In the early 2000's, women in New York and other U.S. cities got a less-than-gentle reminder about age and fertility: bus-size billboard ads trumpeting "Advancing Age Decreases Your Ability to Have Children. Infertility is a disease affecting 6.1 million people in the United States." Accompanying the ad was an unsettling image of an upside-down baby in the shape of an hourglass. The ad was part of an information campaign from the American Society for Reproductive Medicine and the American Fertility Association, which defended itself against charges of alarmism by noting that few women are aware of exactly how aging affects their fertility.
In this, the reproductive specialists were right: Women are well aware of the biological clock's damnable tick, but until recently many of us were a little vague on just what that meant. In an online survey of 12,500 women conducted by the American Fertility Association in 2001, some 88 percent of us had no idea of the age at which fertility begins to decline -- and 39 percent thought fertility rates didn't begin falling until age 40.
In reality, women's fertility begins to decline slightly by age 27. Many women are surprised to find that it dips significantly after age 35; by age 40, 50 percent of a woman's eggs are abnormal and the chances of conceiving without a donor egg drop to 7.8 percent. In contrast, men's fertility doesn't begin to decline significantly until after age 50. Men produce brand-new sperm every day, but the quantity and quality of women's eggs declines sharply over the years.
So what are the implications of this staggering knowledge? Should those of us in our 20s and early 30s rush to have children earlier than we had planned? What sorts of options for motherhood are available for women in their late 30s or 40s? Equally important, what needs to change so that both young women and those who postponed childbearing receive support and understanding in their quest for motherhood?
For some women, finding that support -- rarely denied older fathers -- may be harder to achieve than pregnancy itself. In discussing women who have postponed having children, the media appear to alternate between blame and a patronizing sort of pity. In its cover story "Babies vs. Career: Which Should Come First for Women Who Want Both?" Time magazine featured a photo of a thin, haunted-looking female executive cradling a briefcase swaddled like a baby.
Other books and magazine articles have also sounded the alarm, asserting that women who thought they could put off having kids until they reached a certain professional level -- or until they found a loving partner -- may have waited too long. They warn that these women may experience untold bitterness and regret once they realize how difficult it can be to conceive. One fertility specialist quoted in the Time article singled out professional women for a sententious lecture: "[Career women] have been making a lot of money, but it won't buy back the time," he scolded.
But critics say this sort of simplistic interpretation tends to obscure the crucial social and economic factors that force women to delay childbearing. For most young women work is a necessity rather than an option. And if a woman leaves the job market temporarily to start a family, she's likely to earn significantly less money when she returns. In turn, this makes her less financially capable of supporting a family. There are other good reasons to wait as well, be they physical, spiritual, or emotional.
Indeed, a study studies from the U.S. Centers for Disease Control and Prevention document what many of us have known all along: American women are waiting longer to have children. The mean age for mothers having their first child climbed from 21.4 in 1970 to 25 in 2006. And about 1 in 12 women in the U.S. have their first child after age 35. Experts say education and employment are key factors -- 40 percent more women were in the workforce in 2000 and the number completing college had nearly doubled.
"What's so painful and ironic is that in my fertile years, men my age who I was involved with were not the least interested in having children," says one 42-year-old woman undergoing fertility treatments. "And now that I'm with a wonderful man and we would both do anything to have children, I'm infertile."
Precarious ups and downs
"Infertile," of course, does not mean that you can't conceive: It simply means that you have not been able to get pregnant in a year's worth of trying. And the cause of infertility may not be connected to the woman; in about 30 percent of cases, the problem can be traced to the man's sperm, and in another 30 percent of cases both the man's and woman's physiology contribute to the problem.
Whatever the cause, women struggling to get pregnant often feel isolated and alone. "As I go through fertility treatments, I feel like I'm living some sort of secret life," Liza Glass* writes in a journal about her quest to have a baby at age 43. "The month consists of precarious ups and downs: praying for a pregnancy, facing the disappointment when menstruation comes, or perhaps the pain of a miscarriage, then rallying to begin another try. The journey is intensely personal, leaving me vulnerable and testing my emotional fortitude. It is not the subject of dinner-party conversations, nor a matter to discuss with any but close friends. Often it seems I am living in a different world from those around me."
The Northern California writer concludes: "Perhaps most heart-wrenching is the common assumption by strangers (and even by friends who are unaware of my pregnancy attempts) that I have no children because I don't want them. Remarks range from a harried mother's joke -- 'I can see why you never wanted kids!' -- to a coworker's 'Man, do I envy you -- the single's life! You can do anything you want to.' Sometimes I have to blink back the tears. They have no idea what I would give to be in their shoes."
Struggling toward fertility
Denice Dirks of Southern California could likely understand. Only 34 when she first tried to become pregnant, she nonetheless became nervous after she and her husband, Michael, spent several months trying vainly to conceive. Seeking the advice of a specialist, they learned that initial tests indicated minor problems with her husband's sperm motility (the ability of the sperm to reach the egg) and a slight blockage of Dirks' fallopian tubes, but neither of these were significant enough to cause infertility, the doctor said. The Dirkses' case -- like those of a great proportion of the 7.3 million women under age 45 estimated to be struggling with infertility today -- was given the disconcerting diagnosis "unexplained infertility."
What followed for the Dirkses was a three-year roller coaster ride, including endless tests and fertility drug injections for Denice. All in all, the couple underwent five failed intrauterine inseminations (a process in which sperm is injected directly into the uterus), then spent $20,000 on two attempts at in vitro fertilization (IVF). In this process, Denice's eggs were retrieved and mixed with her husband's sperm to form embryos, which were then implanted in her uterus. They suffered a wrenching miscarriage after the first IVF treatment.
"It was the most difficult time of our lives," recalls Dirks. "It was completely draining emotionally, and it put a real strain on our marriage... as well as on our relationships with other friends who had kids." The fertility drugs made Dirks an "emotional basket case," she says, which in turn made it difficult to do her job as a gift planning officer.
But in the end, Dirks, then 38, had a successful pregnancy, and her son Jarrett, was born this fall. Since then, much of the pain she and her husband went through to bring their child into the world has faded, says the new mother. "When I look at my son and realize we finally got what we wanted so badly, I know it was worth everything we went through," Dirks says. "The road wasn't easy, though. I wouldn't wish it on my worst enemy."
Pregnancy by donor egg
The road to pregnancy was even more convoluted for Valerie Jenkins* of Hawaii. For more than a decade, Jenkins and her husband tried to conceive by every means from acupuncture to IVF, beginning when she was just 27 years old. The joyous times in which they succeeded in getting pregnant ended in miscarriage. In 1992, Jenkins was 40 years old. She and her husband, Thad, had all but given up on having their own children when the would-be mom saw an interview with Ruth Pointer (of the Pointer Sisters) on television about how she'd used eggs from another woman to have twins. "The man who was interviewing her was kind of a dolt," Jenkins recalls, "and asked her, as if she were crazy, 'Why would you do this?' And she responded, 'Because I can.'"
That was all Jenkins needed to hear: Pregnancy was again a possibility due to another advance in modern medicine. It didn't matter to Jenkins that her child would carry only her husband's genes, not hers.
But the battle was far from over: It took the Jenkinses four long years to scrape together the money for an egg donor -- and to locate one who was appropriate. The first embryo transfer resulted in a miscarriage, by far the most devastating of all. Unfortunately, the second attempt -- using frozen embryos from the same donor -- did not result in a pregnancy either. On the third and final attempt, using the last of the donor's eggs (which were also of the poorest quality), the doctor was so pessimistic about Jenkins' chances that he told her to take a home pregnancy test in the "unlikely event" that she did not get her period.
In fact, Jenkins' period didn't arrive. After an uncomplicated pregnancy at age 44, she gave birth to "the cutest thing you've ever seen," she boasts. "No really, he's gorgeous and he's a great kid. He could be on the cover of a magazine."
Today, her 5-year-old son is starting kindergarten, and Jenkins is adjusting to being an older mom. Along with many women in their 40s who are raising young children, Jenkins has been disturbed by recent press reports with a punitive tone towards women who have waited to have children.
"It's not true that women who postpone childbearing will necessarily have all these problems," Jenkins says. "Yes, your fertility does begin to decline at 27, but I think it's important for women to know that there are choices today, including adoption and assisted reproductive technology. Things have never looked better for people who are infertile. It takes time, money, and patience, and there are emotional heartaches. But if you want to parent, you can parent."
Many women over 40 have no difficulty conceiving, especially if they get prompt treatment for any infertility problems, according to the American Fertility Association. Still, the odds of having a baby decline by 3 to 5 percent each year after age 30, and at a faster rate after 40. Even with invasive fertility treatments, women 40 and over have less than half the chances of conceiving that women in their early 30s do.
Perhaps for these reasons, fertility specialists try to give their patients over 40 the most realistic assessment of their chances for pregnancy. Unfortunately, the message may come across as overly discouraging or paternalistic.
"From the beginning, my MD told me I was lucky to have gotten an appointment with him -- and that he thought my chances of becoming pregnant at 43 were minimal," reports Glass in her journal. "I pointed out that aside from the statistics, my fertility profile looked extremely favorable: I'd been pregnant before, had no medical evidence of a fertility problem, and my gynecologist described my FSH and estrodial levels as 'those of a 28-year-old.' But he insisted that I had almost no chance of becoming pregnant.
"Each time I've met a new doctor at my fertility clinic, I've sat down and told him or her point blank: 'Let me say from the beginning that I am 43, and am well aware of the current statistics on pregnancy rates for women my age. Let's just take that as a given, and move forward from there.'" I explain that the constant harping on this point is demoralizing.
"On each of these occasions, I've had the sense that we've come to an agreement, a true meeting of the minds. I've been praised for my intelligence and sober realism. Nonetheless, after every appointment I've been to at my fertility clinic, my doctors have concluded, like a broken record: 'You're 43, you know. Your chances are really low. We've got to do everything possible.'"
"Maddeningly, during four out of 12 months in the past year, my doctor has been absent, or cancelled my medication cycle due to concerns later dismissed as unimportant. Still, in subsequent meetings, he warns, with a furrowed brow: 'We have to move on this as quickly as possible. You're 43!'"
Many roads to parenthood
No matter what their age, how long to keep trying is a question for most women fighting to become pregnant. After miscarrying an IVF pregnancy, Jeanne Sandecki briefly considered using donor eggs. She and her husband put down their deposit and placed themselves on a waiting list for an egg donor, but changed their minds a week later in favor of adoption. "We decided that if we were going to invest the time, the emotion, and the money to do this, we wanted to know that we were going to have a child at the end of it," Sandecki says. "And we always liked the idea of giving a home to a child that was already born."
Eventually growing discouraged in their attempts to adopt an infant in the United States, the Sandeckis signed up to adopt from Ukraine. Five months later, they made a trip halfway around the world to bring home two baby boys -- one a beautiful 4-1/2-month-old and the other a rambunctious 15-month-old. Sandecki, who is the adoption liaison for Resolve, a national infertility association in Atlanta, is elated about her journey to parenthood: "I just think adoption is the greatest thing in the world."
* Valerie Jenkins and Liza Glass are pseudonyms.
"Babies vs. Career," Time magazine, April 15, 2002
"Fertility, Family Planning, and Women's Health: New Data from the 1995 National Survey of Family Growth," Vital and National Statistics, Series 23, Vol. 19. National Center for Health Statistics, Centers for Disease Control and Prevention.
Interview with Dr. David Keefe, fertility specialist, Women & Infant's Hospital in Providence, Rhode Island
Interview with Pamela Madsen, executive director of the American Fertility Association
Interview with Denice Dirks
Interview with Jeanne Sandecki
National Womens Health Information Center. Infertility. July 2009.
CDC, Delayed Childbearing: More Women are having their first child later in life. NCHS Data Brief, No. 21, August 2009.