Dr. Gunasheela Gynaecologist & Obstetrician, Chairperson Of The Indian Branch Of Royal College Of Obstetricians And Gynaecologists Of U.K.

Several factors relating to the male and female anatomy contribute to decrease in infertility. Aging in the male is accompanied by decrease in libido ( desire for sexual activity). This may be due to sub normal testosterone levels. Where as coital frequency and impotence are the major determinants of infertility in the male, ovulation disturbance becomes the main reason for infertility in the aging female.

The effect of advancing age on gene defects in the male has been widely studied. Several autosomal dominant diseases like marfan syndrome, polyp formation in large bowel ( Polyposis coli ) and polycystic kidneys are all associated with increase in paternal age. It is estimated that the risk of such diseases occurring in the offspring is one in 1000, at the age of 30 – 34, 4.5 in 1000 at the age of 40 – 45 and 37 in 1000 after the 45th year.

Friedman, in his article on genetic diseases in the offspring of the older father has shown that 33 % of the children with autosomal dominant mutational changes were produced by fathers over the age of 40. So it is advisable that men should have their children before the age of 45. Paternal age is also said to affect sex ratio of the offspring with decline in the male vs. female ratio with age.

How does age affect fertility in a woman?

The quality of eggs produced by a woman tends to decline slowly after the age of 25. Early embryonic losses start increasing. These are really sub clinical abortions, but this may not be realized by women as most of these embryos produced by about the 17th -18th day of the menstrual cycle are discharged along with the menstrual flow. This is the result of increasing risk to chromosomal aberrations ( 24 % in younger women and 38 % in women over 35 years of age ) in the embryos produced.

However, apart from oocyte factors, uterine factors also play a major role in age related female fertility. In a study of oocyte donation, it was reported that oocytes from young woman perform differently when transferred to the uterus of women of different age groups resulting in 10% implantation when the recipient is over 40 years as against 23% when the woman was less than 35 years of age.

A study by Meldrum showed that there was a pregnancy rate of 43 % when the recipient woman was less than 40 years and 8 % when the recipient was over 40 years. They suggested that the uterus of the elderly woman was less sensitive to the progesterone hormone required for implantation of the ovum.

For every egg that is released during ovulation in a month, 1000 eggs just perish by a process known as apoptosis. So the egg pool steadily diminishes and it may even be completely exhausted by the age of 38 or 40. Such women may continue to have periods, but these are ovulatory.

Theoretically speaking, women should not postpone her first pregnancy beyond 30 years of age. But women today are ambitious and professionally oriented. They realize that rearing a child is a big responsibility, which demands a lot of sacrifice from the mother. The time required to look after the baby causes interruption in their professional career and they may resent this because it also means a sense of economic deprivation at a time when money is badly required.

So one cannot advise every woman to obey a particular dictum but if a career-seeking woman wants to postpone starting her family, she has to work hard to retain her fertility potential.

• She must maintain a lifestyle that will not allow her to become obese. Obesity itself can be an enemy to fertility. Obese women frequently produce excessive amounts of insulin which itself can disrupt ovulatory phenomena. Excessive insulin produces other metabolic disorders also. Smoking is said to affect tubal motility and can cause increase in incidence of tubal pregnancy.
• Excessive consumption of alcohol can disturb menses. It has been found that drinking more than 1 peg / day ( 100 gm of alcohol / week ) can even cause fetal birth defects.
• Drinking excessive cups of coffee is said to produce fertility problems.
• Even spontaneous abortions.
• Extramarital relationship often result in contracting pelvic inflammatory disease causing tubal blocks and chronic endometrial infection. Aging women may develop high blood pressure, diabetes, endometriosis and myoma. All these can produce problems during conception.

Summary
Decrease in fertility does occur with increase in age. Women marrying after the age of 35 years should not use any method of family planning. If they do not become pregnant within 6 months, they should immediately take the help of a specialist. Aggressive treatment is recommended for such patients. These consist of ovulation induction with a view to produce multiple ova and Intra Uterine Insemination (IUI) even when the couple is capable of normal sexual activity and later Invitro Fertilization (IVF) when everything else fails.

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