Dr. Duru Shah | Impending Menopause: How can fertility be preserved? | For Heathcare Professionals

Introduction: 

The International Menopause Society is proud to provide the interview series for health care professionals on current topics of interest in the field of menopause. In the series, IMS Board Member Dr. Marla Shapiro interviews renowned experts on menopause and midlife women’s health. 

Disclaimer: The views expressed by speakers are their own and may not necessarily represent the views of the IMS. 

Episode Summary: 

In this episode, Dr. Marla Shapiro of the International Menopause Society interviews Dr. Duru Shah, a renowned gynecologist and fertility expert from Mumbai, India. Dr. Shah provides an in-depth exploration of premature ovarian insufficiency (POI) and its implications for young women.

Dr. Shah discusses the definitions and symptoms of POI, and identifies women at higher risk based on factors such as ethnicity, family history, and medical treatments. She also offers valuable insights into fertility preservation techniques, including egg and ovarian tissue freezing, and the future of reproductive medicine.

The conversation delves into the ethical considerations of emerging technologies and the potential future of fertility treatments. This episode is a must-listen for practitioners and individuals interested in understanding and managing POI and fertility preservation.

YouTube Link: The interview is also available on video: https://youtu.be/QHABfcQrdEI  

Relevant Links & Resources: 

• International Menopause Society
• IMPART: The International Menopause Society Professional Activity for Refresher Training (IMPART) is the first educational initiative pertaining to menopause that is internationally applicable to health care professionals working in, or with a special interest in, midlife women’s health. It is aligned with the International Menopause Society’s (IMS) mission to work globally to promote and support access to best practice health care for women through their menopause transition and post-reproductive years, enabling them to achieve optimal health and well-being. 
• Monthly Webinars for Healthcare Professionals 

Host Bio: 

Marla Shapiro C.M.‎, MDCM, CCFP, MHSC, FRCPC, FCFP, NCMP 

Marla Shapiro is a professor in the Department of Family and Community Medicine at the University of Toronto. 

Dr. Shapiro completed medical school at McGill University and trained at the University of Toronto for her Masters of Health Science. She concluded her specialty training in Community Medicine, receiving her Fellowship in Preventive Medicine and Public Health from the Royal College of Physicians and Surgeons of Canada. She also holds a Fellowship in Family Medicine and is currently a Professor in the Department of Family and Community Medicine at the University of Toronto. 

Dr. Shapiro is seen on CTV NewsChannel and is the medical expert on CTV’s National News and NewsChannel. She is the author of the bestselling book, Life in the Balance: My Journey with Breast Cancer. 

Dr. Shapiro is a member of several advisory boards, including the Terry Fox Research Institute. She sat on the Board of Trustees for NAMS for 9 years. She was the President of the North American Menopause Society in 2017 and Scientific Chair of the NAMS Annual General meeting in 2019. She continues to produce and direct both videos in women’s health for health practitioners and the general public for NAMS. The videos can be seen on YouTube and www.menopause.org. She is on the editorial board of both Menopause and Climacteric. 

She received an Award of Excellence from the College of Family Physicians of

Episode Transcript

(00:01):
This interview was supported by an unrestricted educational grant from Viatris.
Viatris had no role in the selection of the topics or the selection of the
speakers and has not vetted or reviewed the content of any of the interviews.
The views expressed by speakers are their own and may not necessarily represent the views of the IMS.
Hello, I'm Dr. Marla Shapiro and I sit on the Board of Trustees at the International

(00:25):
Menopause Society. and today we're joined by someone who's well known to many
members of the International Menopause Society and globally as an expert in
fertility, Dr. Duru Shah.
Duru, can you please reintroduce yourself for those that do not know you,
who you are and what you do?
Thank you so much, Marla, for having me on your show. I'm Dr.

(00:46):
Duru Shah, I'm a gynecologist and fertility expert from Mumbai, India.
I have a center called Gynaecworld and I'm also the chair of CAMS,
that's the Council of Affiliated Menopause Societies, which is the arm of
International Menopause Society.
So today with you, we're talking about the notion of premature ovarian insufficiency

(01:10):
or premature ovarian failure, the notion of impending menopause in young women.
So firstly, for those who are not familiar with the term POI or the notion of
and pending menopause. Can you walk us through that definition?
So POI, it is also known as premature ovarian insufficiency.
In the past, it was also called as premature ovarian failure.

(01:32):
It was called as secondary amenorrhea or menopause, premature menopause.
There are many terminologies, but what we believe today is premature ovarian
insufficiency, where it occurs in women under the age of 40 and they've reached
sort of a menopause wherein, you know, they're not menstruating or they're not ovulating.

(01:53):
And this is something where women can even about say a few small percentage
of women may spontaneously ovulate.
And this is something you must remember that these women, if they're not interested
in fertility, they will still need to use a contraception for some time.
Okay. So for women who are at risk for impending menopause under the age of 40,

(02:14):
are there any things that we can look at that would warn us that this is a woman
who is it's an increased risk compared to a woman who's going to reach the age
of menopause between 48 to 52,
depending on what country you are from. How do we identify these women?
So I think the women, of course, we must know what ethnicity she has.
Even if she's Indian and living in the UK or US, her ethnicity remains Indian.

(02:38):
And women in India reach menopause a little earlier than in the West.
And their age of menopause is roughly around 48, average age is 48 years of age.
Now, how do we identify them? These are women who are having the symptoms which
they would have of menopause.
They would be probably having all their hot flushes and not sleeping well,

(03:02):
their dry vagina, decreased libido, whatever symptoms most of the menopausal women have.
And those are the symptoms which should be there. And the ones who are at risk
are the ones who genetically have a mother who's reached menopause early.
Or maybe she's been exposed to some radiation due to cancer treatment or chemotherapy.

(03:24):
Chemotherapy or maybe she's also a smoker
a chronic smoker or maybe she's
undergone some surgery on her ovaries or on
her uterus which can bring in a menopause a little earlier unfortunately in
our country in the past many women especially in smaller towns etc when they

(03:46):
went through a hysterectomy some of the surgeons even removed their ovaries
saying what is it for these ovaries now.
And this is unfortunate, but it's ignorance. And this is something which doesn't
happen in the cities today.
But yes, it used to happen maybe 20, 25 years ago.
Today, it still happens in smaller towns. So we talk about this notion of ovarian

(04:09):
reserve, that women are born with the eggs that they have, and that if they
are hitting premature ovarian insufficiency at age 40 or younger,
they're losing that ovarian reserve.
So as As practitioners, we can identify some women who've been at risk,
chemotherapy, going to have their fertility impacted.
What can we do in terms of delaying or helping them to be successful if they

(04:34):
have to delay pregnancy for whatever reason?
Yeah, I think it's very important for clinicians to be aware that women can
freeze their fertility. Even men can freeze.
They also can freeze their sperm. burns. Whilst women can have eggs and they
can freeze also part of their ovary.
They can freeze the entire ovary.
They can freeze, you know, their fertility.

(04:59):
Mainly in women today, I think as a medical person, I would say women who are
having cancers at a young age and they need to go through chemotherapy or radiotherapy.
It's very important for the doctor or the gynecologist to counsel her patient
that she needs to freeze her eggs before she goes to the chemo.

(05:20):
So age-wise, you know, is there a cutoff at which point you say,
no, I think you're too old to freeze your eggs?
What must we be thinking about as practitioners in terms of age?
Well, I don't think I would do only the age because, yes, average age is 48 years for menopause.
And we say 10 years before that, the eggs start, you know, sort of not behaving well.

(05:43):
So in short, I would do their test. I would do their FSH,
LH on second or third day of her period if she's still menstruating and I would
do her ovarian reserve in terms of monitoring her on ultrasound on day four,
five of her menstrual cycle,
looking at the volume of the ovaries, looking at the number of antral follicles

(06:03):
or the eggs I see in the ovaries and based on that I would decide whether yes
she needs to freeze her eggs or not.
If I hardly see one or two eggs inside, if I see the ovaries are smaller in size.
If I see her FSH is rising way beyond what it should be, I don't think she should freeze her eggs.
Okay. So if you look at what those options are, you mentioned freezing ovarian

(06:27):
tissue, you mentioned freezing eggs.
What are the difference between those options?
See, if a woman has had, say, is freezing her eggs,
she needs to go do it cycle after cycle she needs
to take hormones she needs to get the eggs ready
and then get them out and then again do another
cycle with the same hormones now if she's
a patient who's a patient who's having some malignancy

(06:50):
and she needs to freeze her eggs so in that
situation it's a good idea actually to take part
of the cortex of the ovary if it's
not ovarian cancer because the concern is if
it's ovarian cancer you may be perpetuating that cancer when
you put back that ovary and hence those ovaries
are being protected in different ways one is

(07:12):
of course freezing the fertility you get the cortex of part
of the cortex of the ovary freeze it or sometimes
it could be also the entire ovary and freezing it
especially if it's a young girl who doesn't have
a big ovary i mean you know a big size
ovary a small ovary you may just take the entire ovary
out and therefore for in these women it's frozen

(07:33):
and question is also if a woman is say suppose
having a radiation therapy we try and
you know do a surgical procedure where we take the ovaries out of the field
of radiation so that i don't get radiation if she's going through chemotherapy
we may give her a gnrh agonist something to suppress the eggs from maturing

(07:54):
and that's when they get worse i I mean,
least affected when they are not mature.
So you bring them into an immature state so that they don't get affected with the chemotherapy.
So there are various procedures we follow to protect the ovary, that is one.
And second is to freeze and freeze the fertility point of view. So this is something...

(08:17):
So what about success rates you know
the rates are good there's no
issue at all because once you have sort of
thawed that ovary and used it of course one normally doesn't really put it back
into the pelvis in that spot because you have to connect it to the uterus etc
you park it up there in the pelvis you stimulate that ovary you get the eggs

(08:41):
out you fertilize with the sperm put it back
in the uterus success rates are pretty good
of course not as good as they would be
otherwise because here you've got immature eggs which
you've got outside and you have to mature them outside outside the body and
you know so sometimes do an in vitro maturation or put the ovaries inside give

(09:04):
the injections let the eggs grow and then get them out so there are different ways of doing it,
though the success rates are not as good as, you know, when you do it with the
ovaries being intact in place,
but it is a way of freezing fertility,
which otherwise you wouldn't have been able to do.
What is the future taking us? So what are the advances and the ongoing research in this field?

(09:28):
We know about egg freezing, you've talked about ovarian, where can we see down
the road that we're going with advances?
So there's a lot of experimenting, experiments happening on how we we can get
hold of the stem cells, which is inside the ovary.
We know that, you know, as when the fetus is in the mother's womb, there are many eggs.

(09:49):
At 20 weeks of pregnancy, there'll be millions of eggs.
But by the time the child's baby is born, those millions of eggs disappear and
you're left with about one or two million eggs.
So the question is that maybe there are stem cells inside which could be converted into oocytes.
That's one. so there's been a sort of a situation wherein they are putting in you know sort of wherein,

(10:12):
rejuvenation they call it they add some plasma rich
platelets inside the ovary and hope that that will help to rejuvenate the the
eggs but of course this is not a standard of care it's not part of actual treatment
it's more experimental but the best is what is expected in future in future
has no X all you do is take a skin biopsy take the skin.

(10:36):
The give it to the lab if the male
doesn't have sperms give a piece of skin to the lab and
then they make eggs and sperms out of that skin so
you just go to the clinic give your skin it's converted
into eggs and sperms the doctor makes the embryos the
eggs and the sperms are united embryos are made and then the couple goes back

(10:57):
to the clinic and those embryos have been tested and tested for this is going
to be a tall handsome boy with blue eyes or this is going to to be a girl with
black hair and black eyes and she's fair, et cetera, et cetera.
She's going to be a pianist. She's going to be brilliant, but she's going to
have diabetes or she may have cancer, something like this.

(11:20):
You see, the doctor is going to say, okay, this embryo has got this problem,
this good part of it, and this is the bad part of it. Now select which embryo you want foot in.
I think that is going to be a major, major problem.
Major problem with ethics as well.
Absolutely. So this is, of course, these are the wider thoughts.

(11:40):
Of course, there's a lot of artificial intelligence happening to select the
best embryo which you can put in so you get the best of results.
That is happening. That is happening. There's a lot of research going on.
There are apps available.
So artificial intelligence is almost there to select the best embryo to put
in so you get the best success rates.

(12:01):
But what I told you earlier is the future. It may happen. I don't think it will be allowed ever.
It will be unethical, but it's possible.
Well, we'll have to come back again in another year or so and update where we're
going and as the future becomes the present. Thank you so much for joining us today.
Thank you so much, Marla, for having me. Thank you.