How long should you try to get pregnant before consulting a specialist in your 20s, in your 30s and in your 40s? What changes as you get older?
Typically, women under age 35 should attempt pregnancy for about 1 year prior to seeking evaluation for infertility. Women older than 35 should be evaluated after attempting pregnancy for 6 months without success. A woman’s egg supply decreases over time, particularly after age 35. In addition, the eggs remaining in a woman’s “repository” accumulate genetic errors over time. Therefore, the risk of miscarriage and the risk of having a child with a chromosomal abnormality such as Down syndrome increase as you age. At the age of 40, approximately 50% of a woman’s embryos can be expected to be aneuploid– contain an abnormal number of chromosomes.
Earlier evaluation for infertility is merited in special circumstances. For instance, if a woman has irregular menstrual cycles or a family history of early menopause, or either partner has a history of cancer, the couple should seek consultation as soon as they decide to have children. Some women in these circumstances will seek evaluation even before deciding to have children.
This is a critical issue today as individuals plan to start their families later in life. Our recent Infertility in America 2017 survey found that, on average, Millennials are planning to wait until after they are in their mid-30s to start their families. This means that they should speak to their gynecologist to learn more about their options to help ensure they are able to have healthy children later on.
What health issues could put you at risk for fertility problems, and at what point should you see a fertility specialist for each?
There are a number of issues that increase a couple’s risk for infertility. Advanced age, particularly age >35 is the risk factor most strongly associated with infertility. Women over the age of 35 who have been having unprotected intercourse for 6 months or longer without pregnancy should be evaluated by their gynecologist or a reproductive endocrinologist.
Irregular menstrual cycles can also lead to difficulties with conception. Irregular cycles can be a sign of polycystic ovary syndrome, premature ovarian failure, or insufficient stimulation of the ovaries by hormones from the brain. Because all of these issues are associated with health problems beyond fertility, it is very important that anyone with irregular menstrual cycles be evaluated by their gynecologist. Indeed, irregular cycles can sometimes be the first sign of insulin resistance or diabetes, malnutrition, endometrial hyperplasia or cancer, or even (very rarely) brain tumors.
Abnormal thyroid function may be associated with infertility, miscarriage, and abnormalities of fetal brain development. Again, because abnormal thyroid function negatively affects not just fertility, but overall health, it is very important that any individuals with abnormal thyroid function be regularly monitored by their primary care physician or an endocrinologist.
Extremes of body weight may also affect reproduction. Individuals with a BMI under 18 (underweight) or over 30 (obese) may be at higher risk for infertility and also complications during pregnancy. Individuals who are underweight or have morbid obesity (BMI >40) should seek expert consultation prior to attempting conception. All couples seeking pregnancy should aim for a healthy body weight prior to conception.
Women with endometriosis are at increased risk for infertility and ectopic pregnancy. Endometriosis is a condition wherein endometrial tissue (which should be found only inside the uterus) occurs outside the uterus. Endometriosis can lead to scarring and damage of pelvic structures including the fallopian tubes and ovaries. It is typically associated with infertility and pelvic pain.
Individuals with complicated medical histories, including history of cancer, inflammatory bowel disease, prior pelvic surgeries, or other health issues may benefit from an early fertility evaluation. Such diagnoses and procedures can be associated with diminished ovarian reserve (low egg count), blocked fallopian tubes, and complications occurring during pregnancy.
What if you already know you have a reproductive issue such as: PCOS, endometriosis, pelvic inflammatory disease, scar tissue, etc. What steps should you take if you’re trying to get pregnant?
Women with known reproductive issues such as polycystic ovary syndrome (PCOS) or endometriosis should be evaluated by their gynecologist or a reproductive endocrinologist as soon as they begin attempting pregnancy. Women with PCOS often will need medication to induce ovulation in order to facilitate conception. Women with endometriosis should have their fallopian tubes evaluated to make sure that the endometriosis has not created scarring which increases their risk for ectopic pregnancy or completely obstructs their opportunity for conception.
Women with a history of pelvic inflammatory disease or multiple prior abdominal/pelvic surgeries should likewise be evaluated for anatomical changes/ scar tissue that would obstruct pregnancy.
Also, for couples in whom the male partner has a complicated medical history, prior exposure to chemotherapy, and/or testicular or endocrine abnormalities, early semen analysis may save the couple many months of fruitless efforts at conception.
Do these common health issues necessarily preclude the chance of a natural pregnancy?
Of course, as with any complicated medical conditions, unexpected or atypical situations can occur. Women with polycystic ovary syndrome can occasionally ovulate spontaneously and conceive on their own. Women with endometriosis can also have spontaneous conceptions, though extra precaution is merited to ensure that they do not have an ectopic pregnancy. Women of advanced reproductive age can sometimes have spontaneous, healthy conceptions. However, these scenarios are less common and thorough early evaluation of women with complex reproductive issues will help the majority of those individuals to be better prepared to plan for and achieve pregnancy.
What should you do if you’ve had more than one miscarriage?
Individuals with recurrent pregnancy loss (more than two miscarriages) should be evaluated by their gynecologist or a reproductive endocrinologist. There are several medical conditions associated with recurrent pregnancy loss, many of which can be corrected. Anatomic problems with the uterus such as a uterine septum, intrauterine scar tissue, and others can cause pregnancy loss. Abnormalities of thyroid function, exposure to environmental toxins, and issues related to blood clotting may also be linked with recurrent miscarriage. Sometimes one or both parents may harbor a chromosomal translocation (genetic issue) which can be addressed through advanced embryo screening techniques.
