What do Millennial women think about infertility?

What do Millennial women think about infertility?

What do Millennial women think about infertility?

Millennial generation were borne between 1982 and 2000. They have commonalities not shared by other generations. Generation Y is the highest-educated generation in American history.

On the Incidence of infertility in the US

The 2006–2010 National Survey of Family Growth (NSFG), indicates that the incidence of infertility among married women aged 15–44 is 6.0% (1.5 million) in 2006–2010, down from 8.5% in 1982 (2.4 Million women).
Impaired Fecundity (ability to have a live birth) among married women aged 15–44 Increased from 11% In 1982 To 15% In 2002, But decreased to 12% In 2006–2010. Both Infertility and impaired fecundity remain closely associated with age. The decline is probably reflects greater delay in childbearing (less women attempt to conceive thus less fit the definition of infertility).

Infertility prevalence can be estimated using two approaches: [1] a constructed measure derived from questions on sexual activity, contraception, relationship status, and pregnancy, and [2] a measure based on estimated time to pregnancy derived from the respondents’ current duration of pregnancy attempt (i.e., current duration approach). Prevalence was approximately twofold higher using the current duration approach (15.5%) vs. the constructed measure (7.0%). Both methods identified similar patterns of effect of increasing age (American Society for Reproductive Medicine 2013).

On Delaying Marriage in Generation Y

According to Pew Research Center analysis of U.S. Census data, 51% of US adults are currently married. Only 22% of Millennial women are married. The median age of first marriage for Gen Y women is 26.5 years and for men 28.7. Currently, there are more unmarried women in their early 30s than at any time in the last 60 years in the US.

What do Millennial women think about infertility? Generation Y : late marriage and late first birth

Millennial Women : late marriage and late first birth

Millenials give birth to their first child  many years later than predecessors. The mean age at first child’s birth for women was 23 and the mean age at first child’s birth for men was 25 and even much later in more recent research (The Guttmacher Institute). One-half of first births to women were in their 20s and two-thirds of first births were fathered by men who were in their 20s. On average, women aged 15-44 have 1.3 children as of the time of the interview.

Delay in bearing a child remains true even after cohabitation and other adult living arrangements are considered. The gap between first sex and first birth is 9+ years for Gen Y and 3+ years for Gen X.


Millennial Women Overestimate their Fertility Potential

Many Generation Y women, age 25 to 35, think a 30 year old woman has a 70-per cent chance of conceiving per month and in a 40 year old is close to 60% (Fertility IQ 2011 Survey, 1,000 women). Women were wrong most often about how long it takes to get pregnant and about how much fertility declines at various ages.
It is not clear why do millennials overestimate their fertility potenials possible explanations could be [1] Ignoring the disconnect between general health and ovarian aging; women can be very healthy and have very few eggs remaining in the ovary.
[2] Media celebrated older high profile and celebrity births in mid 40s.
[3] Some success of fertility treatment in older mothers.

Generation Y women are anxious about their fertility

Perceived infertility is the individual’s belief that she or he is unable to conceive or impregnate, regardless of whether this belief is medically accurate. Overall, 19% of women believed that they were very likely to be infertile, according to a Gutmacher institute 2012 survey of 1,800 unmarried men and women aged 18–29. A survey from Europe indicates that 31% of women and 52% of men believe that dramatic decline of fertility occurs after age 44.

 On The Utilization of Fertility Services by Millennial Women

Millennial women appear to utilize Fertility Service different than generation X. Twelve percent of women aged 15-44 in 2006-2010 (7.3 million women), or their husbands or partners, had ever used infertility services. Among women aged 25-44, 17% (6.9 million) had ever used any infertility service, a significant decrease from 20% in 1995. Thirty-eight percent of nulliparous women with current fertility problems in 2006-2010 had ever used infertility services, significantly less than 56% of such women in 1982. In all survey years, ever-use of medical help to get pregnant was highest among older and nulliparous women (NSFG). Gen Y also overestimate the success rate of IVF.

Consideration of fertility by generation Y without changing reproductive plans include

  1. No harm in evaluation of ovarian reserve. Some women, though very young, do have a diminished ovarian reserve to the extent that delay of seeking fertility treatment is detrimental to there ability to conceiving a biological child
  2. Delaying childbearing does not mean ignoring fertility for an undefined period. Many options can be exercised to preserve fertility, including lifestyle modifications, egg freezing and embryo freezing.
Sex Selection

Sex Selection

Sex selection is considered for one of three reasons:

1. Avoiding sex related genetic disorders. These are genes mostly carried on the X chromosomes and affect boys more than girls since they have one X chromosome e.g hemophilia

2. Family balancing: couples that have children of one sex and desire a child of the opposite sex

1941-2011 Trend: Suppose you could only have one child. Would you prefer that it be a boy or a girl?

Gender Selection, Boy or a Girl

3. Preference: some prefer a child of certain sex due to social factors. Recent poll in The UK  indicates that when 2,129 recently married couples were surveyed, found that 47% admitted that they would prefer to have a son first, with the majority citing practical reasons like boys being “less hard work”. Only 21% of respondents said they would like to have a daughter as their firstborn, and 32% reported having no preference either way. Couples who wanted to have a daughter first see older girls as ‘better role models’ to their younger siblings. In the US a Gallup poll yielded similar answers by American parents, especially men, since 1940s. American women do not have a proportionate preference for girls. American women show essentially no preference either way: 31% say they would prefer a boy and 33% would prefer a girl. More recent trends indicates that American couples prefer girls.

In contrast couples on a waiting list for adoption prefer girls both in the US and India. There is also some evidence that sexual orientation may influence that preference. Gay men are more likely to have a gender preference for their adopted child whereas heterosexual men are the least likely. Couples in heterosexual relationships are more likely to prefer girls than people in same-gender relationships.

The preference is also influenced by geography and politics. The official family planning policy in China, applied to large portions of Chinese, allow only for one child and does not allow sex selection. In the US many couples desire to limit the number of children to 2. If the first child is of one sex they desire the second child to be of the opposite sex


How is the sex of the embryo determined?

Older methods of selecting sex through change in the position or timing of intercourse or sperm sorting are not accurate and are not suitable for sex selection in modern couples seeking a specific sex (the other sex maybe conceived in 30% or more of couples). Modern sex selection depends on genetics. After stimulation of the ovaries, egg retrieval and fertilization, one or few cells from the embryo is obtained. The cells are analysed for each embryo for the X and Y chromosome. Results are obtained and are accurate >99% of the time.

After identification of the X and Y chromosomes, the desired embryo is transferred into the uterus. The embryo that carries the correct chromosome, should survive and be of good quality. Sex selection is more likely to succeed in women with good ovarian reserve, producing a good number of eggs. The larger the number of embryos available for testing, the more likely a healthy embryo of the desired sex is available for transfer.

Learn more about gender selection.


Is it safe for women to get pregnant after breast cancer treatment

Pregnancy after breast cancer treatment

Pregnancy after breast cancer treatment

After treatment of breast cancer to the satisfaction of her oncologist, should a woman who desire to get pregnant be discouraged from doing so? A very critical question considering the fact that there are close to half a million breast cancer survivors living in the US and are in the childbearing age.

Is it safe for women to get pregnant after breast cancer treatment?

For a very long time, counseling of women regarding pregnancy was dependent on the fact that estrogen increases during pregnancy and because estrogen has some effects on both estrogen receptor positive and estrogen receptor negative breast cancers, its probably better if women avoid pregnancy-unless of course another woman is carrying for them, a gestational carrier. This recommendation is not based on strong scientific evidence.

Safety of pregnancy after breast cancer treatment. All the published reports included a total of 1417 women who got pregnant after breast cancer treatment and 18059 who survived breast cancer and did not get pregnant. Women who got pregnant following breast cancer diagnosis had significantly better survival compared to women who did not get pregnant. In fact, those who got pregnant were more than 40% less likely to die because of breast cancer.

Pregnancy after breast cancer treatment

Pregnancy after breast cancer treatment

Important caveat to these studies is the healthy mother bias-the tendency of healthier women to desire and attempt pregnancy and the less healthy women to avoid pregnancy. This may inflate the safety of becoming pregnant after breast cancer treatment. Studies also largely did not address the chance for recurrence. Nevertheless, no study showed detrimental effect in breast cancer survivors who become pregnant. The largest of these studies published by The Danish Breast Cancer Cooperative Group was a population based study and included over 10,000 women who survived breast cancer and were under the age of 45. Three hundreds and sixty-seventy one women experienced 465 pregnancies and 236 deliveries. Women who got pregnant-full term or spontaneous miscarriage, were at least 30% less likely to die from breast cancer. Women with low risk breast cancers enjoyed 45% higher chance for survival after full term pregnancy than similar women who did not get pregnant.

How long should women wait after breast cancer treatment before attempting pregnancy? The majority of experts recommend waiting for about two years as the majority of recurrences takes place within this period. There are differences in recurrence pattern, however, between estrogen receptor negative and estrogen receptor positive tumors. Estrogen receptor negative tumors are more common in younger women and tend to recur earlier-within 2years after treatment. Recurrence of estrogen receptor positive cancers remain as high as 4-5% per year for about 15 years.

Pregnancy in BRCA1 and BRCA2 mutation carriers. In BRCA1 pregnancy does not seem to increase the risk of early onset breast cancer. In BRCA2 carriers, pregnancy may cause a borderline increase in risk of breast cancer before 50, especially when first pregnancy after age 40.

Pregnancy after breast cancer treatment

Pregnancy after breast cancer treatment

Breast feeding is recommended whenever possible in women treated for breast cancer, even if they are BRCA carriers and does not appear to impact breast cancer prognosis and may even be protective in some cases.

Contraception. If pregnancy is not desired as during breast cancer treatment and the follow up period after treatment non hormonal contraception is recommended such as IUD or barrier method e.g. condom. BRCA1 carriers may show an increased risk for early onset breast cancer if they use oral contraceptive pills before the age of 30 or for more than 5 years.

Young women diagnosed with breast cancer are commonly very concerned about their future fertility and safety of pregnancy after treatment. Proper counseling enables them to make appropriate decisions about future reproduction and fertility preservation. At the end of the day, most of the breast cancer battles will be won, some will be lost, pregnancy does not appear to contribute to that loss.

Ovarian Cysts and Fertility

Ovarian Cysts and Fertility

Ovarian cysts are very common during reproductive age women. The cyst has a wall and is full of fluid. Very few of ovarian cysts are cancer after puberty and before menopause. The two most common types are follicular cysts and corpus luteum cysts. These are the result of follicle growth in the ovary (the sac that contains the egg) that either a. does not release the egg and continue to grow or b. releases the egg then the follicle wall now called the corpus luteum closes and reform a cyst. The vast majority of these cysts require just observation as they resolve on their own.


laparoscopic surgery for endometrioma may reduce ovarian reserve

The other two common benign cysts are dermoid cysts and endometriomas. Dermoid cyst is a developmental cyst that are commonly found in young women. It is very rare for them to become cancer. Larger cysts can twist and become painful as they twist the blood vessels of the ovary. This needs prompt medical attention. Endometriomas are benign cysts full of old blood. The wall of endometrioms is similar to the lining of the uterus-endometrium. They sometimes cause pelvic pain.

Benign tumors of the ovary can also include serous or mucinous cysts, they contain thin or thick fluid, respectively. They rarely become malignant. Border-line ovarian cysts exhibit more activity of the cells lining the cyst wall but lack the invasion seen in cancer. Malignant cysts do exist but are not common before the age of 40.

Evaluation of ovarian cysts include clinical history, pelvic exam, careful ultrasound, color doppler to study blood flow into the cyst and blood work to assay tumor markers. Vaginal ultrasound, can in expert hands, delineate the characteristic appearance of the cyst and can reach an accurate diagnosis in 90% of dermoid cysts and endoemtrioms. Sometimes a follow up of six to eight weeks is needed as the majority of follicular and corpus luteum cysts will disappear during this period. Larger cysts that do not appear during that period may require surgical evaluation, usually using minimally acess surgery-laparoscopy.

Fertility preservation in women diagnosed with ovarian cysts. The most important initial task is to exclude malignancy in an ovarian cyst.

Benign cysts– can be managed using observation every 6 months or ovarian cystectomy. Ovarian cystectomy entails making a cut in the ovary and removal of the cyst and the cyst wall. Removal of the cyst wall, inadvertently remove some of the adjacent ovarian tissue. Sometimes that impairs the future function of the ovary and reduces ovarian reserve and possibly the chance of future pregnancy. This is especially true if the surgery has to be repeated in the future or needs to be done on both sides. If the type of cyst is known with high degree or certainty as in the case of dermoid cysts and endometriomas, the cysts are small and not causing any complaints, young women can elect to observe them until they complete their family. If ovarian cystectomy is planned, discussion of the effects on ovarian function should be  initiated as well as evaluation of ovarian reserve before and after surgery. Ovarian stimulation and egg or embryo freezing can be accomplished prior to surgery. For some women, ovarian tissue freezing can also be performed at the time of surgery.

Borderline ovarian cysts. Borderline ovarian cysts can be treated with cystectomy-removal of the cyst, oophorectomy-removal of the whole ovary or hysterectomy with removal of both ovaries. There is no evidence that one treatment is better than the other in terms of survival. For women who desire future fertility removal of the cyst only is a viable option. If the ovary need to e removed, ovarian stimulation, egg retrieval and embryo or egg freezing can be performed prior to surgery.

Malignant ovarian cysts. Malignant ovarian tumors limited to one ovary, can be treated by removal of that ovary with preservation of the uterus and the other ovary. Unfortunately, those that spread beyond the ovary may require hysterectomy and removal of both ovaries.

If you have an ovarian cyst and surgery was recommended, consultation with a reproductive endocrinologist and oncologist or gynecologist can clarify possible effects of surgery on future fertility. Women then will have the opportunity to understand fertility preservation options available for them.

Egg Reserve and Infertility

Egg Reserve and Infertility

Egg reserve means the number and quality of eggs remaining in the ovaries at a given age. It reflects the fertility potential of a woman irrespective of the cause of infertility, even male factor.

Benefits of Testing for Egg Reserve

Testing for egg reserve results should be interpreted with caution. Abnormal values should not be a cause for denying fertility treatment because the predictive power for pregnancy with own eggs is modest. For women, ovarian reserve tests give women insight into the chance of pregnancy with there own eggs. It also may indicate the need to promptly avoid delay in seeking fertility treatment.  For reproductive endocrinologists, the tests have value in designing fertility treatment and selecting the most appropriate fertility treatment protocol. They predict response to fertility medications and allow infertility specialists to select treatment protocol and gonadotropin dose. Egg reserve also predicts the number of eggs retrieved for IVF or egg freezing.

Egg Reserve: Egg Number

Although the number of eggs in the ovaries decrease with age there is significant individual variation in initial number endowed in the ovaries and the rate of decrease. Some young women has low egg number and older with large number of eggs. Ovarian reserve tests are used to estimate this number.

Egge reserve: the number of eggs in the ovaries drops with age

Egge reserve: the number of eggs in the ovaries drops with age


Medical history may indicate low egg reserve in women with prior excision of ovarian cysts, endometriosis of the ovaries,  women who smoke and with family history of early menopause

Antral follicle count

The number of antral follicles in the ovaries (the structures that contain the eggs) can be seen and counted using vaginal ultrasound. Performed by an experienced reproductive endocrinologist, it can accurately estimate ovarian reserve. Low count e.g <10 in both ovaries points to low reserve.

Day 3 FSH, Estradiol

FSH is produced by the master gland in the base of the brain. Estradiol is made by the follicles themselves. Measured in the second or third day of menstrual cycle, high FSH (>12) of high estradiol (>75) points to low egg reserve.

Antimullerian Hormone (AMH)

AMH is produced by the cells surrounding the eggs in small follicles and is a more direct measure of egg reserve than FSH. It can be accurately measured any day in the cycle with  little variations in between cycles. Levels <1.5 ng/dL generally indicates low egg reserve. It correlates well with antral follicle count.

Genetic Screening

Low egg reserve in few women is due to a genetic cause. Fragile X syndrome is a genetic disease that causes low egg reserve and mental deficiency in newborn males. Chromosomal abnormalities e.g Turner syndrome, translocations are also associated with low egg reserve. Genetic screening is performed using a simple blood test before starting fertility treatment.

Egg Reserve: Egg Quality

What does egg quality means ?

Good quality eggs are chromosomaly normal (has 23 chromosomes). The most important factor that prevents the achievement of pregnancy or leads to early miscarriage is an abnormal egg (has extra or missing chromosome or piece of a chromosome). Many eggs at any age in any woman are abnormal and the normal eggs are the ones that are successful in being fertilized with sperm, implant and achieve a pregnancy. These errors takes place when the original cell that produce the eggs divide to reduce the number of chromosomes to half. The division (meiosis) is many times unequal leading to an egg with an extra or missing chromosome.

Age and egg quality

The ovary releases better quality age earlier in life and lower quality age later, for unknown reason. Female age is the most important indicator for egg quality, chance for spontaneous pregnancy and after fertility treatment. Older women need to try longer to achieve pregnancy and at an increased risk for miscarriage, ectopic pregnancy and delivering a baby with chromosomal abnormalities e.g Down Syndrome. This effect of age become clinically evident at age 30 or even earlier. Age is more important than the number of eggs in the ovaries. Young women with few eggs in the ovary are more successful in getting pregnant than older women with many eggs in the ovary.



Testing for egg quality: PGD

Age is the only available noninvasive method to estimate egg quality. Healthy eggs cannot be identified using any non invasive method. It is possible to identify chromosomal errors in the egg during IVF fertility treatment after biopsy of the first polar body of unfertilized egg or after removing one cell from an embryo after the egg is fertilized then test this material for chromosomal abnormality. This process is called PGD or preimplantation genetic diagnosis. It is important to remember that PGD is not proven so far as method of enhancing fertility potential. It simply detects if the egg or embryo is chromosomaly normal or not but will not make an unhealthy egg healthy.

Read more about ovarian reserve and low response to ovarian stimulation in my review here.

Egg Freezing

Egg Freezing

Women freeze their eggs for one of two reasons

  1. Elective: freezing eggs to use later on to avoid age related decrease in egg quality and number. This is a fertility solution for fertile women.
  2. Medical indication: women diagnosed with cancer and require surgery or chemotherapy that will reduce ovarian function, egg donation and egg banking, failure of the the male to produce sperm at the time of IVF.

Is egg freezing suitable for me?

You need personalized information about ovarian reserve and reproductive system before deciding on egg freezing. Ovarian reserve is an estimate of the number of eggs in the ovary and their quality. The number of eggs is estimated using vaginal ultrasound for antral follicle count, AMH levels and day 2 or 3 FSH and estradiol. AMH levels > 1.5ng/dL and antral follicle count > 12 indicate decent number of eggs in the ovaries.

Egg quality is reflected by age. The younger the age, the more chromosomally normal eggs are available in the ovary.

Women 38 or younger freezing more than 8 eggs have excellent chance to become pregnant when eggs are thawed, fertilized and transferred to the womb. Live birth rates decline with age but some live births took place from eggs frozen up to age 44.

Approximately 90% of eggs stored using vitrification survive thawing and 75% of them fertilize. Each egg thawed has the potential to produce a baby approximately 10% of the time (5 to 15% depending on age). Commonly, three to four eggs are thawed and two to three embryos are transferred. This will yield a reasonable live birth rate per cycle. The American Society For Reproductive Medicine does not consider egg freezing an experimental technology anymore.

What do I need do to freeze my Eggs?

Ovarian stimulation: using injection medications to recruit multiple follicles and produce multiple eggs, instead of one egg only in a natural cycle. Medicine is self injected daily for approximately 10 days and monitored using estrogen levels and ultrasound every two to three days. A trigger injection is finally given.

Egg retrieval: eggs are harvested under sedation 36 hours after the trigger injection. Eggs are obtained using a needle through the vagina without an incision.

Egg freezing: Vitrification method is used. Four hours after retrieval, Mature eggs are mixed with a cryo-protecting solution. Two to three eggs are placed on a special device cryotop that is sealed and plunged in liquid nitrogen or nitrogen vapor. Immature eggs can also be frozen.

The cycle can be repeated. Also some of the eggs can be fertilized using donor sperm if desired.

What happens after I freeze my eggs?

Frozen eggs Can be stored for a very long time, possibly indefinitely. Eggs can also be transferred to other facilities or countries.

When you are ready, with a partner: try natural conception, investigate other fertility factors, consider fertility treatment or finally use the eggs.

When you are ready, without a partner: try IUI using donor sperm or IVF using donor sperm or fertilize the frozen eggs with donor sperm.

Utilizing your frozen eggs: The steps to utilize your eggs are

  1. Preparation of the lining of the uterus using estrogen (no injections) or during your natural cycle,
  2. Egg thawing in the embryology lab,
  3. ICSI: injection of one sperm into each egg,
  4. Embryo development and transfer is observed in the lab and
  5. Transfer of one or more embryos into the uterus

Is egg freezing safe?

Babies born after thawing the eggs, fertilization and transfer into the uterus do not have higher risk of abnormalities compared to those born from after transfer of thawed embryos or naturally conceived. However, there has not been as much babies born using this technology or long term follow up as in the case of embryo freezing.


If you did not attempt to conceive by age 30 or earlier, consider evaluation of ovarian reserve and egg freezing if you do not intend to get pregnant soon. Obtaining personalized information about egg reserve is the primary step in deciding if egg freezing is suitable for you.