The Trouble with Talking About Fertility

In these progressive times in which women and men are delaying marriage and children, too, the topic of female fertility — and how it's not going to be there forever, ladies! — seems to come up again and again. But what really are we supposed to do with this information?

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In these progressive times in which women and men are delaying marriage and children, too, the topic of female fertility — and how it's not going to be there forever, ladies! — seems to come up again and again. This time there's a trend story component to it, in a piece in the Wall Street Journal. More doctors are now broaching the topic of fertility with their female patients, as Sumathi Reddy writes.

Well, O.K. Given that 20 percent of American women are waiting until 35 or later to begin families, per the American Congress of Obstetricians and Gynecologists, doctors are feeling a certain obligation to remind their patients that they don't have all day to make babies. "OB-GYNs say they are increasingly making [the fertility conversation] as routine as asking about contraception during annual visits. They are educating patients about fertility rates, which gradually begin to decline around age 32 and then rapidly decline after age 37. And they are discussing the risks of miscarriage and chromosomal abnormalities, which increase at age 35 and above."

Information seems a good thing, particularly as "advances in fertility treatments and media coverage of women conceiving in their 40s and even 50s have led some people to believe they can beat the biological clock." Not all women can. But not all twentysomething women can get pregnant, either. "Genetics largely determine which women will still be fertile at 40 and which ones won't," writes Reddy. So what to do, particularly if you're in your later 30s and still aren't sure you want to start a family?

Education, good. Doctor's time spent talking to patients (when it seems like the 7-minute average for patient-doctor interaction still holds), that's good too. I'm especially in favor of doctors pausing to ask questions, or, more importantly, answer them, and making the effort to show patients they're not too busy for them, whatever those questions may be. A women who is not pregnant and never has been who visits the OB-GYN may sometimes feel like a second-class citizen compared to the women there who are having babies. So it's great that doctors see an importance in spending time talking to these patients about their options.

But. I don't think there are very many women in their thirties and beyond who don't know that with age comes a decreasing chance of getting easily pregnant, or getting pregnant at all. This is something we've been told over and over again for years. This is why people talk of "biological clocks" and know exactly what that means. It's information available widely on the Internet. I mean, come on! There are Yahoo! Answers topics devoted to the question. Certainly, there's a benefit of a doctor talking to a patient about it frankly, in so much as the doctor can even help and so long as it's less scare tactic and more information — but a doctor who thinks his or her patient just has no idea? That's probably not true in a lot of cases.

Further, the reason women in their 30s and beyond aren't having babies isn't, I'd wager, because they have no idea that someday their fertility might end. It's because, possibly, something other than having babies is more important to them. It's because they don't know if they want kids, or because the right situation in which they imagine having kids (with a supportive partner? With the financial stability to do so?) hasn't yet occurred. And it's because, yes, they hope that when those things do occur, they will still be able to have children, if that's what they decide they want to do. But in the interim, what is a person supposed to do with this information that their fertility may be tick-tocking away?

The choices for a woman in her later thirties who still might want to get pregnant seem to be as follows: Freeze your eggs, if you have the money (with varied results). Get pregnant now (with or without a partner, who may or may not even be on the horizon). Just deal with it, wait, and hope for the best — maybe there will be technological advances; they're making them every day! And maybe in the end you won't even want kids. Not everyone has to have children, which is another aspect of these discussions that people don't talk much about. If we consider procreating the ultimate goal of life, of course women are going to feel stressed and freaked about reaching a point at which this goal is impossible to naturally achieve. But is having kids really the be-all and end-all? Can you be happy without them? This is stuff the doctor — who assumes you probably want kids — doesn't tend to delve into, but it would be valuable for all women (and men) to have this conversation among themselves.

Of course, as we talk, technology will continue to advance: As Reddy writes, "There are tests that can be done, typically by fertility specialists, to assess a women's ovarian reserve. Dr. Soules says a relatively new blood test measures the so-called anti-Müllerian hormone, or AMH, level. The hormone is produced by the ovary in the process of forming a follicle and can give a general sense if a woman has a low, medium or high reserve of eggs." As you might expect, the test has a varying sort of accuracy to it, and doctors are quick to say that it might not be able to predict what will happen in two or three years (plus, not all doctors want to give this test to patients, perhaps because it doesn't absolutely guarantee anything, either). "Although a low AMH level is consistent with greater difficulty getting pregnant, the measure can't be used to predict who will or won't conceive," says one whom Reddy quotes.

That's exactly the problem. Knowledge is good, but it may not change anything at all. As much as we talk and talk and talk and even stew about female fertility, the individual decisions related to it are ours alone. While the cliché is that knowledge is power, for the 36-year-old woman informed that the time in which she may get pregnant is rapidly decreasing, that knowledge can feel more like a bear trap. What are you supposed to do with it? Step in it? Ignore it? Walk warily around it knowing it's there? I'm not so sure.

That doesn't mean, of course, that doctors shouldn't talk to patients. I just am not sure that this hasn't already been happening for a long time now. I am sure that there are varying degrees of success with it. I am sure we're going to keep talking about it. But no doctor can tell you what to do. You have to figure that out for yourself.

Photo: Doctor Richard Paulson, M.D. Professor of obstetrics and gynecology, and director of the USC Program for Assisted Reproduction, center, with Doctor Melvin Thornton, assistant professor of obstretrics and gynecology, left, and Mary Francis, IVF embryologist, outside the University of Southern California Health Center Wednesday, April 23, 1997 in Los Angeles. Paulson and his colleagues believe that their patient, a 63-year-old woman, represents the oldest succesful pregnancy on record in the world [at the time]. 

This article is from the archive of our partner The Wire.