It’s 2019 and shockingly little about the conversation on reproductive choice has changed. While the ominously ticking biological clock in older ads has been replaced by more “empowering” messages (on Instagram, naturally) urging women to freeze their eggs for the cost of a manicure, the underlying message is the same: If you want kids one day, better hurry, because those ovaries aren’t getting any younger.
Science has made a bit more progress—assisted reproductive technologies like IVF have helped millions of women become moms when getting pregnant naturally wasn’t in the cards, and hormonal tests that can give you insight in to your fertility future have gotten more accessible—but it can’t erase the biological bottom line: fertility declines with age. Women in their 30s are now officially having more babies than women in their 20s, according to CDC data, but technology still may not be keeping up with a sharp demographic shift: women are putting off pregnancy.
The average age of first pregnancy varies wildly across the country but is steadily creeping upwards; the national average age of first pregnancy back in 1970 was 21—in 2017, it was closer to 27. Twenty-seven is still young in reproductive terms—fertility doesn’t begin to enter the danger zone until your mid-30s—but many women, especially in big cities, are pushing the limits, getting closer and closer to the reproductive fringes. In Miami, the average age of first time mothers is 30; women in Manhattan are putting pregnancy off until 31; in San Francisco, first-time moms are 32 on average.
Why women put off pregnancy (or choose to skip it all together), doesn't really matter; whether it's a matter of waiting for a promotion, the right partner, or just to feel ready for motherhood, that choice doesn't need to be justified. But it should also be made with all the facts: In your mid-20s—peak fertility years—the chances of getting pregnant naturally each time you ovulate are around 25 percent. But by 30, that number slips to 20 percent; at 35 it’s around 15 percent and by 40, your chances of getting pregnant naturally hover around 5 percent. The longer women wait, the less optimistic their reproductive chances.
It’s no wonder egg freezing, billed as the empowering way to take control of your future, is on the rise. “We’ve done a really good job of pushing the conversation forward and women are so much more proactive about it,” says Jaime Knopman, M.D. a board-certified reproductive endocrinologist and directory of fertility preservation for CCRM, a fertility clinic in New York. “But on the flipside, I think we’ve created a little bit of hysteria.” Proof: the vast majority of women who freeze their eggs never use them. One small study published in Human Reproduction in 2017 found the number of women who go on to fertilize and implant the eggs they put on ice might be as low as 6 percent. With average egg freezing costs between $30,000 and $40,000, that’s a massive amount of potentially wasted cash.
Whether egg freezing is a savvy move that is indeed “empowering” or just another way to scare women into making certain decisions about their bodies depends on why—and when—you’re doing it. If you want to get pregnant at 30, your chances of conceiving naturally (which is exactly what happened to the majority of women in the study after icing their eggs) are still high. If you have other things on the agenda and don’t foresee motherhood becoming a priority until you’re pushing 40, it can be a smart move.
So how did we get to this point, where we’re investing so much fear and angst and actual dollars into a maybe-someday solution? Because we lack good information.
What we know about our reproductive health and our basic fertility is woefully inadequate—77 percent of women in a recent Glamour survey incorrectly thought health could trump age when it comes to reproductive odds. (It doesn’t—more on that later.) Smart decisions can only be made with good information, so Glamour partnered with fertility testing company Modern Fertility to cut through the fear mongering and misinformation and ask over 300 women what they really know about the modern state of fertility. It turns out, despite the fact that we’re talking about fertility more than ever, the facts are still elusive—over 70 percent of the women we surveyed wished they knew more about the factors influencing their fertility future. “Knowledge is the most important thing—you need to be educated in order to make good decisions down the road,” says Dr. Knopman. “Knowing what happens to your fertility and knowing that there are options—and that not all options are created equal—is important."
Here’s what you need to know about the modern state of fertility to save yourself serious debt and regret—whether you want to have kids now, in 10 years, or aren’t quite sure yet.
Age does matter—more than anything else.
“Age is the single most dominant factor in determining fertility and success with fertility treatments. It matters above all else,” says Paula Brady, M.D., assistant professor of obstetrics and gynecology at the Columbia University Irving Medical Center, and reproductive endocrinologist at Columbia University Fertility Center. “Women are born with all the eggs we'll ever have, so time takes its toll in a very real way—particularly after age 35.”
It seems like there should be an override switch to neutralize Mother Nature as you pursue the here and now of your career, dating life, or personal journey to self-discovery; but the fact of the matter is, no amount of yoga, organic meals, or cutting edge tech can erase the effects of time on fertility.
Age impacts two key factors of fertility: egg quantity and egg quality. The latter dictates how well eggs are primed for fertilization and are capable of seeding a healthy, ongoing pregnancy. Both decline with age but it’s the drop off in egg quality that really causes trouble. “Over time, eggs start to accumulate little genetic changes that increase the risk of infertility and of miscarriage,” Dr. Brady says. That risk rises continuously through the 30s, beginning a sharp swing around 35. “It's not a cliff,” Dr. Brady says. “It's not like when you're 34.9 things are going to be so much different than when you're 35.0. It's just a time to be aware that things start to change.”
Health is important, just not in the way you might think.
The majority of women Glamour surveyed thought that being healthy could short circuit a ticking biological clock. “I hear that all the time. People are like, but I eat organic!” says Dr. Knopman. Health does matter—it influences the health of your pregnancy—“but your ovaries don’t really care how many apples you eat in a day or if you always go to the gym,” Dr. Knopman says. “Those things will make you healthy in your pregnancy, and that’s a huge advantage—you have less risk of gestational diabetes and high blood pressure—but you will still have the same challenges actually getting pregnant.”
The major exception to the rule: smoking. A cigarette habit will do a number on just about every major health system—your heart, your lungs, even your skin—including your reproductive system. Smoking kicks egg loss into overdrive—women who smoke enter menopause an average of one to four years earlier than non-smokers. (The verdict on vaping is still out: “The problem with vaping is that everyone thinks it’s not as bad as cigarettes but we don’t really know what it does yet,” says Dr. Knopman.)
Weight can also impact your chances of having a baby (that goes for male partners too). “Obesity in women increases the rate of miscarriage, and is associated with worse outcomes for fertility treatments,” Dr. Brady says.
IVF is not a silver bullet.
Success rates with IVF—often hailed as a magic bullet—hover around 5 percent for women in their early 40s. “People are really shocked to hear that,” Dr. Brady says.
Really shocked. Fertility doctors see women every day who’ve been led to believe that egg-freezing and IVF are insurance policies with limited risks and hopeful guarantees.
IVF is revolutionary science that has allowed over 8 million births to women who otherwise wouldn’t have been able to get pregnant, since the procedure was first pioneered in the 1980s. But “most of the success of IVF is based on the age of the female,” Dr. Knopman says. “The younger you are when you make the embryos the better chance those embryos are going to be viable and lead to a viable pregnancy.”
It’s far from a fail-safe promise, but the technology (and the ad campaigns surrounding it) has given an inflated sense of confidence about what fertility treatments can and can’t do. “People come in at 40 and say, ‘Oh I’m going to do IVF,’ and I tell them okay but this may take us a lot of rounds and it may not work,” Dr. Knopman says. In other words, you can’t just throw money at the problem: “It’s not always a slam dunk,” she says.
It also matters where you do your IVF. It’s a technically challenging procedure, part art, part science, and not all IVF clinics are up to the challenge. “Not all labs can do egg retrieval and storage the same way,” Dr. Knopman says. “Lab conditions can alter the embryo.” Before handing over your credit card, your body, or your dreams of future pregnancy, ask the clinic the right questions: How many eggs have you frozen? How many eggs have survived the thaw? How many eggs have made embryos?
Look for a clinic associated with the Society of Assisted Reproductive Technology, which provides oversight and keeps tabs on a clinic's success rate.
Taking hormonal birth control doesn’t impact your fertility.
“One of the biggest myths I hear is that the pill hurts your fertility and that long-term pill use is not good,” says Dr. Knopman. That’s not true. Let us repeat: Hormonal birth control—whether you use the pill, the ring, the patch or a hormonal IUD—doesn’t hurt your fertility.
“What birth control won’t protect you from is egg loss,” Dr. Knopman says. “Most of us are born with about one to two million eggs. By the time we get our first period, most of us have about 350,000 eggs—you lose a significant amount before you even menstruate." Each month, regardless of whether you're ovulating or not, around a thousand eggs die off, their cells absorbed back into your body. "From the first period to the last period, you’re constantly losing eggs no matter what you do," says Dr. Knopman.
One factor that does impact your ovarian reserves: family history. No matter how far off your baby-making plans, when you are ready to start thinking about fertility, you should talk to your mom before you talk to your gynecologist. “Women who have had sisters or mothers who went through menopause early—around age 40—definitely should discuss that with their gynecologist,” says Dr. Brady. It’s not a death sentence for your ovaries but it is a good opportunity for a little proactive fertility assessment. “If your mom had an earlier menopause and we think you might too, maybe you’re a candidate to freeze your eggs, so in the future there’s less worry about what your ovaries are doing,” Dr. Knopman says.
If you want to put a pin in pregnancy, you should have a plan.
Conversations about fertility can be off-putting—like yet another paternalistic conversation about what women should be doing with their bodies. “Women don’t want to feel oppressed by this biological clock feeling—we have enough to worry about,” Dr. Brady says. “The American Society of Reproductive Medicine tried to do some public awareness about reproductive aging years ago”—picture a baby bottle shaped like an hourglass—“and it really did not go over well for these reasons.”
Today’s cartoon eggs colonizing Instagram feeds aren’t any better. But upping your awareness of the factors influencing your fertility doesn’t mean you should run to the nearest egg freezing clinic and slap down a credit card.
Information, especially information about your body, is power. When we asked women what they would do if they found out they had fewer eggs than average for their age, 72 percent said they’d start a conversation with their doctor about what that means for them. Asking your OB-GYN about the factors in your health history that might tip the scales one way or the other is a good place to start.
You can also get some insight with a blood test that measures hormones associated with the number of eggs you have—it’s just one aspect of what goes into getting pregnant but it’s a good jumping off point for a conversation with your doc.
The important thing: “This has to be a conversation that’s had in context,” says Dr. Knopman. No single test can lay out your fertility future with complete certainty just as no single decision like freezing your eggs can guarantee you’ll beat the biological clock. Understanding your fertility isn’t a single stat or snapshot, says Dr. Knopman—it’s an ongoing conversation.