Many women today are delaying pregnancy until later in life. Their reasons vary, from focusing on their education and career to traveling or even waiting out complicated situations such as the COVID-19 pandemic.
Some millennials are pressing pause on parenthood for financial reasons, too, pushing the average age for first-time moms in Dallas County to 26. For women with college degrees, the average is 30.4 years old.
This trend runs counter to a biological reality: The chances of getting pregnant decreases as women age because the number and quality of eggs in the ovaries diminishes over time. Remaining eggs in women 35 and older are more at risk of developing abnormal chromosomes which leads to higher risk of miscarriages or chromosomal abnormalities in pregnancies.
Women and their partners aren’t always aware of the potential effects of delaying pregnancy, particularly because they may see friends their age – or older celebrities – having babies in their 40s and beyond. What appears to have been an easy path to pregnancy for others may have involved several cycles of in vitro fertilization (IVF) or costly fertility treatments.
These are some common statements we hear in the clinic:
- ‘’My mother had me when she was 46.’’
- ‘’I learned about reproductive biology in middle school, but I didn’t know fertility declines with age.’’
There is emerging evidence that fertility potential in women and men is declining due to environmental factors, poor nutrition, and increases in stress levels – that’s why if you’re planning to delay pregnancy, it makes sense to take a proactive approach.
UT Southwestern’s fertility assessment team can provide answers and help you create an actionable path toward parenthood.
Fertility assessment timeline
Before fertility testing, women ideally should (for a brief time) stop using hormonal birth control, which can reduce the accuracy of test readings.
While commercial fertility “blood tests” to measure ovarian reserve may provide reliable results, they only give a “snapshot” of the wider picture. At UT Southwestern, we follow a comprehensive fertility assessment pathway of one month of the menstrual cycle. We schedule specific exams and tests at certain points so we can get the most impactful data. The male partner also can provide a sperm sample at one of these visits.
While each patient’s timeline is unique to her cycle, this is a typical assessment plan that our specialists follow:
Day 1: The first day of bleeding on your period
This day signals the official start of your fertility assessment process.
Days 2-5: Ovarian reserve testing
Our specialists may recommend an internal ultrasound and blood tests for preconception counseling (including rubella) and hormone levels in the early follicular phase, in which we test for follicle stimulating hormone, estradiol and anti-mullerian hormone (AMH) to determine ovarian reserve.
An internal ultrasound uses a wand-shaped device to view the structures of the uterus from the inside. Patients say it feels like getting a Pap smear. Imaging from the ultrasound can help us rule out or diagnose gynecological conditions that can affect fertility, such as advanced endometriosis, endometrial polyps, and uterine fibroids.
The AMH test tells us the level of the hormone in a sample of your blood. AMH levels decline with advancing age. There are age-specific ranges that will help assess the normal egg reserve. While AMH blood testing provides a reliable test for ovarian reserve, it does not predict the egg quality, chances of a pregnancy, or when a patient will begin menopause.
In some cases, the exam and test lead to a diagnosis of polycystic ovarian syndrome (PCOS), in which ovulation and periods are irregular.
Days 5-10: Examining the fallopian tubes
Between days 5 and 10, we perform a hysterosalpingogram (HSG) to outline the uterus and see whether the fallopian tubes are blocked by scar tissue or infection, which can prevent an egg from traveling from the ovary to the uterus.
A HSG test may only be recommended for women with long standing primary infertility or those who have had multiple abdominal surgeries, which can cause scar tissue and fallopian tube blockages, HSG tests may also be recommended for women with a history of longstanding primary infertility, STIs, or endometriosis.
HSG provides a real-time snapshot of the status of your uterus rather than relying solely on initial imaging or ultrasound. The procedure involves threading a thin tube through the vagina and cervix. We then inject a contrast material (dye) into the uterus. The X-rays follow the dye as it moves into the uterus and fallopian tubes.
Abnormalities will be outlined in white and unblocked fallopian tubes will fill with dye. The dye then spills into the pelvic cavity, where the body resorbs it. If the fallopian tube is blocked, we might recommend laparoscopic surgery to open the tube . In certain case scenarios, they may need to consider IVF treatment.
Days 10-14: Assessing the uterine lining
In women who have regular periods, halfway through your cycle, we perform an ultrasound to examine the endometrial thickness (the lining of the uterus) and get information from the ovary to track ovulation. Endometrial abnormalities such as scarring, polyps, or fibroids can also be diagnosed at this time.
Knowing the ideal window around which ovulation happens can inform timing for sex. Sperm can last three to five days in the female body while an egg lasts approximately 24 hours after ovulation.
Day 21: Blood test to measure progesterone
Approximately 6-8 days after ovulation, blood progesterone levels can provide more information that ovulation has occurred. This hormone also helps thicken the lining of the uterus and prepare it for a fertilized egg. This is commonly known as the Day 21 progesterone test.
Options for subfertility or infertility
After the assessment, your team of specialists will meet with you and your partner to discuss results. If you’ve gone through testing and found nothing out of the ordinary, you may not need fertility treatment. Your doctor will recommend next steps, which may include seeing other health specialists for underlying conditions or seeking counseling to manage the emotional challenges of trying to get pregnant.
If you choose to delay pregnancy, talk with a doctor about your options. They may recommend:
- Egg freezing (cryopreservation), which involves stimulating the ovary to produce multiple eggs, which are harvested and either fertilized and transferred to the uterus or stored for future use.
- Embryo freezing, which involves freezing and storing fertilized eggs for future use.
- IVF involves injections of medication to stimulate the ovaries to produce multiple eggs, which are retrieved and fertilized in a laboratory. The egg is implanted in the uterus and the uterine lining is supported with additional hormones to potentially sustain pregnancy.
While we offer conventional IVF, UT Southwestern has a niche in minimal stimulation and mild stimulation IVF (led by Orhan Bukulmez, M.D., Chief of the Division of Reproductive Endocrinology and Infertility). This is a treatment protocol that we use for women with diminished or very low ovarian reserve. The treatments use lower doses of medication than conventional IVF treatments.
Fertility treatments are increasingly covered by insurance providers. If a male partner’s tests show abnormalities, we can arrange an appointment with one of our male fertility specialists.
In some cases, due to medical conditions or advanced age, pregnancy may not be possible, which can be devastating for patients who want to become parents. Talk with your care team about more avenues to parenthood, such as using gamete donation (egg or sperm donation), adoption, or gestational carrier treatment. Though there are extensive laws related to gestational surrogacy, it can be a rewarding experience for the surrogate and expecting parents.
Finding hope for prospective parents
We understand the anxiety and stress that can accompany pregnancy planning. Getting a personalized fertility assessment can help you understand your chances of becoming pregnant today, the potential risks of waiting, and ultimately guide your decision about the timing that makes sense for you. Our goal is to help you make informed decisions about your current and future reproductive health.