More Doctors Broach Delicate Topic of Women's Age and Fertility Rate

Wall Street Journal
June 4, 2013
More Doctors Broach Delicate Topic of Women's Age and Fertility Rate
She was 34, married, and seeing her longtime OB-GYN, Mark Jostes, when he broached the topic of children. Did she want them?

Some day, she responded.

"Some day is approaching and I don't want you to get to the point where you figure out that you finally want to have kids and it will be much harder for you at that point," the St. Louis resident recalls him saying.

Ms. Erwin and her husband got right to work, getting pregnant about six months later. She gave birth to a baby girl two weeks after turning 35. Now 37, Ms. Erwin, who works as an environmental consultant, is pregnant with her second. She credits Dr. Jostes with giving her the "kick in the pants" she says she needed.

It's a touchy topic: broaching the issue of having children. But OB-GYNs say they are increasingly making it as routine as asking about contraception during annual visits. They are educating patients about fertility rates, which gradually begin to decline around age 32 and then rapidly decline after age 37. And they are discussing the risks of miscarriage and chromosomal abnormalities, which increase at age 35 and above.
About 20% of U.S. women—a growing share—wait until after age 35 to begin their families, according to data compiled by the American Congress of Obstetricians and Gynecologists. Even with significant advances in assisted-reproductive technology, or ART, a woman's age can be a factor in getting pregnant. A healthy 30-year-old has about a 20% chance each month of getting pregnant, while a healthy 40-year-old has about a 5% chance each month—in many cases, even when using ART, the data show.

Doctors say advances in fertility treatments and media coverage of women conceiving in their 40s and even 50s have led some people to believe they can beat the biological clock. And though more women are pursuing fertility treatments, such as in vitro fertilization, using egg donors and freezing eggs and embryos, experts note that such procedures are expensive, rarely covered by insurance, and offer no guarantee for conception. Nationally, the mean age of first-time mothers was 25.4 years in 2010, up from 24.9 years a decade earlier, according to the latest data from the Centers for Disease Control and Prevention.

"I hear many people say 40 is the new 30. But not reproductively, it's not the new 30," says Cynthia Austin, medical director of in vitro fertilization at the Cleveland Clinic. "Our ovaries are aging at the same rate they did 50 years ago." 

 Rick Erwin
Kaly Erwin with daughter, Annie. The St. Louis resident, 37, says her OB-GYN gave her the 'kick in the pants' to have a child.

Genetics largely determine which women will still be fertile at 40 and which ones won't. "Fertility is absolutely a wild card," says Laurie Green, an OB-GYN in San Francisco. "At 30 I start talking to patients. I always tell them that we don't have a crystal ball, we don't know who is going to be fertile and who is not."

For decades women have struggled with how to balance their career with reproductive plans, and some have opted to delay childbearing in order to advance in the workplace. So the decision on when to have children is a complicated one.

Guidelines from the American Congress of Obstetricians and Gynecologists say clinicians "should encourage women to formulate a reproductive-health plan and should discuss it in a nondirective way at each visit." Among topics for discussion are a woman's, or a couple's, desire for children, the optimal number, spacing and timing of children in the family and age-related changes in fertility, the guidelines say.

One effort to encourage women not to wait too long turned controversial. The American Society for Reproductive Medicine, which represents fertility specialists, launched a Preserve Your Fertility campaign in 2001, which included an upside-down baby bottle that was an hour glass. Some women's groups criticized it as a scare tactic.

Michael Soules, the society's president during the campaign, says he feels women are now more knowledgeable about fertility and age. Dr. Soules, founding physician at Seattle Reproductive Medicine, says he would like to see more OB-GYNs broach the topic with patients.

Sometimes doctors are concerned about alienating patients by bringing up the topic of fertility. "I think I've rubbed people the wrong way. Often it happens with patients that are a little bit older," says Tamika Auguste, an OB-GYN at MedStar Washington Hospital Center in Washington, D.C.
"I've had, like, a 42-year-old say, 'Why aren't I getting pregnant?,' " Dr. Auguste says. "I say, 'I'm sorry, it's the science. At 42 you have fewer eggs and older eggs than a 28-year-old. At this point you really need to speak with an infertility specialist.' " Dr. Auguste says some patients get hostile and don't believe her; she usually doesn't see those patients again.

Dr. Jostes, the OB-GYN who counseled Ms. Erwin, says discussing fertility with patients can sometimes be like being a relationship counselor. He says he discusses with patients how they might balance their desires for careers, finding the perfect man and a desire to have children. "I try to go with general, easy questions to try to feel them out," he says. "You can tell if they're willing to talk with a few leading questions."

"Sometimes a good line when a lot of these couples are trying to decide is, 'There's never going to be a perfect time,' " Dr. Jostes says.

Victor Klein, an OB-GYN with North Shore-LIJ Health System in Great Neck, N.Y., says he tries to avoid being too blunt. Still, he will write down statistics on, for instance, the increased risks of having children with Down syndrome. The risks, he says, go from about 1 in 900 at age 30 to 1 in 100 by age 40, and 1 in 50 at age 42. If a woman is 40 and expresses a desire to have a child for the first time, he says he will send her straight to a fertility specialist.

Dr. Klein says he also discusses fertility with women who are single. When single women in their mid- to late-30s come to him without a partner, he will discuss the option of egg freezing. Improvements in technology led the American Society for Reproductive Medicine last year to lift the experimental label from the procedure, which can cost over $10,000.

Because it is the age of the eggs—not the uterus—that most affects the success of conception, egg freezing allows women to preserve younger eggs and then use them later through in vitro fertilization. Dr. Klein says two of his patients, ages 37 and 35, recently opted to freeze their eggs. "It's a duty to our patients to talk about it as something to consider," he says.

There are tests that can be done, typically by fertility specialists, to assess a women's ovarian reserve. Dr. Soules says a relatively new blood test measures the so-called anti-Müllerian hormone, or AMH, level. The hormone is produced by the ovary in the process of forming a follicle and can give a general sense if a woman has a low, medium or high reserve of eggs.

Some doctors say the test can't predict what will happen two or three years down the road. Samantha Pfeifer, an associate professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania, says the test is usually used to determine what dose of fertility medicine to use for IVF. Although a low AMH level is consistent with greater difficulty getting pregnant, the measure can't be used to predict who will or won't conceive, she says.

Still, Dr. Soules says, "To simply do an AMH test to get a sense of a woman's egg number is generally a good idea."


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