The Clinical Challenge of Delayed Childbearing and Advanced Maternal Age

The Clinical Challenge of Delayed Childbearing and Advanced Maternal Age

Speaker: Lisa Doran ND, Barefoot Health Naturopathic Clinic, Ajax, Ontario

Clinical Case – Maria

Maria is 42 years old. She has been trying to conceive for 3 years without success. For the past 18 months she has been working with a fertility clinic in downtown Toronto where she has been diagnosed with infertility of unknown cause and advanced maternal age. She has completed the usual testing of her hormones, imaging studies of her uterus and fallopian tubes as well as genetic testing. She has completed investigative cycle monitoring and seems to be ovulating normally; she has participated in medicated cycles to stimulate increased follicle development with success; she has had 3 IUI’s and has attempted two IVF cycles without success. Her partner has normal healthy sperm. She is attending at my office for the first time to begin exploring her options with a Naturopath.

Maria is a healthy woman, she has a healthy diet, she works out 3 times a week and participates in yoga one time a week. She has no significant health history. She has been healthy her whole life with no major illnesses or hospitalizations. Menarche age 12 with normal menses. Birth control pill from age seventeen until age thirty eight. She has a job that she enjoys working for a non-profit organization of which she is the executive director. She admits to long hours but is passionate about what she does so doesn’t see this as a stressor. She tells me, “I know I am 42 years old but I feel 30. I am sure that I have the eggs of a 30 year old”. She and her partner have found this journey difficult. She says that they are trying to be gentle with each other but both are from ethnic backgrounds where childbearing is important and both are getting a lot of pressure and questions from their families. She admits to increased stress at home and that love making is not as spontaneous or fun as it has been in the past.

Maria is feeling frustrated that she has not conceived, she feels that they have tried everything. Her fertility doctor has just started discussing the idea of donor eggs with them and both Maria and her husband feel that this is not what they want. They want to achieve a healthy natural pregnancy on their own.

Is There an Ideal Time to conceive?

The ideal age to give birth in order to reduce associated maternal and newborn health risks and complications resulting from maternal ages either too young or too advanced has been determined to be a twelve year period between the ages of 22 and 34 (Mirowsky, 2005) . Before the age of 22 the risks associated with adolescent pregnancy and birth are quite high and after the age of 34 we again see increasing serious risks for both mother and baby.

Defects to Egg and Sperm Quality

The risk of trisomy 21 starts at around 30 years of age with more pronounced effects over 35 years. (Schmidt, 2012)

Errors in chromosomal displacement and abnormal tubulin placement during early division of the blastocyst increases from 17% in young women (less than 30 years of age) to 79% in women over 35 years (Battaglia, 1996).

Of note more recent studies have shown the risk of Autism Spectrum Disorder increased significantly with each 10-year increase in maternal age. (Croen, 2007)

IVF and The Risk of Twin Pregnancies over the Age of 35

Twin pregnancies within an ageing uterus leads to an entire class of new complications during advanced maternal age pregnancies of multiples such as:

- hypertensive complications (50%),

-diabetes in pregnancy (31%) and

- hospitalization in pregnancy (69%).

-Women over 40 carrying twins have increased risk of prematurity and lower birthweight as well as

-high rates of interventive and operative births (Simchen,2009)

Naturopathic Approaches to Wellness (Fertility)

1. The persistent insistence of avoiding pregnancy in puberty and beyond and the use of artificial hormone disruption through chemical birth control in young women must be reconciled with the knowledge of the biologically ideal time to conceive for both maternal and newborn health.

1. Increasing public awareness of the impact of advanced female and male age on reproductive outcome is essential for people to make well-informed decisions on family planning (Schmidt, 2012)

1. Lifestyle Medicine
2. Exercise equivalent to 60 minute walk 5-7 days a week
3. Nutrition – whole, live, fresh foods – focusing on anti-inflammatory principles of plant based, high omega 3 and healthy fats, whole or cracked grains and legumes and minimal animal fat.
4. Lots of good healthy water.
5. Regulating the sleep cycle 7-9 hrs are necessary
6. Reducing stress and introducing stress management techniques.

Protecting the Health of Eggs and Sperm

-A normal effect of ageing and ovulating regularly every month is a decrease in ovarian reserve.

-Another normal effect of ageing is oxidative stress that our eggs experience from simply being exposed to our normal physiological functions, the environment we live in and our modern food.

-Part of our role as naturopathic doctors is to work with women to

• understand how to decrease their toxic burden in a meaningful way, is discussions around hormonal imbalances and hormonal disruptors found in common household chemicals, cosmetics and the food we eat.
• Use of green tea and polyphenols
• Plant Based Diet
• Balanced Blood Sugar
• Exercise
• how to use anti-oxidant therapy to protect their cells from oxidative damage
• Inositol Powder by AOR 9.0 g per day (1 scoop)
• N-Acetylcysteine 1500 mg each day ( 1 cap 3x a day)
• Acta-Resveratrol 240 mg each day ( 1 cap 3x a day)

• how to participate in detoxification and cleansing programs in a way that will benefit their fertility.

Useful Supplements

-Fish Oil

-Vitamin D

-Folic Acid and Methyl folate

Hormone balancing and regulation

1. Acupuncture – Timing of treatment, use of electrocurrent
2. Jane Lyttleton
3. Debra Betts
4. Common points
5. CV3
6. CV4
7. Xie Zhong
8. Ki 3
9. Sp6
10. Liv 3
11. LgI4
12. Yin Tang
13. GV 20

1. Herbs
2. Angelica sinensis,
3. Rehmannia glutinosa,
4. Actaea racemosa,
5. Chamaelirium luteum,
6. Caulophyllum thalictroides,
7. Dioscorea villosa,
8. Vitex Angus Castus

Teas and Infusions

• Alfalfa Leaf (Medicago Sativa)
• Red Raspberry Leaf (Rubus Idaeus)
• Nettle Leaves (Urtica Dioica)
• Lemon Balm (Melissa Officinalis)
• Red Clover Tops (Trifolium Pratense)

Pregnancy over 35

Pregnant women over 35 years are at increased risk of complications in pregnancy compared with younger women. These risks include:

-uterine fibroids,

-hypertension, (Muhieddine, 2002),

-placental abruption, (Joseph, 2005)

-gestational diabetes,

-placenta previa, and

-malposition of the fetus specifically breech presentation. (Jolly, 2000)

Advanced maternal age also contributes to an increase in spontaneous abortion or miscarriage. In younger women 13.5% of pregnancies intended to be carried to term end with fetal loss. At age 42 years, more than half of such pregnancies resulted in fetal loss and by the age of 45 years 75% of pregnancies will end in miscarriage. (Nybo Andersen, 2000)

Naturopathic Approaches to Wellness (Pregnancy)

1. Working towards prevention always – if we know that there are certain increased risks in pregnancy over 35 we can take steps to avoid the onset of these complications.
2. Beginning pregnancy in Optimal Health - emphasizing healthy nutrition, stress reduction, regular physical activity
3. Monitoring – Thyroid and Adrenal Functioning, Chinese Pulses and diagnosis
4. How do we help reduce hypertension?
5. How do we help reduce gestational diabetes?
6. Maintaining qualities of qi to sustain a healthy pregnancy – Ki and Sp.
7. Care in choosing their primary care team
8. lower the very common anxiety older moms may feel when they approach the time to give birth.
9. This allows women to feel prepared and empowered when their labour begins.
10. Optimally they will surround themselves with a team that helps them feel safe,
11. they will choose a birth place where they are comfortable and
12. they will be able to relax and trust that their body will labour naturally and normally without the need for intervention or surgical birth.
13. counselling activities such as fear discovery exercises, art therapy, and journaling.
14. Using Pre-Birth Acupuncture to avoid Induction of Labour
15. Activities to promote Optimal Fetal Positioning

Labour and Birth Over 35

Mental Health considerations: Primiparous women aged 32 years and above express more worry and have more anxiety about their upcoming births than younger women. (Aasheim ,2013)

Women older than 35 years are at increased risk of complications during birth compared with younger women. These risks include

-operative vaginal delivery ,

-elective Caesarean section,

-emergency Caesarean section,

-postpartum hemorrhage,

-preterm delivery before 32 weeks gestation,

-low birth weight below the 5th centile,

-and stillbirth. (Jolly, 2000)

These effects are all pronounced over 40 years of age. (Schmidt, 2012)

Naturopathic Approaches to Wellness (Labour and Birth)

The largest risks are associated with operative deliveries

Avoid the Cascade of Intervention

-Pre-Birth Acupuncture – Describe Protocol

-Botanical Medicine

-Homeopathy

-Nipple Stimulation

Get SUPPORT – Midwives, Doulas – Gentle, non interventive Birth

Post Partum Over 35

1. Breastfeeding. A positive postpartum outcome of delayed childbearing is that older mothers tend to be better educated prenatally about breastfeeding, intend to breastfeed, have partners that support breastfeeding and tend to breastfeed beyond six months of age. (Scott, 1999)

1. Recovery. Postpartum women over the age of 35 may face the challenges of a long and difficult recovery after a complicated pregnancy and an operative, complicated birth.

1. Grief. These women also face the possibility of children born with disabilities and the subsequent grief and uncertainty this can bring.

1. Post Partum Depression. Feelings of overwhelm and sadness or trauma from a complicated birth or a sick infant can increase a woman’s chance of developing post partum depression.

After the Post Partum Period – Parenting Over 35

Most women and men who delay childbearing find that the disadvantages of this delay in terms of postpartum concerns and parenting concerns are

-lack of energy for parenting,

-less available lifetime to spend with children,

-anticipated ageing related health issues and

-anticipated stigma as older parents. (MacDougall, 2012)

Naturopathic Approaches to Wellness (Post partum)

A Gentle, non-invasive vaginal birth is much easier to recover from than a surgical delivery.

Women who recover faster after their birth report more positive feelings about their birth and report that they feel more attached to their infants.

Naturopathic care postpartum is often simply:

- supportive and answering questions,

-assessing post partum mood,

-assisting with breastfeeding questions and

-ensuring that optimal nutrition and adequate rest are part of the post partum care plan.

Recovery

-5 Herb Tonic for Post Partum Recovery: Eleuthrococcus, Polygonum, Holy Basil, Ashwaghanda and Rhodiola

-Placentea Pills

-Monitor Thyroid and Adrenal function carefully and treat as needed

-Mother Warming

-The Golden Month – emphasize discussion with patient about really what this means – 2 weeks in bed with baby, 2 weeks around the bed and then a slow emergence back into duties.

-Emphasize SUPPORT, REST, NUTRITION

• Nettle Leaf Infusion a la Susun Weed
• Nourishing Soups – Bone Broths, Homemade Vegetable Soup
• Healthy Proteins for tissue repair

Post- Partum Depression

-Frequent communication and offering supportive resources

-Home Visits if Required

-Support with Breastfeeding

-Relaxation and Guided Visualization

-Encourage Retreat and Rest ** often is a result of feeling overwhelmed.

-Fish Oil – EPA

-Magnesium

-Hydrotherapy

-Homeopathy Key Notes

-Herbal Medicine

• Chamomille, Lemon Balm, Oat straw, Alfalfa

-Acupuncture

• Common Points: Ki 3, Sp 6, Sp 9, ST 36, HT 7, PC6, Yin Tang, GV20

Mother Warming Using Moxa

Recovery after birth generally entails 6-12 weeks of rest, warmth, good nutrition, healthy hydration and keeping responsibilities and stimulation to the very minimum as you bond with your baby, feel comfortable with breastfeeding and allow your body to recover from your pregnancy and birth. Mothers who allow themselves this time to recover report dramatic differences in the incidences of post partum depression, they feel more energetic and they feel that they are more able to take on the challenge of life with a new baby.

What is Mother Warming? In Traditional Oriental Medicine and in many South East Asian traditional cultures the practise of “Mother Warming” is very common. Sometimes it is performed by keeping warm stones under the cot of the recovering mother, sometimes it is performed by using burning herbs that will warm the acupunture points of the abdomen and lower back. Mother warming is very simple to perform and can be performed either in-office or at home with assistance from a partner or helper. Mother warming is recommended to assist with recovery after you have a baby and works to help tone the uterus, restore energy after birth and help new mothers feel rejuvenated.

What is Moxa? Moxa is a common plant called Mugwort (Artemisia argyi Folium) that is used as a heat source to stimulate acupuncture points. The plant is compressed into long “moxa sticks” or cigars and burnt over a very specific acupuncture point.

Before using moxa you will need to prepare the following:

• A cigarette lighter or candle.
• A small ceramic or glass dish to place any ash in that may form on the moxa stick during treatment
• A small towel to place under the area being treated in case any ash is dropped.
• A glass screw-top jar containing sand to extinguish the moxa when the treatment is finished.

How to use the moxa stick

1. Urinate before beginning the moxibustion procedure. Since the moxibustion used to treat breech babies stimulates your bladder meridian, you may experience an overwhelming urge to go to the bathroom before you are done performing the technique.

1. Lie down comfortably on a flat surface. Be sure that there is a pillow under your head and under your knees. A hot water bottle on your lower back is often nice as well. Expose your abdomen from your belly button to the top of your pubic symphisis.

1. Light your moxa stick by simply lighting one end with a cigarette lighter or by holding over a candle flame. It may take several minutes to light correctly but when the stick is correctly lit, you will be able to hold the lit end two to three centimeters from the back of your hand and feel a pleasant radiating warmth.

1. Hold the lit end of the stick over the area to be treated, maintaining a distance of at least two to three centimeters so that there is never any direct contact with the skin.

1. The therapeutic time for moxa use is 20 minutes. The moxa is moved slowly and gently either with the bare stick or cigar or in a holder from navel to pubic symphysis for 20 minutes. The mother will feel a lovely warmth in her abdomen.

1. Any ash that forms on the end of the stick can be gently brushed off by using the edge of the small dish, so that the moxa stick remains hot. If you suspect there is no longer any heat coming from the moxa stick, check by holding it two to three centimeters away from the back of your hand. Re-light if there is no radiating warmth. Never touch the lighted end of a moxa stick even if it no longer appears to be glowing.

1. When treatment has finished, place the moxa stick in a glass jar with sand in it and screw the lid firmly on so that the moxa stick is deprived of oxygen and cannot continue to burn. The moxa stick can then be re-lit for repeated treatments according to the instructions you received from your Naturopathic Doctor or midwife. General recommendations are to repeat this treatment once a day for 10 days in conjunction with other non invasive techniques such as specific warming foods as well as herbal teas you may be prescribed and supplements to aid and speed your recovery. Please ask your Naturopathic Doctor for more information.

Adapted from: "The Essential guide to Acupuncture in Pregnancy and Childbirth" by Debra Betts © 2010

References

1.Aasheim, V., Waldenstrom, U., Rasmussen, S., Schytt.E. Experience of childbirth in first-time mothers of advanced age – a Norwegian population-based study. BMC Pregnancy Childbirth. 2013; 13: 53.

2.Battaglia, D.E, Goodwin P, Klein N.A and Soules M.R. Fertilization and early embryology: Influence of maternal age on meiotic spindle assembly oocytes from naturally cycling women Hum. Reprod. (1996) 11 (10): 2217-2222.

3.Betts,Debra "The Essential guide to Acupuncture in Pregnancy and Childbirth" 2010

4.Croen, LA, Najjar, DV, Fireman,B and Grether JK. Maternal and Paternal Age and Risk of Autism Spectrum Disorders Arch Pediatr Adolesc Med. 2007;161(4):334-340.

5.Delbaere I, Verstraelen H, Goetgeluk S, Martens G, De Backer G, Temmerman M. Pregnancy outcome in primiparae of advanced maternal age. Eur J Obstet Gynecol Reprod Biol. 2007 Nov;135(1):41-6.