The importance of ‘the fertility talk’

Making patients aware of how fertility decreases with age can be difficult, because for many patients, it is a touchy subject. Today’s ob/gyns are saying they are working to make the conversation as routine as the talk about contraception, according to a recent Wall Street Journal article titled “More doctors broach delicate topic of women’s age and fertility.”

According to Laurie McKenzie, MD, a reproductive endocrinologist and director of oncofertility at Houston IVF in Texas, as well as a member of the Contemporary OB/GYN editorial board, the article is timely. “For ob/gyns, family practitioners, or internal medicine physicians, this is a valuable discussion to initiate when female patients are seen in their reproductive years,” she says. “But it’s important to make it spontaneous and nonjudgmental in tone.”

Laurie J. McKenzie, MD

Dr. McKenzie notes the significance of not making assumptions when planning to discuss reproductive issues. “We have to be sensitive when approaching the subject, and we don't want to make the assumption all women want to have children. There are many different ways to have children and build [a] family, such as embryo adoption, child adoption, and foster care. And more women are choosing child-free living.”

The discussion usually entails some education on fertility rates, which according to the current literature, begin to dip near age 32 and significantly drop after age 37. (See the American College of Obstetricians and Gynecologists [ACOG] Committee Opinion No. 413, 2008.) Other relevant discussion points are the increased risks of miscarriage and chromosomal abnormalities in older women.

In simple terms, Dr. McKenzie advises asking patients who are not using contraception, as well as those who are using it, whether they have plans to become pregnant. “You may ask, ‘Are you planning to have a family? If so, what path are you planning?’ Then you can have the discussion related to age-related fertility,” she says.

Data from ACOG show that approximately 20% of women postpone starting their families until after age 35. Dr. McKenzie says it’s important to help patients understand that fertility declines with age. “Patients mention celebrities having kids at age 43, for example. How are they doing it? The vast majority of women in that age group are utilizing donor eggs. However, it is also important to realize that there are noninvasive tests that patients can use in their 20s, 30s, and 40s to gauge their own fertility, such as the AMH (Anti-Müllerian Hormone) blood test.”

She says AMH normal ranges are usually 2.5 to 4.5. If the value drops below 1, she says, “these women will often have a harder time getting pregnant and often will have higher miscarriage rates.”

So at what age is it appropriate to begin talking to patients about fertility, especially because many women want to advance in their careers while also having healthy families?

ACOG guidelines state that clinicians “should encourage women to formulate a reproductive-health plan and should discuss it in a nondirective way at each visit,” the WSJ article states. ACOG Committee Opinion No. 313 of 2005 addresses discussion points such as a woman's, or a couple's, desire for children; the optimal number, spacing, and timing of children in the family; and age-related changes in fertility.

“The main point here is having the discussion-bringing it up with patients. They're often erroneously assuming they have a lot of time. Usually there’s not as much time as they thought,” Dr. McKenzie says. 

Different ob/gyns try different tactics, some of which may be more successful than others. For instance, Mark Jostes, MD, in St. Louis, likens initiating the fertility/having-a-baby talk to being a relationship counselor. He told the WSJ, “I try to go with general, easy questions to try to feel them out. You can tell if they're willing to talk with a few leading questions.”

Another ob/gyn, Victor Klein, MD, with North Shore-LIJ Health System in Great Neck, New York, provides the patient with plenty of facts, according to the WSJ. He’ll explain that older mothers face greater risks of having a child with Down syndrome, for example.

It may be that practical issues, rather than reluctance, are what prevent ob/gyns from discussing declining fertility with patients. “Often there is so much to cover at the annual well visit-Pap smear guidelines, depression, other female-related issues. As a result, fertility often takes a back seat to other discussions,” Dr. McKenzie says. “So often there’s a reluctance to bring it up because of time constraints or because physicians feel they are pressuring their patients to get pregnant right away.”

Age-related fertility decline. ACOG Committee Opinion No. 413. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2008;111:1495–1502.

The importance of preconception care in the continuum of women's health care. ACOG Committee Opinion No. 313. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2005;106:665–666.

Reddy S. More doctors broach delicate topic of women's age and fertility rate. June 3, 2013. http://online.wsj.com/article/SB10001424127887324682204578517683273638050.html. Accessed June 10, 2013.