It’s not uncommon for me to be asked by a patient, “So, how much time do I realistically have left in my fertility? When should I really start to get stressed about having kids?”. And it’s not a surprising question, given we’ve seen the average age of motherhood, and first-time mothers, increase. In fact, according to the CDC, the amount of births to women over age 40 has increased 2% since 2016, and has been slowly increasing over the last few decades. We have societal changes, and medical advances, to thank for these statistics; more women are in the workforce than in decades past, and medical advancements in fertility have helped women achieve successful, healthy pregnancies at older ages. My answer for when you should get pregnant? Whenever that time is right for you. While it’s important to understand and consider your body’s own limitations (When do certain risks increase? Around what time will I no longer be able to naturally conceive?) it’s also important to educate yourself on your options- and follow a timeline that makes sense for you.
So what is fertility, exactly? To put it simply, fertility is the ability to conceive a child. Unfortunately, there is no 100% accurate way to predict fertility aside from getting pregnant. According to UptoDate, about 80% of couples will conceive within 6 months of actively trying to conceive, and 85% within 12 months. But what if you’re older, or wanting to wait later to have kids? How could that impact your chances?
Advanced Maternal Age: what is it, what are the risks?
In the healthcare world, we consider pregnancies to be of “advanced maternal age” when a patient is 35 years of age or older at time of delivery. It’s a harsh term, sure, but it is an important one. Why? Certain risks can increase when you’re over a certain age. It doesn’t mean they’re bound to happen, but it does elevate your chances of having a bumpier pregnancy (or time trying to conceive) than, say, a 22 year old. According to ACOG, fertility begins to decline at age 30. By age 45, ACOG says, it is extremely unlikely that a woman could naturally conceive (meaning, without the help of assisted reproductive technology, or “ART”). The risk of miscarriage also increases with age; uptodate states that rates can be as high as 40% in those at or over age 35. But if you have eggs left- if you’re still having a period and still ovulating- then you should be able to get pregnant, right? Not necessarily. While egg reserve (or how many eggs we have left) is important, the quality, and health, of those eggs is equally so. Aging can mean a smaller reserve of healthy eggs, which can increase the risk for chromosomal abnormalities, such as down syndrome. Additionally, older age can also increase the likelihood of anatomical conditions that can impact successful conception and pregnancies, such as fibroids and endometriosis. During pregnancy, mothers over the age of 35 are at an increased risk of certain complications, like preeclampsia, gestational diabetes, and placental problems. This all sounds grim, but here’s a positive: a healthy pregnancy at age 35 or older is possible, and is actually fairly common. As a healthcare provider, I like to counsel patients who are considering pregnancy at an older age (or at any age!) to maintain a healthy lifestyle. Avoid alcohol and smoking, exercise regularly, eat a healthy diet, get plenty of sleep, drink lots of water, and practice healthy stress-management. I know that all of this is much easier said than done, but starting your conception and pregnancy journey off with a healthy baseline will set you up with a higher chance at success. If you’re healthy, the chances of having a healthy pregnancy are good- at 22, or at 37. Aside from maintaining a healthy lifestyle, fertility preservation options, such as egg freezing and IVF, have become much more mainstream in order to help women reach their childbearing goals.
Fertility Preservation
Older eggs can make pregnancy, and fertility, trickier, but what about an older uterus? A uterus, even at an advanced maternal age, can still successfully carry a healthy pregnancy. According to UptoDate, “reproductive aging is primarily related to the age of the oocyte (the egg) and is influenced very little, if at all, by the age of the uterus”. Enter reproductive endocrinology and advanced reproductive technology. These medical advances have paved the way for higher rates of conception and pregnancy, particularly in those 35+. Because the information about these procedures can be confusing, I turned to a knowledgeable friend for some explanation. Ellen Rogers, a women’s health nurse practitioner currently practicing in fertility, says, “There are lots of great options for women today. We have the capability to freeze eggs, or create and freeze embryos (with donor sperm or partner’s sperm) for use in the future, or even attempt pregnancy with the use of donor sperm now”. Below, you’ll find my Q & A with her regarding two very popular procedures, IVF and egg freezing.
In Vitro Fertilization (IVF)
What is IVF?
According to Ellen, “In Vitro Fertilization is the process in which fertilization takes place outside of the body, in a controlled lab. It involves a series of daily injections to generate multiple eggs over the course of around 10-14 days. During that same time period, multiple blood draws and ultrasounds are also performed. The eggs are then surgically removed during a process called an egg retrieval. The eggs are then inseminated (combined with sperm) outside of the body. Once the eggs fertilize, they are then called embryos. The embryos grow in the lab for 5-6 days before an embryo is transferred back into a woman’s uterus, or before they are frozen for genetic testing”.
Who should consider IVF?
“IVF is the most aggressive form of fertility treatment we have to help individuals or
couples overcome infertility. It can also be used for individuals or couples who do not have any fertility issues, but who want genetic testing performed on their embryos prior to pregnancy. For those dealing with a diagnosis of infertility, specific populations who should consider IVF include women with diminished ovarian reserve or advanced maternal age, women with blocked fallopian tubes, women with long time unexplained infertility who have failed other treatments, or couples needing to use a surrogate”.
What is the genetic testing for?
“We now have the capability to screen embryos for chromosomal abnormalities. We call this preimplantation genetic screening (PGS). It has been such a game changer in the world of IVF. PGS has increased success rates of IVF across the country. It is a great option for women over the age of 35, because we know that women over the age of 35 have an increased risk of miscarriage due to chromosomal abnormalities associated with older eggs. Anyone planning to go through IVF should consider doing PGS, but I would strongly encourage women 35 or older to consider PGS”.
Oocyte Cryopreservation (Egg Freezing)
What is egg freezing?
“Egg Freezing begins similarly to IVF, by hyperstimulating the ovaries with injectable medications over the course of about 10-14 days. Once a reasonable number of eggs are considered to be mature (via ultrasound), the ovaries are then triggered with an injection to induce ovulation. We like for at least 50% of the egg cohort growing during the cycle to be mature before we trigger ovulation. The eggs are then retrieved surgically during an egg retrieval. The lab will freeze any mature eggs retrieved from the surgery. It involves daily injections and multiple visits to a fertility clinic for ultrasound monitoring and blood draws. The recovery time from the egg retrieval surgery is minimal”.
Who should consider egg freezing?
“There’s no great, concrete answer to this. Ideally, any woman who knows that she would like her own, biological child one day should be considering her fertility options. More women are delaying childbearing these days, sometimes even into their 40’s, for a variety of reasons- careers, lack of a male partner, finances, travel, and so on. Egg freezing is a way to preserve those younger, healthier eggs, so that women have the freedom to delay childbearing with more peace of mind. I think women in their early 30’s, who aren’t currently ready for pregnancy, should be thinking about their options and having discussions with their healthcare providers about their fertility. Based on the results of some simple blood testing, women can reasonably decide if they want to freeze their eggs sooner rather than later, or not at all. Another population that we are unfortunately seeing more of and should be considering egg freezing are women set to undergo treatment for cancer. Due to the increased awareness of egg freezing and advances in technology, we are freezing more eggs for patients undergoing chemotherapy or radiation treatment for cancer (prior to initiation of therapy)”.
The Good News
The good news is that, if you’re considering a later child-bearing path, there are options. Natural, healthy pregnancy and childbirth after 35 is not only possible, but extremely common. For those struggling with infertility, or those considering single-parenting (via donor sperm, donor egg, or surrogacy), IVF may be a great option. If you’re considering single parenting, check out this organization, which provides resources to those thinking about, in the process of, or currently mothering solo. The Single Mothers by Choice organization also helps to connect women locally, so that support is never too far away. If you’re entering your late 20s or early 30s and know that childbearing is not in the near future, it may be worthwhile to discuss fertility preservation options, such as egg freezing, with your healthcare provider or with a fertility specialist. Being proactive about your health and future goals is an important step in the overall process to achieve pregnancy- on your own time.
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Resources
https://www.acog.org/Patients/FAQs/Having-a-Baby-After-Age-35-How-Aging-Affects-Fertility-and-Pregnancy#are
https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Female-Age-Related-Fertility-Decline
https://www.asrm.org/
https://www.uptodate.com/contents/fertility-preservation-for-deferred-childbearing-for-non-medical-indications
Kara Earthman, WHNP-BC
Kara Earthman is a Nashville-based women's health nurse practitioner and writer. Kara's work and advice have been featured in both Healthline and Modern Fertility.
