Fertility after forty? Don’t Count On it.

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Age can be a touchy subject for many women. This is particularly true when talking about age and fertility. However, I always feel it’s best to give my OBGYN patients in Queens and Long Island straightforward, honest information about their health. Women everywhere should be aware that their fertility declines with age.

Your age affects the health of your eggs. Women reach the peak of their fertility at around age 24. After this age, egg quality slowly deteriorates until around age 37, and then deteriorates more rapidly until about age 42. After roughly age 42, fertility for most women basically falls off a cliff. While some women in their mid-forties will achieve a pregnancy, many more will be disappointed.

I have this conversation with patients several times each week. Here’s the typical scenario: A patient in her forties tells me that she wasn’t ready to start a family earlier. Maybe she was focused on her career, or had a first marriage that didn’t work out. Closing in on age 40, she meets a special partner, and they start getting serious. After courtship, marriage, and a few carefree early years, she’s finally ready to have a baby. She’s been trying for 6 months and nothing has happened.

This is where the tough conversation starts. For women who have passed their reproductive prime, solutions may not come easily. Some women will respond to fertility treatments. Some women may choose a donor egg. Others may choose adoption. And many, many other women will be disappointed.

As I see it, age-related fertility decline is a public health emergency in this country. This problem can be soul-crushing for women, totally disrupting their life plan. But worst of all, many women are completely unaware that fertility is typically impaired after age 40. A study (admittedly, funded by a pharmaceutical company) found that the overwhelming majority of women interviewed did not realize that 70% of women over 40 will experience problems with fertility.

I have three recommendations to help spare women the painful experience of not being able to conceive in their forties.  

#1. Be Realistic with your Life Plan

For many ambitious women, childbearing is an afterthought. First, they want to get that promotion, make partner, finish their training, buy their home, etc. Certainly, I respect women who take their professional goals seriously, but women should realize that these choices may sometimes require a serious sacrifice: Women who PLAN to start their family in their forties are setting themselves up for disappointment.

Other women let bad relationships get the best of them. Maybe they are with a long-term partner who is not ready to commit, or they are already married but the marriage is failing. I’m not advocating jumping ship at the first sign of trouble. Rather, I advocate for fertility awareness: Women should be aware that their peak reproductive years occur from age 20-35, and plan accordingly. After age 35, women do not have time to wait for their guy to grow up, or to hope for a dead marriage to come to life. If having a family is part of their life plan, they must make changes, or move on.

#2. Seek Consultation Early for Fertility Issues

It takes an average of five months for healthy young couples who are trying to conceive to achieve a pregnancy. Some couples will be successful in the first month, and other healthy couples can take up to a year to conceive. This can be completely normal, so ob/gyn guidelines suggest that no fertility workup is required during the first year of trying: A nervous young couple who are concerned that they haven’t achieved a pregnancy after a few months without protection can be appropriately reassured, and advised to return to the office after a few more months of trying.    

But for women over age 35, a year is too long to wait. At this age, the clock is tick, tick, ticking. Women over 35 who want to conceive should be proactive, and should seek consultation with a fertility expert early in the process. The current recommendation is for women in this age group to seek consultation after 6 months of trying to conceive, but I’d be happy if women made an appointment after 3 or 4 months. This is not to suggest that every woman over 35 with a few months of unprotected intercourse under her belt should have aggressive fertility intervention, but a little education early in the process goes a long way. Women can be counseled to correct some bad habits (stop smoking, or maybe lose some excess weight), coital timing can be discussed, and a realistic timeline for intervention can be established.

#3 Consider Freezing Your Eggs

Unlike men, who continue to make new sperm every day, women are born with their entire life’s supply of eggs. Over time, these eggs tend to deteriorate. Women in their forties may still release an egg every month, but the quality of the egg may not be adequate to achieve a successful  pregnancy.

Wouldn’t it be great if we could take a few eggs when women are at their reproductive peak, and store them for later use? Wouldn’t that give many women an opportunity to see where life takes them, to accomplish their professional goals, or to let their relationships take their natural course? This would take so much pressure off women, giving them the opportunity to conceive when the time is right.

It seems like science fiction, but the option of freezing one’s eggs is increasingly becoming mainstream. Once reserved for women with medical needs (e.g., to preserve eggs prior to chemotherapy, which can be toxic to the ovaries), cryopreservation of healthy eggs is now more commonly used for women to electively take control of their fertility.

The process of egg freezing (oocyte cryopreservation) typically involves using injectable medications to stimulate many eggs to develop, and then undergoing a minor procedure (egg retrieval) to collect the eggs. Eggs can then be frozen indefinitely for later use.

Probably the biggest obstacle today is cost: The whole process—including medications, monitoring, and retrieval—costs thousands of dollars, and (in the absence of a medical condition) is generally not covered by insurance. As with all medical interventions, there are risks, both medical and emotional. Women must consider whether they are willing to assume the ongoing costs of storing their frozen oocytes, and also consider what will be done with their frozen eggs if they are not needed.

We refer women who are interested in freezing their eggs to reproductive endocrinologists (i.e., fertility specialists). We work with several individuals and groups throughout Brooklyn, Queens, and Nassau with programs and protocols in place for cryopreservation of oocytes.

Women should start thinking about freezing their eggs before it’s too late. The exact timing will depend on a variety of factors, including ovarian function and life circumstances, but it generally makes no sense to freeze eggs at age 40, since oocyte quality is already impaired at this age. In general, women should have this conversation with their gynecologist around age 30, or before.

I make a point of initiating this discussion early, so women can decide what steps they wish to take to preserve their fertility. I’m relieved that after counseling, some of my patients have chosen to freeze their eggs. I rest easier knowing that they’ve got options.

Personally, I believe that age-related fertility awareness should be consciously taught—by mothers, by schools, and by the media. Women should be aware that fertility declines markedly as they age, and should plan accordingly.  In this age of personal empowerment and unrestricted access to medical advice, women should not be blindsided with this information after reaching age 40. 

The decision to preserve your eggs is highly personal. It’s best to talk through your options with a trusted and knowledgeable resource, like your gynecologist.

We’re ready when you are.

A clinical message from Dr. Andre Saad, FACOG


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