Dr Sarah Jarvis MBE | General practitioner, Trainer, and Fellow of The Royal College of General Practitioners, and Medical Writer and Broadcaster, UK
ESHRE hosted a fascinating panel entitled ‘The pressure paradox: can egg freezing tune out the tick tock of the biological clock?’ facilitated by Dr Sarah Jarvis. The session looked at the relationship between age and pregnancy and how social egg freezing impacts this. We spoke to Dr Jarvis about what led her to become a GP and heard her insight into the panel discussion, delving into the topic of age and pregnancy and the importance of educating women on their individual fertility windows.
What first attracted you to a career in healthcare?
I’m quite unusual; I haven’t just wanted to be a doctor since I was a child, I have wanted to be a general practitioner (GP)since I was 8 when the GP came to my house and gave my father an injection. He was wonderfully kind to me and let me delve around in his bag: he even gave me a needle and syringe and I practiced injecting my teddy bear. Ever since then, I knew that I wanted to be a GP. It never crossed my mind that there was any other kind of doctor because I come from a family where my parents were incredibly healthy and didn’t believe in doctors. The only doctor I met was a GP and I wanted to be like him. When I decided I wanted to become a GP, it was all about making people better. I think the big difference is that in the intervening 30 years there has been much more focus on not just making people better, but keeping people well and on prevention. We have also started talking about the psychological distress associated with fertility problems.
Are we seeing a change in the relationship between age and pregnancy?
There is absolutely no question that we are having children later. Woman are doing it; the question is whether they understand the implications of that. If we look at Spain, as an extreme example, in the last 40 years they’ve gone from a mean age for having their first child of 25 to a mean age of 31. The average age in many European countries, such as Spain and Italy, is now over 30; as that is an average it means there is a significant number of people at the top end who are wanting to have their first baby over 35, over 38. I think there is a huge issue.
We’ve got women who are economically independent; they don’t feel pressured to get married young, to become dependent on a husband and have a baby. At the same time, it’s getting increasingly difficult for them to afford their own homes due to the cost of housing. Long gone are the days where a couple could get married, the husband would work, the wife would stay at home, and they could still afford a very nice life. These days women have the want, and absolutely have the right, to work alongside the man. It is often not financially viable for just one half of the couple to be working. Women are putting off having babies when they are not financially stable or feel they’re not; they could also perhaps be waiting longer to find the ideal partner.
Does social egg freezing increase or alleviate the pressure on women to have children at a young age, rather than when they are ready?
There is huge pressure within the media and from society to say, ‘age is not a barrier anymore, 40 is the new 30’. In many respects, it is, but it does women no favours not to be more honest about the fact that that does not apply to reproduction. The problem is that women are very much unaware of the facts. The facts may not be palatable, but they are the facts, nonetheless. So, the likelihood of conceiving drops sharply from your early to mid-30s. At the same time, your likelihood of miscarriage increases dramatically and that is largely because the quality of the egg (and with it the likelihood of a successful pregnancy and taking home a healthy live baby) decreases significantly.
We are looking at 20% of eggs being aneuploid (completely unviable) at the age of 20, compared to 60% by the time you reach the age of 40. The likelihood of a successful, natural conception and a healthy live birth reduces dramatically in your 30s. At the same time, the success rate of IVF is absolutely not what my patients expect. They really do believe that if they go through IVF, it will all be fine. Not only is it not guaranteed at any age, it gets less and less successful as time goes on. The Human Fertilisation and Embryology Authority (HFEA) data suggest it goes from about 43% success at age 18–34, by the time you get to 38 or 39 that figure is about 30%, and by the time you get to 43–44 the likelihood of successful IVF with a successful live birth has dropped to 10%.
How is the ‘Be Ready, Whenever You’re Ready’ campaign helping to achieve this?
One of the really important points to make is that egg freezing is absolutely not for everyone and women have to be in a position where they can make an informed decision. They need all of the facts, and those facts have to be balanced and not skewed by the media. The ‘Be Ready, Whenever You’re Ready’ campaign provides facts about why women need to start thinking about their fertility at a younger age, reducing the chances of them being disappointed. It also allows women to hear the experiences of other women who are in their position, who have gone through similar experiences. It is unbiased: I have gone through it with a fine-tooth comb to ensure it is absolutely unbiased information on the likelihood of success, for instance of natural conception, of IVF, of egg freezing. It empowers women to have a conversation with their healthcare provider. Women need to consider these facts before they reach the age where these factors kick in.
How important is it to fully educate women on their individual fertility window at an earlier age to ensure that they can make informed decisions and manage realistic expectations?
This is hugely important. Unfortunately, I still regularly see women coming in too late. In my experience, when I talk to women about their likelihood of having a successful pregnancy from IVF later in life, they can be hugely overly optimistic, and these are often highly educated women who don’t recognise that their fertility starts to decline. They do not understand what egg freezing is. I think they need to understand that, for instance, if they are looking at egg freezing, what it is giving them is an opportunity to freeze their eggs when they are of (and I hate the term higher quality), but unfortunately in terms of successful pregnancy, they are higher quality. They also need to be aware that even egg freezing needs to be thought of early; to put that into perspective, even if you do manage to get 10 oocytes, if you take them from a woman under the age of 35, the likelihood of having a successful pregnancy is 43%, if you take them from a woman who is over 35, that drops to 25%.
What is one of the biggest challenges to providing women with the correct information on fertility preservation options?
The short answer is the media. The mass media tells women that they do not need to think about it because we have got fertility options, we have got IVF, it has been 40 years since Louise Brown. Once women have got over that, we need to help women to understand that IVF is not the answer for all and that egg freezing is not suitable for everyone but that it is suitable for many women if they think about it at the right time.
Do you expect to see the average age of women having their first child to increase in the next few years?
I certainly do not think it is going to go down. I think it may increase further. Some of the increase, in some countries more than others, has been because of a drop in teenage pregnancy at the bottom end of the age spectrum. There is no question that there are fewer women having unwanted or unplanned pregnancies in teenage years. That is good news, but it is important to bear in mind that it will skew the figures to an extent. I think this continued increase is likely to slow down; however, there is a significant ongoing pressure on women to be financially independent to be in a position where you can have a baby as pregnancy and babies seem to be more expensive with every passing year. I do think women are going to continue evermore to delay the time to get to where they feel they are in a financially stable position.
Is there an area of fertility preservation that you hope to see gain more attention in the future?
There are two; the first is that we need to continue to try and educate women about the statistics on fertility decline. Secondly, I would very much like to see more awareness of the options including social egg freezing, and that is freezing for purposes other than medical reasons. Non-medical egg freezing does not mean there is no medical procedure involved; the term social egg freezing means freezing for non-medical reasons.
As someone with a wealth of experience in healthcare, what advice would you give to those starting out their career today?
Know the facts, whether they are palatable or not. Don’t believe everything you read in the media about older mothers; it is definitely not as easy as it looks. Don’t believe that we have fertility sussed and that IVF means that anybody can have a baby whenever they want. Do understand that options such as egg freezing aren’t suitable for everyone, but it is essential to know all about it so you can make an informed decision. Do understand that even egg freezing will not work forever and that as with natural conception, the success of egg freezing reduces with age.