total treatments required to have a family. And if you can bank the embryos when you're younger, it will save you treatment burden in the future and will also improve your success rates in terms of having a baby now and later.
So that's one thing. PGT testing is something we can do to know that the embryos in our embryo bank are good quality embryos. And it can be very revealing. And it can be very confronting because quite often when we do test embryos for women in our 40s, 9 out of 10 are going to be abnormal and we're going to be able to diagnose that they're unable to make a baby. It does truly become the exception to the rule that an embryo can make a baby for every person. And when that happens is a little bit different woman to woman, couple to couple. But the trend is that... when you are in your 20s, the average embryo can make a baby. And when you are in your 40s, the average embryo cannot make a baby. It has to be the exceptional.
So how IVF can help in women that it can help. And IVF cannot help all women in our 40s. That's really important to say. There are some patients who come and it is too late for them. We can't necessarily recognize that straight away and we will always try to help. There are some patients who come too late and who ultimately, despite their best efforts, do not succeed with their own eggs. It is another important point for those patients to say that they can still succeed potentially with a donor egg.
Another thing that I would say, and this can be sometimes a confronting thing to say, and I mean it with no disrespect to anyone or any patient. Patients start, and this is again the denial of age and the denial of the fact that age is queen, and the denial of the fact that egg quality is the most important thing in IVF. Patients start to jump at shadows when IVF is not working in our 40s because we don't want to admit to ourselves that it is the egg. And patients start to invest in experimental therapies, thinking, what can I change? What can I do? And the reality is there is a limited amount that you can do in terms of improving egg quality short of optimizing diet and lifestyle. There are books written about it. There is no evidence supporting that we can rejuvenate the ovary. And there are experimental therapies that we try. These are icing on the cake therapies. They are not impactful in a major sense. So we do our best, but we are yet to crack the solution of the aging ovary.
It is far more likely that you have egg quality problems if you are in your late 30s and early 40s than you have weird asymptomatic autoimmune rare issues. And I can't tell you how many patients I've seen across the course of my career who've gone deep dive into all kinds of immune therapies and experimental therapies, tortured themselves through IVF regimes that are completely evidence lacking, and then get pregnant quickly with a donor egg on nothing at all. And it was always the egg. It was always age. It wasn't anything else.
So that's something that I feel quite strongly about in my practice. I think there is the medical ethics framework of first do no harm, but I think it's important to recognise that we shouldn't really be offering therapies if they're not evidence-based and if there's not a hypothesis of how they might be helpful, because you can do harm as well as good with these things.
Jordi Morrison: Do you have any statistics around how effective IVF is for this age group, the over 40s?
Dr. Raelia Lew: IVF is not the problem. IVF is amazing. We can only work with what we have. So where egg quality is the problem, IVF in its technology is not the answer. And when IVF doesn't work, it's not the technology that was at fault. It is the egg. And in terms of that... we see it with egg freezing. We are so good at freezing eggs. We make beautiful embryos from frozen eggs, even for older women, and they get pregnant. Because the eggs are younger. Because of the egg. So the ingredients are important. And we know this intrinsically. Everybody knows it. If you have beautiful, fresh produce, you're going to make a tastier meal, right? The ingredients are important.
So, you know, but that's not very comforting if you happen to have waited too long to have a baby and didn't realize, and here we are. So how can IVF help? Numerical advantage. And also just by ruling out the rogue elements where things can go wrong. So for example, when you think about it, when you release an egg naturally in a natural cycle, how do you know it's ever going to meet a sperm? How do you know the fallopian tube is going to pick that egg up actually? And it's not just going to go floating the wrong direction in the pelvis. You don't. How do you know that it's going to go down the fallopian tube and get to the uterine lining at the right time? These are random things that we hope will go right and they don't always go right. So one of the ways that IVF can help is making sure that an embryo actually gets to the womb and has a chance that month.
And another way that IVF can help is by ensuring that we have the best possible chance, the best possible opportunity to create a good embryo in that month. So instead of just one egg releasing, we try and encourage multiple eggs to release and so we have the opportunity to make embryos in a way that is numerically advantageous and we're more likely statistically to find a good one. And that's I think the most important way that IVF can help for women where the average embryo is not going to be successful. And I think that's why IVF is not the answer for women with a diminished ovarian reserve quite often. If you have a very diminished ovarian reserve at advanced maternal age, then IVF statistics are very sombre without the use of egg donation. It's telling that in cultures where egg donation is commercially available and readily available, such as in the United States, women are encouraged to take that route at a much earlier age than they would necessarily be here in Australia, where that is not an asset that we have easy access to. So the culture of medicine is also influenced by the environment of practice.
Jordi Morrison: We've mentioned throughout these episodes about a few options such as egg freezing and donor. In terms of egg freezing, this is obviously the best option for a later pregnancy if you've frozen your eggs when you were younger.
Dr. Raelia Lew: I can't tell you how many patients that I've treated in the last few years who are in our 40s say to me, God, I wish I had frozen my eggs. And they didn't even know about it. They didn't know it was an option. It wasn't a mainstream option for the generation. This is changing, actually, which is great. But when you think about it, egg freezing was considered experimental until 2012 when it was labelled non-experimental. And when it had just been labelled non-experimental, nobody was doing it. We were offering it, but there wasn't much uptake. And I think it's been really something that the uptake has been demonstrated in Australian stats, but also stats around the world, to have been exponential in the last couple of years. And we will see the fruit of that in the unfolding decade. And I always say when people say oh not that many people have come back to use their frozen eggs, I can say actually as an IVF doctor every single year I see more patients coming back to use their frozen eggs. It's just we haven't been doing it for very long and patients take five to ten years to come back. And it's only been a little while that people have actually been doing it.
So look, there are lots of arguments about egg freezing. It's not for everyone. It is very expensive. Our government, unfortunately, has not yet had the foresight to fund it for everyone who wants to do it. I think that's a mistake and I hope it's one that will be rectified in future generations. But it is something that not every woman can afford and not every woman has thought about. It is invasive. It's a lot to go through. It's challenging, but it's an amazing resource. And for those out there who are in their 30s and are not in a position to or immediately able to have a baby but do want a baby one day, my message to you is go out there and freeze your eggs if you can, because it'll make things a whole lot easier for you if you need IVF in the future to have that asset of younger, healthier eggs that have a better prognosis intrinsically.
Jordi Morrison: And then donor eggs, which we've touched on a little bit. At what stage of treatment or conversation would you bring up donor eggs as being an option?
Dr. Raelia Lew: Look, for some patients, I bring it up right from the beginning. For some patients, if a patient comes and sees me and they're 42, 43, I will help them and I will try my very best to get them there with their own egg. But I'll discuss donor eggs from the beginning, from the very first consultation, because there's a significant risk that they may require them ultimately. And planting that seed and letting them know that at least it's an option is very reasonable. We support women up until 45 if they wish to try with their own eggs. Even though the chance is very low, it's still a chance. And we still have babies through IVF for women in early to mid-40s.
After that, if a patient comes to see me and she's 46, unless she has frozen eggs that she's frozen herself, we would go straight to egg donation. There would be no other option, egg or embryo donation, because the chance is just not there to try with your own egg anymore. There will be occasional, and this is the problem with anecdotal issues, there will be occasional women who do get pregnant and have a baby over 46. That's it. I think we all know someone who spontaneously got pregnant in their 40s and it's like, okay, but that's one. But the thing is, if you look at the bell curve of the population, they are the outlier. And if we normalise the outlier, then we're actually just deluding ourselves. It's just like at the 2000 Olympics, Cathy Freeman ran really fast. I couldn't run, ever. So look, we're not all the extreme and we can't base recommendations for most people on extreme outliers.
So yes, there will be people in the world. I think the world record is actually over 50 for a spontaneous conception, last time I checked, but that is extremely uncommon. And in IVF, we treat people who can't get pregnant, not people who actually get pregnant at 50. The recommendations for contraception, by the way, to continue until age 50. That's often to prevent miscarriages because it's more likely to get pregnant and have a miscarriage over 45 than it is to get pregnant and have a baby.
Jordi Morrison: You mentioned embryo donation. So this is when we get to talk about how it's men as well, not just the woman over 40.
Dr. Raelia Lew: Yeah, sure. So one problem women in our 40s is we're more likely to have partners who are the same age or older. And men in their 40s, particularly mid-40s and beyond, while they still make sperm and they can still father children and so they don't suffer infertility in the same way that we do, the burden of infertility that they do suffer is higher. So men with poor sperm, their sperm gets worse as they get older. Men with good sperm, their sperm gets worse as they get older. Certain conditions are more common in advanced paternal age. Autism, schizophrenia, de novo genetic mutations of single point mutations, such as, for example, achondroplasia, which people may know as dwarfism. These things are more common as men father children later in life.
So there certainly are what we call epigenetic changes. There was a study by Yuzpe and a group of other reproductive clinicians in his practice that looked at whether chromosome error in embryos, so whole chromosome error aneuploidy, was increased in advanced paternal age and it isn't. And back to the egg is queen. It's all about the egg when it comes to that. But having said that, when we look at DNA fragmentation in sperm and when we see that women in our 40s, if we do happen to have a younger partner or a younger donor, we do better actually. So the DNA damage in the sperm is better corrected by younger eggs, and if we give older eggs better sperm they do better. So there certainly is a male factor contribution. Men are not off the hook. They need to be on their best behaviour.
So if your partner is older and you're trying to get pregnant against the odds, don't smoke, don't do that. You have to be on your best behaviour. Minimize alcohol, diet and lifestyle. Don't overheat. Get varicose veins treated. All of those things are important. Make sure that your other medical conditions are under control, vitamin D replete. Get the sperm as healthy as possible because the egg is challenged. Don't make her life harder than it has to be.
Jordi Morrison: When does fertility truly end? Is there a point where pregnancy is no longer possible?
Dr. Raelia Lew: There's a point where pregnancy is no longer advisable. So it's unheard of for most people to have a heart attack carrying a baby when they're 25. It is not unheard of for that to happen if you're 55. So even with your own frozen egg or embryo or your donor egg-derived embryo, it's really not advisable to become pregnant. Pregnancy is a massive stress on the female body. Growing a human is a massive stress. The blood pressure changes, the circulation changes, your heart strain changes. You have to be fit to be pregnant and we become unfit to be pregnant.
So I would say that if a patient comes to me and even using a donor egg, donor embryo, and wants to become pregnant over 50, and actually probably over 45, I would send them for a physical and a maternal fetal medicine assessment so that they get some realistic feedback as to what will pregnancy do to me, what is my risk of dying from being pregnant, because there's no point having a baby if you're not there to raise your baby. And is pregnancy going to put me in hospital? Is pregnancy going to cause me long-term physical disability? If the answer is yes, that's a real chance, then maybe you shouldn't become pregnant. So we certainly want the health of the mother to be prioritized. This is very sexist because men can father children and not have these problems, but they don't have to be pregnant.
Jordi Morrison: Yeah, that's the main thing that I would say. The egg is the limiting factor, but you can become pregnant long after egg quality is gone, as long as you have a workaround, either a frozen egg, a frozen embryo or donor. So the real limitation on pregnancy is female health, maternal health and risk. Those are the physical limitations of carrying a pregnancy when we're older. What are the ethical considerations around a pregnancy in your 40s and beyond?
Dr. Raelia Lew: The things that people think about are whether we're going to be around to raise our child. Will our child end up a carer for elderly parents? Will our child have the opportunity to know their grandparents? Will they have a sibling? Those kind of questions. But on the other side, we live for a long time in general and we live longer than we ever have before. And so maybe we need to worry about that and maybe we don't. I think it's a really complicated area. It's a societal thing. We are having babies later, everybody. Is that a good thing? Is it not? I guess it's complicated.
Jordi Morrison: To finish off, what's your advice for women who feel like time is running out but they still want to explore their options, whether they're ready now or not?
Dr. Raelia Lew: Come and seek help. You'll get honest advice from me. You'll get honest, heartfelt advice and you will not be led down a garden path. Advice can sometimes be very confronting. And fertility treatment is not for everybody. No one will be coerced or forced into anything they don't want to do. But if you are worried that time is running out and you want to have a full understanding of your options, seek the advice of a fertility specialist. Go to your GP, get a referral and come have a chat about your personal circumstances.
Jordi Morrison: Thank you, Raelia.
Dr. Raelia Lew: Thanks, Jordi.
Jordi Morrison: To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram @knockeduppodcast and join Raelia @drraelialew. And email us your questions to podcast@womenshealthmelbourne.com.au.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.