Thirty-seven and counting

The harsh reality of women's fertility decline

Illustration by Patrick Ledger

Brigitte Adams always wanted to have kids one day: a boy and a girl. “My mom’s a first-grade teacher, and there’s a whole library of children’s books she’s saved for me,” says Adams, 40. Two years ago, she talked to her doctor. “He said, ‘Just get pregnant now,’ ” but Adams, who divorced at 34, was single. “I’d like to have a traditional family,” she says. “I wasn’t ready to have children by myself.” Last year, she froze her eggs.

Like Adams, women in their mid- to late thirties are turning to egg freezing to slow the biological clock, putting aside a stash of eggs to gain more time to have a child. Elective egg freezing is fairly new, and not all fertility clinics offer it, but it’s about to go mainstream. On Oct. 19, the American Society for Reproductive Medicine (ASRM) lifted its “experimental” label on egg freezing, citing findings that younger women are about as likely to get pregnant whether using fresh eggs in a fertility treatment, or previously frozen ones. While the ASRM doesn’t set rules for fertility clinics, merely provides guidelines, more are bound to start offering the procedure—and more patients will seek it out. Women late in their reproductive years may be disappointed: not even this cutting-edge technology can halt the female fertility decline.

The ASRM’s new recommendations say egg freezing can help certain women, like cancer patients who might suffer infertility after chemotherapy, or couples using IVF, if the man can’t give a sperm sample the day his partner’s eggs are retrieved. But it stopped short of recommending egg freezing for the purpose of delaying childbearing, especially among older women. “We don’t have good data on women who are older,” says Dr. Samantha Pfeifer, head of the ASRM Practice Committee, which wrote the new recommendations; most of the studies so far have been in women under 30. Egg freezing can be a costly procedure, and takes a physical and emotional toll; there’s concern about giving patients false hope. Yet older women like Adams are the ones “most clamouring for the technology,” Pfeifer acknowledges.

Adams had her eggs frozen at 39—an age many fertility clinics would already deem too old for the procedure. Many won’t do it if the patient is over 37 or 38, when egg quality and quantity steeply decline. LifeQuest, a private clinic in Toronto, won’t freeze a woman’s eggs past 37. After that, “fertility takes a nosedive,” says medical director Dr. Ken Cadesky. In Vancouver, Genesis Fertility Centre offers egg freezing with no strict age cut-off, although “in our experience, freezing over age 37 isn’t a good alternative,” says co-director and co-founder Dr. Al Yuzpe. “I’ve been in the field of infertility for 42 years, and we’ve seen an evolution. The one thing we’ve never been able to overcome is the effect of female age.”

Despite this, women in their late thirties are increasingly seeking out elective egg freezing. They’re hoping that science can help them achieve a traditional family, ultimately one with a father who is known and present, rather than an anonymous sperm-bank donor.

Adams, who runs a website called Eggsurance, calls egg freezing the new birth control pill, an option that empowers women and increases their choices. But even this promising technology can only help so much. On the Eggsurance blog, Adams describes meeting a “lovely woman” who’d left a corporate career and was considering egg freezing. “Then she mentioned her age: 42. I did not have the heart to tell her she was already too old,” Adams writes. “She would find out soon enough.”

Across the Western world, women are waiting longer than ever to have kids. The average age of Canadian women giving birth moved from 27 to almost 30 over the last two decades; the proportion of first births among women 35 or older went from four per cent in 1987 to 11 per cent in 2005, according to the Society of Obstetricians and Gynaecologists of Canada (SOGC). The newsstands are populated with pregnant stars or new moms in their late 30s and 40s: Drew Barrymore, Uma Thurman, Salma Hayek. Everyone knows somebody who had a kid at 39 or 40.

But the truth is that women who can conceive naturally late in their fertile years are an anomaly, and science can only help so much.

Virtually every woman is aware of the “biological clock,” but many still don’t realize how rapidly fertile years slip away. In a 2012 study of U.S. university students, 83 per cent of women and 91 per cent of men thought the age at which women experience a slight dip in fertility is older than it is (in reality, it happens between 25 and 29). Two-thirds of women and 81 per cent of men made the same mistake for the age at which it steeply decreases (after 35). “They’re viewing it as after 40, sometimes after 45 or 50,” says author Brennan Peterson, a psychology professor at Chapman University in Orange, Calif. “That’s so beyond the mark.” A woman freezing her eggs at 38 “is doing it at the wrong time,” he says. “The time to freeze them, in truth, is when she’s in her mid-20s.” Of course, planning a life is rarely so simple. “It would take a very forward-thinking woman to do that,” Peterson says. “Most people don’t believe they’re at risk for infertility if they delay.”

A woman is born with all the eggs she’ll ever have: about one or two million at birth, a number that dwindles to less than half a million by the time puberty hits, then continues to drop until menopause. During her reproductive years, she will ovulate perhaps 500 eggs. The rest die off. “Between the two processes, women probably lose 1,000 eggs for every month they ovulate,” Yuzpe says. A woman’s eggs are large and tricky to freeze, like “big water balloons,” says Pfeifer.

The first human was born of a frozen egg in 1986, but it’s taken decades to perfect the process. “Social” egg freezing, the elective kind, has taken off partly thanks to a newer technique called “vitrification,” a sort of flash-freezing that’s replacing the older slow-freeze method. (LifeQuest, which has offered social egg freezing for about two years, adopted vitrification just a few months ago.) “The success of egg freezing has only come to the fore since we’ve been able to use vitrification,” Yuzpe says. When eggs are frozen this way, “they don’t form ice crystals, which can destroy the egg and damage genetic material.”

At LifeQuest, the egg freezing program is still a very small part of the clinic’s overall practice. About 200 people have been in touch about it, and 70 have gone ahead with the procedure or are booked to do so in the near future, Cadesky says. These are mostly single women in their early 30s “who were not in a relationship, and starting to worry about the prospects of their fertility dwindling before they find someone,” he says. “They’re looking for a backup, an insurance policy.”

Social egg freezing is not offered at the Mount Sinai Centre for Fertility and Reproductive Health in Toronto. Older women seeking egg freezing are “an incredibly vulnerable group of people,” says medical director Dr. Ellen Greenblatt, “and there are ethical concerns about giving them a false sense of security. Reproductive technologies can’t make up for the egg quality issues that happen with aging.” Greenblatt agrees with the new ASRM guidelines, which state that there just isn’t enough data on the safety, success rates, cost-effectiveness and potential emotional risks to promote egg freezing to healthy women who wish to delay childbearing—especially not older women. “If you have a 41-year-old woman who wants to freeze her eggs, how do you counsel her on whether it’s worth going through the procedure?” Pfeifer says.

At LifeQuest, all patients undergo counselling before freezing their eggs. “They’re informed that although babies [born of the procedure] have been perfectly healthy up until now, there are no long-term follow-ups,” Cadesky says. “It would be far more comforting with 10 or 15 years [of observation and study], but they don’t have 10 years to wait.” (According to the ASRM, a recent review of over 900 children born from frozen eggs found no increased risks.)

The process is only for the committed. LifeQuest charges $8,600 for egg freezing, including $3,000 for medication covered by many insurance plans. Egg storage, thawing, fertilization and embryo transfer will cost more. It’s also physically and emotionally gruelling. “In essence, it’s half an IVF cycle,” Cadesky says. For both egg freezing and IVF, women inject medication to stimulate egg development; eggs are harvested and, in the case of IVF, fertilized with sperm and re-implanted in the patient. For egg freezing, the eggs are frozen and stashed away; the other half of the IVF cycle will be completed when the patient is ready to use them. “Frozen eggs do not have as high a pregnancy rate as frozen embryos,” Cadesky says, but patients freezing eggs would rather take that chance. Even then, they can’t wait forever. LifeQuest stipulates that an egg-freezing patient must have her eggs fertilized and implanted in her uterus by her 50th birthday, if she’s going to use them. Most fertility clinics won’t treat women after 50, when pregnancy becomes too risky and complicated.

Before Adams had her eggs extracted and frozen, she injected medication into her own stomach for 12 days, twice a day like clockwork, as the doctor had recommended. “The first one was the hardest. I was terrified,” she says. By the end, she was comfortable enough to give herself a shot in a public bathroom, or in her car. When she went in for the procedure, she felt a swirl of emotion. “You’re excited, empowered,” she says. “And then you start being sad or angry—like, why haven’t I met anyone, why can’t I have a traditional family?” After it was done, she felt calmer, more confident. “Now when I’m going out, I’m not laser focused on meeting someone.” Doctors retrieved 11 eggs. She calls them her insurance policy. “If I meet someone, we’ll be working with 39-year-old eggs, as opposed to 42- or 43-year-old ones.”

Six months after Carolyn Lawrence left her husband, she decided to freeze her eggs. “I called my mom, and the first thing she said is that I should do it,” says Lawrence, 35, who lives in Toronto. She’d started a new relationship at that point, but didn’t feel they were ready to have kids. At 32, she started the egg-freezing process. “I thought, time’s ticking.”

Her career was a big motivation. “I run a business and work very hard,” says Lawrence, president and CEO of Women of Influence, a marketing and media company for professional women. “I loved the idea of freezing my eggs because then you don’t have to rush the decision over a career, finances, or a partner.” In her work, she’s seen plenty of women “driving themselves crazy” wondering when to start a family, she says. Egg freezing gave her “peace of mind.”

Two months before Lawrence was scheduled for the egg extraction, she got pregnant—the old-fashioned way. “It definitely was not the plan, but sometimes things happen for a reason.” Lawrence, who remains in a committed relationship with her baby’s father, now has eight-month-old son, Jack. She’s still a big booster of egg freezing. “Professional women have so many responsibilities they’re taking on,” she says. “The ability to freeze your eggs gives you more control and options.”

Whether it’s to pursue an education, career or relationship, there are many good reasons to put off having kids. But eventually women find themselves confronting a biological reality: their most fertile years can coincide with these pursuits. Men also experience a fertility decline, but a much different one. Advanced paternal age appears associated with problems like increased frequency of schizophrenia or autism spectrum disorders, according to an SOGC paper. But male fertility can extend far later in life. Pierre Trudeau fathered a daughter at 71. Canadian-born author Saul Bellow had a daughter at 84.

While Lawrence’s career did factor into her decision, as it does for countless other women, the stereotype of the “career woman” who purposely puts off having kids is actually far from the norm. Delayed childbearing is rarely viewed as a “conscious choice,” says a 2012 study in the International Journal of Nursing Studies. U.K. researchers interviewed women 35 and over about their experiences. While they might have felt ready for a baby at various times, they reported feeling it was out of their hands: factors like a relationship, finances, health and fertility were seen as beyond their control. The biggest influence was the need for the right partner. “I am leaving it later than I would have chosen to do,” one subject, 38-year-old Vicky, told the team. “I would have done it in my early thirties if I’d been with the right person.”

Women and men who plan on having children one day—just not now—should be informed about their fertility, says Dr. Jo-Ann Johnson, a professor of obstetrics and gynecology at the University of Calgary and co-author of a recent SOGC report on delayed childbearing. In doctors’ offices, that message is often lost. “We’ve been spending so much time and effort in prevention of pregnancy in younger women, that we’ve completely ignored the epidemic in older women,” she says. “The message we need to get out is it’s neither patronizing nor inappropriate to inform women there’s an optimal window to avoid complications and disappointments down the road.” Yuzpe too believes that “fertility counselling” should be offered alongside contraception counselling. Peterson agrees. “What we want to avoid is the 40-year-old who’s healthy, ready for kids, with the nursery all set up—and now realizing she can’t.”

Age-related infertility can be heartbreaking. Kathy John, a 42-year-old kindergarten teacher in Surrey, B.C., got together with her husband, C.S. John, when she was 37; he was 35. She’d been previously married, but left when it became clear her ex didn’t want kids. Kathy and C.S. started trying to get pregnant a month before the wedding, when she was 39. Soon, they realized there might be a problem. After visiting a fertility specialist and trying more conservative treatments, the couple decided on IVF. “For us, that was a big deal,” C.S. says. “We’d just had a wedding and paid for the house. After spending a couple of thousand on the other treatments, it cost $12,000.” IVF didn’t work. “I felt like I was sliding,” Kathy said earlier this summer. “It’s taken me the last three years to be okay with it.” C.S., a filmmaker, is making a documentary about the experience called On Infertile Ground. (Yuzpe is an executive producer.)

In July, the Johns left for the Czech Republic for an egg donation. It’s illegal to compensate egg donors in Canada, which can make it difficult to find one here, and seeking a donor in the U.S. is “prohibitively expensive,” C.S. says. “I’m nervous, but I’m glad to be moving on,” Kathy told Maclean’s shortly before leaving for Prague. In September, they announced happy news: Kathy is pregnant with twins, due in mid-March, right around their wedding anniversary.

Egg donation is the last remaining option for women who wish to conceive, but can’t. Patients can undergo IVF with a donor egg up until 50 without much decline in success rate. Still, many are hesitant to give up a genetic link to the child. “Not a lot of patients turn up wanting to have an egg donor,” Yuzpe says. “They say, ‘I want to get pregnant.’ We raise the issue of an egg donor.”

When it comes to aging eggs, science hasn’t produced any magic bullets—but patients are often too quick to believe technology will be their saviour. “There’s definitely a perception: ‘IVF will do it for me if I can’t get pregnant on my own,’ ” says Karla Bretherick, a post-doctoral fellow at the B.C. Cancer Agency and a co-author of a 2010 report on Canadian perceptions of female fertility. “There’s an unawareness of the fact that fertility with IVF declines with age as well.” According to the Society of Obstetricians and Gynaecologists of Canada, in 2007, the Canadian live birth rate after IVF (with their own eggs) was about 37 per cent for women under 35, 27 per cent for those 35 to 39, and 11 per cent for those 40 or over. Advances in reproductive technology have produced a “false sense of security,” says the report.

It’s one reason so many are still caught off-guard by fertility’s decline, a feeling Adams describes on her blog. “We spend so much of our lives trying not to get pregnant. We take birth control, use condoms, practise the rhythm method and then—bam—it is too late. Our ovarian reserve is diminished. Our eggs are no longer healthy. Like Wile E. Coyote [running off a cliff] we are surprised by our fate, but we knew we were on a cliff and that the cliff had a drop-off point.”

Freezing her eggs gave Adams some clarity. “I really toyed with the idea of being a single mom,” she says. But after the procedure, Adams realized it’s not the right decision for her. “With my personality, and where I am in my life, and not having a lot of family nearby, I just thought I can’t be a single mom.” She’s holding out for a partner to fertilize those eggs. But at the same time, Adams is coming to terms with the fact she may never use her eggs at all. “I’m thinking that in the next few years, if I don’t have children, I probably won’t,” she says. She’s got the rest of her life to focus on; even so, the prospect of giving up such a long-held dream makes her sad. “What I believe now is that I want a traditional family. Hopefully I will meet someone and that will happen.”

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