In the 1970s, the women’s rights movement was born anew with the creation of the National Organization of Women, the Equal Rights Amendment and the emergence of noted feminists like Bella Abzug, Shirley Chisolm and Gloria Steinem.
These women and others changed American society. Women in ever greater numbers gained success and prominence in business, politics, education and elsewhere. And, not surprisingly perhaps, began delaying something only a woman can do: Becoming a mother.
Recently, the Centers for Disease Control and Prevention (CDC) published a new report indicating that more and more women are postponing motherhood, continuing a trend that dates back more than 40 years. In 2012, the number of first-time mothers age 35 and older was nine times higher than in 1970, said the CDC.
Women may decide to delay pregnancy for many reasons including educational goals, career plans or finding the right partner. According to the CDC, the average female college graduate starts a family at age 30. The benefits to waiting may result in healthier partner relationships and financial stability, giving parents’ peace of mind and their children additional social leverage, but it may also come with increased health challenges. Today, women live longer and enjoy healthier lifestyles, but this does not change the normal age-related decline in fertility, especially after age 35, say health experts.
“Age is the most impactful factor affecting fertility,” said Antoni Duleba, MD, director of the Division of Reproductive Endocrinology and Infertility at UC San Diego Health System. “At the age of 35, a woman reaches a crucial five years where a significant decrease in fertility occurs. Even if an egg is fertilized, there is a higher risk of an embryo carrying abnormal chromosomes that can result in miscarriage or a baby born with Down syndrome.”
A female is born with all the eggs her body will produce. Both the quality and quantity of eggs wane with age, but with advancements in medicine have come more options to diagnose and combat infertility.
“Our understanding of fertility issues and our ability to help women are improving year by year,” said Sanjay Agarwal, MD, director of Fertility Services in the Department of Reproductive Medicine at UC San Diego Health System. “The most important step for a woman age 35 or older is to seek help if she has not become pregnant after six months of trying. It’s a tragedy when someone who is 42 comes to see me after trying for six years. Why didn’t you come see me earlier?”
Duleba agrees, adding that both men and women should undergo a fertility evaluation with experts. He has seen cases where a woman sought treatment, but her male partner was not evaluated. By the time the pair realized that he had the problem, her eggs were in poor quality. In approximately 30 to 40 percent of cases, said Mike Hsieh, MD, a urologist who specializes in male infertility, it is the male partner who needs help.
For a woman with fertility problems, after reviewing her medical history a fertility specialist might recommend a blood panel to check her hormone levels. For a closer look at the uterus, an ultrasound could be suggested. Thankfully, women today may have an alternative to the commonly used x-ray hysterosalpingogram (HSG), a procedure traditionally used to evaluate the fallopian tubes that involves releasing a dye into the fallopian tubes. This procedure is uncomfortable and sometimes painful.
The UC San Diego Health System fertility clinic is the first in the county to use a new ultrasound tool called FemVue Sono HSG to assess the fallopian tubes. In the clinic, a physician delivers a mixture of saline and air bubbles into the uterus which then flows into the fallopian tubes. Under ultrasound, the doctor can watch the air bubbles as they travel through the tubes to determine if there is a blockage.
“The standard x-ray approach involves pressure and usually significant cramping as the dye is administered. Some patients are actually allergic to the dye and the pain level prevents others from even doing the test, which is a key component in the diagnostic workup of infertile couples,” said Agarwal, who is also director of the UC San Diego Center for Endometriosis Research and Treatment. “The new approach is not only much more comfortable for patients, it also uses saline and so the issue of allergy does not arise. Also, we are able to assess the cavity of the uterus in a very detailed manner at the same time, all without x-rays.”
Technological diagnostic advances, like FemVue Sono HSG as well as the use of preimplantation genetic screening (PGS) with in vitro fertilization (IVF) has led to an increase in successful pregnancies and healthy births for women unable to conceive on their own, said Duleba. Freezing a woman’s eggs or embryos for future IVF procedures has greatly improved with a technique called vitrification, in which the eggs are flash frozen using liquid nitrogen.
“Some patients choose to harvest their eggs in their 20s because of a medical condition or a family history of early menopause,” said Duleba. “Most patients begin to think about it in their early to mid-30s. By this age, women should start considering their options and develop a plan. I recommend they undergo a fertility assessment and become familiar with options available to them for future family planning, including options for women who are single.”
For women who cannot conceive with hormone treatments and inseminations, IVF may be their best choice. If egg quality is in question, complementing the procedure with PGS provides an opportunity to test a blastocyst for chromosome abnormalities. Choosing healthy embryos reduces the chance of miscarriage and greatly increases the chance of a healthy baby being born.
The incidence of chromosomal abnormalities is one in 160 live births in the United States. The effects of these abnormalities, known as aneuploidies, can be severe, from developmental delays and neurological disorders to infertility and death. Incidence rates rise with maternal age, most notably after age 35.
On the horizon are a DNA sequencing procedure and software tools for prenatal screening that may lead to an increase in successful conception for women considered to be “older” first-time moms. Current diagnoses often rely upon invasive tests that sample amniotic fluid or placental tissues for fetal DNA. While highly reliable, these invasive tests may cause infections in a pregnant woman and pose as much as a 1 percent risk of miscarriage and fetal loss. The new method relies upon sequencing genetic material from the fetus that circulates naturally and freely in the mother’s bloodstream and it can be obtained through an ordinary blood draw.
Pregnancy for older women increases health risks not just for the unborn child, but for the women themselves. They might experience high blood pressure or diabetes, but with quality obstetric care most of these can be managed well, said Agarwal.
Although a woman may not be able to control age-related changes, she can improve chances for conception by maintaining a healthy weight and diet, manage stress, limit alcohol and caffeine, and refrain from smoking.
“Smoking is one activity a woman can choose to do that will kill her eggs, decrease her fertility and bring earlier the onset of menopause,” said Agarwal. Men should also heed this advice to avoid smoking in order to improve sperm quality.