Thursday, September 8, 2011

Pregnancy at 40 -- How realistic is it?

Why is it that some women wait until they are 40 to begin trying to conceive? Is it that finally their lives have settled down enough to contemplate children as the next step? Are they in a new marriage that they hope will be blessed with parenthood? Is the tick of the biological clock getting louder and louder? Are they feeling out of sync as some of their friends are anticipating grandparenthood? Or, as a recent New York Times article posed, do women who physically look much younger than their age actually believe their 40-year-old eggs are up to the challenge of conceiving a healthy baby?

Certainly there are many reasons and circumstances that cause a woman to try to become pregnant. But waiting until age 40 is risky, no matter what one’s motivation. Particularly worrisome is the belief that it’s just fine to wait until the time “seems right.” I would be the last person to advocate trying for a pregnancy when the timing is all wrong – that’s risky in a different sort of way, as the consequences of adding a new baby to an already stressful life can be devastating for all concerned. But if there is a guiding assumption that becoming pregnant at (or after) 40 is a breeze for a healthy woman, then we need to challenge that assumption.

Let’s start with the information most of us were given in eighth grade health class: females are born with all their eggs, as opposed to males who begin producing sperm at puberty and continue to do so into old age; neither old eggs nor sperm of older men are as healthy as those of younger adults. Defective sperm or eggs can be at the source of infertility, pregnancy loss, or congenital defects in newborns. The most healthy fertile years for women are in their twenties, when their bodies are mature, when their eating habits (hopefully) are healthy, when they can understand what they are reading about good reproductive health, and when they are capable of restricting behaviors known to harm developing fetuses, such as smoking, drinking, or substance use.

So how is it that some women reach their forties assuming that conceiving and carrying a pregnancy to a healthy birth will be a smooth process? Some of these women have forgotten their eighth grade health class lessons and haven’t brushed up in the intervening years; others have never initiated a discussion with their ob-gyns about fertility and the risks of first trying to conceive in their late thirties; and still others, who have done everything to keep their bodies supple and young-looking, believe mistakenly that their bodies contain young and healthy eggs. In fact, their eggs are aging, with higher risks for chromosomal abnormalities, and their hormone levels are progressing closer to those of menopause with each passing year. By the time a woman is 40, most doctors would agree that her chances of getting pregnant each month are approximately 5 percent.

But women are increasingly being influenced by the sensationalist magazines in the grocery store, the Hollywood stars celebrating birthday number 40 with a baby (or multiples) in arms, and the television coverage given to sex-symbol actresses who, at age 40, are embracing new parenthood. No longer are woman and their partners being guided by the factual information about aging eggs and infertility. Or aging eggs and pregnancy loss. Or aging eggs and birth defects. Now only a prolonged inability to conceive or unexpected news from prenatal tests may be what shocks them into conversations with their ob-gyns or propels them to an infertility clinic.

That is when they are likely to learn the news that the Hollywood coverage never revealed: that donor eggs, donor sperm or a surrogate may be necessary for a woman in her 40’s to have a baby. This then becomes a new pathway that some couples decide to pursue. And for couples with determination, energy, patience and a significant amount of money, they may yet be able to bring a baby into their lives. But others may be deterred at the immense disruption that medical, legal and financial efforts will introduce into their relationship, their health and their work lives. For those women and their partners who once believed it was possible to use Hollywood as their guide in matters of fertility, the wake-up call may have come too late. And with more and more domestic and international adoption agencies placing age limit restrictions on prospective parents, the feelings of loss become even more profound.

How can we move beyond this gulf of misinformation and move women and couples more realistically in the direction of planning for parenthood? Clearly it would help if the Hollywood new 40-something parents would come clean and be open about the extraordinary means (including financial) they have pursued to welcome children into their lives. It also would be an important medical contribution if ob-gyns and Planned Parenthood staff would routinely query their patients about whether and when they are thinking about conceiving. And if those same reproductive health care offices had literature about infertility and pregnancy loss on their tables that are too often crowded with parenting magazines, it might lend a bit of balance to the way women view the issues on which their doctors can advise them.

Women have worked far too long for reproductive freedom to be thwarted by an unexpected twist of fate in our late 30’s and early 40’s. We need to talk with our peers, to encourage balanced reading material in ob-gyn waiting rooms, to raise with our sons and daughters the issues we hope they remember from their health classes, to advocate for insurance companies to cover costs associated with infertility, and to remember that reproductive advances come with many costs at many levels that just may be too much for the prospective 40-something parent to afford.