Dr Gedis Grudzinskas is one of the most respected names in fertility. He is angry. Fed up of potential patients being given false hope by the baby-making industry, he is distinctly unimpressed by this week's findings that it may soon be possible to predict to within four months when a woman is likely to go into menopause. And, by extension, whether she can afford to put off having children.
"I've used this test in clinical practice and it's not easy to interpret," he says, referring to the blood tests developed by a group of Iranian scientists who presented their work this week to the European Society of Human Reproduction and Embryology in Rome. The test measures levels of Anti-Mullerian hormone (AMH), which controls the development of follicles in the ovaries, from which eggs develop. The researchers say the AMH level is an accurate predictor of the timing of the menopause. Some reports this week claimed an over-the-counter version could be available within three years.
"It's a useful enough test, but I don't think it provides enough information. Is it actually going to help society and women in some way?" Grudzinskas pauses, witheringly. "What worries me is that a 'normal' result [ie, a prediction of menopause around the early 50s] may encourage people to wait to conceive. It's far more useful to use age as an indicator of fertility."
This is the uncomfortable truth, of course, which, after four decades at the sharp end of the fertility industry, has become Grudzinskas' bugbear. We must stop pretending that medical advances allow the luxury of delaying starting a family, he says. "Fertility declines from 28," he says. "For some women, that happens very quickly. In others, it's a slow process. The decline then accelerates in the mid to late-30s." Even if you were able to predict the date of your menopause and know exactly how many eggs you had left, "we're not at the stage where the test can tell you how those eggs will function. The number of eggs does not mean the eggs are healthy and normal." He sighs heavily.
Grudzinskas is speaking to me from Rome, and sounds tired and, occasionally, grumpily Australian. Born to Lithuanian refugee parents in Germany in 1945, the family left for Australia when he was four, only shortly after his grandmother predicted that little Gedis would grow up to become a doctor. Her prophecy came true, with her grandson coming to London as a research fellow at St Bartholomew's and the Royal London Hospital School of Medicine and Dentistry (Barts) in 1974. Married for more than 40 years, he has three children and lives in central London.
Eventually professor of obstetrics and gynaecology at Barts and former medical director of the Bridge Fertility, Gynaecology and Genetics Centre, he has worked in reproductive health ever since his arrival here. He describes his mission in life as "to maintain and enhance reproductive health in women, prevent infertility and preserve fertility in cancer patients." He started out specialising in screening tests for foetal wellbeing, then moved into developing diagnostic tests for the first trimester of pregnancy. "My interest was taking me earlier and earlier into pregnancy. And at the same time, IVF was taking us even earlier."
He now runs an independent, private practice in Harley Street, where, he says, he is as likely to advise patients against fertility treatment as to advocate it.
His patients come to him for his legendary bluntness. "If telling people the truth is letting them down or it means I am providing information that decreases their level of expectation … Well, I have been working in this field for some time. Many women – in their mid-30s, late-30s, early 40s – have said to me, 'Why didn't somebody tell me before?'" He is getting grumpy again. "Imagine you were getting on with your life at 34 or 35, getting married, trying to conceive and you go to see your GP aged 36 because you haven't conceived, and he says, "Come back in a year when you're 37." Then you find your ovarian reserve test comes out very low. How would you feel about the advice you were given a year ago? Things can change very quickly. I don't think it's ever right to say to anybody, wait."
He does have a way of putting things. "In a woman of 30, one in three embryos that look normal will be genetically flawed. It may not implant or it may lead to early or late miscarriage. Or Down's syndrome. At 40 it goes up to two out of three embryos. At age 44, even higher." In other words, even for a relatively young woman (aged 30), with a normal pregnancy, a healthy baby is never guaranteed. This sort of opinion is rarely voiced, but is one that Grudzinskas' clients are desperate to hear.
There are too many unacknowledged facts surrounding fertility, he adds. "Where do we learn about fertility? TV, the internet, these fabulous pictures of women in their 40s in Hollywood walking around with babies. Everybody assumes that they're genetically theirs, but they're not necessarily." (He means the older the patient, the more likely the chance of success with younger, donor eggs.)
"This is what has intrigued me in recent years," Grudzinskas goes on. "That the age women have their first child is increasing slowly. In the UK it's a bit over 31. Even in Lithuania the age is starting to go up there too. It can happen very quickly, over a period of just 15 years. Something is happening in society. I don't think it's directly related to how women view themselves. And it's too easy to say that the world of full of males who can't commit to relationships. There is something else going on." He fears it may be linked to a misplaced trust in medical advances.
"Women should avoid delaying starting their family until their 30s. But society has to change for that to happen. Women should be given adequate time to have the child without losing opportunities for career development. At the moment, we are seeing women who tend to do better in the workplace behaving like men [ie postponing childbirth or not bothering at all]. Is that what we want?" He has the opposite concerns to activists who argue that we are becoming overpopulated. He wants to encourage more babies. "We need more babies to sustain the economy. As it is, we are not going to have enough people to support the ageing population."
The other unspoken cruelty behind fertility treatment is the gender bias, he adds. "There are many more limitations to women's fertility than to a man's. A man may only have two sperm to rub together and that may be sufficient to derive a live birth. The technology has its limits for women." And it is, like nature, notoriously unpredictable. He has seen couples with very low numbers of eggs "and, abracadabra, they conceive naturally." But many people are over-reliant on IVF – not fate – as their fallback. "And going on that IVF merry-go-round with all the drugs and the stress, given the limited return ..."
We also need to confront our illusions about having a genetic child if we are going to put so much faith in medical solutions, he adds. "I will say to couples who come to see me, 'Look into your heart and tell me what it is that you want. Is it to have a child that is of both of you? Or not necessarily? Is it that you wish to be pregnant? Should the pregnancy be genetically yours?'
'Some women will say, 'I know my eggs will be too old, but I want his baby.' There are women who have reached the stage where they are happy to be the birth mother but not the genetic mother. Another couple once said to me, 'Thank you, but we've decided that we'd like to use donor eggs and donor sperm. We'd like to share the responsibility of the child not being genetically ours.' In effect they decide to 'adopt' an embryo. Others will say, 'We have decided to accept our situation. We will either go and adopt or we will remain childless.'"
He is fascinated by the developments in cryobiology – the freezing of eggs and of ovarian tissue for cancer patients, for example – but worries once again that they will encourage some people, wrongly, to delay. "I'm a great enthusiast for these advances for couples who have conditions that may render them sterile or infertile. And we've made more advances with young women than with men in these areas. But for women who want insurance against infertility? Yes, it could help but … "
He recalls a woman who came to him, aged 43, having had her eggs frozen at 35. She didn't manage to conceive but argued that the process had helped her psychologically. "She said: 'I've had eight years where I've been able to lead a normal life without wondering whether every month counted.'"
Another patient, a single woman in her late 30s, came for an appointment with her mother and after hearing Grudzinskas' argument, she said, "'I know a man. I am going to call him Mr Compromise.' She was going to try to conceive normally." There is a lift in his voice. He convinced someone. "I thought it was lovely that she came with her mother too," he adds.
He has one last jibe at the NHS. Now guidelines allow for three free IVF cycles on the NHS for women aged 23-39. This week, the National Institute for Health and Clinical Excellence announced that it is reviewing the age limit. Despite Grudzinskas' assertion that women must try to conceive earlier and naturally, he would like to see more IVF on the NHS. "I don't think the NHS does enough. There is this awful word 'rationing'. Each trust has its own rules and, typically, many women are excluded on the basis of age, weight and so on. Yes, now they are saying that age is going to be removed from some parts of the NHS as a restriction, but I still think they could do more."
Encouraging earlier childbirth should be our prime concern, though, he adds: "This really is an issue for the whole of society. The most important thing in my mind is to highlight the limitations of the technology."
