When Should I Have Kids?
Let’s talk about your fertility, understand how age impacts reproduction, and discuss when an evaluation by a fertility specialist is recommended. Even if you already have kids, learn more about what your friends and family may be going through.
Should I be planning now?
The number one question I get asked as a fertility doctor is: “When should I have kids?” I think it speaks to the heart of why I really started my Instagram in the first place. The fact that we as women are not taught about our bodies, educated about what is normal and what is not normal, or told what happens as we let time pass. We are told we can have it all and that we should chase our dreams, which I love. Please set amazingly fantastic goals, but friends, please do not ignore your fertility in the process. I'm not trying to scare you. This is not a scare tactic, and I do not believe that every woman needs to go out and freeze her eggs out of fear for her fertility. I'm challenging you to think. I'm asking you, what is your goal when it comes to your fertility or your family, or having kids? There are no right or wrong answers. If this is you, this is your life, these are your dreams, and you can't plan for something if you don't identify it as important to you. So you must start from within.
Let’s dive right in!
This post is full of numbers and statistics. These are averages and odds, and every single person is on their own unique pathway. They have their own odds or probability. The truth is, we don't know unless we know, and that's the whole point of this post.
Odds of getting pregnant per month
So the odds of getting pregnant permit a cycle, so not overall, but per month that you have a period is called fecundability. So these are just the odds of being pregnant at the end of a given month. The average fecundability for most young women, under the age of 32, is approximately 20 to 25 percent. So most couples in this age range who try to get pregnant will be pregnant within four months, and by one year of trying, about 15% will not be pregnant. The definition of infertility is the percentage of people who are not pregnant after one year of trying. Infertility impacts one out of every 8 women. Your fecundability also decreases with the number of times you’ve been trying to get pregnant. Even if you're under the age of 30, and you are just starting to try to get pregnant. Your odds of success are 20 to 25 percent. However, if you've been trying for over a year, your odds are 5 percent per month. If you've been trying for over two years, your odds are two to three percent per month. It’s not zero, but that is not nearly high enough for any of us to feel comfortable taking a wait-and-see approach, especially if you want more than one child. Your fecundability markedly decreases with age, especially if you have never gotten pregnant in the past.
Fecundability and Age
So if you're trying to get pregnant for the first time and you're 35, your chance of getting pregnant is about 12% per month, at age 38, it's 5% per month, and at age 40, it's 3% per month. Once you've had a child, these numbers are not quite as scary, so it's 20% at age 33, 15% at 35, 13% at 39, and 8% at 40. Overall, you can see that once you hit over that 35, these numbers start to really go down, and part of this difference is because women who've never gotten pregnant or tried to get pregnant may have underlying fertility issues that we don't know about.
Why is it harder to get pregnant as we age?
Two different mechanisms contribute to it being harder to get pregnant as we get older, and it's really important to understand that they are different, so you can understand how your fertility changes. The first is that we run out of eggs, and the second is that egg quality decreases. What I mean by egg quality is that as we age, there's an increase in the number of random genetic abnormalities in our eggs. This also causes a higher rate of miscarriage. It's really related to age and the rate of miscarriage increases as you get older too, so it's about 15% to 20%. When you're under 34, it's 20% to 30%, when you're 35 to 39, and when you're 40 and over, it's over 50%. That means if you are 40 and have never gotten pregnant, your chance of getting pregnant per month is 3%. If you get pregnant, your chance of miscarriage is over 50%. Neither of those numbers is zero, but the odds of ending up with a baby from that is not very high.
IVF is not foolproof.
Something that I see all the time is women come in to see me, and they just rely on the advanced technology that exists in my field. They come in and they say, “I'm just going to do IVF, and it'll all work out because that tech is so amazing.” The tech is amazing, but it is not a cure all. It's not a woman's fault for feeling this way. If you've ever thought this, I am not blaming you. Society glamorizes celebrities childbearing at older ages, and they've not always been clear about the mechanisms by which that pregnancy occurred. Many of these celebrities used donor eggs or froze their eggs at younger ages. Society has made it so that fertility is such a personal goal that we're not even talking about the truth about how it happens and how we get pregnant.
Running out of eggs
Almost every woman I talk to know they're going to run out of eggs and go into menopause. However, let's think about some of the numbers. So you have the most eggs you're ever going to have while you are inside your mother's womb, which is about six to seven million. From there on, you have a constant decrease in your egg number. There's only about 300,00 by the time you start puberty, and you only ovulate about 400 eggs over the course of an average reproductive life span. I often get asked, “If you're born with one to two million, but you only ovulate 400 eggs, what happens to all of the other eggs?” The easiest way to think about this is that you have all your eggs in a vault inside your ovaries, and I don't know how many you have in your vault. Nobody knows, but at the start of each month, a group of eggs is released from the vault and they can come to the surface of the ovary. We can see these eggs on ultrasound. We call them the antral follicles, we can count them, and that number means something. Those antral follicles are how many can respond to FSH (follicle-stimulating hormone) in a normal month. FSH comes from the brain and it stimulates one egg to ovulate. The rest of the eggs that have been released from the vault do not get stimulated. That month they will die. When we start talking about IVF, egg freezing, or fertility treatments, all we do is give more FSH than the brain can make. We stimulate all of those eggs to surface and grow instead of dying. We can't make more eggs come out of the vault, so if you are starting to run out of eggs and fewer eggs are being released every month from your vault, there's nothing I can do about it. When you're running out of eggs, all of our treatments become harder. Women have to go through more cycles for egg freezing or for IVF because there is strength in numbers.
Ovarian Reserve and Testing
When we talk about this number of antral follicle count, that's one measure of something we call ovarian reserve. In the fertility world, we measure ovarian reserve to try to determine where you are on the pathway of egg decline. Some women run out of eggs earlier than others, and when you have a lower number of eggs you should for your age, we call this DOR or diminished ovarian reserve. You can run out of eggs and go into premature menopause. Like almost every fertility doctor, we've had patients in their 20s and 30s who have run out of eggs prematurely. Another common evaluation of ovarian reserve is a blood test, and this test is called AMH or anti-Mullerian hormone. It's made from the cells that surround all of those small antral follicles, and the number of eggs that are released from the vault likely correlates with how many are left behind. So when you have more eggs, more are released every month, and when you have fewer eggs, fewer are released every month. However, it's not usually consistent. Usually, we say 20% to 30%, but those of us in clinical practice sometimes even see it more. You can have good months and bad months. I tell my patients that I use AFC and AMH to place them into a category, above average, average, low, or critically low, and this can help us determine what the next best steps for you are based on your goals. You may modify your reproductive goals based on the information you get. You may come up with a new timeline in terms of conception, you may consider egg freezing, or you just may accept that alternative path to parenthood, such as donor eggs or adoption.
Ovarian Failure
There are a couple of other blood tests that also fall into the category of tests of ovarian reserve on cycle day two through four, so if day one is the first day you start your full flow of bleeding, we can check FSH and estradiol. A high FSH is diagnostic of menopause or ovarian failure. The brain is sending out all the FSH it has and trying as hard as it can to get an egg to respond and nothing responds. This is ovarian failure. The brain keeps sending out that FSH, no egg grows, no estrogen is made, and the ovary has nothing to give. I cannot make a woman's ovaries grow eggs even with the highest doses of medication. Once your ovaries have entered failure or your FSH starts rising, you're not going to respond to high doses of FSH. Those cases are really hard, that's where as a fertility specialist, you have to tell your patients that their opportunity for a genetic child has now passed.
Expanding your vision of parenthood
If you want to carry a baby, give birth, breastfeed, bond with that baby, that's beautiful. You can do that, but you’re going to have to get on board with eggs from another woman. You can start looking at adoption or other forms, or accept that maybe your pathway doesn't include children. None of those are easy places to come to, and I know that, but it's important to have that information so you can make the appropriate plan for yourself. There's a lot of variation for each individual woman based on how many eggs you're born with, which is somewhat random by genetics or the maternal environment during pregnancy, but egg number and egg quality or independent factors. If you are young and running out of eggs, they are still better quality than an older woman.
Egg Quality
Age is the only safe marker we currently have to quantify egg quality, meaning I don't have a test I can do to see if your eggs are good or bad. What we do know is that as we age, the proteins that hold our chromosomes apart inside our eggs start to break down, and that's why we see that uneven split in your chromosome number. This is what's called aneuploidy or an abnormal chromosome number, which is the number one cause of miscarriage. It increases with age. There are probably many other factors that actually do impact egg quality that we cannot study because we don't have a test. If we can't evaluate the quality of your eggs, I can't do a study to see what impacts it. Likely things like stress, diet, inflammation, illness, impact how your body and eggs are functioning. Just because something is hard to study doesn't mean that it's not important or impactful. This is why most fertility physicians, myself included, are huge advocates for healthy living and optimizing lifestyle factors, which may appear to positively influence natural fertility. Another statistic I use that resonates more with women who are in their early 30s is that for every year over the age of 30, the probability for ongoing pregnancy decreases by about 1.5% per year, and that number is really meaningful.
Female Physicians and Fertility
I'm going to switch things up and approach this in a different way because I think this sheds a lot of light on the topic, and if you follow me on Instagram, we’ve talked about this. So there was a study in the Journal of Women's Health in 2016 that showed that over 24% of female physicians had infertility, and I told you earlier that the average rate of infertility is 15%, so that's huge. That's much higher. The average age for the first pregnancy for these women was years later than the national average, and I'm not surprised by that. It is normal that many female physicians delay childbearing. What I found shocking about this study is the difference in the knowledge of female physicians about infertility and treatment success rates. At older reproductive ages. Most of these female physicians thought that if you were over 40, IVF had a 33.8% chance of resulting in a pregnancy. It is much lower. These are highly educated women who understand the complex physiology of the body, have learned something about reproduction in their training, and overestimate IVF success rates at older ages. So of course, the general population does, too.
What is your goal?
I know I'm always talking about that question, but I mean it. When it comes to having a family, what is your goal? So for me, I wanted kids, and I knew I wanted to wait until I was further into my training to try to achieve that. However, I also knew that if I couldn't have genetic children, it would be okay. I would be open to exploring a donation or adoption. I wanted kids on my own, but if it had to happen another way, that would have been okay for me. That knowledge gave me some freedom. I was lucky and found my partner early in life, and he was on the same page. Many of you know my fertility journey wasn't easy. I had multiple miscarriages, an ectopic pregnancy, and our path had lots of heartache and doubt along the way. However, we got there and have the two best kids on Earth. I know how hard it is to be in that space and think about this and wonder if that dream or that goal will ever be achieved for you. It is okay if you have a different goal. You just need to know what path you're on. I see women struggle with this all the time. They thought they'd be fine with whatever happened, but in reality, they want a child and that genetic connection. The combination of them and their partner coming together to make a child is part of what makes it magical. If that is you, do not be late to the game.
3 Pieces of Advice
Make sure you are making your best effort with each cycle. Understand what impacts fertility. Learn how to track your cycles, and make sure they are regular. If your periods aren't coming regularly or you are having severe pain or difficulty with intercourse, go see an OBGYN or fertility doctor right away.
Talk to your OBGYN or a fertility specialist about testing your ovarian reserve. They can do an AMH blood test, and even though it's not perfect, it could categorize you and at least make you feel that the timeline in your head makes sense for you. Certainly, if I was younger and married and found out that my aim was low, and I might have a short timeline, I might have changed my current pathway.
If you know you don't want to have kids until after you’re thirty-two, but you really want genetic children, you should consider seeing an REI to learn more about egg freezing. If you're starting age is 35 to 37 and you’d like to have more than one child, then that recommendation is even stronger.
Could egg freezing be for me?
I'm going to give a final note on egg freezing. I often see patients who are concerned about their reproductive potential, I do a test of ovarian reserve, we talk about what they should do with this information, and I believe that egg freezing can really be a game-changer for the right woman. It can allow you freedom and flexibility for your family planning, which is really beautiful because life is dynamic. How you feel now may not be how you're gonna feel in five or ten years. It’s important to remember not all women who freeze eggs will have a child born from those frozen eggs. The process will not work for everyone for a variety of reasons, so it's not insurance, but it's an opportunity. It is placing an investment in you and your reproductive future. Many women who freeze their eggs will get pregnant naturally without a problem and may never use their eggs. They may use them for second or third children, but regardless, they were proactive in preserving fertility.
My challenge for you.
I really want you to allow those numbers to sink in. I think it's a little information overload but think about it. I really want you to take away that there is a huge knowledge gap for women when it comes to fertility, and this is a problem. It’s what I want to change, and I need your help. We need to empower ourselves and each other with knowledge about our bodies, our fertility, and our struggles. So if you're up for it, I want you to share one fact from this with somebody else. I also want you to think about your goals, specifically when it comes to childbearing if you've not had a child yet. What is the pathway that's important to you, and how can we take the best steps to try to get there? If you are struggling with infertility, I'm not trying to make any of this harder for you. The last thing I want is for you to read this and feel like the world is crashing down on you. If you're struggling, make sure you trust your doctor, and just go all-in on the process and believe in it. It can be a marathon, my friends, but just remember, you're not alone. We need to talk openly about our struggles if we feel comfortable because others are struggling too. Other people think they are alone, and view struggle as a failure. Failure is hard, but it's not a failure, it's real life. We are stronger together.