Should You Have Your Baby Now?

Nancy Weil, 44, always knew she wanted kids--but the timing was never quite right. In her 20s and 30s, she was intoxicated by her career as a television producer--she worked late nights, she traveled. A social life? She squeezed it in between assignments. "I thought, 'Hey, I can do my career and have children later'," she says. At 42, Weil met her soulmate and decided it was time. For two years, they've been trying, first naturally, now with fertility drugs. A year ago she conceived, then miscarried. Last month alone, she spent $3,300 on injections. "If you ever told me I'd be having this kind of difficulty, I would have laughed in your face," she says. "I exercise, I eat well, I keep better work hours, but I'm really not in control of what's happening with my little eggs. It's devastating. It's a terrible sense of failure."

These are the dilemmas of babymaking in the 21st century. Women are delaying childbearing as never before: the rate of first births for women in their 30s and 40s has surged in this country--quadrupling since 1970. At the same time, rates for women in their early 20s have dropped by a third. Glamorous celebrity moms like Jane Seymour, Cheryl Tiegs and Mimi Rogers are setting a trend in 40- and even 50-plus motherhood. And headlines touting the latest technological advances (just last month: Australian research fertilizes eggs without sperm) are making it all sound so easy. But our biology hasn't changed one bit. Only about 2 percent of all babies are born to women over 40 every year, and yet every day, doctors say, fortysomething women arrive at their offices pleading to be the exception to the rule--and then are crushed when technology cannot help them.

Alarmed by what they view as a widespread lack of understanding about aging as a risk factor for infertility--and a false sense of security about what science can do--infertility groups have decided to turn up the heat on public awareness. This fall the American Infertility Association, a patient-advocacy group, will pepper doctors' offices with pamphlets educating women about how age can affect fertility--and what can go wrong. And next month the American Society for Reproductive Medicine, the nation's largest professional organization of fertility specialists, will launch a bold ad campaign that will debut on buses in New York, suburban Chicago and Seattle. The headline: advancing age decreases your ability to have children. The message: women "in their twenties and early thirties are most likely to conceive." The image: an upside-down baby bottle in the shape of an hourglass. "It's kind of like issuing a warning," says ASRM president Dr. Michael Soules, who spearheaded the campaign. "It's our duty to let people know."

That warning strikes at the heart of a complex web of emotional issues in women's lives. Women today have grown up with the expectation of "having it all": material wealth, career success, marriage and children. But many find the yellow brick road to motherhood littered with obstacles: lack of a partner, husbands who aren't ready, financial insecurity, divorce. "The idea that you can choose what age you'll be to have your children is a ludicrous proposition for most women," says Kim Gandy, president of the National Organization for Women, who delivered the first of her two daughters when she was 39, "as though you can simply snap your fingers and say, 'OK, I'm the right age,' and then have all the accouterments magically appear--the stable relationship, financial stability, life stability." For those who find themselves wanting children in their lifetime but are unable to envision having them now, the pressure and the anguish can be unbearable. Throw a tick-tock ad into the mix and it is bound to stir up controversy. Cindy O'Keefe, 28, who is single and wants to have kids, had a visceral reaction to the ad. "That's pressuring women in their 20s and 30s to conceive," she said, shouting over the lounge music at a trendy New York City bar. "That's sick!"

Women have had strong reasons to believe in the promise of technology, which has worked wonders for tens of thousands since test-tube baby Louise Brown's birth 23 years ago. Researchers can now not only mix egg and sperm in a petri dish, they can genetically test embryos for certain abnormalities, then weed them out before implantation. Science has made enormous strides in treating male infertility, which accounts for nearly half of all fertility problems: a single, sluggish sperm can be hunted down, then injected directly into an egg. Surrogates can carry babies for women who can't. And now donor eggs can be sucked out of one woman's ovaries and transferred to another's, giving life to couples who might have had no chance at all. The advances, both astonishing and alarming--the Florida grandmother who delivered a baby son for her daughter, the 63-year-old California woman who became a first-time mom--have changed our conception of parenthood forever.

And there's more going on in the lab, where scientists have been looking for new ways to attack the most frustrating problem in infertility today: the older woman's egg. Freezing eggs on college graduation day might seem like an ideal solution, but the success rate of that technique so far has been dismal because eggs tend to crystallize in sub-zero temps, disrupting their chromosomal integrity. Now researchers are experimenting with a variation on the theme: freezing slices of ovarian tissue, which contain thousands of eggs in an immature state. The procedure is being done for chemotherapy patients who hope one day to restore their fertility. It's far too soon to know if it will ever work, but the most optimistic doctors speculate that in the future some kind of freezing technique could be available for healthy young women who just want to wait. Last month French researchers reported a new development in the process: after implanting frozen pieces of ovary into sheep, the animals gave birth to several healthy lambs.

The boldest and most complicated solution to the aging egg is about as sci-fi as baby-making gets: manufacturing whole new versions of eggs. Already, researchers have experimented with a procedure called "nuclear transfer," in which they suck the nucleus (which contains a person's DNA) out of an older woman's egg, then transfer it into the cytoplasm (which houses the cell's energy source) of a younger egg. Voila! A 45-year-old woman, the theory goes, can have her own genetic child with the boost of a 25-year-old's eggs. And as if that weren't far out enough, scientists are even fiddling with ways to get rid of the older egg altogether. A team from Cornell University's Weill Medical College recently reported that it could make precursors to new eggs that appear to be chromosomally normal using the nucleus of another cell in the body merged with young donor cytoplasm. For women like Lindy Faier of Chicago, who is single and "old enough to be president," the future of assisted reproduction holds enormous promise. Faier spent her early adult life studying to be a lawyer; she's about to graduate from medical school. She'd like a baby, and while she knows she's pushing the odds, she still has hope. "I often think technology is going to rescue me," she says.

But the odds, say doctors, are that it probably won't. These experimental technologies are just that, experimental, and may never be available to humans. Some variations of nuclear transfer have already run into a major stumbling block. Because the experiments involve the swapping of cell parts--a process that uses some of the same steps involved in cloning--the FDA has stepped in, warning researchers that they must submit to the arduous process of biological drug approval before continuing to experiment with human cells. And the technology that does exist--in vitro fertilization and its variations--is financially, physically and emotionally draining. "It's like PMS times 1,000," says Adriane Stark Adler, 41. What's more, success rates decline significantly as women age: for women in their 30s, about 33 percent; after 43, they drop to well under 10 percent. As wonderful and improved as science is, says Dr. Mark Sauer, of Columbia University's Center for Women's Reproductive Care, "we haven't seen any real improvements in treating women over 40. You can't change biology."

Biology has always made fertility a delicate proposition. A woman is born with a finite number of eggs, which gradually get ovulated or die off as she ages. And older eggs, which are less energetic than younger ones, have a harder time making it through the fertilization process. Among healthy couples in their mid-20s who are not using birth control--at a time when most American women have babies--about one in four will get pregnant each month. By 30, fertility rates begin to slowly decline. But the greatest risk, say doctors, is pushing childbearing to the late 30s and 40s, when the chance of conception drops by 5 to 10 percent a year. By 43, when older eggs are far more likely to develop chromosomal abnormalities, the odds of getting pregnant through fertility treatments are so grim that most clinics strongly resist performing IVF with a woman's own eggs--they don't want to offer an ineffective option, nor do they want to drag down their own success rates. Miscarriage soars as women age--from about 15 percent in women aged 25 to 30, to about 40 percent in women over 40.

Statistics, however, never tell the whole story, and fertility doctors see a skewed population of patients. Some women conceive easily after 40, and others in their 20s struggle for years unsuccessfully. That margin for hope has convinced June Cohen, 31, that she can wait. Single and loving it, Cohen is aware that it may get harder for her to conceive later in life--"I don't know that there is a woman alive who isn't aware of her biological clock," she says--but she also wants to be the kind of supporting, devoted parent her mother was to her. "I'm not there yet," she says. "I know I want to have kids but I know I want to have them later. And I'm really, absolutely, not worried about that."

Fertility doctors are worried--so worried, in fact, they have decided to warn women that science can't always beat the biological clock. The ASRM says its $50,000 campaign, paid for by the group's annual budget, is aimed at educating women just like Cohen. Called "Protect Your Fertility," the campaign--which is linked to a Web site to be unveiled this week--will also highlight three other risk-factor public-service announcements: smoking, sexually transmitted diseases and body weight. The aging issue is clearly the most sensitive. Early on, the association had trouble finding a creative agency to design the campaign--some wouldn't touch it--and there were internal debates about whether the ad could be presented "without beating up women or encouraging adolescent pregnancy," says Soules. At one point, the group had pulled aging out of the mix altogether. But in the end, says Soules, "we feel it's the responsible thing to do." Support groups for infertility patients, like Resolve, which has chapters nationwide, agree wholeheartedly. "Aging is the issue that is coming up time and time again," says executive director Joan Bowen.

Ads are not the only answer, say fertility specialists--obstetrician-gynecologists should be doing more to educate young women during regular exams. Baby boomers' parents may have had kids in their 20s, but boomers themselves--the birth-control-pill generation--entered adulthood confident that they could schedule their reproductive lives. Many, like Nancy Weil, believed that staying fit and healthy would keep them young, not realizing that their ovaries were aging much faster than the rest of their bodies. A new Internet survey of thousands of women, to be reported at a scientific meeting this fall, found that while women have an excellent understanding of birth control, they tend to "overestimate the age at which fertility declines," says Dr. Richard Scott, of Reproductive Medicine Associates in New Jersey, who analyzed the findings. Dr. Jane Rosenthal, a psychiatrist at Columbia University, says she counsels infertility patients in their 40s who feel betrayed by the medical profession for not telling them more. "Many women are angry at their gynecologists who they feel didn't talk turkey with them about what's going to happen as they get older," she says.

Pamela Madsen, executive director of the American Infertility Association, wants to try to change that. She's hoping her educational pamphlets about infertility (the campaign is funded by Organon, which manufactures both birth-control and fertility drugs) will not only educate women, but empower doctors to raise the issue. "It's great that we have birth control and that women have a choice," says Madsen. "But part of that choice and reproductive freedom is the freedom to have a baby. What we've done is fed women this myth that they are in complete control of their reproductive lives and they can do it all. We fed them a fairy tale."

Afraid to offend or intrude, most doctors don't raise the question of fertility unless asked. The American College of Obstetricians and Gynecologists has no standard policy. OB-GYNs routinely ask their patients whether they are sexually active and if they are practicing birth control. But Dr. Owen Montgomery, an OB-GYN at the University of Pennsylvania School of Medicine, says he would not necessarily ask a woman under 35 about her reproductive plans--though he's happy to give her information and answer questions if she asks. Women are very aware of both their fertility and the choices they're making in life, Montgomery says. To assume otherwise is to underestimate their intelligence. "This is not a secret. They hear the ticking as loud as anybody else," he says. "It's not like they woke up and said, 'Oh my God, I forgot to get pregnant'." Jodi Solovy, 32, a stay-at-home mother of two, agrees. "I think women are going to have babies when they want to," she says. "If doctors say something, it might make them feel bad or even scare them into having them before they necessarily want to."

Other obstetricians say it's important to make the first move--even if it means stepping over the boundary of personal choice. Dr. Robert Gunby, of the Baylor University Medical Center in Dallas, says he begins asking women about having children when they're around 32. "I start saying, 'I'm not trying to pry into your business, but as women mature, their eggs aren't as fertile'," says Gunby. "Some women take offense at that, like I'm trying to push them into being pregnant, but I feel obligated to explain that to them. Otherwise they reach the age where they have no choice."

Many women say they have absolutely no regrets about waiting--whether it's a conscious choice or life circumstances--even if they end up having no children or choosing to adopt. Others are thrilled to be older mothers. Karen Eubank, 45, of Dallas, had no trouble getting pregnant with her son, Rowan, at 40. She devoted her 30s to her career and her marriage. Now she has the patience for a child. "I'm more generous with my time now," she says. "Being older allows me to be a better mother."

Some question the motives of the fertility doctors. They wonder whether the ASRM may just be launching a public-relations campaign, to make themselves look responsible when they are also the ones helping to raise false hopes by creating headlines about 63-year-old moms. Amy Allina of the National Women's Health Network, a nonprofit advocacy group in Washington, D.C., says the skeptic in her wonders if the group may even have a financial stake in raising worries about getting pregnant. "If women are more anxious about pregnancy, they may be more likely to seek medical help earlier, which would be in the interest of fertility doctors," she says. "I hope that's not what the campaign is about." The ASRM says absolutely not. The fertility business has boomed from about 40 clinics in 1986 to 360 today. "We're overwhelmed with patients already," says Soules. "This truly is altruistic."

One day down the road, scientists say they hope to figure out a way to determine each woman's reproductive age: she could take a test at 23 to predict how fertile she'll be at 40. Or science will unravel the mysterious molecular process that makes eggs age, then slow down the process. And, yes, researchers are working on both. But no matter how astonishing these advances, the human body, which hasn't changed in thousands of years, will stay fundamentally the same. And as long as it does, when, and how, to have children will remain the most personal of all life's choices.