Professor Chii-Ruey Tzeng, President of the Asia Pacific Initiative on Reproduction (ASPIRE), was trained in endocrinology and infertility at Harvard Medical School’s Brigham and Women’s Hospital. He was also part of the team that produced Taiwan’s first in vitro fertilisation (IVF) baby in 1985. In this exclusive interview with Roche Diagram magazine, Prof Tzeng talks about fertility trends in Taiwan and how the Anti- Müllerian Hormone (AMH) can help empower women in family planning.
Women in Taiwan, and across Asia Pacific in general, are getting married later. The average age of marriage for a Taiwanese woman is in her 30’s. While falling fertility is a worldwide concern, the impact is more pronounced in Asia which is home to over half the world’s population.
Falling fertility matters because it can impact economic growth, cultural stability and society as a whole. With higher standards of education, better living conditions and the social empowerment of women, the trend increasingly among women is to seek control on when, and how, to start their families. For example, Prof Tzeng notes that over the last two or three years he has observed a marked increase in the demand for social egg freezing, which is legal in Taiwan.
While we reap the benefits of this as a society it often comes at a high personal cost for couples struggling to conceive.
At birth, women have about two million eggs in their ovaries. This is the entire supply of eggs for a lifetime. As women age, the number of eggs suitable for a viable pregnancy decrease in quantity and quality. This can impact a woman’s ability to get pregnant naturally.
Challenges to conception
However, there are many other roadblocks that women could potentially encounter when trying to conceive, regardless of their age. Prof Tzeng has observed that patients with endometriosis experience significantly greater difficulty in conceiving. Endometriosis is a common condition that occurs in approximately 6 to 10% of the general female population. Among women with endometriosis, about 30 to 50% are infertile.1
Polycystic ovarian syndrome (PCOS) is another concern among women looking to conceive. In fact, at Taipei Medical University (TMU), where Prof Tzeng practices, it is the second leading cause of infertility.
As clinicians, we have a responsibility to raise awareness among both married and unmarried women about their fertility potential.
Prof Tzeng shares that patients with PCOS usually display high levels of AMH.
AMH is a type of protein that belongs to the Transforming Growth Factor beta (TGF-b) family and is usually secreted from the preantral follicles, or the small antral follicles. Prof Tzeng says that he uses AMH to help evaluate symptoms and guide treatment for PCOS patients. For patients with a history of surgery for ovarian cysts who are looking to conceive, he also uses AMH to assess their post-operative ovarian reserve.
AMH as a tool for IVF
AMH levels can help predict the number of eggs that can be obtained during IVF, according to Prof Tzeng. He explains that since AMH levels are not linked to the patient’s reproductive cycle, in other words consistent during the proliferative phase as well as the ovulation phase, he finds this indicator more reliable than other markers which provide varied results depending on the phase of the patient’s reproductive cycle. The ovarian reserve test which measures AMH can give insight into the remaining quantity of eggs and therefore the remaining fertile time for a woman. This, in turn, can empower couples to make decisions about the right time to get pregnant naturally or to consider treatment. “In fact, there are some studies that show that AMH levels are associated with pregnancy outcomes – the higher the AMH levels, the higher the pregnancy rate. So, it is essential for clinicians to use AMH to evaluate the outcome of IVF,” said Prof Tzeng.
AMH is fast becoming the pre-eminent tool for fertility specialists around the world to determine the chances of their patients getting pregnant.
In the past, a woman would leave the decision to fate wondering how many more years she could wait to have children while fulfilling life goals whether personal, such as trying something new, or professional, related to career milestones. This would leave her with two choices: start trying to conceive and find out, or try a few years down the road and hope it isn’t too late.
But AMH is revolutionary because it takes the guesswork out of trying to get pregnant by pinpointing a woman’s chances of getting pregnant today, how that might change and what treatment, if needed, could maximise chances of conception.
Overall, patients in Taiwan have been showing decreased AMH levels over the last two decades according to Prof Tzeng. He suggests that there are many factors in this decline, including environmental toxins which may adversely impact fertility.
“As clinicians, we have a responsibility to raise awareness among both married and unmarried women about their ovarian fertility potential, and that AMH is a very important marker for this. Women should have routine physical checkups that include AMH testing,” said Prof Tzeng.
The fertility landscape, and the tools available to doctors treating patients hoping to conceive, have evolved significantly since 1985 when Prof Tzeng participated in producing the first IVF baby in Taiwan. Back then, IVF was the conventional assisted reproduction method.
Prof Tzeng reflects that doctors today have many different options to aid people in family planning including intracytoplasmic sperm injection (ICSI), cryo-technology to preserve the egg, embryo, and sperm, and preimplantation genetic diagnosis (PGS).
“The fertility potential in this region is tremendous,” said Prof Tzeng. “I hope that we are able to look for better methods as well as better quality of healthcare for women.”
¹Bulletti C, et al. 2010. Journal of Assisted Reproduction and Genetics: 27(8):441-447. Endometriosis and infertility.