Tango, June 30th, 2007
We think the biological clock is unique to women and that men hear it second-hand, via gentle prodding or violent arm-twisting—and some, due to the volume on their televisions, never hear it at all. Is it true that most guys are seeking another decade of bar-hopping and deafening Pay-Per-View while their mates are shopping for ovulation predictor kits?
In my case, I was ready; he wasn’t. I was a month shy of 28 when I met Ben, my future spouse; he was 24. Early on we both glimpsed marriage and kids down the road, but how long was the road? On his map it was long enough to get settled into a career, save a nest egg, and watch The Matrix 500 more times. This meant engaged after two years, married a year later, and kids when the jabbing of my elbow in his side became too much to bear. I wanted three kids and figured my career could wait; I suspected my eggs couldn’t. We took his route, started trying eight months after we were married, and had a baby boy more than two yearsater—with the help of fertility treatment.
Kara and Peter Thornton (not their real names) are in the reverse situation. Before they married—when she was 25 and he was 31—they discussed having kids once Kara reached her late twenties. “Now I’m 28, but I don’t feel ready,” says Kara. “He’s really pushing for kids, but I want to develop my career, travel, have fun. Most of my friends are single; his are all having kids.” Kara and Peter, who live on Manhattan’s Upper East Side, are also at odds over where to raise a family. “He grew up in the city and wants to raise kids in the city. I grew up in the suburbs and want to raise kids there. Having this issue unresolved also makes me hesitant.” Kara expects they’ll compromise: “I could wait four years; he wants them now. We’ll probably meet halfway.”
Compromise is good for relationships. But while you’re synchronizing your heads and hearts, other vitals are seeking your attention with a barely audible cry: There are rarely symptoms of the decline in fertility that begins in a woman’s twenties or even of the plummeting of fertility ten years before menopause, which the average American woman enters at age 51.
In the last few years, the zeitgeist has shifted from “look at all those successful women having their first babies in their forties” to “all those high-achievers who have waited to have a baby are in big trouble.” In her controversial 2002 book, Creating a Life: Professional Women and the Quest for Children, Sylvia Ann Hewlett showed ambitious 40- or 50-something women who’d pursued the dream of “having it all” as facing the devastation of a nest that would never be filled. Some questioned Hewlett’s dark scenario, but her book touched off a “Baby Panic,” as a New York magazine cover described it, and a blitz of media debate (Time, Newsweek, The Oprah Winfrey Show, 60 Minutes) over the right timetable for childbearing.
Proponents of raising awareness encourage ob-gyns to bring up the subject of fertility with women before their window of opportunity slides shut. While some doctors won’t “invade their patients’ privacy” on this issue, offering advice only if asked, others, like Manhattan ob-gyn Dr. Lynn Friedman, do open the discussion, because of trends she sees in her practice. At least half of Friedman’s over-40 patients wishing to conceive end up seeing a fertility specialist, and she has found that those over 42 are usually not successful using their own eggs—a reality that catches many off guard.
“They’ll point out the one person they know who is in her forties and pregnant, and they’ll hang their hats on that one person,” says Friedman. “They’ll hear that a celebrity is having twins at age 52 and they don’t think about the possibility that she’s used donor eggs. Of course women have a right to their privacy, and generally they won’t publicize it if they use donor eggs, but it ends up being misleading to other women. I had a 45-year-old come in saying she wanted to try to get pregnant and when I explained to her that she should see a fertility specialist and look into donor eggs because she had a very small chance of
getting pregnant, she was livid. She got up and stormed out. She did end up needing donor eggs. I don’t know if she was successful or not.”
Friedman broaches the subject with married and single patients alike. “When a woman reaches her mid- to late thirties, I bring up fertility issues with her and let her know about the possibility of freezing embryos if she isn’t quite ready, or using donor sperm to be a single parent,” she says.
Of course, every movement has its backlash. Groups such as the National Organization for Women fear that fertility—awareness advocates are pressuring women into having babies before they are ready. Dr. Alan Copperman, director of the Division of Reproductive Endocrinology at the Mount Sinai Medical Center of New York and part of the top-notch team at Reproductive Medicine Associates, summarizes the debate: “It’s become an issue as to how much we should educate the public versus alarm the public as to the decline in female fertility. Apparently some of the women’s groups feel that educating young women in secondary school health education that their fertility may be falling off in their thirties may dissuade them from pursuing a career, because they are being told there’s a choice they can make: Be a mom, or be a business success. Other groups are suggesting that it is our responsibility, if not obligation, as health-care providers, to educate and say that there really is a decline in fertility. It doesn’t mean that a 35- or 40-year-old can’t get pregnant; it does mean they should be informed up front what their options are going to be and what the potential ramifications of their decisions will be.”
The bottom line? Dr. Margaret Garrisi, medical director of assisted reproduction at St. Barnabas Medical Center’s esteemed Institute for Reproductive Medicine and Science, encourages people to be proactive: “Come up with a plan for having children, just as you would plan for your education or your career.”
Step one, for most people, is finding a like-minded mate. Psychologist Susan Heitler, Ph. D., author of The Power of Two, advises couples to discuss kids early on in their relationship. “If your visions are significantly different, move on,” she says.
Beverly and Bill Nobles of Houston, Texas, reached the decision to have their two kids despite some initial reservations and a significant age difference to consider: She was 28; he was 48 and already had a teenage son. “I was a little hesitant about starting a second family,” recalls Bill, “but it wasn’t hard to convince me. I didn’t get to experience everything the first time around.”(He and his first wife separated when his son was four.) As far as timing, Beverly says they didn’t worry about his fertility—an area where men have the clear advantage—only about Bill’s age as a father. “Once we were married, I felt like it was time, for both of us; all my friends had already started having kids,” she says.
Heitler advises “older” newlyweds to take the plunge, the way the Nobles did: “Conventional wisdom said that being married for a year before conceiving a child was a good idea. That has its merit, in that a significant number of couples who are genuinely ill-suited for each other, or for marriage, do divorce in the first year. However, people marry so late now that this window of experimental time is no longer an option. Better to just go for it, and to fix whatever marital problems emerge, than to forego being able to have children at all.”
Fine, if you both know unequivocally that you want them, but what about couples who find themselves see-sawing on the decision, and even wondering whether to have kids at all? “Kim brought up the subject of having children about six months into our dating,” says Michael Civisca, a 41-year-old singer who lives with his new wife in Buffalo, New York. “Because of my career and exposure to every misbehaved child that ever existed in restaurants and candy aisles, I wasn’t in favor of it.”
Kim had always wanted kids, and “slowly Michael started saying he could see himself having them,” she recalls, “but he wanted us to be financially stable and have the time to devote to them.” Now Kim, a 36-year-old lawyer, is the one who is stalling: “I’m so wrapped up in building my business that I think I’d have a nervous breakdown if I became pregnant.” Michael expects they’ll try in a year or two. He prefers “visions of attending my child’s college graduation standing up, not sitting in a wheelchair.” But, he adds, “I’ve seen countless friends with children in two-career homes. It isn’t pretty, and neither are the parents
after a while. I believe a married couple should enjoy their marriage first.”
Dory Hottensen, a clinical social worker who teaches a seminar entitled “Deciding to Have a Baby—or Not” at the 92nd Street YMHA in Manhattan, reports a trend away from the classic she’s-ready-he’s-not scenario. “Usually it’s the woman who is ambivalent and the man who is all for it,” Hottensen says of her seminar attendees. “Women are concerned with the physical aspects of pregnancy, self-image, and the effect on their careers. They’re feeling pressure to ‘do it all’ and they aren’t sure they can. Men take more responsibility in childcare than in times past, but ultimately most of it falls on the woman.” Hottensen’s course covers the concrete issues—finances, living situations, support—and deeper psychological issues, such as fears about parenting that stem from childhood. “Couples need to explore all the pros and cons as deeply and completely as they can and understand that some ambivalence is normal,” she says.
And Diane Sollee, who as Director of the Coalition for Marriage, Family, and Couples Education sees many couples debating when to start a family, believes a little mutual soul-searching, and even conflict, now can reap benefits down the line. “The research is clear: It’s never the issue but how you
handle it that is key,” she says. “There will be many intense issues about little Johnny besides when to have him. This is a good issue around which to hone couples skills so Johnny will grow up with two happily married parents.”
CONCEPTIONS & MISCONCEPTIONS
Since the first “test tube” baby, Louise Brown, was born in 1978, doctors have brought more than one million IVF (in vitro fertilization) babies into the world. The next frontier is egg cryopreservation (freezing a woman’s eggs and then thawing, fertilizing, and implanting them years later), which has been successful in about 75 cases worldwide, though the rate is still one percent per egg, at best. Researchers also have been removing ovarian tissue, freezing it, and then transplanting it back into the body. Doctors in Belgium froze the ovarian tissue of a cancer patient seven years ago, before she underwent chemotherapy. Last September, she had the first baby ever born from an egg produced by re-implanted ovarian tissue.
Life expectancies are increasing; the window for motherhood is too. As the next generation of women head out to buy their first business suits, they may be able to stop off at the egg bank, make a deposit, and buy themselves more time —a decade or two—before shopping for maternity wear. Dr. Zev Rosenwaks, director of the renowned Center for Reproductive Medicine and Infertility at Weill Medical College of Cornell University, predicts that, in the long-term, doctors will be able to “reproduce eggs, maybe reproduce sperm, and make infertility obsolete.”
But for now, as Rosenwaks cautions, a woman’s best chance of becoming a mother lies with her natural eggs. Your best plan is to get informed about your fertility—don’t assume that if the stork won’t bring you a baby, your doctor can.
I.
Misconception “Fertility starts to decline in a woman’s late 30s and most women can have children naturally in their 40s.”
Reality Fertility begins to decline gradually in a woman’s late 20s and goes into a free-fall around age 40. By age 42, a woman has less than a ten percent chance of getting pregnant without donor eggs, and many fertility clinics discourage women over 43 from attempting to get pregnant with their own eggs.
When the American Fertility Association surveyed more than 12,000 women in 2001, many incorrectly assumed that the waning of female fertility begins in the late 30s. They were way off. “A woman’s fecundability—her chance of becoming pregnant in a single month—falls from at least 20 percent in her 20s, to between 10 and 15 percent in her mid-30s, to 10 percent at best at age 40, to a mere 2 or 3 percent by age 45,” estimates Dr. Copperman. With an average age of 38, many of the patients at his practice “are going to have egg-quality issues,” he says, which lead not only to problems getting pregnant, but also to increased miscarriage rates and potential genetic abnormalities. Dr. Copperman advises that any woman over 35 should go in for an evaluation “sooner rather than later. Certainly after six months of timed trying, it’s time to investigate.”
II.
Misconception “The best way to conceive is not to have sex for a week and then give it one good shot when the woman’s temperature goes up.”
Reality Having sex early and often—about every other day from about four days before a woman thinks she’s going to ovulate until a day or so after—makes conception most likely. If you wait for a week, Dr. Copperman explains, “First of all, you’re going to have a whole bunch of old sperm there, rather than fresh sperm if the man had ejaculated a day or two before. Secondly, part of the time, you’re going to miss ovulation. Ideally, you really want the sperm there before the egg is released.” Sperm can survive for several days, while the egg loses viability quite rapidly, some estimate within 24 hours. While day 14 is the standard, the time of ovulation varies from woman to woman and sometimes from cycle to cycle. Charting temperature, noting cervical mucus changes, or using ovulation-predictor kits will help a woman become more familiar with her cycle and determine the best time to conceive.
III.
Misconception “Just relax and you’ll get pregnant.”
Reality There is no convincing scientific evidence to show that stress leads to infertility. Anyone struggling to conceive has probably been advised to “just relax,” by well-meaning friends and family. However, this suggestion has no basis in science and can be hurtful, as it implies that the woman’s actions or frame of mind are causing her infertility—that it’s her fault. “There really is no difference in fertility if the woman is extremely anxious, if she’s a trader on the stock exchange, or if she’s meditating in Tibet,” says Dr. Copperman. There is the same chance of an egg and sperm getting together, the same chance of a pregnancy ensuing, the same chance of a miscarriage.
IV.
Misconception “Birth-control pills decrease fertility.”
Reality Birth-control pills have not been shown to decrease fertility; actually, the pill can help protect fertility and may reduce the risk of ovarian cancer by up to 40 percent. Pill users may experience a decrease in the likelihood of endometriosis and tubal diseases, as well as the alleviation of some symptoms of polycystic ovarian syndrome—all of which can lead to infertility. Also, recent studies suggest that in the couple of months right after a woman stops taking the pill she may experience a boost in her fertility; i.e., this is a good time to try. However, the pill does not enable a woman to stockpile eggs for future use.
V.
Misconception “Condom use doesn’t relate to fertility.”
Reality The use of condoms decreases the risk of contracting sexually transmitted diseases, so condoms do protect fertility. Fifteen million new cases of STDs are diagnosed each year in the U.S. Many more STDs—which often show no symptoms—go undiagnosed and untreated, making it even more likely they will lead to fertility problems. Women have it worse than men: STDs are transmitted more easily to women and they cause more damage to the female’s delicate reproductive system. In women, STDs can cause pelvic inflammatory disease (PID—a common cause of infertility) and tubal disease (which is implicated in about 20 percent of infertility cases), scarring ducts and tissues and increasing the risk of ectopic pregnancies and miscarriages.
VI.
Misconception “A big, strong guy is usually more fertile.”
Reality Physical size and strength do not correlate to sperm count. A “male factor” is involved in as many as 50 percent of infertility cases—odds which justify the brief embarrassment of producing the sperm sample. (Fertility clinics have private rooms with pornographic media for this purpose, and many clinics allow patients to tote a sperm sample from home as long as it can be brought in promptly.) The process is certainly more pleasant than much of the prodding and pricking female patients must tolerate. “I think every couple having trouble conceiving should undergo a semen analysis, certainly prior to performing any invasive procedures on the wife,” says Dr. Copperman.
VII.
Misconception “Birth-control pills decrease fertility.”
Reality Birth-control pills have not been shown to decrease fertility; actually, the pill can help protect fertility and may reduce the risk of ovarian cancer by up to 40 percent. Pill users may experience a decrease in the likelihood of endometriosis and tubal diseases, as well as the alleviation of some symptoms of polycystic ovarian syndrome—all of which can lead to infertility. Also, recent studies suggest that in the couple of months right after a woman stops taking the pill she may experience a boost in her fertility; i.e., this is a good time to try. However, the pill does not enable a woman to stockpile eggs for future use.
VIII.
Misconception “Condom use doesn’t relate to fertility.”
Reality The use of condoms decreases the risk of contracting sexually transmitted diseases, so condoms do protect fertility. Fifteen million new cases of STDs are diagnosed each year in the U.S. Many more STDs—which often show no symptoms—go undiagnosed and untreated, making it even more likely they will lead to fertility problems. Women have it worse than men: STDs are transmitted more easily to women and they cause more damage to the female’s delicate reproductive system. In women, STDs can cause pelvic inflammatory disease (PID—a common cause of infertility) and tubal disease (which is implicated in about 20 percent of infertility cases), scarring ducts and tissues and increasing the risk of ectopic pregnancies and miscarriages.
IX.
Misconception “A big, strong guy is usually more fertile.”
Reality Physical size and strength do not correlate to sperm count. A “male factor” is involved in as many as 50 percent of infertility cases—odds which justify the brief embarrassment of producing the sperm sample. (Fertility clinics have private rooms with pornographic media for this purpose, and many clinics allow patients to tote a sperm sample from home as long as it can be brought in promptly.) The process is certainly more pleasant than much of the prodding and pricking female patients must tolerate. “I think every couple having trouble conceiving should undergo a semen analysis, certainly prior to performing any invasive procedures on the wife,” says Dr. Copperman.
X.
Misconception “I’m generally healthy, so I’m sure I’m fertile.”
Reality General health does not correlate strongly to fertility, but a healthy lifestyle is important. Women who smoke throw off their estrogen levels, risk tubal pregnancy, and increase the chance of miscarriage, low birth weight, and birth defects. Male smokers significantly lower their sperm counts and increase the percentage of abnormally shaped sperm. Moderate alcohol consumption—a glass of wine with dinner—probably won’t diminish fertility, but much more than that may cause menstrual disorders and abnormal sperm production. Doctors also warn against excessive caffeine consumption while trying to conceive: Stick to one or two caffeine drinks a day. “Just say no” to any recreational drugs, as even limited use can affect male sexual function and disrupt ovulation. Being overweight or underweight—20 percent off your ideal weight in either direction—may hinder fertility in women. Moderate exercise is good, but women should avoid exercising to the point where their cycles are disrupted.
XI.
Misconception “I’ll get pregnant a month or two after I start trying.”
Reality The average couple of 30-year-olds takes six months to conceive naturally. “People think as soon as they try they’re going to get pregnant,” says Dr. Friedman. “They hear about all their friends who got pregnant in one month, but the couple who’ve been trying for a year or more probably isn’t announcing that.” About 75 percent of women will get pregnant within six months. Around 15 percent may pass the 12-month mark, which is when a couple is considered “infertile.” Before starting to try, a woman should see an ob-gyn for a check-up and make sure that all of her immunizations are up to date.
XII.
Misconception “I’ve had a baby already, so I won’t have a problem having more.”
Reality Secondary infertility—having difficulty conceiving after having conceived in the past—is almost as common as primary inferti-lity. Dr. Copperman explains that the causes of secondary infertility are the same problems many couples experience the first time around: “It could be egg quality, tubal disease, uterine problems, or even a newly acquired male factor. So even if a couple has gotten pregnant in the past, if they’re having difficulty it’s important to go through the basics—check the eggs, sperm, fallopian tubes, and uterus—because we often find that things change over time.”
XIII.
Misconception “Infertility is uncommon.”
Reality Infertility affects about ten percent of Americans of child-bearing age. Pamela Madsen, the executive director of the American Fertility Associa-tion, aims to educate the general public, employers, and legislators, but it’s an uphill battle, she says: “On a recent trip to Washington, [I was] meeting with a top Republican aide about fed-eral legislation for infertility. This aide turned to me and said, ‘Infertility? Doesn’t that only happen to anorexics?’” Part of the problem is that those coping with infertility feel alone and ashamed, and they may share their difficulties only with their very closest friends and family—if they share them with anyone. Infertility should not carry a stigma, and the more informed people are (thanks to brave souls like Madsen, who are willing to speak out about their own struggles to have children), the less isolated and helpless infertility sufferers will feel.
