Commentary

General medicine Women's health
Volume 184 - Issue 7

Missed conceptions: the need for education

Authors:  Michael G Chapman, Geoffrey L Driscoll and Bryony Jones

Med J Aust 2006; 184 (7): 361-362. || doi: 10.5694/j.1326-5377.2006.tb00274.x
Published online: 3 April 2006
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Delayed childbearing is not an issue to “keep mum” about

For fertility specialists, there is no more difficult and depressing news to break to a woman seeking a baby than “Sadly, it’s too late. You’re menopausal.” In our experience, this situation is encountered with ever-increasing frequency as the age of first attempting to conceive increases. With 1% of the female population menopausal by 40 years and 5% by 43 years,1 and with many more perimenopausal, the rising number of disappointed older women is not surprising.

Breaking the bad news requires compassion but realism. Pregnancies are extremely rare in “menopausal” women. Even for those still menstruating, a high follicle-stimulating hormone level in the early follicular phase sounds alarm bells. Pregnancy rates in such women are much less than 2% per cycle, even with “high-tech” approaches such as in-vitro fertilisation (IVF).2

How big is the problem of delayed childbearing?

The average age of women bearing their first child in Australia has risen from less than 26 years in 1991 to nearly 30 years in 2003.3 First births in women over 35 years now account for 12% of all births, compared with 6% a decade ago — and those women are the lucky ones. The average age of women undergoing IVF treatment has risen from 31 years in 1993 to just over 35 years in 2003.3,4 The proportion of women commencing such treatment in their 40s has risen from 13% to almost 25% over the same period — that is, one in four women undergoing IVF treatment is at least 40 years of age.

Why is childbearing delayed?

Bachrach, in her Personal Perspective,5 raises the critical issues that lead to delayed childbearing — career goals, the perceived need for financial security, and/or delay in finding a long-term partner (either through distraction by the pursuit of personal development, or because of lack of interest from a man in forming such a relationship). While 20th century feminism carries significant responsibility for encouraging women to be more self-centred and independent, a changing male attitude to early childbearing also must be acknowledged.6,7 Life can be too much fun to be tied down by wife and children.

What are the limits to what we can achieve?

Belief in the ability of assisted reproductive technology (ART) to overcome the “biological clock” and achieve a pregnancy in most women and at almost any age is ill-founded. Despite great advances in ART (a woman at 40 years in 2006 now has the same chance of becoming pregnant with an IVF cycle as a 30-year-old woman in 1995),4 over 80% of women having ART treatment will not conceive in their first cycle. Even when a pregnancy occurs, older women have a substantially higher risk of miscarriage and fetal abnormality.4 One in six pregnancies miscarries in a 30-year-old, but by 40 years the risk is one in four. Down syndrome occurs in 1 : 1000 pregancies at 30 years of age but 1 : 100 pregancies at 40 years. The success of technology will always be limited and probably never be able to reverse the relentless deterioration in egg quality and number in the late reproductive years.

What can the medical profession do?

The general community certainly does not seem to sufficiently appreciate how age affects fertility. Our personal experience with referring general practitioners suggests that the concept of age affecting fertility is widely acknowledged but that the specific, current facts are not known, and there is some evidence to support this.8 Some GPs carry the message they learnt at medical school, that only after a year of trying is it appropriate to refer for help. This is fine for women younger than 35 years, but for older women, earlier referral should be the norm — even if only to confirm that there are no potential barriers to conception. As in Bachrach’s experience, blind reassurance for 12 months may be seen, in time, to have been a terrible mistake.

We suggest that any GP, or appropriate other doctor, consulted by a woman over 30 years of age should initiate queries about any plans for parenthood. Doctors can educate women and their partners about the loss of fertility with increasing age and encourage early conception. Similarly, when a doctor sees a new couple over 35 years of age, the doctor should initiate a positive push to consider childbearing — if that is part of their life-plan — as a matter of some urgency.9 We need to reverse any view that raising this matter would be paternalistic or “not politically correct”.10

What can be done in the community at large?

Increased public awareness of the risks of delaying childbearing is vital. Government concerns about the rising costs of ART could best be addressed by reversing the trend towards increasing age of first conception. We believe that a little money spent on education would be more than repaid by a reduction in the age-related demand for ART.

In 2004, the Fertility Society of Australia initiated the concept of a national education campaign focusing on fertility preservation. As part of their presentation to the Abbott Committee on ART in October 2005, the Fertility Society of Australia and the IVF Directors’ Group urged the Committee to recommend the provision of federal government funding for the campaign. While it would cover many health issues that affect fertility (eg, smoking, obesity and sexually transmitted diseases), a major plank of the campaign could also be to encourage earlier childbearing. This would focus not only on women but also on men, who are often the procrastinating party.7

Barriers to the decision to seek pregnancy earlier need to be examined. For example, workplace reforms should encourage rather than discourage childbearing. Flexible hours and on-site, affordable childcare would bring women back into their jobs earlier and so assist in their desire to be successful on all fronts. But, ultimately, we need to spread the message that there are significant risks of long-term failure and disappointment if women delay attempts to conceive until they reach the age of 35 years or more. Early referral could potentially prevent the disappointment expressed in Bachrach’s Personal Perspective.5

Authors

  • Michael G Chapman FRANZCOG, MD, CREI1
  • Geoffrey L Driscoll FRANZCOG, FRCOG, CREI2
  • Bryony Jones MB BS, MRCOG3
  • 1. School of Women's and Children's Health, University of New South Wales, Sydney, NSW.

Correspondence: michael.chapman@sesiahs.health.nsw.gov.au

Competing interests

None identified.

References

View this article on Wiley Online Library