Cassandra’s prophecy: why we need to tell the women of the future about age-related fertility decline and ‘delayed’ childbearing

This anonymized paper describes the author’s experience of age-related infertility and unintended childlessness. It outlines her journey from diagnosis to treatment success and clinical pregnancy through assisted reproduction using oocyte donation, followed by subsequent early miscarriage. It makes subjective observations about treatment she received and presents her impressions of how discourses of knowledge dissemination, communication and care were constructed in the organizations she encountered. It sets her own reflections alongside broader observations on the challenges facing women today when planning a family and draws attention to what she perceives to be the misleading myths and misunderstandings concerning reproduction that these women are now subject to. In the light of this, it offers some suggestions for modified public health messages and new approaches to sex education and health screening that may consequently help to empower tomorrow’s women (and men) to take full control over their reproductive lives in the 21st century. The paper takes as its mascot the figure of Cassandra, daughter of King Priam and Queen Hecuba. She was loved by Apollo, but resisted him. In consequence, he rendered useless the gift of prophecy that he had bestowed on her by causing her predictions never to be believed.     

Cassandra’s prophecy: a public heath perspective

A public health approach to informing women about age-related fertility decline is best targeted indirectly through professionals.     

Cassandra’s prophecy: a response from a sex education perspective

A sex education practitioner’s response to the article ‘Cassandra’s prophecy’, focusing on the author’s question about the feasibility of introducing in schools more balanced and honest information on reproduction. The response is, sadly, somewhat negative at the present time.     

Cassandra’s prophecy: medic or mother? Exploring the relevance of age-related fertility decline to women in medicine

This commentary presents a response to ‘Cassandra’s prophecy’ from the perspective of a final-year medical student, in an attempt to gauge the particular relevance of age-related fertility decline to female doctors. Women in the UK are increasingly trying to have children at an older age, with a resultant rise in the incidence of age-related fertility decline and obstetric problems. The literature suggests that the trend towards older motherhood is seen particularly among highly educated women, but that such women lack sufficient knowledge about how fertility and obstetric outcomes decline with age. Recent data indicate that female doctors have children significantly later than women in the general population, but are overall no more likely to remain childless. However, there is significant variation between different specialties; for instance, female surgeons have children significantly later and are more likely to be childless by age 35, as compared with both male surgeons and female doctors in other specialties. This commentary explores various explanations for and implications of these data, in the context of recent changes in NHS workforce gender demographics.     

Fetal reduction: is this the appropriate answer to multiple gestation?

Fetal reduction techniques, experiences at Northwestern University of Evanston, Illinois, USA, and ethical issues are discussed. The use of fetal reduction pertains to higher order multiple pregnancies due to successful fertility treatments. The risk associated with multifetal pregnancy is preterm delivery i.e., 29-31 weeks for quadruplets. In addition, survivors often have a high risk of congenital abnormalities and complications related to prematurity. 1978 marked the 1st time selective termination was possible. Other terms include "selective" birth, reduction, feticide, abortion, and multiple pregnancy reduction. The procedure takes place in the 1st or 2nd trimester, and procedures are similar to an elective abortion but with different techniques. Although there are many techniques, the preferred one is transabdominal cardiac puncture and injection of potassium chloride. A highly skilled ultrasonographer is essential for a successful technique. The complexity of the technique is one where the physician from a 2-dimensional screen must envision a 3-dimensional picture of the uterus and contents. Accurate needle placement is important. The reports from 7 clinical trials using the intracardiac potassium chloride technique are presented. The Northwestern experience includes 25 reductions between 1987-91 using fentanyl and midazolidocaine analgesia and general anesthesia with 1% lidocaine. Gestational age ranged from 9 to 13 weeks. There was total loss in 2 cases and deliveries in 8 cases including neonatal death of a very preterm set of twins. At or = 37 weeks, there were 11 pregnancies. 11 patients were or = 35 years, and 4 of the 20 30 years. In 33% of cases, only 1 pregnancy was left, which is dissimilar to other studies. Many difficulties may be faced with a complete pregnancy loss where there is a lack of support for the decision for fetal reduction. 2 concerns are mentioned in the ethical debate: the adequacy of counseling and the criteria for determining how many reductions per pregnancy. Difficulties arise in physician counseling when patients are unable to assimilate complex and detailed information, and physicians may not accurately convey information. Institutions may bias patient counseling. When an abnormality exists, the decision is easy; but with multiple normal development, the recommendation is twins. The Northwestern recommendation involves patient and family decisions and joint discussion of risk. The likelihood of severely premature delivery and maternal morbidity should also be considered, as well as the medical cost incurred with delivery and care of preterm multiple infants i.e., 1.2 million dollars for delivery of quads at 27 weeks. Science should be directed to reducing multiple pregnancies by refining technique and using fetal reduction as an interim technique. Fetal reduction is not appropriate for all multiple pregnancies.     

Women’s reported weight: is there a discrepancy?

Objective: To compare self-reported pre-pregnancy weight & delivery weight with documented pre-pregnancy & delivery weight and determine whether there are differences compared with the Institute of Medicine’s (IOM) guidelines. Methods: This is a retrospective analysis of 234 women. Inclusion criteria included documented height, self-reported pre-pregnancy weight, self-reported delivery weight, documented pre-pregnancy weight ± 12 weeks from last menstrual period, and documented delivery weight ± 2 weeks from delivery. We determined the difference between self-reported pre-pregnancy weight vs. documented pre-pregnancy weight and self-reported delivery weight vs. documented delivery weight. Using documented pre-pregnancy weight and documented delivery weight, we calculated gestational weight gain (GWG) relative to IOM criteria. Results: Self-reported pre-pregnancy weight was 2.94?kg less than documented pre-pregnancy weight (p?<?0.0001). Self-reported BMI was 1.11?mg/kg² less than documented BMI (p?<?0.0001). Self-reported GWG was 3.01?kg greater than documented GWG (p?<?0.0001). Ninety-eight percent of normal weight correctly classified pregravid BMI in contrast to 86% of obese (p?<?0.005) and 73% of overweight (p?<?0.001). Conclusions: Overweight and obese women underestimated self-reported pre-pregnancy weight & overestimated GWG, thereby mistakenly categorizing IOM guidelines.     

Cassandra’s prophecy: a psychological perspective. Why we need to do more than just tell women

The most salient psychological issue in the article ‘Cassandra’s prophecy’ is the lack of fertility knowledge. This lack of knowledge exhibited by both Jane and the medical professionals resulted in a delay in trying to get pregnant and in seeking and receiving appropriate care, ultimately resulting in inadvertent childlessness. We identify five educational initiatives to increase fertility knowledge and personal awareness in order to promote informed decision-making about fertility health issues. These initiatives cover: (i) better sexual education for children; (ii) family planning for young adults that involves value and preference clarification about future parenthood goals; (iii) public health campaigns to increase awareness of the risk factors associated with reduced fertility; (iv) investigation of adherence to fertility guidelines within the medical profession; and (v) clearer information about the benefits and limitations of available fertility treatment. The future of fertility health care must be centred on providing people with information leading to informed choice about all aspects of their own fertility health. Empowerment may mean that people can better optimize their fertility health and be more likely to reach their parenthood goals.     

How to rate performance: is a standardized patient the answer?

Clinicians have studied the effectiveness of their IVF practice with a presumed goal of process improvement. The use of standardized patients to compare IVF outcomes is questioned.     

Gonadotropins and the uterus: is there a gonad-independent pathway?

In the gonads, LH and hCG act via the same receptor to stimulate the production of progesterone in the luteal phase of the menstrual cycle and in early pregnancy. There are numerous reports that these two hormones can have direct actions on the uterus in addition to their indirect actions via stimulation of ovarian steroid hormones. However, unlike the situation in the gonads, various uterine tissues have been shown to respond to the related hormones FSH and TSH or the alpha-subunit common to these hormones. These additional actions cannot be mediated by the gonadal LH/hCG receptor. There have also been a series of reports that the uterus contains LH/hCG receptors. Attempts to characterize the molecular structure of these receptors have been difficult; thus, the possibility of a variant receptor cannot be excluded. The possibility also exists of a nonhomologous receptor, which would explain the differences in ligand specificity in uterine tissues. I will review the evidence regarding gonadotropin action in nongonadal tissues, primarily the uterus. In addition, the data regarding receptors will be reviewed. Finally, the clinical areas informed by this information will be explored.     

Young women’s intentions to delay childbearing: A test of the theory of planned behaviour

Objectives: The general purpose of the present study was to examine the applicability of the theory of planned behaviour (TPB) in accounting for young women’s intentions to delay childbearing. Background: TPB has been successfully applied in numerous studies examining intentions to have/not have a child but, to date, intentions to delay childbearing has not been explicitly examined within this framework. The present study addresses this gap by examining childless women’s intentions to delay motherhood within the framework of the TPB. Methods: Sixty-nine young, childless women (M_age = 21.0) completed a self-administered TPB questionnaire encompassing intentions to delay childbearing past the age of 30 and measures of attitudes, subjective norms, perceived control, as well as the beliefs underlying these global constructs. Results: Attitudes, subjective norms, and perceived control all significantly contributed to account for 61% of the variance in intentions to delay childbearing past the age of 30, but perceived control emerged as the most significant predictor, accounting for 24% of the unique variance. Following a targeted examination of the belief structure underlying perceptions of control over delayed childbearing, five control beliefs emerged as significantly related to the global measure of perceived control. These beliefs were related to personal health, fertility, and belief that one will be in a stable relationship in the future. Confidence in the longevity of fertility was the prime contributor to perceptions of control. Conclusion: The results provide preliminary support for the applicability of the TPB model in accounting for intentions to delay childbearing among a sample of young childless women.     

Manipulation of the follicular phase: Uterodomes and pregnancy - is there a correlation?

Background  

Manipulation of the follicular phase uterine epithelium in women undergoing infertility treatment, has not generally shown differing morphological effects on uterine epithelial characteristics using Scanning Electron Microscopy (SEM) and resultant pregnancy rates have remained suboptimal utilising these manipulations. The present study observed manipulation of the proliferative epithelium, with either 7 or 14 days of sequential oestrogen (E) therapy followed by progesterone (P) and assessed the appearance of pinopods (now called uterodomes) for their usefulness as potential implantation markers in seven women who subsequently became pregnant. Three endometrial biopsies per patient were taken during consecutive cycles: day 19 of a natural cycle - (group 1), days 11/12 of a second cycle after 7 days E then P - (group 2), and days 19/22 of a third cycle after 14 days E then P - (group 3). Embryo transfer (ET) was performed in a subsequent long treatment cycle (as per Group 3).     

Salpingitis, salpingoliths, and serous tumors of the ovaries: is there a connection?

We have observed luminal and mucosal calcifications frequently surrounded by a mantle of bland epithelium in the fallopian tubes ("salpingoliths") of women with serous tumors of the ovaries. These lesions resemble noninvasive peritoneal "implants" in women with advanced stage atypical proliferative serous tumors (APSTs) and micropapillary serous carcinomas (MPSCs). The presence of salpingitis and salpingoliths was prospectively evaluated in 358 women with a variety of nonneoplastic and neoplastic ovarian conditions and compared with 87 previously reported women with APSTs/MPSCs in an effort to determine whether these lesions were specifically associated with serous tumors. The frequency of chronic salpingitis among women without ovarian pathology was 27%, and the frequency of salpingoliths was 4%. Serous epithelial tumors (cystadenomas, APST/MPSC, and carcinomas) were significantly more often associated with chronic salpingitis (53%) and salpingoliths (32%) than all other cases with or without ovarian neoplasms (p<0.01). APSTs/MPSCs were associated with salpingoliths significantly more frequently than all other groups (p<0.001). For patients with APSTs/MPSCs, salpingoliths were found significantly more often in advanced stage (FIGO II and III) patients (51%) than stage I patients (24%) (p<0.01), but salpingitis, present in 60% of these patients, was not stage-dependent (p>0.05). Chronic salpingitis was identified in 66% of women with endometriosis, which was significantly more frequent than those with normal ovaries (27%) (p<0.001). In conclusion, fallopian tube abnormalities may be related to both the high frequency of infertility and the noninvasive peritoneal implants in women with APSTs/MPSCs. Whether the fallopian tubes with salpingoliths are the source of the peritoneal "implants," the recipient of implants, or are independent is unknown. In addition, the high frequency of salpingitis in women with endometriosis may be related to the mechanism of endometriosis-associated infertility.