Book Review: When Reproduction Meets Ageing: The science and medicine of the fertility decline

When Reproduction meets Ageing: The Science and Medicine of the Fertility Decline

By Dr Nolwenn Bühler

Published by Emerald Publishing

ISBN-10: 1839097477, ISBN-13: 978-1839097478

Buy this book from Amazon UK

At a recent socially distanced neighbourhood get-together in northern Nevada, my neighbour introduced me as an author and health writer.

'And what area of health do you focus on?' one new acquaintance asked eagerly.

'Well,' I hesitated, 'many find it socially awkward or uncomfortable... ' before I ploughed ahead and declared: 'I write mostly about the shortcomings of in vitro fertilisation and its failure impacts.'

My husband was more direct: 'IVF does not live up it its hype. It fails some 75 percent of the time – we experienced it first-hand.'

The now sympathetic new neighbour had a confession. 'My sister-in-law had an awful time. Her IVF failed several times.' She then enquired plaintively: 'Why don't more people know about this?'

This conversation stayed with me as I completed reading Nolwenn Bühler's book, When Reproduction meets Ageing: The Science and Medicine of the Fertility Decline. While far from an easy read, due to the mostly dense, academic language, Bühler provides a useful new look at the biological clock and how often it's miscalculated as well as the hazards of a 'one-size-fits-all' presentation of fertility.

A senior lecturer at the University of Neuchâtel, Switzerland, and a senior researcher at the University of Lausanne, Bühler writes with the heaviness and precision of a Swiss clock.

Pro Tip: Read the Afterword First

The afterword is where Bühler truly animates her work and cuts to the chase of her years-long research and its unfortunate collision with COVID-19 and multiple social justice and climate change issues. Realising the 'insignificance' of her topic against such a backdrop, she asks: 'Why should we care about the biology of old eggs? The nature of age-related fertility decline and its multiple materialisations? Why should we care about the role of assisted reproductive technology (ART) in the encounter between ageing and reproductive technologies which are so expensive that they are mostly the preserve of the wealthy anyway?'

Fortunately, she found her answer: It offers a 'small contribution to a much broader picture' that will be useful for practices and advance further reflections and research.

The day I finished Bühler's book, Australia offered up a more accessible, messy feature story subtitled thus: How one 'fat, hairy, gruff guy' is tackling the stigma around not having kids. He summed up the experience at a fertility clinic this way: 'IVF provides "toxic hope."'

The toxic hope and misunderstandings inherent in ART procedures – from IVF to egg 'donation' to egg freezing – lies in their 'presumed power' to provide definitive answers. Bühler introduced the 'presumed power' turn of phrase on page 108. It is one of many nuggets buried in a book that teases at why so many today confuse what's possible with ART with what's probable.

Conflicting Fertility Messages Revealed

Bühler first sets out 'how to understand the contested reality of reproductive ageing from a social science perspective' and 'how to deal with two conflicting views that not only the biological reality of age-related fertility decline might be more social than usually assumed, but also that this biology might matter much more than usually thought.'

She invites readers 'to focus on the science, medicine and technologies of reproduction as spaces where different realities of fertility decline materialise' and 'to question what these multiple materialisations do to this 'fact of life.'

Bühler consistently points to the mixed messaging that muddies the waters for those who may one day want to have children. There's the truth about biological fertility decline and the 'empowerment' narrative advanced by those whose business models rely on postponing childbearing.

Dehumanising Characterisations

The disembodying – particularly of women – happens shockingly often across much of ART-related academic writing. The lack of humanity can be disturbing for readers who have intimate knowledge of ART procedures and their trauma-inducing outcomes. When the book lays out the mechanics of reproduction and the history of age-related fertility decline, it sometimes unintentionally neglects the painful, enduring realities that women and men across the biological and ageing spectrum have and do face when considering or relying on the promise of ART procedures.

There's plenty of discussion in the early chapters on feminist theory and sterile references to biological processes, organs, cells, and procedures. For example, Bühler interviews a Swiss reproductive biologist and shares a dispassionate conversation had while jointly reviewing the images of egg cells extracted from a younger and an older patient. The biologist announces: 'Eggs of older women tend to be deformed.'

Okay, but ouch. The caretaker of those eggs likely had great plans for nurturing those precious life-giving ingredients into so much more. At times the gynaecologists and IVF specialists interviewed for the book speak in such clinical terms it's hard to know if they're treating animals on a farm or humans sitting in their waiting rooms.

It's only later, in Chapter 5, when Bühler relates a meeting with a friend suffering infertility travail that she clearly sees the fertility span as 'undefined and associated with a mixture of hope, doubt and willingness to trust.' It's also then she questions whether she has been 'simply believing what the clinicians told me.' Bühler admits to complicating long-standing conventional wisdom by opening the 'black boxed' reality of age-related fertility decline in the clinic to 'understand how the reality of age emerges from various choreographies in clinical encounters and patients' experiences of reproductive treatment.'

With several differing case studies, patient interviews and field work, Bühler further reveals the gravity of the ART diagnosis and the deeply personal, emotional impacts on those undergoing tests and procedures. The clinical staff descriptions border on abusive – from heartlessly relying on medical jargon and statistics to being downright harsh, judgmental, and dismissive.

This leads us to a chapter on the 'ageless mother' and the promise of extending fertility through the use of other women's eggs, something prohibited in Switzerland. Reproductive tourism, a growing ART field, is required. Missing from the Bühler's discussion of egg 'donation' as a 'clinical choreography' and the social, legal and biological age limits of motherhood are the harmful mental and physical health impacts for the 'donor' and the potential child conceived and delivered. Waves of donor-conceived children are now stepping forward to demand human rights and protections (see BioNews 1032). Bühler instead focuses narrowly on age-related fertility decline as pathological or physiological, and on the ART requirements and desires of the ageing mother-to-be.

Recurring Theme: Truth Versus Hope

Chapter 7 is particularly enlightening as it explores the controversy between the two versions of reproductive ageing: 'the so-called fixed pool model and the stem cell model.' Bühler highlights a larger challenge endemic to all forms of ART – the 'oscillating between a regime of truth and a regime of hope.'

Some of the latest generation of 'self-defining optimists,' for instance, hope to cash in on pursuing ageless fertility where women are 'no longer faced with the idea that there's just a fixed bank account of eggs at birth with only withdrawals and no deposits.'

Stuck in the middle are women once again trying to decipher what to believe: the ART optimists who believe 'in future promises and reducing the gap between themselves and actual facts,' or the critics and pessimists who 'hold to the facts.'

In reviewing the critiques of research aimed at reversing ovary ageing, for example, industry concern for women suffering with infertility who might wrongly hope that new help awaits seems secondary to practitioners who fret still more about damage to 'the public image of the field.'

Bühler rather dryly notes: 'The boundary work performed by reproductive biologists along the lines of fantasy versus reality, and optimism versus pessimism, have shown how, in addition, the ontological status of these cells, and consequently of reproductive ageing, depends on the position taken towards established facts and future promises.'

Bühler concludes her book with a rethinking of the materialisation of age through the lens of its political implications. This is where the book will have greater appeal to non-academics and academics alike. She points out that 'in ageist societies, although old age is generally devalued and depreciated, the ageing of men is valued more positively than the ageing of women.'

Not surprisingly, Bühler notes, 'reproductive ageing in women is described in negative terms as loss, decay, and passivity,' and in her field work, age was only an issue for women who waited too late to have children whereas loss of fertility for men was discussed in relation to the effects of polluted environment or oestrogen in the food supply. In short, women are seen as individually responsible for their fertility problems, a 'stark contrast to the collective responsibility indicated for male infertility.'

In a world facing multiple social justice, public health, climate and economic challenges, this book makes a strong case for a slowing of new market pursuits for fertility extension technologies until the basics are improved. How? Through earlier, comprehensive fertility education, more compassionate care and support as well as prioritising safety and health over profits for all involved in ART procedures.

Buy When Reproduction meets Ageing: The Science and Medicine of the Fertility Decline from Amazon UK.