Reproductive problems affect more and more Bulgarian families, and the age at which couples decide to have their first child continues to rise. According to specialists, this is one of the main reasons why more and more people are turning to assisted reproduction. The good news is that modern medicine offers increasingly effective solutions, and early consultation with a specialist significantly increases the chances of a successful pregnancy. What else is good to know… Dr. Alexander Kunev, MD, a specialist in reproductive medicine at the Assisted Reproduction Unit of Burgas University Hospital, speaks to FACT.
- Dr. Kunev, in recent years, more and more couples have been experiencing difficulties conceiving. What is the reason for this alarming trend?
- Every second couple has reproductive problems, especially the generation over 30-35 years old. In general, the trend is career growth, postponing the time for a first pregnancy, which, however, sharply reduces the chances of achieving one. There are more and more problems not only on the part of the man and the woman, but also complex ones - there are many endocrine, immunological factors. The truth is that a patient rarely goes to a reproductive specialist. First, he seeks information from a general practitioner, then from a specialist obstetrician-gynecologist, but very few colleagues are profiled in the field of assisted reproduction. The earlier a person gets informed and visits a specialist, especially a unit like ours at the University Hospital Burgas, where everything is in one place, the better. My belief is to make a diagnosis within an hour and move forward to find a solution.
- When should a couple seek help from a reproductive medicine specialist instead of continuing to try on their own?
- According to standards, it is considered to wait between 9 and 12 months. For a woman who has been pregnant or given birth - 6 months. The truth is that for a young and healthy couple, if there is no pregnancy within two months, it is good to look for a reason in the third. The reason can be very banal - from not finding the right day to have sex (because a woman's ovulation is different, it is not always on the 14th day), or even more banal - sex is too frequent and the man's material is very rare. Then you just need to take a break.
- You are investigating the factors that influence the success rate of intrauterine insemination. What are the most important factors for the success of this procedure?
- When there is a true cervical factor (i.e., an anatomically or functionally narrowed cervical canal), when there is a slight male factor. But the truth is that the main limiting factor is age. Up to 30 years, about 10-15% get pregnant. After 35-40 years, the lower limit gets pregnant - 5-6%. And with in vitro fertilization, it is believed that there is a success rate - the younger they are, 25-26% is a good success rate. The truth is that if you choose young patients, you will have a high rate. Most of our colleagues do not have this privilege, because we work with women of a more mature age. There is still no upper limit for the procedure - there is some moral one. Usually after 45-50 years, up to 55 is possible. Even if a woman does not have a period, she can be stimulated and have it done. The question is to explain to the woman whether after 55 years she will be alive, healthy and functionally active, so that she can raise a child until she is a teenager when she is 70.
- How do you judge whether it is appropriate for a given couple to start with insemination, or is it better to move directly to an in vitro procedure?
- When no definitive factor for infertility has been found and the couple is under 30, one always starts with insemination. If the woman is 35-40 and the chance of insemination seems negligible, one can also start with in vitro. The inconvenience with these patients is that if you don't hit the mark with what to start with and do a hyperstimulated in vitro procedure, there may be no reserve for anything after that. And the truth is that with three unsuccessful inseminations, most patients are entitled to free in vitro procedures, financed by the Assisted Reproduction Fund.
- There is still an opinion that the cause of infertility most often lies with the woman. -What does practice show - what is the share of the male factor…
- It is always 50/50 – on the man’s and the woman’s side. More and more men are starting their sexual life early, more and more men are using substances such as alcohol, cigarettes and drugs, which sharply reduces the quality and quantity of the material (sperm). On the other hand, many women have genetically inherited diseases such as thrombophilia and others – Hashimoto’s, for example, which are not diagnosed. Very often, just one consultation with an endocrinologist and adding an additional amount of medication or a change in eating habits can lead to the desired pregnancy.
- To what extent does age affect the reproductive capabilities of a woman and a man and what are the most common misconceptions on this topic?
- The truth is that young patients become pregnant with fewer procedures, efforts and medications. On the other hand, there is a maxim in gynecology: as long as a woman has a uterus and a period, she can give birth. The truth is that before 16 and after 37 years, the division spindle during cell division is incomplete. The division spindle is like an internal "rope system" in the cell that divides the chromosomes with the genetic material equally. When it is "incomplete", this system is unstable and makes mistakes, which is why the baby can receive too few or too many chromosomes (as in Down Syndrome). In very young girls, this system has not yet reached full maturity, and after 35 years it begins to wear out. Therefore, at these ages, getting pregnant is more difficult or there is a higher risk of abnormalities. The good news is that modern medicine has quick and safe tests at the beginning of pregnancy that detect these mistakes in time. And it is important that the patient is informed.
- What are the greatest achievements of reproductive medicine in recent years and how do they increase the chances of couples having a child?
- The individual approach. In vitro fertilization is not a panacea - it is still a technology from the 1950s, i.e. it is already considered old. For me, it was invented to solve the problem of the tubal factor - the obstruction of the fallopian tubes and the severe male factor. The truth is that cloning is coming, which already exists in medicine, but is not legal. There are also debates about surrogacy, for which people travel to other countries and pay huge amounts of money. Why shouldn't it develop in our country? When people come for a check-up, I strive to establish within one day what the problem is. I have had cases where just by changing jobs, changing diet and exercise regimen, and taking cheap medications, things have happened without expensive and complicated procedures.
- What would you say to people who are afraid or worried about seeking help at an assisted reproduction clinic?
- The most common concerns among women are whether they will experience pain, how long it will last, what to expect. In general, the entire egg retrieval procedure lasts no more than 5-10 minutes, everything is under general anesthesia. The monitoring and conditions offered by our department exclude the possibility of complications such as pain, bleeding, discomfort. It is not in vain that our patients stay for 2 hours after the puncture. The stimulation itself is not worrisome, the riskier part of the procedure is the follicular puncture, but when it is done with experience, when the doctor is routine and avoids unnecessary complications, everything is fine. The procedure takes about 14-15 days, of which only the egg retrieval is more painful, but it is within the acceptable range.
- What options does the Assisted Reproduction Unit at the Burgas University Hospital offer?
- The unit has all the available equipment, specialists and staff for the diagnosis and treatment of every type of infertility - male and female. We have a sufficiently well-developed system and database of donor genetic material from men, patients are also consulted for donor-recipient procedures, I hope that we will soon develop the possibility of egg donation.
- If you had to send one message to couples who have been dreaming of a child for years and are already losing hope, what would it be?
- There is always hope and I have seen countless happy stories. Any woman who has a uterus that is not deformed beyond recognition by fibroids or endometriosis, even if her cycle has stopped, hypothetically has a chance.