ADVANCED MATERNAL AGE FOR PREGNANCY , DELAYING CONCEPTION TO LATER YEARS

This is defined as pregnancy intention above the age of 35 by some protocols and above age 40 by other criterias . Still , the consensus is that pregnancy above the age of 35 is considered to bear risks and this becomes pronounced with more advanced ages .As women become more empowered and busy with careers , this is becoming a norm in a majority of our Kenyan setting; especially the urban population . 

I personally got my first child at mid-30s

and my second 20months later and this was contributed by a variety of reasons amongst them delay in settling down due to socio-cultural issues . In the waiting time, I immersed myself in career progression. I still consider this time a reasonable age with the many rapid changes in current times.I still have room for more children but I have to weigh and balance with rapidly advancing age ; do I want a child in my 40s? I would have conceived no.3 by now but I must balance other important life needs too.

A woman's peak reproductive fertility years are between the late teens and late 20s. By age 30, fertility starts to decline. This decline happens faster from mid-30s. By 45, fertility has declined so much that getting pregnant naturally may be unlikely.

A woman is  born having 1-2 million potential eggs in ovarian follicles, by the time they  reach puberty there is only a store of between 300,000 and 500,000. Although a woman ovulates between 400 and 500 times in their life, and although, each time, there may be only one egg (ovum) that ovulates, hundreds of follicles are lost with each ovulation. 

It is believed that there is an accelerated decline in ovarian follicles pool at the age of 37–38 years when it reaches below a critical of 25,000. Subsequently, more decline occurs. It is believed that this phenomenon is accompanied by a declining quality due to aging oocytes. It’s not uncommon to see more and more miscarriages in women past this age due to poor quality ovums.

An individual’s speed of decline in fertility after age 35 is dependable on a number of issues amongst that individual probable age of menopause , any surgeries involving the ovaries , smoking and aggressive medical treatments such as cancer treatment that may affect fertility. Unfortunately one cannot tell their exact menopause timing and this is only a retrospective backward diagnosis after it has happened . I have seen patients in menopause as early as age 43 others as late at 52. 

Most common factor for diminished ovarian reserve is age .There is a more rapid decline after age 40. It may vary amongst individuals ; some women get to menopause earlier hence a more accelerated loss in quantity and quality in their pre-menopasual years (years that preceded their actual menopause time) which for them could be in their late 30s . For other women , they may still stand a good chance of a natural conception in their 40s especially if they are to have late menopauses above age 50. I have personally delivered a good number of  women between ages 40 and 44. Others have had to undergo IVF with donor eggs due to critically low ovarian reserves ; this varies from client to client , and their individual test results  . I know of a woman who conceived spontaneously at age 48; she thought that she had a pelvic tumor only to be met by a bouncing female fetus at 20 weeks ; baby is all grown now and in primary school ( this is an isolated rare case and should not be used a confidence bench to delay conception). 

About one in one hundred (1 in 100) women experience early menopause(below age 40). Sometimes the event is genetic; other times, it results from a health condition or curative medical treatments. This is one of the reasons that fertility preservation (egg freezing)is a hot topic in the cancer field. Women facing chemotherapy or other cancer treatments may risk compromising fertility, so freezing eggs beforehand makes sense.

I will not be surprised to see more career-oriented women do egg freezing to conceive much later via IVF once their career and life goals are met.  It’s already a common trend in the first world countries and may be picking up in the major towns in Kenya. 

The association of pregnancy complications with advanced age appears to be on a continuum such that risks increase with increasing age at the time of the pregnancy. Likewise, studies evaluating the effect of chronic medical conditions such as diabetes, hypertension, and obesity, which may exacerbate pregnancy-related morbidity, appear to demonstrate an increasing risk with increasing age at the time of pregnancy. Therefore, recent studies have commonly divided the age of individual pregnant women at age 35 years and older into 5-year increments: 35–39 years, 40–44 years, 45–49 years, and 50 years and older, which better stratifies the possible pregnancy risks associated with advancing age. 

Women who are pregnant above age 35 are managed as high risk pregnancies and prevention and early detection of key pregnancy morbidities is key . Its not uncommon to see the Gyanecologist insist on folic acid prior to conception and in the first trimester to prevent risk of congenital anomalies and thus risk of miscarriages .There be more keen scans in 1st trimester to predict possible aneuploidies (chromosomal anomalies) and more detailed follow-ups to prevent and detect any complications in these pregnancies . Countries and centres in Nairobi that offer genetic screening would be more keen on this in pregnancies especially those  above age 40. I commend women who come to us for pre-conception care because they are aware that they are at advanced ages. 

So yes , let us embrace this discussion. Let women be aware about dipping ovarian reserves so that they don’t delay their attempts at conceptions too much ; any Gynecological issues should be sorted in advance to give time for fertility care and treatment way before menopausal ages . If one has a Gyanecological surgery to pave way for fertility care , let this be done early. Presence of menses is not an absolute ticket to confirm fertility wellness ; this is a big misnomer in the population ; women who delay first child conception just because they get monthly menses should be educated. 

Let us also educate each other about possible risks of advanced-age pregnancies . See your Gyanecologist to weigh about decisions on late conception  (especially if you already have children) to walk with you safely in case you settle on an advanced age pregnancy . 

Technology has come to us and has helped tons of women conceive through IVF . For women with critically low ovarian reserves , donor egg is a growing trend in our society and enables such women to conceive and carry to term their children.

We also have IVF with own eggs for women in their 40s with unexplained infertility who may not have the luxury of trying longer naturally due to rapidly advancing age and fear of impending peri-menopause . This year alone I have delivered three sets of twins of women we sent for IVF in their early to mid 40s who we thought we couldn’t waste time any longer . Oh the joy in those mother’s faces remains ached in my heart and soul forever . Did you know that currently in Kenya TSC Teachers and National Police Service are directly covered for IVF services without any delays in waiting times or complicated processes? They simply walk in , get tests done and are scheduled automatically if they qualify .

This is a very sensitive topic ; I hope I didn’t scare or offend anyone. We however must educate one another and prevent mistakes that we have seen in others . See your Gyanecologist for more personalized care . Don’t wait too long for that baby, run around and try care before it’s too late . Still don’t make irreversible mistakes and settle in a wrong union because you want babies pronto; very tough balance - being a woman can be rough. I find myself identifying more with my clients because I am a woman , who has gone through the seasons . I would gladly refer and support m a woman who say is sure she wants donor sperm conception in the meantime as they figure life ; yes I would !!

OVARIAN CANCER - THE DISEASE WITH VAGUE SYMPTOMS

Enter patient *Miriam . She is in her 50s, carries some gloom and worry on her face . She has  usual menopause symptoms and is managing them well ; but you see , her friend got diagnosed with stage IVB Ovarian Cancer . She didn’t have any symptoms beyond menopause symptoms ; some bloating here and there , occasional insomnia, some back pains and arthritis , on and off  loss of appetite and occasional mood swings . She is worried because she wonders if her friend could have been diagnosed earlier had she seen a Gynaecologist more often . She worries if she would be to be in the same boat in the future if she doesn’t keep checking . She asks me if there  is any screening test for ovarian cancer like we do for the cervix . At this time I also a remember a story told by one of my patients of a lady who died in this month of June and diagnosis of advanced ovarian cancer was only made at autopsy ; her wasting and symptoms were so vague she withered away before a diagnosis could be made . 

Miriam had many other questions including if we could remove ovaries and entire reproductive system after end of childbearing age to prevent future cancers . She asks me if there are  particular symptoms to be keen on. She worries if her friend’s daughters and sisters are now at risk of ovarian cancer . Keep reading , you will get answers in the write up . 

It’s important to remember that there are 3 different broad categories of ovarian cancers including ovarian cancers we see much early in children up to early 20s. For this write-up I’m focusing on Epithelial type of Ovarian Cancers ; the ones that mostly inflict ladies in age 40 and above (may rarely occur earlier), are notorious for severe malignant effects and high morbidity and mortality . 

There is no clear cut screening modality for ovarian cancer unless for very high risk clients with genetic predispositions or strong family histories of ovarian , breast and endometrial cancers ( and colon cancer - I won’t go here lest I bore you with advanced Gyane-oncology)  . Routine tumor markers and ultrasounds/other imaging have not been seen to reduce the burden of advanced disease at diagnosis in the general population. The tumor marker for ovarian cancer called Ca-125 can be somewhat non-specific in some situations and thus not a good screening modality for the general population but only a useful tool in suspected ovarian cancer. 

Some risk factors for ovarian cancer are as tabled below 

Nulliparity ( having had never given birth)

Early menarche ( early age at first menses)

Late menopause

White race

Increasing age

Family history

Personal history of breast cancer

Ethnic background (European Jewish, Icelandic, Hungarian)

Postmenopausal hormone therapy

Pelvic inflammatory disease

Having more children, late beginning of menses, early menopause ,  is postulated to be protective against ovarian cancer . The daily combined contraceptive pill (despite its other risks) is known to be protective against ovarian cancer due to prohibition of ovulation . Uninterrupted ovulation (eg in nulliparous women) is thought to cause repetitive ovarian surface ‘damages and repairs ’ during expulsion of the monthly ‘egg’  may cause mutations and thus risk of cancer .

If you are client that has passed through my hands for permanent family planning i.e tubal ligation , you know that I’m a die-hard for total removal of the Fallopian Tube and not simply a knick and cut . I routinely do Total Salpingectomies (I remove the whole tube) because this is also known to be protective against ovarian cancer. Studies have shown that a significant number of ovarian cancers originate from lesions the finger-like ends of fallopian tubes i.e the fimbriae . 

Family history of breast or ovarian cancer has been associated with Ovarian Cancer

•Approx 10% of patients have an inherited genetic predisposition with mutations in a gene called BRCA1 and BRCA2

 

•A family history of ovarian cancer in a 1st degree relative, that is, a mother, daughter, or sister, triples a woman's lifetime risk 

 

•The risks further escalate with two or more an affected 1st degree relatives, or with other individuals with premenopausal breast cancer.

We have testing for the BRCA 1 and 2 gene mutations in Kenya , extremely costly but a good guide on which patients can undergo prophylactic removal of both ovaries after completion of child bearing or by age 40 years. Labs like Kalebi Lab , Lancet etc are currently doing the tests in Nairobi. 

So back to Miriam’s question , can we remove the ovaries for everyone fearing ovarian cancer ? Absolutely not unless a genetic mutation is confirmed . Remember the ovaries have an estrogen producing function even in menopause albeit in reduced quantities. Estrogen is important for many other benefits in the body and protection against cardiovascular diseases and for general well being in almost all body systems including bone, skin and brain health  ( story for another write up). So women undergoing surgeries say removal of uterus due to fibroids , the ovaries are mostly never touched and are left in-situ. 

Symptoms : Ovarian cancer is typically portrayed as a “silent” killer that lacks appreciable early signs or symptoms. This is a misconception. Symptoms are there but vague. The difficulty is distinguishing these symptoms from those that normally occur in women especially in menopause . In general, persistent symptoms that are more severe or frequent than expected and have a recent onset warrant further diagnostic investigation. Fatigue, indigestion, inability to eat normally, constipation, and back pain may be noted . Abnormal vaginal bleeding or postmenopausal bleeding  occurs rarely but if it occurs it must be investigated. May present with nausea, vomiting, and signs of intestinal obstruction. Any unexplained weight loss or a feeling of an abdominal swelling or a mass  of suspicious increase in abdominal girth must be investigated. 

Once you see your Gynaecologist , appropriate tests and imaging will be done and further management initiated if disease is confirmed or suspected .

For Miriam , we offered her a well detailed menopause guide talk,general examination including BP,  a thorough breast , abdominal and vaginal gynaecological examination , we did cervical cancer screening via HPV testing as it was due and did an abdominal-pelvic ultrasound with focus of endometrial thickness, ovaries , and search for any abnormal findings . 

A yearly Gyane-visit may be reasonable for all women and especially in menopause . Genetic testing of the gene mutations despite the high cost ( ~130,000 - 150,000 Kenya Shillings) is not unreasonable in current times to  high-risk clients ( we third world countries are very quickly catching up with standard procedures done elsewhere). Maybe insurance companies can partly or fully cover this if we are ever going to reduce the incidence and burden of the monster that is ovarian cancer . These same gene mutations are also important for patients at risk for breast cancer who may need prophylactic mastectomies(removal of breasts) >> hey the breast in Kenya is considered an organ for the general surgeons and not the gyanes’; I call upon my surgeon colleagues to consider doing a blog/vlog/talk on breast cancer as well . 

May you have healthy and productive ovaries all days of your life . Amen . 

I tried to simplify the blog as much as possible to avoid being too academic and to minimise medical jargon . Feel free to ask any questions or to pop in for a consultation. 

EMERGENCY CONTRACEPTION - NOT JUST P2; THERE ARE BETTER METHODS

 

Rael * 23 year old final year university student walks into my clinic . She is anticipating her final exams and soon thereafter start plans for a wedding with her fiancé Daniel*. They have been very careful with their safe days and using protection but last evening , they had an unprotected moment and she is ovulating today. She comes in because she wants advice on the best emergency contraception that is very efficient  and without complications. She is not ready for a baby now and would like to focus on finishing school , getting high grades  , getting a job and starting the tedious dowry/wedding preparations with Daniel. Her cycle has been very regular to the dot and she is sure that she has a very big chance of conceiving from the previous night’s encounter .

I’m surprised that we have younger ladies who are very armed with information and I congratulate her for seeking care timely and wanting to take control of her life . She says that my blog ( whose link was shared to her by a classmate)on not fearing contraception before marriage opened her eyes.  

Emergency contraception according to WHO refers to methods of contraception that can be used to prevent pregnancy after sexual intercourse. These are recommended for use within 5 days of intercourse but are more effective the sooner they are used after the act of intercourse.

Emergency contraceptive pills prevent pregnancy by preventing or delaying ovulation and they do not induce an abortion. In case ovulation has already occurred, methods like the copper-bearing IUD prevents fertilization by causing a chemical change in the uterus and fallopian tubes that is toxic to sperms before they can reach the egg for fertilization. The copper-bearing IUD therefore acts as a spermicide, killing or impairing sperm so they cannot reach the egg. Copper IUDs do not contain any hormones, but release copper ions, which are toxic to sperm. They also cause the uterus and fallopian tubes to produce a fluid that contains white blood cells, copper ions, enzymes, and prostaglandins  which is also toxic to sperm.The very high effectiveness of copper-containing IUDs as emergency contraceptives implies they may also act by preventing implantation.

Emergency contraception cannot interrupt an established pregnancy or harm a developing embryo; therefore doesn’t induce abortion and so it’s legally allowed.

Emergency contraception can be used in a number of situations following sexual intercourse. These include:

• When no contraceptive has been used or was forgotten e.g in patients on the daily pill  .
• Sexual assault when the woman is to be protected against conception 
• When there is concern of possible contraceptive failure such as a condom burst or slippage
• Miscalculation of the  safe window or when not sure how to calculate
• Patients with sudden expulsion of an intrauterine contraceptive device (IUD) during or immediately after intercourse 

So back to Rael , we get talking and the two main methods  available locally are discussed which are as follows

• The high dose progesterone pills (150mg of levonorgestrel) popularly known as the P2  which should be taken within 72 hours of sexual intercourse  (these pills can also be taken in 2 doses of 75mg each, 12 hours apart). This should not be abused and it’s recommended to be used infrequently and mainly during the fertile window.
• The copper IUCD which should be inserted within 120 hours (5 days)of unprotected intercourse 

The pill will have same side effects like the oral contraception pills and if vomiting occurs immediately on taking the pills then it should be repeated immediately. The P2 has a failure rate of around 2% and the resultant pregnancy might be an ectopic pregnancy but this is rare. The P2 pill is also associated with irregularities of subsequent menses . 

The copper IUD (Copper-T) is 99.2% effective as an emergency contraception if put within 120 hours . The downside is that it has to be put  by a professional and may be unreachable by most especially younger students who may shy away from fertility clinics . The less than 1% that conceive would also most likely have an ectopic pregnancy but this is very rare . The advantage is that the woman can keep it as a continued effective contraception method and can last for upto 10 years . Removal is easy in the clinic and can be done by any medical cadre as long as the strings are visible .

The IUCD is also non-hormonal so no hormonal side effects like weight changes , menstrual irregularities are encountered . The return to fertility on removal is instant. 

Rael opted for the IUCD . Luckily I had a a sterile insertion set and piece ready in the office and I was able to insert it for her immediately after confirming that her pregnancy test was negative (we have been conned by patients before so we always want to confirm). She was glad that she took medical consultation and saw a professional . Her next menses came on time and she is busy preparing for her exams . 

I hope this is well understood. Take charge of your life ; do not let an oops moment change the trajectory of your life . 

POSSIBLE EXPLOITATION OF THE YOUTH FOR SPERM/EGG DONATION IN KENYA

 There has been an organ (mainly kidney) donation scandal being addressed in the nation that has gotten many talking . This reminds me of another ‘organ’ or ‘product of an organ’ that we don’t discuss enough ; the subject of sperm or ovum(egg) donation .  I have had the chance and opportunity to work/learn in a few fertility IVF clinics both locally and abroad . The regulation abroad is very stringent to the extent of people buying gametes abroad (from developing countries in Africa and Asia) to avoid the very tight regulations of such transactions in countries like Canada and U.S.A. There are no proper regulations in the Kenyan Legislature and so as long as a donor is over 18 years and signs a legal document , there are no real legal frameworks to safeguard them . Our law (or is it a Millie Odhiambo Bill that is yet to become law) however discourages financial gain from the same but it’s a very grey area because tokens of appreciation to ease the process  are not categorically banned . 

In Kenya, the Assisted Reproductive Technology (ART) Bill, 2022 outlines the legal framework for gamete donation and other assisted reproductive technologies. The Bill prohibits the use of sperm/ovum from donors under 18 years of age, except with parental consent for a minor's future procreation e.g in those minors undergoing cancer treatment that may permanently affect their fertility. It also prohibits the sale and transfer of gametes, zygotes, and embryos. Additionally, the Bill regulates the licensing and operation of facilities offering ART services, including sperm banks. 

Here's a more detailed look at the key aspects of the law: 

1. Donor Eligibility and Consent:

• A donor must be a fit, healthy, typically between 18 and 45 years of age, willing to undergo rigorous testing. 
  
• The donor must agree to relinquish all legal rights to any children resulting from the donation. 
  
• Sperm/egg from donors under 18 is prohibited for use in assisted reproduction, unless for the minor's future procreation with parental consent. 
  

2. Prohibition of Commercialization:

• The sale or transfer of gametes, zygotes, and embryos is prohibited, meaning they cannot be bought and sold.
• The Bill aims to prevent commercial exploitation of assisted reproductive technology. 

My focus today will be on the young over-18 female university students. For male donors , it’s a simple masturbation with no prior drugs , invasive theatre procedures or possible life threatening complications from unregulated donations .

I had a recent discussion with my mother ; Madam-Z and we agreed that unto age 24, one needs to be under guidance and may not be trusted with major life changing decisions - I do not support marriage ; especially of men below this age - this my own personal view . The same applies to organ or gamete donation by our very young college girls . Most end up getting serious mental health issues later ; they may worry about their anonymous multiple offsprings out there in the world, some may get some complications from the egg-retrieval processes that may bring serious uncertainties and anxiety , others may end up perpetually guilty for secretly doing what their parents would never consent to . 

I remember recently reading in a doctor group about a young university girl who had to undergo a major abdominal surgery following a pelvic abscess(pus accumulation) obtained following an egg-retrieval process gone wrong . She had only been pain 30,000 Kenya Shillings and the I.V.F centre did not want to be involved in her care because this was beyond the contract she had signed . Such a surgery that she underwent would cost not less than 100,000 shillings in the rural setting ; the costs may be triple that in Nairobi and this many not be fully catered for by SHA. What about the possible resultant future Subfertility that may arise from this iatrogenically caused infection ? Is 30,000 shillings worth this headache ?

One notable personality , talked about how she almost died from OVARIAN HYPERSTIMULATION SYNDROME (OHSS). You see , a woman ovulates one mature ovum per month unlike a man who ejaculates more than 20million sperms per ejaculate . More eggs are usually required to assist in the IVF process and so a series of hormonal drugs and injections are usually given to stimulate production of many eggs in the cycle sometimes to more than 20 . Depending on the dosages , some girls may over-react and get into a hormonal crises called OHSS which if not well managed can be life threatening; this results from over-stimulation with many follicles produced and resultant very high oestrogen hormone levels  . The body swells up with fluid everywhere including the lungs and these patients may develop life threatening blood clots . Most most of these cases have to be managed in HDU or even ICU with supportive management of all organs affected . In countries with well regulated practices , OHSS occurs in about 1-3 % of women undergoing IVF egg retrieval ; the situation may be worse in our country . Rarely the over-stimulated ovary with many follicles may twist (torsion)due to the abnormal heaviness from many follicles leading to a a major surgery or sadly  loss of an ovary from this torsion. Management of OHSS may end up costing hundreds of thousands all from earning less than 100,000 from egg donation ; the price depends on ‘quality of egg and profile of donor with beautiful students doing STEM courses or courses known to attract exceptionally bright students earning more; it is what it is !!

My take is that these students must be protected .A 19 year old may not be as mature as a 38 year old hustler . Is thorough patient education done ? I doubt it . Holders of national I.D cards automatically become eligible for these unregulated transactions.

Has anyone also thought about future consanguinity ? Of siblings marrying in the future ? There are medical students (male) who survive fully in university by sperm donations and some may donate more than 50 times ; helping over 50 families get multiple babies (do the math, we may be talking about total 200 children over a 5 year college period) . There is no regulation whatsoever  in Kenya on how many times one can donate gametes  . One day we will have siblings marrying each other or procreating together . The future isn’t far because this has been a practise for close to two decades in Kenya  - I have personal friends who donated a a few times in sperm banks in Nairobi when they were younger.

I have no problem with gamete donation ; I have a number of very grateful women in my clinic who have benefited greatly from ‘anonymous purchase’ of eggs from ovum banks and are on their 2nd/3rd pregnancies . I also have a few couples with male infertility problem whose marriages and image in society has been saved by sperm donation from strangers . I fully embrace it but let us protect our very young girls from exploitation unless if helping their relatives . I’m worried both about physical complications and also unseen mental health issues that may arise . 

I want to beseech parents to move with the times and stay alert on these emerging issues in society that may never have been in existence during our times . A new expensive phone by your daughter may not necessary be from a sugar daddy but may be from unregulated egg donation . Talk to your girls , befriend them , be open and make sure they are well provided for and that they learn to live within their means; I believe hardly no girl donates eggs to an anonymous stranger for the goodness of humanity but mostly for financial gain. For those girls who are very sure about these donations , let us make sure that the contracts protect them fully and that any possible mental issue is dealt with accordingly . Dear girls can we open up to our mothers/sisters/gynaecologists before embarking on donation if we are not very sure ? I have no problem with older women(especially those with children) who take it up . Let us keep talking . Thank you!