Monthly Archives: December 2021
Half of women over 35 who want a child don’t end up having one, or have fewer than they planned
Half of women over 35 who want a child don’t end up having one, or have fewer than they planned
December 7, 2021 6.06am AEDT
Author
- Karin Hammarberg Senior Research Fellow, Global and Women’s Health, School of Public Health & Preventive Medicine, Monash University
Disclosure statement
Karin Hammarberg receives funding from The Australian Government Department of Health. She is a Senior Research Officer at the Victorian Assisted Reproductive Treatment Authority.
Monash University provides funding as a founding partner of The Conversation AU.
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At age 35, one in four Australian women and one in three men were hoping to have a child or more children in the future. But by age 49, about half report they haven’t yet had the number of children they hoped for.
That’s according to the Household, Income and Labour Dynamics in Australia (HILDA) 2021 report, released today. Over 20 years, HILDA has tracked more than 17,500 people in 9,500 households.
While some of the 49-year-old men may still father a child later in life, this is unlikely to be the case for women at that age.
In Australia and other high-income countries, there has been a long-term downward trend in the fertility rate: the average number of births per woman. In 2019, Australia hit a record-low of 1.66 babies per woman.
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Read more: Australians want more children than they have, so are we in the midst of a demographic crisis?
Low fertility rates are partly a result of more people not having children, either by choice or through circumstance. About a quarter of Australian women in their reproductive years are likely to never have children.
Why are women having fewer children?
There are many reasons why people have no or fewer children than planned towards the end of their reproductive years.
One contributing factor is the average age when women have their first child has increased in the last few decades and is now almost 30 years. This is in part explained by women spending more time in education and the workforce than they used to.
Read more: Balancing work and fertility demands is not easy – but reproductive leave can help
Another reason is some women don’t find a suitable partner or have a partner who is unwilling or “not ready” to commit to parenthood.
It’s also possible limited knowledge about the factors affecting fertility leads to missed opportunities to have the number of children originally planned.
But whatever the reason, having children later in life will inevitably affect the number of children people ultimately have. While most women who try for a baby will succeed, some won’t, and some will have fewer children than they had planned to have.
Fertility declines with age – so does IVF success
The risk of not achieving pregnancy increases as a woman gets older because the number and quality of her eggs decline.
By 40, a woman’s fertility is about half the level it was when she was 30. And sperm quality decreases with age too, starting at around age 45.
Increasingly, people who struggle to conceive turn to assisted reproductive technology (ART) such as in-vitro fertilisation (IVF).
There was a 27% increase in the number of treatment cycles in the 2020–2021 financial year compared to the previous year, according to data released today by the Victorian Assisted Reproductive Treatment Authority (VARTA).
But unfortunately, IVF is not a good back-up plan for age-related infertility.
On behalf of VARTA, researchers at the University of New South Wales tracked thousands of women who started IVF in Victoria in 2016 to see what had happened to them by June 30, 2020. The graph below shows the proportions of women who had a baby after one, two or three stimulated IVF cycles, including the transfer of all fresh and frozen embryos that resulted from these.
Women who started IVF when they were 30 years old had a 48% chance of a baby after one stimulated cycle, a 62% chance after two cycles and a 67% chance after three cycles.
But for a woman who started IVF at age 40, there was only a 13% chance of a baby after one stimulated cycle, a 21% chance after two cycles and a 25% chance after three cycles.
Fertility options for over-35s
So, what are the options for women in their mid-30s who want to have a child or more children?
The Victorian Assisted Reproductive Treatment Authority data reveal some women aren’t waiting to find a partner. Over four years, there has been a 48% increase in single women using donor sperm to have a child, and a 50% increase among same-sex couples.
But the number of men who donate sperm in Victoria has remained the same, so there is now a shortage of donor sperm.
The option of freezing eggs for later use is also used by more and more women. Almost 5,000 women now have frozen eggs in storage in Victoria, up 23% on the previous year.
But it’s important to remember that although having stored eggs offers the chance of a baby, it’s not a guarantee.
For women in their 40s, using eggs donated by a younger woman increases their chance of having a baby. Our study showed women aged 40 and over who used donor eggs were five times more likely to have a live birth than women who used their own eggs.
But finding a woman who is willing to donate her eggs can be difficult. Most women who use donated eggs recruit their donor themselves and some use eggs imported from overseas egg banks.
So while people might think pregnancy will happen as soon as they stop contraception, having a baby is not always easy.
Read more: Egg freezing won’t insure women against infertility or help break the glass ceiling
Can Prozac treat COVID? Perhaps, but a related drug may be better
Can Prozac treat COVID? Perhaps, but a related drug may be better
December 9, 2021 6.21am AEDT
Authors
- Jennifer Martin Professor of Medicine and Chair of Clinical Pharmacology, University of Newcastle
- Richard John Head Emeritus Professor, University of South Australia
Disclosure statement
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
University of South Australia and University of Newcastle provide funding as members of The Conversation AU.
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Republish our articles for free, online or in print, under Creative Commons licence.
- The rise of Omicron, the latest SARS-CoV-2 variant of concern, reminds us how quickly things can change during the pandemic.
Only a few weeks ago, we were hearing about a range of potential new COVID-19 antiviral drugs and antibody treatments. Now researchers are asking if such drugs will still work to treat Omicron, with its multiple new mutations. We’ll be hearing more about this in coming weeks.
However, another approach to treating COVID is to “treat the host”. Rather than target the virus itself, this involves treating the body’s overwhelming response to the virus. This approach is less susceptible to new viral variants.
And for this, we have some progress with, at first glance, an unlikely group of drugs to treat COVID-19 – antidepressants. These include fluoxetine (for example, Prozac) and the related drug fluvoxamine (for example, Luvox). It’s early days yet. But here’s what we know so far.
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Read more: Why an antidepressant could be used to treat COVID-19
How could antidepressants treat COVID?
The antidepressants under investigation are SSRIs or selective serotonin reuptake inhibitors. These commonly prescribed mood-altering drugs block “reuptake” of the naturally occurring chemical messenger, serotonin, by nerve cells in the brain; some antidepressants stop serotonin being broken down. These mechanisms leave more serotonin available to pass messages between nearby nerve cells.
There are two ways SSRIs could have an effect on COVID-19.
First, human biology is frugal
Biological “frugality” sets the scene. It takes a lot of effort for the body to make a single important molecule and a huge undertaking if you need hundreds of them. So, biology directs important molecules to multi-task.
For example, we all make serotonin by introducing a few changes to the chemical structure of the essential amino acid tryptophan, commonly present in food.
Serotonin is then tasked with being:
- a messenger in the brain
- a molecule to cause contraction in the gut
- an inducer of platelet clotting, and
- a modulator of how blood vessels work, including how they constrict and how they interact with the immune system.
The virus responsible for COVID-19 drives a devastating hyperinflammation in serious disease. This involves many of the systems serotonin strongly regulates – inflammation, platelet clotting and proper functioning of blood vessels.
So there’s a potential link between drugs that influence serotonin, and COVID-19.
Read more: Diarrhoea, stomach ache and nausea: the many ways COVID-19 can affect your gut
Second, drugs can open different locks
Drugs often act as a “key” to open certain locks in the body. However, in some cases, the “key” is not that specific and can surprise us by opening additional, unrelated locks.
This is called a pleiotropic response and is the basis of using existing drugs for new purposes (repurposing).
This may also explain why a mood-altering drug may be effective in serious infection. As we’ll see later, it may open the lock to influence inflammation.
Read more: Explainer: how do drugs work?
Have people tried SSRIs for COVID?
There have been a number of clinical trials showing favourable COVID-19 outcomes for people taking SSRIs.
In a preliminary study, outpatients with COVID-19 symptoms treated with fluvoxamine were less likely to deteriorate over 15 days compared with those taking the placebo.
Another study found patients hospitalised for COVID-19 who took antidepressants – including the SSRI fluoxetine, and non-SSRI antidepressants – within 48 hours of admission were less likely to be intubated or die than those who didn’t take an antidepressant.
The latest evidence comes from a major independent study published online in late October. This found people diagnosed with COVID-19 who took fluvoxamine reduced their chance of symptoms deteriorating or needing to go to hospital, compared to those who took the placebo.
Although few studies have directly compared fluvoxamine with fluoxetine to treat COVID-19, the bulk of the best quality evidence suggests to date suggests fluvoxamine may have the greatest promise.
However, there are a number of studies on broader effects of other SSRIs including fluoxetine.
Read more: We can expect more COVID drugs next year. But we’ve wasted so much time getting here
What could be happening?
It is likely our frugal biology is at work, in particular the influence of serotonin on platelets and blood clotting.
SSRIs may be reducing the incidence or size of blood clots, heart attacks and strokes we’d usually see in severe COVID-19.
SSRIs could also switch on anti-inflammatory pathways in the body, independent of any serotonin effect. Different SSRIs have different capacities to do this, which may explain why some SSRIs seem to have a greater effect on COVID-19 than others.
For instance, fluvoxamine is a more powerful key to unlock the sigma-1 receptor, which has a significant role in controlling inflammation. Fluvoxamine may also increase melatonin, which has anti-inflammatory effects.
What we still want to find out
Despite promising clinical trials, in particular for fluvoxamine, researchers still want to know:
- is this a class effect? In other words, would all SSRIs work? Although fluvoxamine is widely available, it is not on the World Health Organization’s list of essential medicines, whereas fluoxetine is. So we need to know if these drugs are interchangeable within the class of SSRIs, or even with antidepressants more broadly
- we still don’t know the precise mechanism behind why these drugs seem to work. But how much more data would we need before we start treating these patients in hospital?
- could fluvoxamine work for vaccinated people? Or is the potential mainly for those unvaccinated, and more likely to have severe disease?
- we need further information on possible side-effects of using SSRIs in COVID-19 patients, particularly if we are using doses different to the standard antidepressant dose. However, since SSRIs are existing and commonly used drugs, we already know a lot about how they work in the body, and any possible adverse reactions.
That said, based on the results to date with fluvoxamine in particular, we consider it needs to be added to the list of candidate COVID-19 drugs for further testing and evaluation.
Omicron may not be the last variant of concern. And by “treating the host” with existing drugs – SSRIs being just one example – we can offer patients options that are not at the mercy of future, unknown variants.
SSRIs can be dangerous if used in a dose that is too high for a particular person. These drugs should only be prescribed by your doctor. The drugs also have a number of potential drug interactions, increasing the risk of serotonin syndrome, which can be life-threatening.
Dentists admit feeling pressured to offer unnecessary treatments
Do I really need this crown? Dentists admit feeling pressured to offer unnecessary treatments
November 2, 2020 12.34pm AEDT
Author
- Alexander Holden Senior Lecturer in Dental Ethics, University of Sydney
Disclosure statement
Alexander Holden has received funding from the Dental Council of NSW, the research reported in this article being supported by an Education and Research Grant. He is also a director of the Australian Dental Association, both at a National and NSW state level and is a director of Filling the Gap, a charity providing pro-bono dental care to vulnerable members of society. Alexander is also a member of the NSW Registrations Committee of the Dental Board of Australia.
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University of Sydney provides funding as a member of The Conversation AU.
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If your dentist recommends a crown, your wisdom teeth extracted, or some other common treatment, you may wonder whether it’s really necessary.
We don’t know how common such over-servicing is. However, our research, which includes interviews with Australian dentists in private practice, published today, shows it is an issue.
Not only is this a problem for patients, some dentists say they feel pressured to recommend unnecessary treatments. And the way dentists are paid for their services actually encourages it.
Read more: How often should I get my teeth cleaned?
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What is over-servicing in dentistry?
Over-servicing can occur in many types of health care, with various definitions. But in dentistry, our research defines over-servicing as when dental treatments are provided over and above what’s clinically justified, or where there is no justification for that care at all.
Over-servicing in dentistry is reported internationally and discussed online.
And we’ve known about it in Australia for some time. In 2012, a Sydney dentist went to court and was fined more than A$1.7 million for performing almost $75,000 worth of treatment on one patient, knowing it was unnecessary and would be ineffective.
In 2013, another Sydney dentist was found guilty of over-servicing elderly nursing home patients, some of whom had dementia. He filed down their teeth to fit them for crowns they did not need, without anaesthesia.
However, over-servicing can be less extreme than revealed in these landmark court cases. Dentists we interviewed said they often felt pressured to over-service as part of their day-to-day practice.
Read more: Five commonly over-diagnosed conditions and what we can do about them
What we found
We analysed interviews with, and diary entries from, 20 Australian dentists working in private practice, the first study of its kind to include their perspectives on over-servicing.
Most dentists we interviewed had felt pressure to provide unnecessary care. Pressure came from practice owners, or their own need to meet financial commitments.
They spoke about a culture in some practices of “finding treatment” to do, rather than simply treating the issues patients had:
I quit my first job because they were overly commercial and I figured that out about two weeks in because there it was very much a matter of, “how many crowns are you doing per week? We expect our clinicians to be doing at least a crown a day” and there was no real care factor towards, what does the patient actually need? It was very much a matter of, “Okay, you’re seeing a new patient, see if you can get this much revenue out of that one”.
Why does this happen?
Most private dentists in Australia earn their wage linked to how much treatment they provide. So this fee-for-service model provides an incentive for them to provide more treatment, rather than less.
However, over-servicing isn’t inevitable. Some participants said their professional identities as dentists helped them place patients before profit:
Look, I’d always put my professionalism first. There’s been a couple of times when I’ve recommended a crown and I sort of thought “OK, am I doing this because the crown is a high-end item or because I really believe it’s the best thing for the patient?”, and I always go with what I believe is the best thing for the patient.
The dentists we spoke to also said they spent a lot of time considering how they managed patient care in a system inherently skewed to promote over-servicing.
So what happens when you shift away from purely a fee-for-service model? This might include a monthly fee for having a patient registered with a practice or service, as trialled in the United Kingdom.
The amount of clinical treatment reduced, with patients noting little change in the service they received.
Read more: Two million Aussies delay or don’t go to the dentist – here’s how we can fix that
How do we tackle this?
We could address the culture of over-servicing by changing the way dentists are paid, away from a pure fee-for-service model. Payments could be linked to measurable improvements in oral health, rather than purely just how much dentists do.
However, with fee-for-service being so entrenched in Australian dentistry, we admit this would be a difficult task, despite the increased awareness of the topic that research like ours brings.
Read more: 50 shades whiter: what you should know about teeth whitening
What if I’m not sure I need a recommended treatment?
If you’re not sure why your dentist is recommending a certain treatment, ask. You can also ask about the pros and cons of other options, including doing nothing for now and keeping an eye on things.
If you’re not satisfied with the answer, you can ask for a second opinion. One thing to consider is that you’ll need to ask your dentist for a copy of your clinical records and x-rays (to avoid these needing to be taken again). And if visiting another dentist, you probably will need to pay for another consultation.
If you’re unhappy with your care, the best place to complain to first is your treating clinician; dentists really value receiving feedback and the opportunity to put things right.
Could marijuana break your heart?
Featured Articles in Internal Medicine In the News
Could marijuana break your heart?
Naveed Saleh, MD, MS, for MDLinx | January 23, 2020
It’s easy to get caught up in the marijuana hype. After all, everywhere you turn, there seems to be a new weed-based gummy or marijuana-infused tea. And more states are legalizing marijuana for both medicinal and recreational uses. Some of the most popular and common therapeutic uses for marijuana include relief for anxiety, nausea, and chronic pain. Keep in mind, however, that smoking marijuana produces many of the same toxins, irritants, and carcinogens as cigarette smoke, which have been shown to increase the risks of cancer and heart disease.
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Emerging research has linked marijuana use to adverse cardiovascular effects.
Although more studies on the health effects of marijuana need to be done, emerging research has linked marijuana use to adverse cardiovascular effects.
Physiologic effects
In new users, marijuana increases heart rate, slightly raises blood pressure levels, and can result in orthostatic hypertension. Over time, users become habituated, blood pressure drops, orthostatic hypotension dissipates, and heart rate slows. This habituation results from reduced sympathetic tone and increased parasympathetic tone.
“Marijuana’s cardiovascular effects are not associated with serious health problems for most young, healthy users, although occasional myocardial infarction, stroke, and other adverse cardiovascular events are reported,” wrote the authors of a review article published in The Journal of Clinical Pharmacology.
However, they cautioned that “[m]arijuana smoking by people with cardiovascular disease poses health risks because of the consequences of the resulting increased cardiac work, increased catecholamine levels, carboxyhemoglobin, and postural hypotension.”
Myocardial infarction
Cannabis is a rare trigger of myocardial infarction, according to the results of an oft-cited study that was supported by the National Heart, Lung, and Blood Institute and the American Heart Association. Notably, of 3,882 study participants with acute myocardial infarction, 124 (3.2%) reported marijuana use in the prior year. Of these patients, 37 said they smoked within 24 hours of a heart attack, and 9 said they did it within 1 hour of a heart attack. On a related note, these users were more commonly men, were more likely to also smoke cigarettes, and were less likely to exhibit a history of angina or high blood pressure.
Importantly, among these patients, the risk of heart attack was 4.8 times higher within the first hour of smoking and rapidly dropped thereafter.
Cannabis arteritis
Making its first appearance in the literature in the 1960s, the phenomenon of cannabis arteritis has been described in 50-plus cases ever since. This condition, which is similar tothromboangiitis obliterans, develops in young adults who smoke pot.
Thromboangiitis obliterans, or Buerger disease, is a rare disorder that causes the blood vessels of the arms and legs to inflame, swell, and thrombose. Of note, tetrahydrocannabinol (THC)—the primary psychoactive cannabinoid found in cannabis—is hypothesized to trigger the clotting cascade, which leads to thrombus formation.
Unlike thromboangiitis obliterans, people with cannabis arteritis are more often younger and male. Furthermore, limb involvement is more commonly unilateral.
Although the cause of cannabis arteritis remains to be elucidated, experts hypothesize that it could be due to arsenic byproducts that result in inflammation of the endothelium.
Vasospasm
The most frequent cause of vascular events secondary to marijuana seems to be reversible arterial vasospasm. Furthermore, THC has been linked to coronary vasospasm-induced cardiomyopathy.
Although the mechanisms underlying such vasospasms are unclear, autonomic nervous system dysfunction could play a role, thus resulting in waves of vasoconstriction-dilation. Furthermore, in chronic pot smokers, THC could irritate the vascular endothelium, resulting in an increased risk of vasospasm.
Atherosclerosis
Some researchers have suggested that marijuana could contribute to atherosclerosis.
“Stimulation of the [cannabinoid 1] and [cannabinoid 2] receptors has also been shown to modulate the function of cytoskeletal elements in the vessel wall, which may elicit an inflammatory cascade, resulting in atheroma formation. Because pulmonary and [cardiovascular systems] are populated with [cannabinoid 1] and [cannabinoid 2] receptors, marijuana use has been hypothesized to be involved in the progression of atherosclerotic disease,” wrote the authors of a review article published in Missouri Medicine.
However, more research on this subject is required.
Stroke and heart failure
According to high-powered research presented at the American College of Cardiology’s 66th Annual Scientific Session, marijuana use is linked to a 26% increased risk of stroke and a 10% increased risk of heart failure—even after adjusting for demographics, health conditions like obesity and hypertension, and lifestyle risk factors such as smoking and alcohol use.
Bottom line
Marijuana is a difficult drug to study because it’s still classified as a Schedule I substance by the federal government. Nevertheless, some researchers have shown that it can negatively impact the cardiovascular system. Although these effects may be minimal in otherwise healthy people, those with heart disease are at increased risk.
Postnatal psychosis is rare, but symptoms can be brushed aside as ‘normal’ for a new mum
Postnatal psychosis is rare, but symptoms can be brushed aside as ‘normal’ for a new mum
November 11, 2021 2.10pm AEDT
Author
- Diana Jefferies Senior lecturer, Western Sydney University
Disclosure statement
Diana Jefferies does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Partners
Western Sydney University provides funding as a member of The Conversation AU.
We believe in the free flow of information
Republish our articles for free, online or in print, under Creative Commons licence.
The period after birth of a child is supposed to be a time of great happiness for women. However, a significant number of new mothers will experience a mental illness at this time.
One is postnatal psychosis (also known as postpartum or puerperal psychosis). It’s not related to postnatal depression.
Postnatal psychosis affects one to two in every 1,000 new mothers, or about 600 women each year in Australia.
But our interviews with women who have been diagnosed with this rare but serious condition show their symptoms were often dismissed as a normal part of adjusting to motherhood.
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What is postnatal psychosis?
Postnatal psychosis affects women across all cultures and geographic areas.
The condition can put a woman at risk of self-harm or suicide and, on rare occasions, of harming others including her new baby or other children.
We don’t know what causes it. But contributing factors may include sleep deprivation, and rapid hormone changes associated with pregnancy and childbirth.
The risk of postnatal psychosis increases if a woman has a history of bipolar disorder or has had postnatal psychosis before. One woman tells her story.
What are the symptoms?
Symptoms can begin in the first few days after giving birth but may not appear until up to 12 weeks afterwards.
Some women have manic symptoms
- manic symptoms include feeling they do not need to sleep, and are powerful and strong
- women may have unusual experiences, such as seeing or hearing things others cannot. They may believe things that are not true
- they can also make unrealistic and impulsive plans, can be disorganised or forgetful, and talk very quickly
- their moods may change rapidly or they may seem excessively happy.
Others have depressive symptoms
- depressive symptoms include a loss of energy and an inability to sleep or eat
- women may have thoughts or auditory hallucinations that they are a bad mother and they may say they wish to die. Hallucinations or delusions (false beliefs) point to postnatal psychosis rather than to postnatal depression
- women may find it difficult to complete activities, such as caring for themselves or their baby, or attending to other tasks in the home
- they may believe they are helpless, hopeless and worthless, especially as a mother
- they can become isolated and no longer enjoy activities.
Women say it’s traumatic
Women say postnatal psychosis is traumatic, especially if they do not get help when they first report symptoms. But it can be challenging to diagnose because of the stigma surrounding mental illness around the time of giving birth.
Women say they are reluctant to disclose unusual symptoms as they feel ashamed they are finding motherhood difficult and worry they may lose custody of their baby
When we interviewed ten women, who had experienced an episode of postnatal psychosis in the past ten years, we discovered another barrier to diagnosis.
Women said they knew they had unusual symptoms, such as not being able to sleep or changes in the way they thought or behaved, but they found it difficult to get help. Often, they were told these symptoms were a normal part of adjusting to motherhood.
Their postnatal psychosis was not identified until their only option was admission to an acute mental health unit and separation from their baby.
So we need more education about the condition for health-care workers. By identifying the condition earlier, this gives women more treatment options.
There are treatments
Once diagnosed, the condition can be treated with antipsychotic and mood stabilising medication, prescribed by a psychiatrist or other treating doctor.
This is very effective but medication is often not started until the symptoms have become very severe and the woman requires hospitalisation in an acute mental health unit, without her baby. This separation can compromise the developing bond between them.
So early diagnosis can potentially reduce the time a woman may spend in an acute mental health unit.
Read more: Postpartum psychosis: as we work to find causes, mothers still aren’t getting the support they need
Admission to a mother-baby unit
Best practice is to admit women and their babies to a mother-baby unit, which is usually linked to a hospital. This allows women to continue to care for their babies with the support of child and family health-care professionals.
However, publicly funded units are only available in Victoria, South Australia, Western Australia and Queensland. In New South Wales, two public mother-baby units are being built. In NSW, the only existing one is a private facility, which many families cannot afford.
Read more: Historical hospital records can show us what not to do in helping psychosis patients
Helping others
The women we interviewed said they developed support networks with each other. One woman told us:
You feel like, okay, that was such a hard experience, is there a way that we could make that a little less hard for the women who are going to go through it next time?
Women wanted to tell their stories so others would better understand postnatal psychosis and could find it easier to get help.
If this article has raised issues for you, or if you’re concerned about someone you know, contact the following organisations for more information or support: Perinatal Anxiety & Depression Australia (PANDA), 1300 726 306; Centre of Perinatal Excellence; Beyondblue, 1300 22 4636; Lifeline, 13 11 1
Dr Colin Holloway 