Having a baby may be the dream of many women; unfortunately, some couples may not be destined to have a baby, or more than one baby. Women who are having difficulties conceiving always have hope that it will happen one day. As a doctor facing a couple with the fact that they can’t try any more is a very hard task. It could be similar to facing a cancer patient. As a physician we have a duty towards patients, we have to present facts very clearly to allow couples make an informed choice of what to do next.
Age is a major factor when it comes to fertility. It is well known that the older the woman gets the less likely for her to get pregnant. Fertility tends to decrease after the age of 34, and is definitely significantly low as woman approach 40. Couples planning to undergo IVF treatment should be clearly informed about the success of the procedure based on age and the results of investigations. In general the success of IVF beyond 40 may be in the range of 5-10%. There is no harm for a couple to keep on trying whatever the age of the woman as long as they got the facts right. However; it is important to note that if two hormones called the FSH and LH are raised then it means the ovaries are not responding and most probably unable to produce eggs.
Couples need to know that the risk of having congenital abnormalities is raised with age. The risk of having a down syndrome baby is high after the age of 35 where roughly 1 in 380 women of that age will have a baby with down syndrome compared to 1in 1500 at 25 years of age. At 40 the risk is about 1in 90 and by 43 the risk is 1in 30. There are tests available during pregnancy to test for Down syndrome. Amniocentesis can be done after 15 wks of pregnancy to check the number of chromosomes which is the problem with Down syndrome. There is a test called fish test which can give the results within 48 hours. This means if the couples refuse to have a Down syndrome baby, they will have to terminate the pregnancy and undergo an abortion. This may have major emotional and physical consequences on the couple.
Couples producing diseased offspring, whether they are related or not, may have to stop trying for a baby. If the investigations show that one of them or both are a carrier of a major gene defect, they may be told that all their offspring will suffer from a major illness or may be given a certain percentage. Sometimes the chances of having a diseased baby may be 25 or 50%, which means they may have to keep on trying until they are blessed with a healthy child. This would require early testing in pregnancy and terminating the unhealthy pregnancy.
Another reason why couples should stop trying for a baby is the presence of a major systemic illness of the mother to be. Like Women who suffer from major problems like renal failure, hepatic failure, heart disease etc. They may be instructed not to get pregnant any more. Pregnancy may worsen the condition of the mother which can leave her after the pregnancy with a major disability. Pregnancy may be even fatal. It is important in these situations to get a good advice about the best method of contraception. As in some conditions most of the known contraceptives would be contraindicated. Sterilization which is a permanent method of contraception may be the only solution. This means tying the tubes leading to the womb, which are called fallopian tubes, thus stopping the eggs from reaching the womb, likewise preventing the sperms from entering the tubes and fertilizing the eggs. The same procedure may be done instead to the husband where the tubes allowing the passage of sperms to the outside may be blocked. A procedure known as vasectomy, in fact it simpler than tying the women’s tubes and may be done under local anaesthesia.
Women who had major problems in a previous delivery may be advised against any further pregnancies. For example, women who had a traumatic delivery, end up having a torn womb known as a rupture uterus. Obviously if the uterus has been removed then pregnancy can’t take place. But if the womb has been repaired then there is a high chance of a rupture uterus in the following pregnancy. This is usually fatal to the baby and may be to the mother as well due to major haemorrahge. Women who suffered a high blood pressure and ended up having fits and being admitted to the intensive care unit should be careful about going through another pregnancy. There is a chance of the condition recurring in a future pregnancy and again this may be fatal to the mother.
The number of previous caesarean section (CS) may be an important factor in limiting future pregnancy. In general there is no consensus of the allowed number of CS; some women have had 6 or 7. But the more CS done the more likely it is for complications to happen. Trauma to the bladder, ureter or bowels may occur. There is a risk of rupture uterus during pregnancy with overstretching of the uterus. Most obstetricians feel that 3 or 4 CS may be enough in order not to subject women to further risk. The mode of delivery of the first child is an important factor in determining the fate of future deliveries. Women who have had CS for the first baby will almost always have CS for the second pregnancy in Egypt. Although in other countries like the UK most women having had CS will be offered vaginal delivery. In Egypt usually they will be offered CS. If the second delivery is by CS then any further deliveries will be by CS as well. It may be worth considering undergoing tubal tie with CS if it’s the third or fourth.
Rhesus negative women married to Rh positive men are at risk of having major problems with their pregnancy. An injection called anti D needs to be administered during pregnancy and after delivery. Failure to do so may allow certain antibodies to be produced by the women. These antibodies attack the future pregnancies leading to a condition called hydrops where the baby is born full of water. This is usually fatal unless complicated therapy is given to the mother and baby before hand. Women who have formed these antibodies may reconsider having any future pregnancies. However, new therapy used recently may have very promising results with such cases.
Any couple hoping to have a baby should be properly counseled. The facts have to be clearly presented to both of them. They have to be aware of all the implications especially in the situations mentioned above. At the end of the day it’s their decision whether to try for a baby or not.