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  1. Home
  2. Books
  3. Reproductive Ageing
  • Cited by 13
Publisher:
Cambridge University Press
Online publication date:
February 2014
Print publication year:
2009
Online ISBN:
9781107784734
DOI:
https://doi.org/10.1017/CBO9781107784734
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
Series:
Royal College of Obstetricians and Gynaecologists Study Group
Information

Book description

Reproductive ageing affects both individuals and wider society, and obstetricians and gynaecologists are witness to the impact of reproductive ageing and to some of the fears and misapprehensions of the general public. This book raises awareness of societal trends and their implications. The wider importance of the subject to the whole of society is emphasized by contributions from outside the world of obstetrics and gynaecology, both within and outside medicine. The 56th RCOG Study Group brought together a range of experts to examine reproductive ageing. This book presents the findings of the Study Group, with sections covering:background to ageing and demographicsbasic science of reproductive ageingpregnancy: the ageing mother and medical needsthe outcomes: children and mothersfuture fertility insurance: screening, cryopreservation or egg donors?sex beyond and after fertilityfertility treatment: science and reality - the NHS and the marketthe future: dreams and waking up.

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Contents

Page 2 of 2

Contents
  • 21 - Assisted conception: uses and abuses
    pp 227-236
  • View abstract

    Summary

    Cytogenetic abnormalities of the human oocyte, as described by Pellestor, are remarkably common and there appears to be a multifactorial effect of maternal ageing. Aneuploid embryos are common following in vitro fertilization (IVF), even in unstimulated cycles. Egg freezing has proved to be technically much more difficult than embryo freezing. Ovarian failure is an untreatable condition but the opportunity for pregnancy can be restored by egg donation. Success rates are high and are maintained with increasing age. If the uterus cannot support a pregnancy, for example because of fibroids, or if the potential mother is too unfit for pregnancy, surrogacy will be required. In reviewing the uses of assisted reproduction, some 'abuses' have been revealed. The infertile couples seeking help can be desperate for treatment and therefore be vulnerable to suggestion. Reproductive tourism is burgeoning, driven by women's needs for treatment but also by commercial interests.
  • 22 - Future fertility insurance
    pp 237-242
  • View abstract

    Summary

    This chapter presents a discussion between an number of experts on fertility. Each person presents his/her views on future fertility insurance. According to Herman Tournaye, vitrification will completely change the clinical approach that is present today. On the other hand Helen Picton says that even with vitrification, we have to have good eggs to vitrify. If we can get the quality of the egg right, vitrification of metaphase II (MII)'s is what we will see being used in clinical practice, and successfully. Roger Gosden feels that embryo freezing should be offered where possible. There is need to raise awareness of the possibility of 'early ovarian ageing'. When discussing screening for early ovarian ageing, and fertility insurance, the question is whether any of these tests could be transferred from the field of assisted reproduction to the general population to be used in asymptomatic young women to predict their future fertility.
  • 23 - Contraception for older couples
    pp 245-258
    • By Diana Mansour, NHS Newcastle and North Tyneside, Community Services, New Croft Centre, Sexual Health Services, Market Street (East), Newcastle upon Tyne NE1 6ND
  • View abstract

    Summary

    Male or female sterilisation is chosen by almost 50% of British couples in their 40s as their main method of contraception. Of these, 15% of men and 12% of women choose either vasectomy or tubal occlusion. Vasectomy is the most effective contraceptive method available, with failures now quoted as having a life-time risk of one in 2000 after two azoospermic samples taken 2-4 weeks apart at least 8 weeks after the procedure. Mirenai (Schering), the levonorgestrel-releasing intrauterine system (LNG-IUS), is an ideal contraceptive method for the older woman. Epidemiological data support the prescribing of combined hormonal contraceptives (CHCs) to non-smoking, normal-weight, low-risk women who do not suffer from migraine until the menopause. The median age of the menopause in Western women who do not smoke is 51.3 years. Symptoms of the menopause are often masked in women using CHCs but some may complain of vasomotor symptoms in the hormone-free week.
  • 24 - Ageing, infertility and gynaecological conditions: how do they affect sexual function?
    pp 259-272
  • View abstract

    Summary

    The sexual needs of ageing population have been ignored by healthcare professionals and policymakers. Their sexual needs, for example, are rarely part of a care plan for the elderly. The negative stereotype of a 'dirty old man' is prevalent. Erectile dysfunction increases with age, lower economic status, diabetes, heart disease and hypertension. As women go through the menopause, there are significant decreases in sexual responsiveness, frequency of sexual activity, libido and tender feelings for partner. Men in infertile couples had decreased satisfaction with intercourse and a trend to lower desire than their fertile counterparts. Changing sexuality with age may be further influenced by gynaecological procedures such as hysterectomy and urinary incontinence treatments. Urinary incontinence studies report an association between incontinence and sexual dysfunction of between 26% and 43%. Psychosocial factors and mood are just as important as physiological and pathological processes in ageing women.
  • 25 - Sex beyond and after fertility
    pp 273-274
  • View abstract

    Summary

    This chapter presents a discussion between fertility experts on sex beyond and after fertility. Health carers and health professionals can have difficulty recognising that older people have sexual needs. They question why the intrauterine system (IUS) uptake rate is so low considering it is such a suitable form of contraception and also has added healthcare benefits. Primary general practitioners underprescribe long-acting methods including IUS. In a recent survey in the USA, 30% of obstetricians and gynaecologists said that they worry about the use of intrauterine devices because of infection. It is a myth that the IUS cannot be used in nulliparous women as it is going to cause infertility and all of those things. There was a European study in the 1980s, with a prototype IUS releasing 20 micrograms per 24 hours of levonogestrel versus a copper intrauterine device (IUD).
  • 26 - What should be the RCOG's relationship with older women?
    pp 277-286
  • View abstract

    Summary

    Reproductive rights remain one of the most important issues for different kinds and different phases of women's movements, but they do not exhaust the ethical concerns of moral philosophers concerned about women's position, any more than they do the range of concerns proper to the Royal College of Obstetricians and Gynaecologists (RCOG). The RCOG should lobby for a lower breast cancer screening age and for genetic testing enabling a more targeted approach, while opposing the growing commercialisation of genetic testing, and oppose genetic patents that particularly affect women, for example patents on the BRCA1, BRCA2 and HER2 genes. The RCOG should back a safe sex campaign and more funding for sexual health clinics aimed at women over reproductive age. It is neither patronising nor paternalistic for the RCOG to use its specialist knowledge, legitimacy and clout to prevent the 'lady from vanishing'.
  • 27 - Reproductive ageing and the RCOG
    pp 287-290
  • View abstract

    Summary

    This chapter presents a discussion between Sean Kehoe, Donna Dickenson, Diana Mansour, Maya Unnithan, and Peter Braude. Each participant discusses points on reproductive ageing and the society's perceptions between men and women, commercialization of the HER2, BRCA1, and BRCA2 genes, and the role of the Royal College of Obstetricians and Gynaecologists (RCOG). People often think STIs [sexually transmitted infections] are infections only of the young women. According to Braude, we are working towards bringing in stem cell coordinators, who will help reach an agreement on what kind of things would be reasonable to do - and that is not only about women. What RCOG can do is to look with a 'gender lens' - because it will bring up other lenses around social justice. Dickenson says that we should oppose body shopping for both sexes and can act together and have a stronger chance of success.
  • 28 - Evidence-based and cost-effective fertility investigation and treatment of older women: moving beyond NICE
    pp 293-302
  • View abstract

    Summary

    Summary data from the Human Fertilisation and Embryology Authority (HFEA) give a comprehensive overview of outcomes of in vitro fertilization (IVF) in the UK. The National Institute for Health and Clinical Excellence (NICE) guideline took an evidence-based approach to the whole literature on infertility management and encompassed activity across primary, secondary and tertiary care. The tertiary care aspect was largely focused on assisted reproductive technologies (ART) and advanced pelvic surgery. NICE funding advice is based on complex cost-effectiveness modelling designed to provide cost per quality-adjusted life years (QALYs) gained as a result of the intervention under consideration. Pregnancy rates are affected by the factors that include the case mix of the clinic, with clinics that predominantly treat less complex cases. Fewer older women or cases with less extended durations of failure to conceive being likely to have higher success rates.
  • 29 - Bang for the buck: what purchasers and commissioners think and do
    pp 303-312
    • By Berkeley Greenwood, National Infertility Awareness Campaign (NIAC) and Portcullis Public Affairs
  • View abstract

    Summary

    Science has developed on from the now relatively basic and clumsy process of in vitro fertilisation (IVF) simply mixing gametes together outside the body and re-implanting them. When National Institute for Health and Clinical Excellence (NICE) examined the question of infertility, it used a fairly basic estimate of cost effectiveness related to the numbers of cycles performed and their cost and likely success rates in various age bands. Criteria with regard to secondary infertility inadvertently discriminate against older people, since these are more likely to be in second or third relationships. Denying a couple the chance of treatment if there is a pre-existing child from any previous relationship seems especially harsh but is frequently applied. Good evidence exists on the Human Fertilisation and Embryology Authority (HFEA) database as to the value of the treatment, and success rates have continued to rise over the past 10 years.
  • 30 - Fertility treatment: science and reality – the NHS and the market
    pp 313-318
  • View abstract

    Summary

    This chapter presents a discussion between Diana Mansour, Berkeley Greenwood, David Barlow, Siladitya Bhattycharya, Berkeley Greenwood, and Susan Bewley. Each participant presents his/her points pertaining to science and reality, and NHS and market with regard to fertility treatment. Bewley questions if the relief of infertility and the costs of pain and stress could be measured in quality-adjusted life years (QALYs), do taxpayers not wish to help two couples for their pound, rather than one. There is more infertility, thanks to treatment existing, than in the days when treatments did not exist. Primary prevention of infertility is also critical. The cost of a live birth becomes twice as expensive beyond the age of 39, hence the existing NICE guideline recommends funding up to the age of 39. In Greenwood's view, 40 is a reasonable cut-off. IVF will see a reduction in monies if there is funding for more NHS treatments.
  • 31 - In our wildest dreams: making gametes
    pp 321-328
  • View abstract

    Summary

    The stages leading to the production of gametes within the gonad may be divided into four stages: initiation, specification, migration and colonisation. Human embryonic stem (hES) cells can be derived from the inner cell mass of human blastocysts derived by in vitro fertilization (IVF) and are defined by their property not only of being able to replicate themselves but also in being pluripotent. When injected into oocytes, the gametes were able to produce diploid blastocysts, with both XX and XY in equal proportions. Apart from providing an extraordinary test bed for examination of the morphological, chromosomal and molecular changes that occur during gametogenesis, the experiments have provoked an excitement at the possibility of developing both male and female gametes in vitro. The fact that embryos could develop into blastocysts and perhaps even outgrow into stem cells themselves, gives little reassurance of long-term safety after implantation and of normal fetal development.
  • 32 - The future: dreams
    pp 329-330
  • View abstract

    Summary

    The development of inducible pluripotent stem [iPS] cells is terribly exciting. Generally, veterinary science has been helpful, barring one anomaly that is that no one got intracytoplasmic sperm injection (ICSI) to work in animals. In horses ICSI is extremely difficult. ICSI did not work when they tried it in mice. It worked in humans by accident in Brussels and the humans were able to take advantage of it. Subzonal insertion of sperm (SUZI) was tried and the sperm was injected into the cytoplasm of the egg. However, all the other developments such as egg and embryo freezing, were started in mice and then moved to larger animals. If an embryonic stem cell line is developed from a female blastocyst, then we will only be able to generate X carrying sperm and not Y carrying sperm.
  • 33 - Managing expectations and achieving realism: the individual journey from hope to closure
    pp 331-338
  • View abstract

    Summary

    In the UK at present, financial restraints make it impossible for some couples with fertility problems to consider assisted conception. Generally, patients will always be able to find a new clinic, or a new doctor, willing to treat them if they have the money to pay, and many cling to stories of exciting new developments in the field, hoping that this will give them one last opportunity to become parents. Infertility is generally a lifelong problem and the consequences of coping with involuntary childlessness are long term. There are some gender differences in coping strategies and it has been found that women find infertility more stressful, experience more anxiety and depression, and use passive coping strategies more often. At present, couples who give up fertility treatment are not routinely offered help or counselling. There are a number of books that may be helpful to couples facing involuntary childlessness.
  • 34 - Managing expectations and achieving realism: the ‘realpolitik’ of reproductive ageing and its consequences
    pp 339-346
    • By Zoe Williams, The Guardian, Kings Place, 90 York Way, London N1 9GU
  • View abstract

    Summary

    The Institute of Public Policy Research (IPPR) report describes the number of children that women say they want in their 20s as a 'baby gap', compared with the number they have had by the time they are aged 45 years. The flip side to the poverty trap is the trap at the other end of a woman's fertility span: involuntary childlessness, at worst, or the lesser but still meaningful, baby gap due to starting too late and only being able to have one child. The encouraging features, such as the end of the pay gap between the genders and more flexible working practices so that part-time work does not necessarily have to be menial, are things that government and society are working towards anyway, as pleasing goals in their own right. If women still procrastinate, new models for welfare and benefit and redistribution of wealth will have to be found.
  • 35 - The future: waking up
    pp 347-350
  • View abstract

    Summary

    This chapter presents a discussion between Siladitya Bhattacharya, Zoe Williams Kate Brian, Stephen Hillier, Roger Gosden, Susan Bewley, David Barlow and Peter Braude. Each partticipant presents his/her points on the message that needs to go out to people that there is a finite time over which women are able to reproduce. This exercise would have to be with government support because there needs to be some kind of neutrality. According to Williams, it is well to decide that full-time childcare should be available freely to people in order to increase the birth rate, but this is secondary really because the ethical position is that this provision helps people who need money. The HFEA [Human Fertilisation and Embryology Authority] statistics show there are more single women having IVF. The Government must be involved, but it is implementation that must be worked on.
  • 36 - Consensus views arising from the 56th Study Group: Reproductive Ageing
    pp 353-356
  • View abstract

    Summary

    Reproductive ageing in women is caused by declining number and quality of oocytes. The Royal College of Obstetricians and Gynaecologists (RCOG) should promote the view of a shared responsibility in addressing the problems associated with reproductive ageing and encourage an acknowledgement that personal and social circumstances play a role rather than placing blame on individuals. The RCOG should urge greater transparency and accuracy in depicting assisted reproductive technology success rates, including the cost and clinical efficiency of full cycles (full cycle implies cryopreservation of embryos). There are no contraceptive methods contraindicated by age alone. Older women may use combined hormonal contraception unless they have co-existing diseases or risk factors. Further research is needed into characterisation of existing and novel ovarian biomarkers to provide clinically useful prediction of current and future fertility. National data collection covers live births and terminations of pregnancy but should be expanded to include information about miscarriage.

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