When is it too late to have children? Does it work less and less on its own? Are we relying too much on modern medicine? Dr. Jochen Tigges, specialist in gynecology and obstetrics, has answers.
When is the right time, purely biologically speaking, to have a child?
Dr. Tigges: Relatively early. The chances of having a child are best between the ages of 20 and 30.
However, many couples only decide to have a child in their mid to late 30s. Is it often too late to get pregnant naturally?
There is a relatively big difference between your mid and late 30s. Pregnancy rates are fairly constant until the age of 30, but then decline slightly until the age of 35. Between 35 and 40, the probability of pregnancy per cycle drops significantly. For 35-year-olds we have a pregnancy rate per ovulation of around 15 percent, and for 40-year-old women it is only five percent or less.
Why is that?
Egg quality decreases with increasing age. While sperm are constantly being produced from the stem cells, women are born with the eggs. And so the eggs are exposed to everything that a woman is exposed to throughout her life: radiation, environmental influences, stress. All of this reduces the quality of the DNA packed in the egg cell, which makes it harder to fertilize as it gets older and the fertilized egg cell also has a harder time developing into an embryo.
Can the quality of the eggs be determined?
No, unfortunately that’s not possible yet. We currently only see this during treatment, when we carry out artificial insemination. However, we also experience surprises here. The quality of eggs can be very poor even in very young women, and at the same time we treat women aged 41 or 42 who develop three beautiful embryos from three fertilized eggs. But on average, one can say that for a 35-year-old woman, about two out of three fertilized eggs become embryos, while for a woman over 40, only a maximum of one. What can be measured, however, is the woman’s egg reserve.
So how many eggs are there in total?
Yes, this can be determined via the anti-Müllerian hormone in the blood. This value gives us indirect information about how many eggs are currently maturing, and from this we can draw conclusions about how large the total follicle pool is that is currently available. However, this does not make it possible to predict what things will look like in two to three years; for that to happen, the value would have to be determined more frequently.
Should you have this value determined in advance, even if you are not currently planning to have a child?
Absolutely yes. I always have patients who are very young and for whom this value is very low.
What does that mean then?
On the one hand, it can mean that these women stop ovulating very early and then have no chance of getting pregnant naturally. But even if, for other reasons, pregnancy is only possible with the help of artificial insemination, it will be even more difficult to obtain the eggs later.
And they could then also be preserved using social freezing if it is not the right time to have a child yet?
In my opinion, this should always remain a plan B. It is a good option to collect and freeze eggs early, but even this is no guarantee of a child. At that point, we don’t yet know how the eggs can be fertilized, how the embryos will develop from them and whether a pregnancy will result. This is a type of insurance that you cannot rely on 100%. But if having a child doesn’t fit into your life plan at all, then it’s definitely better than doing nothing.
Do many couples wait too long to have children or rely too heavily on modern medicine?
No, I don’t have that impression. For most couples, things just happened the way they did, for example, the partner was found late, or you were very focused on your career and family planning was simply not present. Unfortunately, it is not well known in society that it becomes so much more difficult to have a healthy child once women reach the age of 40. I don’t have the impression that the women or couples deliberately wait long. But yes, patient couples are getting older and older, and that is also a problem for which reproductive medicine can only offer very limited treatment approaches.
Do more and more young couples also need fertility treatment?
We also have young couples, and quite a few of them, mostly women with PCOS syndrome who do not ovulate, and they then come to us for hormone stimulation. The number of women with menstrual problems or those who do not ovulate at all is also increasing. Obesity and unhealthy diet, for example, also play a role here.
Is there a lack of knowledge about the cycle and fertile days, or are the couples already informed enough when they come to you?
Very different. I actually still have patients at 36, 37 who still believe that the fertile time is when they have their period. Many are really well informed, but not all of them.
Do you then send such couples home again with the necessary information?
When the couples come to us, we first take a detailed anamnesis. In addition to the physical examinations, there is always the question of what you have tried so far. If everything is physically normal and the couples haven’t tried it for very long, we’ll give you some tips, especially if we notice that something didn’t go quite so well before.
When is fertility treatment recommended?
I especially recommend that couples who want to have children but are not really able to have it, go to a center early on to get checked out. I know it’s still a shameful topic, but it really shouldn’t be. The number of treatments has been increasing for years, and the quality of semen in men is decreasing due to, among other things, harmful environmental influences or unhealthy lifestyles. The recommendation for couples is to try to conceive naturally for twelve months until the woman turns 35, but for people over 35, only six months. If you have previous illnesses such as undescended testicles in men or chlamydia in women, it is better to come earlier so that we can use all options to help the couple.
What do you think of the age limits that are set for statutory health insurance companies to cover the costs?
Difficult question. The age limits were set long ago by a large commission. Personally, I don’t understand why the couples have to be at least 25 years old, and the upper age limit is also very narrow. Even women aged 41 or 42, for example, still have a chance of having a child; it depends on the individual situation.
In your opinion, is there an age limit that you would set?
To a certain extent it is individual. For example, the egg cell reserve and quality are important. You should then actually weigh up the effort, costs and physical exertion and see whether you can still recommend treatment from a medical and ethical point of view. In our practice we have a treatment limit of 45 years, after which treatment definitely no longer makes sense. This is the case in most practices.
Because then the physical requirements are no longer present?
The chances of success are actually close to zero. Even if you manage to transfer an embryo into the uterus, the chances of a live birth are less than one percent.
How many attempts does it take on average until it works?
Let’s assume an average 35-year-old woman. It has an average pregnancy rate per embryo transfer of 35 percent. In order to determine the pregnancy rates, however, you cannot add them up per attempt, but rather you have to look at the cumulative rates. Half of all couples are pregnant after two embryo transfers, 60 percent after three and around 66 percent after the fourth. This means that the three attempts covered by the health insurance companies may be quite short. Where possible, I always recommend freezing excess eggs during treatment.
What costs do couples incur on average?
The costs for the first three attempts at IVF treatment (egg and sperm are brought together in a test tube) are around 1,600 euros per treatment cycle. For a more complex ICSI (a sperm is injected directly into the egg under the microscope) it costs around 2,200 euros. However, if the couples are not covered by the insurance, for example because they are not married or the first three attempts did not work, you have to expect costs of around 4,500 euros for an IVF treatment and even 7,500 euros for an ICSI.
So if it doesn’t work out in the first three attempts or the couple doesn’t meet other requirements, the desire to have a child can become very expensive. A lot of couples can’t afford that, and their dream of having a child fails because of the bank balance. What should change?
From my point of view, it would make sense if the health insurance companies, for example, would fully cover the first three or, better yet, four attempts. The couple would then have more money to finance additional services such as freezing fertilized eggs and thus save money in the next attempt. As a result, more children would be born and that would in turn pay off for society.
Dr. med. Jochen Tigges is a specialist in gynecology and obstetrics with a focus on gynecological endocrinology and reproductive medicine. Since 2018 he has been working at TFP Kinderwunsch Düsseldorf as a specialist in fertility treatments.