When I was
35, unmarried but still hoping for children someday, I asked my doctor if I should be
concerned about my chances of getting
pregnant as I got
older. Not at all, he assured me:
Women are having children into their 40s nowadays.
You have plenty of time, he said.
That was more than ten years ago, just as a boom in "late-timing"
motherhood began. Birthrates for U.S. women in their 30s—and 40s and 50s—have increased dramatically since
then. (For a rundown on the statistics, see "The Aging of Pregnancy in
America.") Celebrity culture has kept
pace featuring pictures of 40- plus actresses,
such as Geena Davis and Madonna, cuddling their newborns. The news isn't that middle-aged women are having children—more women had
children after 40 in the 1960s. But few of those women were having their first child. For reasons that aren't
clear, it is far easier to have your third, or eighth, child after 40 than your first. The real news is that so
many women are now having their first child late in life.
My doctor
wasn't incorrect in his early '90s optimism about later first-time pregnancy—it
does happen more these days. At the same time, the truth is that older would-be
moms are having trouble getting pregnant, more are resorting to expensive,
lengthy infertility treatments, and many are eventually discovering that they
will not bear their own children after all. The number of infertility
procedures performed between 1996 and 1998 jumped 27 percent. The number of
childless women age 40 to 44 has doubled in the past 20 years. A
survey conducted by Sylvia Ann Hewlett and described in Creating a Life:
Professional Women and the Quest for Children (Talk Miramax, 2002) found that
42 percent of high-achieving women in corporate America were still childless
after age 40, a majority of them not by plan. The problem isn't limited to the
business world: Recent studies suggest that women in academia may be even more
likely to be childless than their corporate sisters.
Though
some of these women have clearly made a choice between family and their
professions—or are unwilling to
undertake parenthood without a partner—most have not made such choices. Rather,
they have been caught out by biology. It takes several years to complete professional schooling and to
establish a career. But if a woman waits for a
suitable time in her career before having children, she may find herself in a race between her
own declining fertility and the passage of time.
Assessing Your Fertility
In the past few
years, it has become increasingly clear that reproductive biology harshly
separates older women into two groups: women who can get pregnant without a lot
of medical intervention, but whose ability to sustain a pregnancy is more
compromised than their fertility; and women whose fertility has dipped below a
critical line and who require interventions, such as assisted reproductive
technology (ART). For the first group, there is good news: Huge strides have
been made in troubleshooting miscarriages, maintaining pregnancies, handling
labor complications, and caring for preterm infants—all important issues in
late-timing pregnancy.
For the second group, the news is much more grim. According to
figures from the Mayo Clinic, a woman's fertility
is highest around age 20. Typically,
fertility drops 20 percent after age 30, 50 percent after age 35, and 95 percent after age 40. After
age 40, reproductive function diminishes drastically: Half of a woman's eggs are chromosomally abnormal at age 40; by
42, that figure is 90 percent. And should an older woman get pregnant, her
chance of miscarriage increases to more than 50 percent by her late 40s. Even
the most advanced fertility treatments can't reverse such reproductive decline.
As recently as a decade ago, fertility specialists were much more optimistic
about first pregnancies at midlife, given improved overall fitness and advances
in reproductive medicine. Now these specialists—and a generation of women—have
found instead that certain aspects of fertility are much more intractable than
they thought.
Optimizing Odds In Your Late 30s
One month
from age 39, I became pregnant on my honeymoon. I miscarried at 19 weeks and,
ten months later, miscarried again at 16 weeks. My doctor sent my husband and
me to a fertility specialist, who uncovered an underactive thyroid, cleaned out
fetal tissue from one of the earlier losses, and made a controversial
diagnosis-embryotoxic factor-in which theoretically my immune system fought off
pregnancy as a foreign invader. The specialist prescribed progesterone
supplements to boost my body's ability to hold on to a subsequent pregnancy,
explaining that no one knew exactly why the progesterone helped. You will have
your child, he promised us at our last appointment. That fall, when I was 41,1 discovered I was pregnant again.
Between thyroid pills, progesterone, and sheer good fortune, that pregnancy
lasted. Our daughter, Ursula, was born on June 1, 1998.
Women in
their late 30s can do much to improve their chances of getting pregnant. The
fertility odds are workable: About two-thirds of women ages 35 to 39 can become
pregnant within a year. Given these odds, women can take a number of steps to
improve their fertility. Some are simple common sense: Stop smoking; reduce or
eliminate use of alcohol and caffeine; maintain an appropriate weight; reduce
stress. Even moderate alcohol use—as few as five drinks a week—can impair
fertility. Likewise, consuming more than two cups of caffeinated coffee a day
has been associated with lowered conception and increased miscarriage.
Naturopath
Bonnie Nedrow, ND, LM, who teaches at Bastyr University near Seattle,
encourages her midlife patients to focus on what they can control. "We are
looking for optimal health, which is more than functional health," she
says. "A woman's body will wait to make a baby until things are
optimal." Nedrow gives each patient a hormone work-up, checking levels of
progesterone, estrogen, thyroid hormones, and others. Then she advises them
about cleansing the liver, which processes the majority of the body's hormones;
balancing the diet; stabilizing menstrual cycles; and reducing both the woman's
and her partner's stress levels.
A stable,
predictable menstrual cycle is an important indicator of good reproductive
health. "Many women have a long history of taking birth control
pills," says Jana Nalbandian, ND, a Bastyr University colleague of
Nedrow's. "When a woman decides she wants to get pregnant, her system is
used to being regulated by hormones introduced into, rather than released by,
the body. For certain women, it can take six months to a year for the body to
regulate on its own."
A woman's
weight also affects the regularity and effectiveness
of her cycles. According to the Mayo Clinic, body
fat levels that are 10 percent to 15 percent above or below normal can throw
off a woman's reproductive cycles.
Being overweight can mean estrogen overload. "We live in an
estrogen-dominant world," says Nalbandian, pointing to the hormones used
in meat- and dairy-products production, as well as the "estrogenic
effect" of some pesticides. Because of these excess hormones, even women
who aren't overweight may be at risk for estrogen overload and resulting
fertility problems, Nedrow says.
Both
doctors encourage their patients to avoid processed and sugar-rich foods and to
replace them with organic, hormone-free, and pesticide-free foods. Nalbandian
recommends eating beets, leafy greens, artichokes, and carrots to cleanse the
liver and remove excess estrogen from the system. Nedrow suggests a daily
serving of four ounces offish, which is rich in essential fatty acids, to aid
the digestive system. "Our grandmothers were right about cod liver
oil," she says.
Women who
are underweight also are at risk for menstrual irregularity and infertility.
Women who adhere to intense exercise regimes share some of these risks. Strict
vegetarians may experience fertility problems if they don't get enough vitamin
B12, zinc, iron, and folic acid in their diets.
Luckily,
most of these problems can be resolved through changes in nutrition. "If
you are a fairly healthy 35- year-old woman with a healthy reproductive
system," says Nalbandian, "you should be able to improve your chances
of becoming pregnant simply through diet and lifestyle choices."
Additionally,
Nalbandian- advises using herbs to support the
natural reproductive process, such as chaste
tree berry (Vitex agnus castus) for regulating cycles, and herbal teas, such as
raspberry leaf (Rubus idaeus), to tone the uterus. To move bile through the
liver, she recommends dandelion root (Taraxacum officinale), a gentle, nontoxic
cleanser. But because many herbs can contribute to miscarriage, once a woman
becomes pregnant, Nalbandian warns, she must stop taking ail herbal
preparations until she consults her doctor.
Acupuncture
may also be effective. Earlier this year, German researchers at the Christian
Lauritzen Institute announced that acupuncture-treated subjects increased their
success rate for in vitro fertilization by nearly 50 percent (Fertility and
Sterility, 2002, vol. 77, no. 4). By relaxing the uterus, they theorized,
acupuncture helps the uterine lining become more receptive to an embryo.
Throwing The Dice After 40
My husband
and I felt
time working against us in our hope for a second child. Ursula passed her third
birthday without a sibling. Wanting to avoid interventions such as in vitro
fertilization, but recognizing that my fertility was surely waning, we gave
ourselves until the end of 2001 to get pregnant.
For women
over 40, the reproductive die has
largely been cast. Genetics plays a heavy-handed roie in the ability of a woman
over 40 to become pregnant. If her eggs, which have been in her body since
before her birth, remain viable in sufficient numbers, she should be able to
become pregnant. If she does not have enough "ovarian reserve," she
will not become pregnant without egg donation.
In a
clinical report issued in January 2002, the American Society for Reproductive Medicine (ASRM) advised
doctors to screen women over 35 for
ovarian reserve. Typically, this is
done by measuring serum basal levels of follicle-stimulating hormone (FSH) and estradiol, two of the
so-called pregnancy hormones. Subtle changes in levels of these hormones are
associated with a reduced ability to conceive—and, not surprisingly, also are associated with perimenopause, when
a woman’s hormone levels shift away from reproduction. "Genetics may
predispose some women to early increased FSH levels and others to late
menopause," says Judy Stern, PhD,
an embryologist at Dartmouth-Hitchcock Hospital in Lebanon, New Hampshire. My
grandmother had her second child at age 44; a great-aunt had her fourth child
at 46. Was there hope for me?
Even
if a woman can become pregnant past 40, it's likely to take her a year or more
longer to conceive than a younger woman. For one thing, the cervical mucus that
aids sperm in fertilization usually lasts for four days in a woman in her 20s,
Nedrow says, but for less time as she grows older. "By 40, it's down to
less than a day," she says. Even something as seemingly benign as taking
antihistamines, which dry up all mucous membranes, she warns, can decrease an
older woman's chances for pregnancy.
*
The
best advice: Optimize your individual chance of getting pregnant by optimizing
your health in general— and see a trusted health care provider as early as
possible in your attempt to get pregnant. "Due to the shorter time frame,
I tend to be more aggressive with clients over 40," Nedrow says. "I'm
likely to order more tests, use progesterone supportively, and jump in there
with herbs right away."
Never
Say Never Both naturopaths can cite many examples of women in their late 30s
and beyond who have followed their holistic, healthy living suggestions and
become pregnant. But they also caution that where there are underlying
fertility issues, more intervention may be needed, and pregnancy may be
achieved with more difficulty, or not at all. At some point, older women may
find themselves confronted with assisted reproductive technology's poor success
rates—a 43-year-oid woman using ART has a 3 percent chance of delivering a baby
(women in their early 30s who use ART have a better than 30 percent chance)—and
the knowledge that time is running out.
When
New Year 2002 came, Jim and I counted our blessings as a single-child family,
forgetting that we had one more cycle to check. Our son, Virgil, was probably
conceived in the final days of 2001, just before deadline. He arrived early,
induced at 35 weeks after placental abruption—something I, at age 46, was at
increased risk for—and was born perfectly healthy on August 22, 2002.
Genetics,
luck, or physical good fortune allowed me to have two children in my 40s. But, I
am certain, no doctor today would assure a 35-year-old woman that it was wise
to wait another five years, or more, before trying to get pregnant. More
likely, that doctor would give her the harder facts and statistics that we know
now. Then, if she chose, they would work together to devise a strategy for
seeking the miracle of children.