What you need to know ...
- A study conducted by the Dubai Health Authority (DHA) found that as of 2016, nearly 50 per cent of women in Dubai were suffering from issues pertaining to pregnancy.
- Statistics also show that the number of women seeking infertility treatment in Dubai could rise to 9,000 by 2030.
- If there is one single factor that plays a big role in infertility, doctors say it is a woman’s age.
Nadia is 38 years old, happily married with a great job in the UAE. She and her husband Amer had to struggle for many years before reaching the level of financial comfort they are at now. Perhaps it was time to start a family.
But, life was not ready to cooperate. They were one of the four couples being affected by infertility in developing countries, according to the World Health Organisation numbers.
The UAE Human Development Report for 2018, released in June by UAE University in collaboration with the United Nations Development Programm (UNDP), stated that the fertility rate has dropped significantly in the country.
The study states that the fertility rate in UAE was 6.3 births per women in the early 1970s dropping across the years to reach 1.8 births in 2015.
So, infertility is on the rise?
Dr Pankaj Shrivastav, director of Conceive Fertility Hospital in Dubai, said: “I do think that both male and female infertility is on the rise, and there are multiple reasons for this. Most are lifestyle-related.”
The statistics speak for themselves, according to Dr Jaya Shahul Hameed, a specialist obstetrician and gynaecologist at Aster Al Rafa Clinic, Abu Dhabi.
She said: “A study conducted by the Dubai Health Authority (DHA) found that as of 2016, nearly 50 per cent of women in Dubai were suffering from issues pertaining to pregnancy. Statistics also show that the number of women seeking infertility treatment in Dubai could rise to 9,000 by 2030.”
Dr Khaled Koteich, a consultant obstetrician gynaecologist at Saudi German hospital, explained that fertility patterns in the world have changed dramatically over the past few decades. Today, 46 per cent of the world’s population lives in countries with low levels of fertility, where women have fewer than 2.1 children on average.
Infertility is counted as the number of children born alive to a woman, disregarding that some women are capable of conceiving, but risk of miscarriage rises with age.
Dr Diana Kayal, specialist in obstetrics, gynaecology, reproductive medicine and infertility at Bourn Hall Fertility Clinic, Dubai, agreed: “There could be many reasons for this, including lifestyle, work pressure, stress, weight gain and even eating unhealthily.”
We look at the many causes:
Diet and obesity
Having a balanced diet is one of the key factors in ensuring that the decline in one’s fertility does not begin early.
Dr Shrivastav said: “As a woman’s body mass index (BMI) increases, hormonal imbalances like polycystic ovary syndrome (PCOS), which are hidden as long as she is fit and slim, become more apparent. So a woman who has completely normal menstrual cycles and is able to create eggs every month – once she puts on 10 to 12 kilograms and the hormonal imbalance kicks in, she stops making eggs, her periods become irregular and she finds it more difficult to get pregnant.”
According to Dr Hameed, following a healthy, balanced diet prior to conception does not just alleviate problems during pregnancy but is also associated with a lower rate of birth defects.
She said: “Women who are strictly vegan must supplement their food with iron, folic acid and vitamin B12, otherwise their fertility might get adversely affected. Processed and fatty foods should be avoided, along with excess sugar intake, in order to prevent the onset of obesity.”
Dr Ahmad Fakih, a gynaecologist focussing on reproductive endocrinology and infertility at Fakih IVF clinic added: “Obesity creates hormonal problems, leading to irregular ovulation and irregular periods.”
However, Dr Kayal cautioned: “It’s extreme weights, you should not be too thin or too fat - extremes are not good. We should eat a healthy and balanced diet and exercise; but don’t over exercise either.”
Therefore, a relatively low-carb diet is recommended to keep weight under control.
“If women become obese, it will affect their menstrual cycle,” states Dr Arva Dhanaliwala, specialist obstetrics and gynaecologist at Welcare Hospital Dubai.
Weight gain is a volatile factor that has an immediate impact on fertility.
It’s extreme weights, you should not be too thin or too fat - extremes are not good. We should eat a healthy and balanced diet and exercise; but don’t over exercise either.
Dr Hameed added: “Obesity affects a woman’s fertility by causing an imbalance of hormones, resulting in problems with ovulation. This is especially true in women who are planning on having their first child.”
Dr Shrivastav said: “As a woman puts on weight, her insulin resistance becomes worse, and she requires higher and higher levels of insulin to control her sugars. Finally, the body cannot increase the insulin anymore, and that is when that woman becomes diabetic.”
He added that the issue is not just a problem for women, but for men as well.
“It’s the same thing with men. Obesity in a man, or his fat cells, convert the male hormones into female hormones. That is bad for sperm production and the libido – all these compromise a man’s fertility.”
If there is one single factor that plays a big role in infertility, doctors say it is a woman’s age.
The average age of women at their first birth has risen over the past four decades, according to US-based Centers for Disease Control and Prevention (CDC).
Dr Shrivastav said: “Women today, are studying for longer, pursuing careers, getting married later and planning to start their families later on in life. As a woman’s age increases, her fertility is on the decline. A woman’s fertility peaks at about 26 to 28 years and it’s downhill after that. After 35, the decline in fertility is sharper, and after 40 it is precipitous.”
He explained the reason behind the ticking of the biological clock.
“A girl is born with the entire number of eggs she needs in her life. So, she is born with about 4 million eggs, and by the time she reaches puberty, it comes down to about 300,000 – 400,000. Then, she loses eggs every month. She makes one egg every month, but to make that one egg, she loses about 900. As a woman is ageing, there are fewer eggs left behind in her ovary and unfortunately, what is left towards the end, is not of such good quality. By quality, I mean chromosomal characteristics of the egg.
“At the age of 30, a woman will have chromosomal abnormalities in 40 per cent of her eggs. By the time she is 35, it affects 60 per cent of her eggs. By the time she is 40, 85 per cent of her eggs are impacted and when she hits 45, chromosomal abnormality affects 90 to 95 per cent of her eggs.”
So while it is possible to have a baby later in life, women must be prepared for the complications that come with age, Dr Hameed added.
“Age can lead to a number of risks such as the risk of not being able to conceive, the risk of a miscarriage, and complications in pregnancy and childbirth.”
Dr Kayal said: “Nature is recognising the embryo formed from these older eggs as abnormal and so it won’t allow it to implant. Or even if it does implant, it’ll recognise it as abnormal and reject it, therefore leading to more miscarriages.”
Dr Arva Dhanaliwala, specialist obstetrics and gynaecologist at Welcare Hospital Dubai, confirms the same. “A lot of women come to the UAE seeking jobs and are very career-oriented. Now, a lot of older women are coming forward, looking to get pregnant. But, they need to understand that fertility declines with age. This is one of the main reasons for miscarriages. As you get older, the quality of a woman’s eggs declines, which causes the risk of miscarriage.”
Polycystic ovary syndrome (PCOS)
It is a disorder that affects one in 10 women of childbearing age, according to the US Department of Health and Human Services.
Caused by an imbalance of reproductive hormones, the disorder creates problems in the ovaries.
Dr Dhanaliwala explained: “A lot of women have the misconception that if they have polycystic ovaries, that they have a cyst on their ovaries. But, it is not that. When we do an ultrasound, many follicles appear on the ovaries as cysts. It is a complex hormonal syndrome. In a nutshell — a woman does not ovulate regularly, which reduces her chances of getting pregnant.”
Younger women want more regular periods, or are worried about acne. So, we treat that. When they get married, a doctor will help treat it for pregnancy.
PCOS presents itself in different ways. Most often, if a woman suffers from it, there is no drug that will cure it.
Dr Dhanaliwala further explains: “Management will always depend on what the woman wants. Younger women want more regular periods, or are worried about acne. So, we treat that. When they get married, a doctor will help treat it for pregnancy. When they get older, they are at a higher risk of getting diabetes. A doctor then treats for that. It is not like an infection that can be cured. At different stages of a woman’s life, the PCOS can be managed based on diet and medication.”
Dr Hameed said: “Women with PCOS have a number of conditions, which may include irregular menstrual cycles, an increase in facial and body hair, increased weight, hyperinsulinemia, and difficulty in conception. With proper treatment, most women with PCOS are able to conceive, however it may take them longer to get pregnant.”
While there is no cure yet, for PCOS, there are many ways women can decrease or eliminate its symptoms. According to the US-based PCOS Awareness Association website, losing as little as five per cent excess weight can help women ovulate more regularly and lessen other PCOS symptoms – and the ideal way to do this is through nutrition and exercise.
Dr Shrivastav said: “In this part of the world especially, in South Asia and the Middle East, there’s a high incidence of PCOS – much higher than anywhere else in the world. Here is where lifestyle comes in – as long as these women are having a healthy life where there is a lot of activity and food intake is restricted, PCOS does not become apparent. But with less activity, increased calorie intake, high caloric food... all this makes PCOS much more prevalent. The hormonal imbalance gets worse.”
Women who have PCOS produce higher-than-normal amounts of male hormones. This hormone imbalance causes them to skip an ovulation (menstrual periods) and makes it harder for them to get pregnant.
Dr Ahmad added: “PCOS can lead to anovulation. Fifteen per cent of women who have PCOS are infertile because of anovulation, which is lack of ovulation.”
A woman with PCOS could go for months without a regular menstrual cycle. In this case, Dr Kayal states that women, who do not want to get pregnant, are advised to go on the contraceptive pill, because it creates an artificial cycle.
She said: “A woman shouldn’t go three months without a period. It is very important to shed the lining of the uterus. You don’t want it to thicken too much and create abnormal or atypical cells.”
Closely tied to PCOS is another condition.
Dr Shrivastav explained: “PCOS is a metabolic disease that is very closely related to diabetes. Both these conditions have a very similar mode of genesis – they both start off with something called insulin resistance, which means that the woman’s body is not able to control its blood sugar with the normal levels of insulin. So, she starts making more insulin, and at high levels, her sugar levels become normal. But the high insulin level has a bad impact on the ovary – it causes the production of more male hormones. This male hormone is responsible for the symptoms of acne, increased hair growth, and stops the development of eggs in the ovary, which is why women see irregular menstrual cycles. This is how insulin resistance can impact fertility.”
Dr Hameed concurred that insulin resistance has a serious effect.
She said: “Firstly, greater insulin production increases the production of testosterone [the male hormone] over estrogen [the female hormone]. Secondly, it prevents ovulation by causing the eggs to mature late, and also affects the quality of eggs, in terms of their size.”
Studies show that insulin resistance can also cause delayed embryonic development, growth restriction of the foetus and birth defects.
But something as simple as moving your muscles can help bring down insulin levels, and avoiding sugar intake while increasing the intake of soluble and insoluble fibres can help slow the absorption of sugars and lower the amount of insulin released.
According to a study by US-based National Institutes of Health, 45 minutes of exercise a day, helps reduce insulin resistance for about a day and a half.
Another imbalance linked to PCOS is hypertension. However, a woman suffering from just hypertension would not have the same issues and it would have no effect on her chances of getting pregnant. Dr Dhanaliwala confirmed that a woman can get pregnant, and the pregnancy, which could potentially be a high-risk one, can be managed.
Dr Kayal concurs: “It will be a high-risk pregnancy, but the doctor would know that the woman is at risk and so the situation can be managed.”
Hypertension, per se, does not really have that much of an impact on fertility, but when it is combined with obesity and diabetes, then it does, Dr Shrivastav added.
Whether used for a short while or in the long term, contraceptives do not affect a person’s fertility.
Dr Shrivastav said: “Contraceptives do not have much of an impact on future fertility. Very rarely, there are some girls who get over suppressed with oral contraceptives and tend to have post-pill amenorrhea. This is when women stop having periods after getting off the pill. This issue can be rectified using some hormonal injections.”
Other means of contraceptives also do not make much of an impact.
Depending on the type of contraceptives used, they actually enhance a woman’s fertility. For example, oral contraceptives suppress ovulation and can help in preventing an ectopic pregnancy in the long term.
Dr Shrivastav added: “Using intrauterine contraceptive devices (IUCDs) or coils placed into the uterus as a contraceptive, can also sometimes lead to pelvic infections, where the uterus lining or the tubes get damaged. But by and large, contraceptives do not have a long-term effect on a woman’s fertility.”
In fact, in some cases, they can actually help a woman’s body.
Dr Hameed said: “Depending on the type of contraceptives used, they actually enhance a woman’s fertility. For example, oral contraceptives suppress ovulation and can help in preventing an ectopic pregnancy in the long term.”
For a woman who isn’t suffering from PCOS and just focusing on family planning, the contraceptive pill does not cause infertility.
Dr Dhanaliwala said: “Once you stop taking the pill, the return to fertility is fast. However, there is an injection that some women take, which is required every three months. Once they stop it, it can take time for them to ovulate normally again. I have seen varying times – from three months to a year.”
Dr Ahmad explained: “Hyperprolactinemia is a condition in which a person has higher-than-normal levels of the hormone prolactin in the blood, produced in the lactotroph cells of the anterior pituitary gland. The main function of prolactin is to stimulate breast milk production after childbirth. Women won’t conceive because the body is acting as if it’s in a lactation stage - postpartum - not a fertility stage.”
Looking at solutions to infertility
For those woman who aren’t ready to get pregnant yet, Dr Kayal recommends a procedure called egg freezing.
Dr Kayal said: “This is when a woman wants to freeze her eggs before she wants to have babies. The ideal age for this is also below 35 years.”
Egg freezing is the process in which a woman’s eggs are extracted, frozen and stored as a method to preserve reproductive potential, as stated in a paper published by the US-based University of California, Los Angeles.
I think every woman should get her fertility levels checked by the time she’s 25 years old.
Dr Ahmad said: “Young women with a short cycle, women who get their period every 21 to 25 days - this is worrisome because it’s a sign of low ovarian reserve. People should not be afraid of infertility since it is very common and the majority of cases can be treated successfully. People should be aware that we can prolong the fertility window by undergoing fertility preservation. Unmarried women in their early thirties should explore their options of fertility preservation or any man or women who is bound to undergo chemo or radiotherapy should also explore their options of fertility preservation.”
Dr Khaled advised: “I think every woman should get her fertility levels checked by the time she’s 25 years old.”
Ask your doctor for an Anti-Mullerian Hormone level test. If your level is 1.5 or below, it’s a good idea to check on the number annually. If it begins to fall, you may want to consider egg freezing if you’re not ready to have a child yet, or artificial insemination (IUI) or go for IVF.
Dr Ahmad said: “Any couple below the age of 35 years (female age) who have been trying adequately to conceive or greater than 35 years trying for 6 months without success are candidates for IVF.
“The success rate will depend on many factors like age, ovarian reserve, sperm quality and reason of infertility.
Success rate in good prognosis patients can reach around 70 per cent per embryo transfer. Women can try as many times as they like, however as physicians we like to help the couple draw the line somewhere since IVF is a process that is costly and can cause emotional, psychological and physical stress. That number is somewhere between 3-6 tries.”
Cases where nothing can be done:
Dr Ahmad explains:”This would be women with ovarian failure, who don’t have any eggs. Therefore, without any eggs they cannot undergo any type of treatment. Also, women without an uterus cannot get pregnant. Similarly, men with azoospermia who do not have any sperm are infertile.”