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When Does Your Fertility Decline? Uh… Sooner Than You Think?

So there was an announcement made last week by the American College of Obstetricians and Gynecologists (you know, that ACOG acronym after your doctor’s name) saying that fertility now starts declining at 32 and picks up speed like a rolling snowball at 37.  So that old 35 advance maternal age line is now more like a hotel swimming pool that has a nice shallow end, then a little dip, and then a big drop off so people can dive head-first without breaking their necks.  Except it’s the opposite.  It’s more like, dive in when the water is shallow because… well… this analogy isn’t working.

The point is, they just took 3 years from your midlife plan.

Except, of course, they didn’t.  This fact has always been there whether we want to recognize it or not.  And a decline is just that, a decline.  If you were going to be infertile at 27, you haven’t suddenly gained years of fertility, and if you were going to be fertile at 40, then you get to keep going with the babymaking.  And a decline is a nice way of saying, “maybe or maybe not.”  It’s sort of the equivalent of the word “nice.”  What does nice mean?  Well, you can make it means sort of anything you want.  You know it’s not bad.  But it certainly doesn’t sound effusively good.  It’s just sort of there.  And that’s what this fact is too.  It’s just sort of there, something you’ve known your whole life: if you want kids, don’t wait.

The Daily Beast has an interesting article on how OB/GYNs walk a fine line in passing along this statistic to their patients.  It’s not difficult for a general practitioner to let their patient know how that case of sugary soda they’re drinking daily may kill them.  It doesn’t present a conflict when an eye doctor tells their patient about advances in laser surgery or a dentist broaches the topic of teeth whitening; especially when there is no pressure in the offer and it’s being held out as a possibility.  I don’t even think it’s a problem if an OB/GYN brings up the idea of egg freezing despite its success rates, the difficulty of IVF, and the cost (emotional and financial).  I look at it as education; placing the ball in the patient’s court.

But what about counseling a person to build their family before they’ve started to build their family?

Encouraging a person to take on responsibilities they may not be prepared to take?  To raise another human being?  To telling them that if they wait it may be too late, but perhaps in turn pushing them before they’re really ready due to a fear of the unknown (which may or may not affect them)?  That’s really tricky.  This advice doesn’t just affect the patient; it affects an unborn human being who may then be born into a situation where the parents are ill-prepared.

And what sort of judgment call do the doctors make?  Do they tell it to all women, regardless?  Tell it only to women above a certain age (and then, what age)?  Tell it to only married women?  Only those they think would make a great parent, or do they tell even the ones who are barely holding their own lives together?  And how do they decide that when all they really know about you is whether or not you shave your legs for the appointment or how your cervix looks?

But if it’s not the OB/GYNs job to counsel on family building, whose job is it?  And if no one is passing along the information, how do we expect women to know it?

It feels like in an effort not to offend or cajole, to not place women in an uncomfortable position socially or over-assume their intentions, everyone is dropping the ball on having this conversation, and in turn, there are plenty of women who feel blindsided when they discover that fertility declines; maybe even sooner than they thought and therefore didn’t know there was a problem they should address in a timely manner when they do start family building.

Do you think OB/GYNs should discuss family building with all women who walk into their office and if so, should it be every appointment, after a certain age, in various situations?

23 comments

1 Rachel { 02.24.14 at 8:21 am }

My doctor asked me a series of questions (Am I married? Is the marriage good? Do I feel valued? Do we have a home? Jobs? etc. etc.) and then asked if I wanted children, before imparting the “fertility declines in your mid 30s” speech. She made sure I was in that place before giving me any advice about when to have kids, which she told me should be in the next couple years for optimum fertility. It didn’t feel like she put pressure on me, and it didn’t feel forced. However, not all Doctors have her bedside manner….so I think it has as much to do with the patients place in life, as it does to do with the Doctors mannerisms.

Essentially, while imparting the knowledge is certainly beneficial, I think it’s a patients responsibility to ask the right questions and do the research. I think it’s the OBGYNs responsibility to tell us HOW to have a baby, but certainly not to tell us when. There are enough resources out there spouting the “fertility declines after 35” statement that the OBGYN isn’t the only way to know this. As a matter of fact, I’ve heard/read about how our fertility declines probably 50 times. Twice it came from my Doctor, and about 15 times it came from my own personal battles with infertility – the rest were before I was interested in fertility or from a completely unexpected source. So the information is definitely out there and if a woman is concerned, she should bring it up with her doctor to make sure she has her bases covered.

2 Michaela { 02.24.14 at 9:46 am }

I was repeatedly told “Women have children in their 40s now!”. “Oh you have time!” by many, including women.

I was told this even at 42!!!

And when I was 38 I said to my OB/GYN that I still wanted to have children and he set up a series of blood tests for me that checked my overall health i.e liver function…BUT not my fertility.

I believe that your OB/GYN should just give you all the medical facts about your downtown! That includes fertility. Remove any questions about jobs, marriages, lifestyle etc. b/c that is none of their business. The medical facts are their business. Not even a “Do you want kids?” question…just a “Here’s how it works. If you want kids, fertility declines at x,y,z…we can run some test to check…”

And they SHOULD be running basic fertility tests i.e. E2 levels, FSH etc. b/c it’s about your health as well as fertility. Hormone imbalances, not ovulating, pof, dor all effect the homeostasis of your body.

The facts about your health!

3 Chickenpig { 02.24.14 at 10:22 am }

Everything Michaela said! Also, the time to talk about fertility is all the time, starting from when girls first go to the crotch doc. And boys too! We do not get enough information on how our reproductive systems work. Girls and boys should know that vd can effect your fertility, as well as injuries and viruses. We should have tests to asses our basic ovarian function as well as a lookie loo at the uterus and tubes before we are thinking of having kids. My fibroid was already there at age 30, lying in wait. My husband’s sperm were already crap by age thirty, probably because of a combination of injury and having the mumps at age 13. (get your kids vaccinated, people!). We thought that starting a family at 30 would be a piece of cake….boy were we wrong. Our fertility had already declined to zero. Thank the gods for ICSI.

4 A. { 02.24.14 at 10:32 am }

I felt the realities of maternal age at 28, and by the time I was married at 30 I knew we needed to get started right away even though, in my heart, I was really scared and less than ready. When I would talk to girlfriends about my fears, they would swat me away with that cliche line, “You have plenty of time!” Uh, no I didn’t. I should have started 5 years earlier, and now I’m in a special kind of hell. I was likewise dismissed by my doctor, who had a responsibility to give me the medical facts, maybe count some antral follicles, etc. Or how about the number of times my various REs claimed, “You’re young! We’ll get you pregnant.” Four failed IVF cycles later…

Even now, my 36 year-old friend who is freaking out because she still hasn’t met Mr. Right, was blown off by her OBGYN when she asked about the timeline, egg freezing, and fears of declining fertility. I felt the need to counter with some reality, over Starbuck’s, even though it’s not what anyone wants to hear. Knowledge is power. It’s not about pressure to build a family. It’s if this, then that, just so you know. Life is full of difficult choices, and biology doesn’t care that career women and dual-income families are all the rage.

5 Michaela { 02.24.14 at 10:40 am }

I told my RE that my OB/GYN didn’t test for FSH etc. when I was 38 and he said the OBs REALLY need to be educated! Funny in a really sad kinda way!

If I had started at 38, I might have had a shot…

6 torthuil { 02.24.14 at 10:45 am }

I agree with above posters; put the information out there. It is also an important point that wonky hormones that maybe be cause/symptom of infertility also affect health in other ways, so it is important not to ignore them. Lots of people still just think of it in terms of egg meets sperm equals baby and it’s just not that simple.

7 LC { 02.24.14 at 10:52 am }

When my OB/Gyn first “diagnosed” me with PCOS at 2o-something, he mentioned that it might impact my fertility (in passing). He followed this up with the super useful question “How many siblings do you have?” (a bunch) “Oh, you should be fine”. Right, ’cause my Mom doesn’t have PCOS and I do…. our relative fertility stats are totally comparable (Not). But when I do get pregnant and tell my (different) OB/Gyn that my mother had all her babies before 40 weeks, that was a stat to ignore… (DD born at 37.5 weeks)

8 Ellen K. { 02.24.14 at 10:58 am }

I think Michaela’s suggestion (“Here’s how it works”) is a good one. I would like to think that all women have access to the basic facts that we, in the infertility community, know too well. But they don’t — or all too often doctors downplay the fertility decline. For most women, at least in the U.S., the annual well-woman exam is their only regular health checkup, and the obgyn has a prominent role. Several of my unmarried or newlywed friends in their mid and late 30s have been told by their obgyns that “they have awhile yet” or “women can have babies well into their 40s.” That’s it. These friends have then eagerly told me this news, and of course they are relieved because the doctor is a trusted source, as opposed to news articles and nagging comments from pesky relatives or co-workers. But I feel that the obgyn is doing them a big disservice. Sticking to clinical facts is best — similar to presenting other health information about breast examinations, cancer risks, etc. They aren’t supposed to wait until a patient asked for information on smoking, alcohol use, overweight, etc. — yet some physicians do gloss over these topics to avoid possibly offending and losing a patient. “The doctor never told me” is sometimes the truth.

9 deathstar { 02.24.14 at 11:33 am }

Here in Canada, you don’t see an OB/gyn unless you have a medical problem, so you see your family physician for annuals Paps and such. Years ago, my doctor noted that I used the withdrawal method for birth control and said well, you could get pregnant and are you alright with that? (Hahahaha. Joke was on me.) I don’t know if doctors have time to discuss family building with you, even when you ask. Seems to me that they don’t really know that much about it until after the fact. They assume you’re fertile until you are actively are trying for a year or have other mitigating factors. I think that when you start going in for your annual Pap test they should just hand you a pamphlet, a well written and researched one. They start pushing mammograms at 40, there’s no reason they can’t start pushing pertinent info when you’re 30.

10 fifi { 02.24.14 at 11:35 am }

Honestly, if my obgyn had told me at the age of 32 that my fertility was on the decline, I would probably have answered tetchily “yes, I KNOW. Doesn’t everyone?” The biological clock is such a big trope in modern media that I find it hard to believe that that people are ignorant of it. Between the ages of 30 (when I split up with my ex-boyfriend) and 34 (when I met my husband), it was to the forefront of my mind more often than was healthy.

11 Jessica { 02.24.14 at 11:37 am }

My RE offers a fertility test package, where I assume they test your hormones and follicle count, for $99. It would be great if this was just offered through your OB every 3 or 4 years. Informed decision making sure beats hysteria.

12 fifi { 02.24.14 at 11:40 am }

Although having said that, information from a doctor is going to be more factual and less emotive than information from the mass media, so I agree with some of the posters about providing the facts. Just because it wouldn’t have helped in my case (because I was already aware of the stats but was unwilling to become a single mother), doesn’t mean that it wouldn’t be useful for other people.

13 Sharon { 02.24.14 at 11:55 am }

I agree, this is a tricky one for doctors. My OB/GYN when I was 27 suggested I have a child (as a “cure” for irregular periods–which it turns out had only become irregular temporarily due to shift work and stress), and my reaction was “Are you kidding?! I’m not even in a relationship, let alone ready to become a mother!”

I am sure that I would have been convinced that I would have been one of the fortunate few who would’ve remained fertile into my mid-to-late 30s no matter what I was told because both my grandmothers conceived children readily and without intervention after age 35. In fact, that’s exactly what happened in my life, and it turned out I was wrong.

14 loribeth { 02.24.14 at 12:04 pm }

I would prefer that drs err on the side of too much information vs too little. My own family dr is a fine dr for the most part, and has excellent connections for any specialists we might need to see… but when I first mentioned my fertility concerns to him (in my mid-30s), he basically patted me on the head & told me not to worry, it would happen.

The province of Ontario had a special task force on fertility & adoption a few years back… among the recommendations were several to do with family drs providing fertility information & possible referrals for testing to female patients as part of the annual checkup. I don’t think many of the recommendations have been implemented to date, however. 🙁

15 kateanon { 02.24.14 at 12:10 pm }

I had to fight for my first RE appointment. Even though I had waited the requisite time, and had other factors medically to worry about, I was cautioned by my primary MD, my ObGyn and my insurance company to wait, as I was in my early twenties. The primary told me I could be having children anytime in the next 20 years. That was my last visit with him. I think most women are somewhat ignorant about fertility and getting pregnant until they try and have a problem. Friends who’ve conceived easily always reply with “you have time” or “it’ll happen when you stop trying”, etc.

I don’t think our ObGyn’s spend enough time educating. I don’t want anyone to feel rushed or pressured, but informed, yes. I would rather know and decide against trying then wait and find out too late, that I perhaps should have re-thought my timeline.

16 Catwoman73 { 02.24.14 at 12:20 pm }

I totally agree that the information needs to be put out there in a non-judgemental way, so that women can make educated choices. But OB’s need to be careful how they approach the subject of declining fertility- as a woman who didn’t even meet my husband until I was on the cusp of turning 33, the last thing I wanted to discuss at 28, 30, or 32 was my ticking biological clock. I already felt badly that everyone I knew was married and having babies- I didn’t need any reminders that I had yet to join the club. I certainly didn’t have the financial means at the time to even consider something like egg freezing, so reminding me of my declining fertility at the time would have felt like badgering me about something over which I had absolutely no power. It is such a sensitive topic, and needs to be approached carefully. I think a pamphlet in the office waiting room, that I could have chosen to read or not read, would have been fine for me.

17 Mali { 02.24.14 at 6:00 pm }

“And that’s what this fact is too. It’s just sort of there, something you’ve known your whole life: if you want kids, don’t wait.”

This needs to be taught in sex ed. It’s something that shouldn’t depend on relationship status, age etc. As we learn before our periods start that they will start, we also need to learn that our fertility will decline in our 30s. Unfortunately, I can’t say I knew this. I knew there was a decline, but not how dramatic it would be. It was not something that was talked about when I was growing up – I was of the era when we were celebrating the lifting (not smashing) of the glass ceiling etc, and when delaying child-bearing (for whatever choice – but career was up there) was becoming accepted and in fact an exciting development in the change in how women were seen in society. Celebrities having children into their 40s just reinforced the view that we really COULD choose! Sigh.

18 Queenie { 02.24.14 at 6:42 pm }

I like the idea of starting in sex ed, and making it a part of routine healthcare. That way, there’s nothing sensitive about it, and everyone learns and understands long before it’s likely to impact their life decisions. I definitely had this discussion with my doctor after my first miscarriage, but only because I brought it up, and specifically asked whether I could wait a bit longer (I think I was about 35 at that point) for work reasons. Her answer was that I could wait a little bit (like a year or so), but she didn’t want me to wait much longer than that, and only thought that was okay because “we knew I could get pregnant.” It all worked out for us, but I can see that advice going astray for others. I think OB’s also need to be better educated about fertility issues.

19 Brid { 02.24.14 at 6:55 pm }

I have never received good information or assistance from doctors, which has now led to a massive distaste for them. Distaste is too easy on them. Google is the answer. The only help I ever got from a doctor was the C-Section. Other than than that… useless. I even got the “just relax” thing from TWO DIFFERENT doctors, about SEVEN years apart. I’m not a violent person, but let me tell you…
Usually, if I’m going to a doctor, I’ve already googled/google scholared extensively, so really, they’re only good for referrals and requisitions.

20 St. Elsewhere { 02.25.14 at 3:43 am }

It’s depressing…that lowering of age.

What if routine hormone testing got relegated with the annual Pap Smears? Will that be more informative for the women. A lot of people I know would not care to ask their doc anything fertility-wise, unless they had any issues in their department. So is it the OB’s job to lecture them on it? I don’t really know and wouldn’t want to make blanket generalizations, really.

21 a { 02.25.14 at 9:16 am }

Maybe this should be a topic covered in middle school health classes. Educating kids about the delicate balance between the need to wait until you’re in the right place in your life to raise children and the need to hurry up and have those children before you can’t any more might be the less-stress way to go. Or maybe it’s too mature of a topic for middle school.

At any rate, the increasing number of things that people are completely in the dark about is starting to scare me.

22 Sara { 02.26.14 at 11:31 pm }

I don’t think that doctors should decide who is ready for information. Obviously there is a certain amount of judgment involved in HOW to present information to different people (they might want to consider using different language when talking to a high-school-educated office worker vs. a professional biologist, for example), but I don’t really see why they should make judgments about who is ready to have children. A single person can be a great mom (or could use the information to adjust her plans regarding how she prioritizes relationships), and a married, wealthy person could be totally unprepared for parenthood or just uninterested in it. I think that providing useful information should be a standard part of routine care. If time is a problem, pamphlets could be used and then the discussion could involve follow-up. People need to know this stuff. Men need to know this stuff too (many men don’t seem to realize that the female biological clock affects them too!), so maybe it shouldn’t just be GYN’s spreading the news!

23 kirstenkarch { 02.28.14 at 1:35 pm }

This represents such an incredible dilema for women. If feel like we should not be cajoling wormen to get pregnant earlier than they are ready to, but at the same time, as health care providers, it is important to help educate women about what is happening to our fertile bodies as we age and help them to make informed decisions about family planning to limit the risk exposure to not being able to realize their dreams of having the family they desire because they thought they were fine to conceive until they were late into their 30’s or early 40’s.

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