IVF : A boon for childless couple even after menopause

Dr ML Goenka *

Human oocyte with surrounding granulosa cells, after aspiration :: Courtesy: RWJMS IVF Laboratory : Pix - wikipedia/ekem

The best time to conceive is between 20 to 30 years age. Female fertility decreases gradually after 30 and declines sharply after 35. Natural pregnancies are extremely rare after the age of 40. Menopause gradually ensues after the age of forty. Although the rate of fertility remains low after the age of 30, the rate of first child birth in this age group has actually increased. This increased is due to late marriages in order to pursue education and careers. Even many women's are attempting conception for the first time after the age of 40.

Approximately 15% of the couples suffer from infertility. More than half of the infertile couples seeking treatment are above the age of 35 years. Changing demographics combined with age related decline in female fertility has led to more and more females asking fertility treatment at an older age.

This age related decline in female's fecundity should be put in the context of the growing disparity in reproductive life expectancy versus overall life expectancy. Compared to a century ago, a woman can now anticipate living an additional 25-30 years, while the age of menopause has changed only by 3 to 4 years during the same period of time. Thus, in the context of longevity, the relative reproductive life span of women has been reduced by almost one half.

As medical advancements continue to push the limits of life expectancies, relativity little progress has been made in arresting the degradation and depletion of ovarian follicular (eggs) reserve.

However with the advent of OOCYTE DONATION technology women may become pregnant after the age of natural menopause. At menopause the store of eggs (oocytes) is exhausted but there is a very little change in uterus (womb). The uterus starts functioning (menstruating) once the hormones are replaced from outside. In oocyte donation technique, eggs (oocyte) are taken from another female (donor) who is below the age of 30 years. These eggs are fertilized in laboratory by in-vitro fertilization (IVF) or test tube baby technique with husband's sperm. The fertilized eggs (embryos) are then transferred after 48-72 hours inside the patient's (recipient) uterus.

The patient (recipient) is given hormones from outside for two to three cycles before the actual oocyte donation cycle to match or synchronize her cycle with the donor. This hormones replacement therapy is continued so that the uterus can support the early pregnancy. After 12 weeks of pregnancy placenta supplies sufficient hormones and there is no need for outside replacement.

The donor's ovaries are hyperstimulated with gonadotropin hormones to produce more number of eggs or oocytes. These eggs are aspirated from ovaries with needle under guidance of vaginal sonography.

The identity of donor is not disclosed at the request of both parties. The donors are screened for hepatitis B & C, HIV infection, Syphills, Cervical cancer, blood group & genetic history. Generally donors are middle class working females who provide their services for remuneration. Donors may be IVF patients, who agree to donate their excess eggs. Known designated donors are another option, typically a family member (for example- sister, niece).

There exist long standing debates regarding payment to oocyte donors for their eggs. Different countries have different regulations for the services of oocyte donors. The payments are construed as reimbursement for time and inconveniencies, and indeed, without payment it is doubtful any country will acquire sufficient donors to meet the increasing demand. In India a donor gets between rupees thirty thousand to fifty thousand for a cycle.

Egg donation is safe and is basically no different from those patients going for standard IVF. Even donors have much less risk of OHSS as they are not going for pregnancy.

The patient (recipient) is also thoroughly screened for any systemic diseases like hypertension, ischemic heart disease, diabetes mellitus and tumors of uterus and ovaries.

Pregnancies of these post-menopausal women may have some complications due to advance age. These complications are hypertension, gestational diabetes, toxemias of pregnancy, intrauterine growth retardation (IUGR). Hence these pregnancies are monitored with utmost care. The complications are manageable and parents can reasonably expect healthy children.

There is some controversies about the age at which a menopausal women can go for oocyte donation. If a woman is in good physical and psychological health, she can go for a pregnancy by oocyte donation up to the age of 50 years. There are many reports where pregnancies have occurred even in the age group of 60 to 70 years by oocyte donation. The couples around the age of 50 years are well settled financially. In a study it has been found that they can take care of new born child even better than the young mothers. As the life expectancy in India has gone up, the child can also complete his studies during life time of parents.

The pregnancy rates following egg donation are excellent in comparison with most other assisted conception treatments. These patients have pregnancy rate of 50-55%. The better pregnancy rate in these patients is because they do not have to take hormone injections, which have some deleterious effect on embryo implantation in uterus.

First oocyte donation pregnancy was reported in 1984 in Australia. During last three decades thousands of babies are born every year by this technique. Demand of pregnancy through donor eggs is increasing every year because of rising percentage of women who remain childless after the age of 35 years.

Oocyte donation is also useful for patients who have premature menopause, primary ovarian failure and women who are menstruating (around 40) but have tried all other methods of conception.

In summary women, who were considered hopelessly infertile due to ovarian dysfunction, now have a very reasonable chance of conceiving and bearing a child by oocyte donation.