Dr. Jones: So you've just done everything you can to get ready to start a family, and now you can hear your biological clock ticking loudly. When should you get help?
You're a 43-year-old woman, and you've heard your baby biological clock ticking. You want to have a baby, and you stopped your birth control, and it didn't just happen. When should you get help?
Well, it depends. Of course, it depends on a lot of things, your health history, and the male part, but actually, we start with your age. And when it comes to this age, sooner is better than later.
We're going to do this in three parts. So if this isn't your age or the age of the person you're worried about, check out our other podcasts because we have done this in three different age groups.
Here in The Scope virtual studio with us is Dr. Erica Johnstone. She's a specialist in reproductive endocrinology and infertility and an associate professor at the University of Utah. Her special techniques for fertility include advanced reproductive technology, some amazing technology that can help people have a family of their dreams who otherwise might not be able to have a family.
She has enormous experience with in vitro fertilization in her clinic and with egg and sperm donations and other advanced technologies. So you're over 40 but not close to 50 quite yet, and you know your biological clock is ticking and you want to have a child. Should you just try for a while or should you try to see someone before you try?
Dr. Johnstone: So I would recommend scheduling an appointment as soon as you start trying. And part of the reason for that is it may take a little time to get that appointment, but we know that for women who are 40 and above, time is absolutely of the essence. And so we wouldn't want women to miss an opportunity to become pregnant because they're unaware of something that may be affecting their chances. So really, the sooner, the better.
Dr. Jones: Right. They might need a little tune-up.
Dr. Johnstone: Exactly.
Dr. Jones: Sooner than later. So who should you try and see, and what will they do?
Dr. Johnstone: So for women over 40, I do recommend seeing a reproductive endocrinologist or an infertility specialist. Now, it is true that sometimes it can take some time to get an appointment, and so it's also a good idea if you have an OB-GYN or can see one quickly, to start with an OB-GYN who can get started in talking to you about your fertility and doing initial fertility tests.
Dr. Jones: Things like sperm count? Or what kind of testing do you think?
Dr. Johnstone: Exactly. So for the male partner, we would do a semen analysis and look at the number of sperm, how many of those sperm are swimming forward, and how many of those sperm have normal head shapes.
For the female partner, we would look at some general health labs. We always want to look at general health and make sure there aren't any important things about your overall health condition, maybe things like diabetes or high blood pressure that can be optimized before you become pregnant.
But then we also look at your menstrual cycles. Are they regular? Are you ovulating every month? We look at your uterus and ovaries for factors that may be making it hard to become pregnant, like certain types of ovarian cysts or fibroids. We make sure the fallopian tubes are open. And then we also look at ovarian reserve, which is looking at whether the number of eggs remaining in your ovaries is normal for your age. Is it higher than average? Or is it lower than average?
Dr. Jones: Most women . . . or I shouldn't say this. Many women have male partners who are about their age. And, of course, some women in their 40s might have partners that are . . . their male partner in their 20s. But it's not uncommon for women in their 40s to have male partners that are in their 60s. Are there any data about men as they get older and their fertility?
Dr. Johnstone: Sure. So men's fertility does decline with age, but at a much slower rate than for women. When women go through menopause, it is extraordinarily unlikely that they would become pregnant naturally again, whereas we know it is possible for men to conceive pregnancies really all the way into their 70s and 80s, but they're more likely to have abnormalities of their sperm.
And then there are certain risks for children born to older fathers, which include neurodevelopmental type diseases. Things like autism and bipolar disorder can be more common in children born to older fathers.
Dr. Jones: So how likely is it that women will be successful having a baby the ordinary way, just trying to get pregnant on their own, when they're, let's say, between 40 and 45 compared to 45 and 50?
Dr. Johnstone: Sure. So for women between 40 and 45, it's actually changing quite rapidly with each passing year. So on average, when we look at large groups of women, of women who want to conceive at age 40, about half will get pregnant naturally. But that decreases quickly to perhaps 20% to 25% by age 42 to 43. And by age 45, it's quite rare to become pregnant naturally.
Dr. Jones: Let's say you're 48. Are there options you should be thinking about from the beginning?
Dr. Johnstone: Absolutely.
Dr. Jones: And the miscarriage rates are higher too. So actually getting pregnant is part of the problem, but staying pregnant is even a bigger problem sometimes.
Dr. Johnstone: Yeah. So as women get into these ages where natural conception is unlikely even with assisted reproduction, the option that's most likely to be successful is using donor eggs. So eggs from a woman in her 20s that will give you a very high chance of being able to become pregnant.
Dr. Jones: Is there any age that's too old?
Dr. Johnstone: This is a really difficult question, and it's one that we're seeing as women in our country and throughout the world continue to become pregnant at older ages.
The risks during pregnancy go up kind of slowly as women get through their early and mid-40s. But by the late 40s and 50s, pregnancy becomes a very high-risk endeavor. As women get into their 50s, if they do become pregnant, a very high chance of having problems with high blood pressure during pregnancy, issues with growth for the baby, potentially serious complications.
And so women who are in their late 40s and 50s and are thinking about pregnancy, we recommend they sit down with a maternal-fetal medicine specialist to really understand these risks for them and what other health conditions they may have that may further increase those risks.
Dr. Jones: Right. There's a famous story from the Bible about Sarah who was 80, I guess. And so I guess I don't . . . When I read that I went, "Yeah, right. That's not going to happen." I mean, I know miracles happen in the Bible, but 80 is really . . . that's not going to be okay.
Dr. Johnstone: No. And I think it's important for people to know when we see women in the media giving birth at very old ages . . . I think the latest I've seen recently was 72. Again, these pregnancies were usually conceived with donated eggs, and sometimes they don't portray just how risky these pregnancies can be.
Dr. Jones: Oh, absolutely. I mean, you see many older movie stars even in their early 60s or their mid-50s who are giving birth and they never tell the specifics because it's a private issue as to where these pregnancies happened, what kind of eggs they were. But whenever I see somebody who's in their early 50s giving birth who's a movie star, I went, "Yeah, right."
Dr. Johnstone: Absolutely.
Dr. Jones: I don't want people to think that that's just an ordinary, common occurrence because then they'll be hopeful, and you don't, unfortunately, know that the person availed themselves of technology right away.
So anyway, as women get closer to the end of their reproductive life, closer to 50, the chances of a successful pregnancy becomes smaller and smaller, and the chances of miscarriage get larger. But there are options that can help you to have the children of your hopes, and we can help.
I really want to thank Dr. Johnstone and all the technologies that she's so good at accessing to help people have their families. And thanks to you for joining us on The Scope.
For women over the age of 40 looking to get pregnant, it is important to start working with a fertility specialist sooner than later. The treatment options available become more limited as we age, so finding the right doctor to help with conception can be a crucial step in your fertility plan. Learn what can be done to help women over 40 become pregnant.
Dr. Jones: So you've done everything you can to get ready to start a family, and now it didn't just happen. When should you get help?
You are a 38-year-old woman and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help? Well, it depends. Of course, it depends, and it depends on a lot of things -- your health and history and the male part of getting pregnant part of the business. But we usually start with age.
And we're doing this in three parts. So if this isn't your age or the age of the person you're worried about, check out our other podcasts.
Here in The Scope virtual studio with us is Dr. Erica Johnstone. She's a specialist in reproductive endocrinology and infertility and an associate professor at the University of Utah.
So let's say you're between 35 and 40, maybe you're 38, and you've been trying to get pregnant for a couple of months and you're a little worried. You've been reading ladies' journals and you know the clock's been ticking. When should you get help? And does the age or health of your partner make any difference?
Dr. Johnstone: Absolutely. So for sort of the typical woman between the ages of 35 and 40, we usually recommend trying for about six months before you seek help. Now, who's the typical woman? This is a healthy woman who generally has regular periods coming about every 25 to 35 days, and a woman who doesn't have serious underlying health conditions.
We would think about seeking help earlier in the case of serious underlying health conditions, irregular periods, or a woman who has previously been treated for cancer with chemotherapy or radiation.
Then when we think about the partner. Some of it, we think about some of the same key things. Generally, six months, but reasons to seek help sooner would be if he has been treated for cancer with chemotherapy, radiation, if he's had testicular cancer even that was treated surgically, if he has other serious health problems, particularly if he has other serious health problems that may be affecting his erectile or ejaculatory function. Again, these would all be reasons to seek help sooner than six months.
Dr. Jones: Who should you see to get help and what will they do?
Dr. Johnstone: In this age group, some women may choose to start with their general OB-GYN for their evaluation, but many women will choose to start with a reproductive endocrinologist. And one of the main reasons for this is that . . . It's important to know for most women between 35 and 40, they will be able to successfully get pregnant, but time is more of the essence for women between 35 and 40.
It could hurt to lose time if you spend several months with your OB-GYN, then get a referral to a reproductive endocrinologist, and potentially it takes another couple of months to be seen. So again, many women in this age group will start with a reproductive endocrinologist.
Those early visits will involve a very thorough evaluation. Key pieces of this evaluation will be asking you a lot of questions about your menstrual history. If you keep menstrual journals, it's wonderful if you have them available for your visit. A very detailed look at your medical history, medications you're taking, surgeries you've had, lifestyle habits, things like alcohol, tobacco use, exercise, etc.
For a male partner, we would look at the same things, medical history, surgical history, key lifestyle factors, and factors affecting sexual function. Then as we go into evaluation, we would start for the male partner, typically, with a semen analysis where we would ask him to give a sperm sample. And then we would look at the number of sperm, how many of those sperm are swimming forward, and how many of those sperm have normal head shapes.
Dr. Jones: So reproductive endocrinologists aren't completely common. There are many people who might be listening to our podcast who live in towns that are not big metropolitan areas.
And so sometimes a reproductive endocrinologist is a long ways away, and that sometimes going to be difficult for people to pack up and drive three or four hours to see somebody. And that could be stressful.
So does stress increase difficulties getting pregnant? I just thought I'd throw that in there because some of us are really stressed out.
Dr. Johnstone: Absolutely. So there've been a lot of studies on this subject and they've been mixed in their findings. So I wish I could say stress has no effect at all. I couldn't say that, but I can absolutely say that stress is not a complete block to pregnancy.
And so I recommend to anyone who's trying to conceive to look for ways to reduce and manage their stress. But the number one reason to do that is because it can take time to get pregnant and we never know how long it's going to take.
And so, for your overall health and for the health of a relationship, it makes sense to try to find ways to manage and reduce that stress. But know that it's okay that there's stress. And the fact that you're worried about this, and the fact that it's hard to try to conceive doesn't mean that you won't get pregnant.
Dr. Jones: I remember a study years ago that just getting an appointment to a reproductive endocrinologist, to a referral fertility center, increased the chances of getting pregnant in the next six months. So that was just people who got an appointment and it was four or five months away compared to people who just tried on their own.
So sometimes doing things that will help alleviate your stress, even though you might have to travel for it, getting an appointment means that you've taken a step to move forward, and sometimes that itself makes you feel a little bit better.
Dr. Johnstone: Absolutely. And I should mention we currently are doing a lot of telehealth visits, and that means you may have the opportunity to gain a lot of information and get a lot of questions answered while sitting comfortably in your home, even if that's several hours away.
And I think that's one of the few bright lights that have come out of the COVID pandemic, is that there is greater availability for telehealth. And again, I think this is something that can really be helpful to couples in making access much better and also in giving you the opportunity to talk about these things from the comfort of your home as opposed to being in the doctor's office.
Dr. Jones: We also know that women as they get into their late 30s are a little more likely, unfortunately, to miscarry if they do get pregnant. And we know that sometimes by the time you've lived on the planet long enough, you've accumulated some illnesses, diabetes, hypertension, other conditions that might make pregnancy riskier.
And of course, just being over 35, some people think makes you a riskier pregnancy. But if you have any kind of medical conditions that you take medicines for, it's important to kind of think about how you get yourself in the best shape to be the pregnant person that you want to be for this baby you want to grow.
Dr. Johnstone: Absolutely. I think one thing I would add to that . . . So, one, if you have health conditions, check in with your doctor, but we also might refer you to a maternal-fetal medicine specialist to prepare for addressing those health conditions. How will your pregnancy affect your diabetes, your high blood pressure? How will your high blood pressure or diabetes affect your pregnancy?
Another thing to think about is some couples begin their fertility journey when they haven't had any medical care for a number of years. And so, if you are starting to try to conceive and you have not seen a health care provider in several years where it's possible that you may have high blood pressure or pre-diabetes that isn't diagnosed, it's a good idea to just get a general checkup at some point within that year before you try to conceive so that we can find these things rather than finding them once you're pregnant. We can do a better job of treating them and preparing you for pregnancy if we know about them first.
Dr. Jones: Exactly. So we aren't so fertile as a species to start with on a month-by-month basis, and we aren't so fertile as we get older. Peak human fertility starts to decline in the late 20s. So if you're in your late 30s, don't wait too long to get help if you aren't getting pregnant right away because we can help.
Thanks to Dr. Johnstone and thank you for listening on The Scope.
If you and your partner have been tying to get pregnant between 35 and 40, you may want to speak with a fertility specialist. The fertility treatments available to you greatly rely on the age of the woman trying to have a child. In this episode, Dr. Kirtly Jones speaks with fertility expert Dr. Erica Johnstone about helping women in their late 30's to become pregnant.
Dr. Jones: You've done everything you can to get ready to start a family, and now it just didn't happen. So when should you get help?
So you're a 28-year-old woman, and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help?
Well, it depends. Of course, it depends. It depends on a lot of things, your health and history, and the male part of getting pregnant part of the business. But we usually start with your age. We're going to do this in three parts. So if this isn't your age, or the age of the person you're worried about, check out our other podcasts about when to get help getting pregnant.
Here in The Scope studio virtually with us is Dr. Erica Johnstone. She is a specialist in reproductive endocrinology and infertility, and an associate professor at the University of Utah. Welcome, Dr. Johnstone.
Dr. Johnstone: Thank you.
Dr. Jones: Well, we're so glad you're here. So let's just say that you, the listener, are between 25 and 35. Of course, you could include 20 to 25. So let's just say you're under 35 years old, and you've decided to try to get pregnant, and you're so excited, but it didn't happen in the first three months. When should you consider getting some help?
Dr. Johnstone: So generally, for women who are under 35, we recommend trying for a full year before you seek help. And that's because it often happens. Close to half of women will conceive within those first three months. There are plenty of women and plenty of couples with perfectly normal fertility for whom it will just take a little bit longer.
Now, there are a few exceptions to that, situations when it might make sense to seek help sooner. One of those is if either the woman or her partner has previously been treated for cancer with chemotherapy or radiation.
Another of those situations is if a woman is having very irregular periods, going 45 days or more without a period, or potentially having no periods at all. Those would be times when you'd want to seek help sooner.
Dr. Jones: I know that people who want to have a baby, when they're finally ready, they want to do it right now. "I just want to have a Christmas baby," or, "I want to have a spring baby. I don't want to be pregnant in the summer." But what should you be doing while you're going to try on your own for a while? What do you tell people when you say . . . It's hard to tell someone to go away and come back in six months. What can you tell people to be doing while they're trying to get their 12 or 13 cycles of trying in?
Dr. Johnstone: Sure. So, first of all, things we think about are just being ready to be pregnant. So some key parts of this. One, take a prenatal vitamin every day. Two, if you're a smoker, I recommend that you quit smoking. The same is true for vaping, any sort of illicit drugs. You want to really limit your use of alcohol and caffeine. I recommend that every woman who's trying to conceive, make sure that she's up to date on her vaccines, including the COVID vaccine.
Then when it comes to actually trying to get pregnant, we think that probably, over time, one of the most effective strategies is just to have frequent sexual intercourse throughout the menstrual cycle, ideally about every other day, three times a week. This should work well. And with this approach, then you don't need to strictly worry about timing intercourse, just frequent intercourse throughout the cycle.
Dr. Jones: Right. Some people really struggle because they want to buy a kit that will tell them when they're ovulating, or they want to use their symptoms. But it turns out that just doing it is the way people get pregnant.
Dr. Johnstone: Absolutely. As it turns out, as many kits and products as there are now, the human race existed for many, many, many generations before the existence of those products.
Dr. Jones: And so who should you see to get help? If you're still a relatively young woman and a relatively young couple, and it's been nine months and you're picking up the phone to make an appointment, because you might not get the appointment next week, who should you be calling?
Dr. Johnstone: So I think for women under 35, it's reasonable to start with your OB-GYN, particularly if you already have an OB-GYN who you've established care with, who you might be able to get in to see sooner. It's also always an option to see a reproductive endocrinologist. And so, for women in this age group, either is a good option.
Dr. Jones: And so what would they do? Let's say you've been trying and it's got to be 10 months or something like that, and you got your appointment and you want to kind of be ready for what kinds of things they might do when you go to visit them. So what would they be doing in this first part of your visits with them and your evaluation?
Dr. Johnstone: One of the first things will be a very detailed history. We'll look at a woman's menstrual history. We'll look at her medical history, any surgeries that she might have had, any symptoms she might have related to her periods, pain with intercourse, things like this. We'll look at a general health history, health habits.
And we'll do the same for the male partner in terms of his general health history, any issues with things like erectile dysfunction, or difficulty with the ejaculation, etc.
And then we'll start with some tests, typically for both partners. So, for the male partner, we will usually do a semen analysis. And so this is collecting a sperm sample after about two to five days of abstinence, so that we can look at the number of sperm, we can look at how many of those are swimming and swimming in a progressive fashion, and how many of the sperm have normal head shapes. And this helps us to say, "Do we think there's a male factor making it harder to conceive?"
For the woman, we will often do some general health labs. Essentially, women in early pregnancy get a lot of blood tests done that are screening tests, looking at blood counts, maybe looking at their thyroid, their blood type, checking their immunity to different diseases, infectious disease testing. We know that every single one of these tests, it would be optimal if there's a problem to find it before pregnancy.
We'll also look at ovarian reserve. And what that means is does a woman have a normal number of eggs for a woman her age? Is it higher than most women her age, or is it lower than most women her age? And one of the important things to know about that is while it's really useful as we talk about treatment, it is not a predictor of who will and who won't get pregnant.
Dr. Jones: It just may help direct what kind of treatment is most likely to be helpful and which might not be?
Dr. Johnstone: Yes, exactly. We'll also typically do an ultrasound to look at a woman's uterus and ovaries, look to see if we see abnormal ovarian cysts, fibroids, polyps, any sort of structural or anatomic findings that might be contributing to the difficulty.
And finally, we would do a test like a hysterosalpingogram or a saline infusion sonohysterogram to assess whether a woman's fallopian tubes are open.
Dr. Jones: Right. So those are the beginning tests, and it helps guide a future therapy, I think. There are circumstances that would make it important to at least get information or get help sooner. You already mentioned that if women's cycles are really irregular, or if either the partners have had treatment for cancer when they were younger, it might mean that they don't have as many eggs and sperm.
But if a woman or her partner has a pretty serious medical condition, we want to make sure that that medical condition is in really tip-top shape before they get pregnant. So sometimes do you recommend people see a specialist, like an OB specialist, before they get pregnant?
Dr. Johnstone: Absolutely. So for women who have significant underlying health conditions or something in their history that might make their pregnancy higher risk than for other women, we'll recommend that they see a specialist in maternal fetal medicine before conceiving to talk about, "Are you on the best medications for your condition? How is that health condition going to affect your pregnancy? And how is your pregnancy going to affect that health condition and the treatment options?"
Dr. Jones: Right. Well, remember, it takes normal eggs and normal sperm, and fallopian tubes, and a uterus to get pregnant and grow a baby. And in humans, it often takes a little time. But don't wait forever. We can help. And thanks to Dr. Johnstone and thanks to you for joining us on The Scope.
If you and your partner have been struggling to get pregnant, it may be time to consider speaking with your doctor about fertility treatments. It’s important to realize that the conception strategies and medical options available to you greatly rely on the age of the woman trying to have a child. Learn the methods to help young women under 35 become pregnant.