Last fall, in San Antonio, Texas, at a session for infertility counselors held in conjunction with the annual meeting of the American Fertility Society, Dorothy Mitchell-Leef strode to the microphone during a question-and-answer period and presented a manifesto of sorts. Mitchell-Leef, a prominent reproductive endocrinologist, declared that in effect women have been sold a bill of goods.
For years physicians have said little as women have chosen to put off having children until their mid-thirties, their late thirties, their forties. The time had come, Mitchell-Leef believed, for a message to be delivered. She told the participants—mostly psychiatrists, psychologists, and clinical social workers—that women should be advised to consider having children earlier in their lives rather than later. In response her audience, most of whom had witnessed the anxiety and grief experienced by older women whose infertility treatments had ultimately failed, burst into applause.
College-educated women now appear to have accepted as a virtual article of faith the idea that babies must take a back seat to graduate or professional school and to the establishment of a career. So the fact that several hundred well-heeled professional women with no particular political ax to grind would applaud the notion of earlier childbirth is surprising (especially since some, including Mitchell-Leer, had delayed childbearing themselves). But the session's participants, like thousands of other infertility specialists worldwide, have over the past ten or fifteen years met vast numbers of couples whose reproductive problems have stemmed at least in part from the age of the would-be mother. Many of these professionals, who have seen the costs of the trend toward delayed childbearing firsthand, now want women to be given a more realistic picture of their reproductive limits.
This concern has been voiced before, most notably in the early 1980s, in response to the publication of a French study revealing that success rates for artificial insemination markedly worsened with each upward tick in a woman's age. Alan DeCherney, then at the Yale University School of Medicine and now the chairman of obstetrics and gynecology at Tufts University Medical School and the president of the American Fertility Society (recently renamed the American Society for Reproductive Medicine), and the epidemiologist Gertrud Berkowitz, then also at Yale and now at Mount Sinai Medical School, were among those who recognized the implications of the report. In an editorial for the New England Journal of Medicine they declared, "If the decline in fecundity after 30 is as great as the French investigation indicates, new guidelines for counseling on reproduction may have to be formulated."
That no such public-health initiative was undertaken can be attributed mainly to social circumstances, which tended to militate against the very notion of such a program. The women's movement was still struggling with a radical bias against making babies (the "cruel institution of motherhood" is how the author Gena Corea once described the evolutionarily assigned role of the female in human reproduction). Furthermore, women of all stripes continued to fight for standing in the workplace. To announce during the Reagan years that the ideal time for a woman to have children was in her twenties was to align oneself, however unintentionally, with "pro-family" advocates who argued that a woman's proper place is in the home tending little ones.
Moreover, family-planning guidelines seemed mundane in the face of impressive developments in the field of reproductive medicine. During the 1970s gynecology had ceased to be a backwater and had begun attracting its share of medical schools' best and brightest. At the same time, researchers who had been experimenting for years with ways to manipulate animal eggs, sperm, and embryos had begun adapting their techniques to human beings. Armed with drugs to regulate hormonal cycles, new surgical instruments, and procedures for literally creating life in the lab, reproductive endocrinologists and gynecologists, along with their embryologist helpmates, assumed the status of latter-day fertility gods. Media reports conveyed the impression that the vagaries of reproduction had been brought under technological control.
In short, an array of social and scientific forces have encouraged collective wishful thinking about the functioning of the body, and increasing numbers of women have continued to put off childbearing without fully understanding the possible consequences of that choice. David Meldrum, a reproductive endocrinologist who has been at the forefront of reproductive technology since the 1970s, and who heads the Center for Advanced Reproductive Care, in Redondo Beach, California, says, "Women aren't told enough about the decline of fertility with age. Many don't realize that if they wait, motherhood may pass them by." A Canadian royal commission appointed in 1989 to examine advances in reproductive medicine and make policy recommendations asserted in its 1,200-page report to the government.
People who want to have children should be aware of the normal decline in fertility as they age and consider this in their decisions about when to have children. Such decisions have to take many factors into consideration, but a knowledge of the biological realities of postponing childbearing should be part of the information couples have available when making this choice.
John Collins, a professor in the department of obstetrics and gynecology at McMaster University, in Ontario, and one of hundreds of experts consulted by the royal commission, has put together a slide show that provides a persuasive visual summary of the "biological realities." Collins selected a dozen pertinent studies of female fertility, plotted data from each study on a standardized graph, and superimposed several curves on each slide. All the curves but one, which derives from a small and perhaps not broadly applicable study, proceed from the upper left to the lower right corner, from age twenty-six to beyond forty. A couple of curves are punctuated by a distinct steepening at around age thirty-one; several others take a bend at around age thirty-six. The remainder track steadily downward, supporting the argument that the ability to conceive erodes incrementally as women age.
Of course, everyone can think of exceptions to the younger-is-easier rule. "There are some women who—bingo!—go out and get pregnant at forty," says Jean Benward, a clinical social worker in San Ramon, California. But those who have waited to start a family only to find themselves locked out of childbearing can be emotionally devastated. Benward has counseled numerous women who, like her, came of age in the 1960s and never suspected that they would not be able to get pregnant whenever they chose. "Infertility is a shock at any age," she says, "but it has come as a particular shock to women of my generation."