A woman's fertility crisis
The July 23-24, 2011 weekend edition of The Wall Street Journal, presents an essay by Ms. Holly Finn, Communications Director of the Skoll Foundation, excerpted from the By-liner Original "The Baby Chase: An Adventure in Fertility (Byliner.com), available as an Amazon Kindle Single. Her essay inspired Dr. Gleicher to respond from a fertility doctor's point of view.
Special Contribution
The July 23, 2011 weekend edition of The Wall Street Journal presents an essay by Ms. Holly Finn, Communications Director of the Skoll Foundation. Titled "My Fertility Crisis," the essay is a professional woman's eloquent and highly personal account of an ultimately failed attempt to achieve motherhood relatively late in life with the help of in vitro fertilization (IVF).
It, however, is not just another story of self pity about infertility, failed IVF, and the challenges of various infertility treatments. Rather, it is a highly sensitive presentation of what may be the principal challenge of today's educated woman in the world. To quote the author: "When we were young, we were taught - again and again - that we shouldn't get pregnant. Now we can't."
Her feelings of guilt erupts, self-critically, from the pages, when she notes that she gave too much time to the wrong men, smoked in her 20s, preferred red wine to sparkling water, ate too much milk chocolate, liked limericks and "knows all she did wrong." As so many other women like her, she, however, really did nothing wrong! What she feels guilty about has practically nothing to do with her, at age 42, still being childless.
I see women like her (and often older) daily at our fertility center. None of them really has reason to be down on herself, because, as individuals, women are mostly powerless in overcoming the major evolutionary developments, radically changing how we live, and, therefore, reproduce. It is not their fault that they gave too much time to the wrong men! Men are different today than they were in prior generations. And so are women, of course! Both date more and marry later; social contracts between partners have radically changed, as the frequency of single motherhood, divorce rates and gay marriages so amply demonstrate. Women used to be left waiting at the altar; now they are left waiting during fertility treatments, as the writer, herself, experienced.
Ms. Finn concludes from her own experience that women should listen to their guts and their gynecologists rather than their bosses, and, for all practical purposes, should choose early pregnancy over careers. Easier said than done in a rapidly evolving world, where women can no longer count on the safety of life-long marriage and support from strong family ties! It is exactly because women, indeed, already follow their guts that they attend college in record numbers, often outperforming their male counterparts not only in school but also in subsequent professional careers.
As a gynecologist and fertility specialist I, like most of my colleagues, of course, constantly try to create awareness about the importance of female age for successful reproduction. The younger the better! But, increasingly, every time I make this point to an "older" patient, I am uncomfortable about unwittingly aggravating her already unwarranted and excessive sense of guilt that is so well depicted in Ms. Finn's essay.
A few years ago, one of our professional organizations, in cooperation with lay groups, initiated a campaign to educate the public about the importance of female age for reproductive success. Such education is, indeed, of importance. I in this context always tell the story of the famous magazine editor who, a number of years ago, in my office was surprised to learn that still having menstrual periods at age 45 said almost nothing about her remaining fertility potential. Up to that point, this highly educated woman had believed that she could conceive as long as she menstruated.
Better education may, indeed, sway some women to have children at younger ages or, as we increasingly see in clinical practice, allow others to consider the merits of the new concept of fertility preservation. Preserving one's fertility potential by freezing eggs is, however, quite an expensive proposition, and professional organizations still widely consider it an experimental procedure.
The reality of evolutionary processes in the developed world is, however, that even excellent education of the public will not really significantly affect essential life choices, which are imposed on women by societal developments. Women will not, and probably in a majority of cases should not, drop out of education and professional careers to have children. I tell my own two daughters almost daily that nothing in today's world is more important for a woman than self-sufficiency, which can only be achieved by completing a good education and entering a career path.
In practical terms this means that we have to expect a continuation, even acceleration of recently observed trends. In our infertility practice, which is well known for serving "older" patients, the average age of newly presenting patients in the last five years has radically increased, and now hovers around 40 years. Ms. Finn notes that at the fertility center in Colorado she attended, the average patient age has gone from 32 to 39 years in 20 years. Both of our centers will see progressively older women and, increasingly, more of them.
But these numbers don't even tell the whole story. Approximately 10% of all women age their ovaries prematurely. This means that they meet ovarian aging milestones, often including menopause, at much younger ages than they should. Women with premature ovarian aging (POA) are, of course, disproportionately represented in fertility practices because they encounter difficulties in conceiving already in their 20s and 30s, which other women only experience in their 40s. If we add these relatively young women with POA to our older patients, over 90% of new patients at our fertility center now present with ovaries that behave "older."
Over the last few years, U.S. national data have also demonstrated, for the first time, that women above age 40 represent proportionately the most rapidly growing patient age group having children. This trend, too, will very obviously accelerate, independent of how well we will succeed in educating the public about the effects of age.
It, therefore, becomes obvious, that, independent of the public's education levels, the two unstoppable trends of older women trying to conceive, and often, indeed, having children will only gain strength.
Women, today, are no longer limited by their own reproductive lifespan (i.e., their ovaries' ability to produce viable eggs) because (anonymous) egg donation has become widely available. In the U.S., egg donation now represents the most rapidly growing fertility treatment within IVF. At our center, egg donation cycles have, respectively, doubled and tripled over the last two years.
Ms. Finn sounds somewhat alarmist in pointing out potential dangers of pregnancies in older women. While it is correct that practically all complications of pregnancy, from miscarriages to medical complications, increase with advancing maternal age, healthy women, who receive appropriate obstetrical care, can, overwhelmingly, expect normal pregnancy experiences and outcomes. Moreover, older women, using the eggs of young egg donors, suddenly, experience pregnancy chances and miscarriage rates commensurate with the donor's age, however old the patients are themselves.
It, therefore, is essential to recognize that even "older" women, left without ovarian function of their own, still have options. While genetic inheritance, very clearly represents one of the primary purposes of reproduction, biological maternity is also of crucial importance to maternal-child bonding. Considering the strong evolutionary trends under way in regards to reproductive habits, one, therefore, can foresee an evolving shift in better recognition of biological motherhood and a relative de-emphasis of genetic maternity. Reproduction can, thus, be expected to continue evolving, and the medical care we specialists in the field are offering has, therefore, to evolve in parallel.
One is left with deep sadness reading Ms. Finn's essay in The Wall Street Journal. Here is a very disappointed and unhappy woman, who, likely, could benefit from additional counseling, both medically and psychologically. After apparently having failed to conceive in quite a number of IVF attempts, including at one of the country's best IVF centers in Colorado (named in the piece), she went back to an anonymous Dr. S. whom she asked, "whether a sane person would bother trying again?"
Kudos to Dr. S. for advising her "there was nothing insane about what she was doing." Decisions to continue or stop treatments are never a matter of sanity or insanity. They are highly personal, and excruciating difficult.
Dr. S., however, also reduced her presumed pregnancy chance for another IVF attempt to less than 5%. Not surprisingly, the patient understood this, together with him/her raising the option of egg donation, as a subliminal message that "time's up."
Is her time really up, at age 42, after producing two eggs in her last IVF cycle, which did not fertilize?
This question is, of course, impossible to answer without knowing more about the patient. As we recently reported in Human Reproduction, (2011;26:1905-9), age 42 appears to be a breaking point between higher and lower pregnancy chances in women with very poor ovarian reserve. In today's practice, women above age 42 represent a substantial portion of our Center's patient population, and, practically every week, we see some of them still conceiving with their own eggs.
Our Center is known for special expertise with "older" ovaries, and well recognized for introducing DHEA supplementation in such cases. DHEA supplementation usually improves both the quantity and quality of eggs and embryos, and, therefore boosts pregnancy chances. But nothing in medicine works in every patient, and there is simply no way of knowing whether we could still have done something for Ms. Finn.
This is, however, also not the principal point to be made: What struck me in reading Ms. Finn's essay was that she did not reflect the anger our profession often faces in publications, describing failed fertility treatment experiences. Instead, she projects a degree of hopelessness and sadness in her message, which is almost harder to take.
What she is really telling us in her piece is that, as a medical specialty, it is high time to recognize that we, to a large degree, are failing a rapidly growing patient population, which urgently needs our help. At our center, we have made the point now for over seven years that "older" women and "older" ovaries represent the cutting edge problem for our specialty. Holly Finn proves us correct!
Norbert Gleicher, MD
Norbert Gleicher, MD, is Founder and Medical Director of the Center for Human Reproduction (CHR) – New York, President of the Foundation for Reproductive Medicine and Visiting Professor, Yale University School of Medicine.
CHR is a leading infertility center in New York City, with world-wide patient clientele, well recognized for its extensive clinical research program, which over the years contributed a number of major breakthrough to the IVF process.
Last Updated: September 7, 2011
