Baby-making goes back to basics

Dr Gedis Grudzinskas is one of the most respected names in fertility. He is angry.

Fed up with potential patients being given false hope by the baby-making industry, he is distinctly unimpressed by the recent findings that it may soon be possible to predict to within four months when a woman is likely to go into menopause—and, by extension, whether she can afford to put off having children.

“I’ve used this test in clinical practice and it’s not easy to interpret,” he says, referring to the blood tests developed by a group of Iranian scientists who presented their work to the European Society of Human Reproduction and Embryology in Rome.

The test measures levels of Anti-Mullerian hormone (AMH), which controls the development of follicles in the ovaries, from which eggs develop.
The researchers say the AMH level is an accurate predictor of the timing of the menopause.

Some reports have claimed that an over-the-counter version could be available within three years. “It’s a useful enough test, but I don’t think it provides enough information. Is it actually going to help society and women in some way?” Grudzinskas pauses, witheringly.

“What worries me is that a ‘normal’ result [a prediction of menopause around the early 50s] may encourage people to wait to conceive. It’s far more useful to use age as an indicator of fertility.” This is the uncomfortable truth, of course, which, after four decades at the sharp end of the fertility industry, has become Grudzinskas’s bugbear. We must stop pretending that medical advances allow the luxury of delaying starting a family, he says. “Fertility declines from 28,” he says.

“For some women, that happens very quickly. In others, it’s a slow process. The decline then accelerates in the mid to late-30s.” Even if you were able to predict the date of your menopause and know exactly how many eggs you had left, “we’re not at the stage where the test can tell you how those eggs will function. The number of eggs does not mean the eggs are healthy and normal.” He sighs heavily.

Having worked at St Bartholomew’s and the Royal London Hospital School of Medicine and Dentistry (Barts) since 1974, eventually becoming professor of obstetrics and gynaecology, Grudzinskas describes his mission in life as being “to maintain and enhance reproductive health in women, prevent infertility and preserve fertility in cancer patients”.

He now runs an independent private practice in Harley Street, where, he says, he is as likely to advise patients against fertility treatment as to advocate it. His patients come to him for his legendary bluntness. “If telling people the truth is letting them down or it means I am providing information that decreases their level of expectation —

Well, I have been working in this field for some time. Many women—in their mid-30s, late-30s, early 40s—have said to me, ‘Why didn’t somebody tell me before?’ “Imagine you were getting on with your life at 34 or 35, getting married, trying to conceive and you go to see your doctor aged 36 because you haven’t conceived, and he says, ’ Come back in a year when you’re 37’. Then you find your ovarian reserve test comes out very low.

How would you feel about the advice you were given a year ago? Things can change very quickly. I don’t think it’s ever right to say to anybody—wait.” He does have a way of putting things. “In a woman of 30, one in three embryos that look normal will be genetically flawed. It may not implant or it may lead to early or late miscarriage. Or Down’s syndrome.

At 40 it goes up to two out of three embryos. At age 44, even higher.” In other words, even for a relatively young woman (aged 30), with a normal pregnancy, a healthy baby is never guaranteed. This sort of opinion is rarely voiced, but is one that Grudzinskas’s clients are desperate to hear. There are too many unacknowledged facts surrounding fertility, he adds.

‘Where do we learn about fertility? TV, the internet, these fabulous pictures of women in their 40s in Hollywood walking around with babies. Everybody assumes that they’re genetically theirs, but they’re not necessarily.” (He means the older the patient, the more likely the chance of success with younger, donor eggs.) “This is what has intrigued me in recent years, that the age women have their first child is increasing slowly.

In the UK, it’s a bit over 31. Even in Lithuania, the age is starting to go up there too. It can happen very quickly, over a period of just 15 years. “Something is happening in society. I don’t think it’s directly related to how women view themselves. And it’s too easy to say that the world is full of males who can’t commit to relationships. There is something else going on.”

He fears it may be linked to a misplaced trust in medical advances. “Women should avoid delaying starting their family until their 30s. But society has to change for that to happen. Women should be given adequate time to have the child without losing opportunities for career development. At the moment, we are seeing women who tend to do better in the workplace behaving like men [postponing childbirth or not bothering at all].

Is that what we want?” He wants to encourage more babies. “We need more babies to sustain the economy. As it is, we are not going to have enough people to support the ageing population.” The other unspoken cruelty behind fertility treatment is the gender bias, he adds. “There are many more limitations to women’s fertility than to a man’s. A man may only have two sperm to rub together and that may be sufficient to derive a live birth. The technology has its limits for women.” And it is, like nature, unpredictable.

He has seen couples with very low numbers of eggs “and, abracadabra, they conceive naturally”. But many people are over-reliant on IVF—not fate—as their fallback. “And going on that IVF merry-go-round with all the drugs and the stress, given the limited return —” We also need to confront our illusions about having a genetic child if we are going to put so much faith in medical solutions, he adds.

“I will say to couples who come to see me, ‘Look into your heart and tell me what it is that you want. Is it to have a child that is of both of you? Or not necessarily? Is it that you wish to be pregnant? Should the pregnancy be genetically yours?”

Encouraging earlier childbirth should be our prime concern, he adds. “This really is an issue for the whole of society. The most important thing in my mind is to highlight the limitations of the technology.”—

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