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Commentary| Volume 27, ISSUE 1, P4-10, July 2013

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Cassandra’s prophecy: why we need to tell the women of the future about age-related fertility decline and ‘delayed’ childbearing

Published:April 22, 2013DOI:https://doi.org/10.1016/j.rbmo.2013.03.023
Cassandra’s prophecy: why we need to tell the women of the future about age-related fertility decline and ‘delayed’ childbearing
Previous ArticleA patient perspective
Next ArticleCassandra’s prophecy: a psychological perspective. Why we need to do more than just tell women

      Abstract

      This anonymized paper describes the author’s experience of age-related infertility and unintended childlessness. It outlines her journey from diagnosis to treatment success and clinical pregnancy through assisted reproduction using oocyte donation, followed by subsequent early miscarriage. It makes subjective observations about treatment she received and presents her impressions of how discourses of knowledge dissemination, communication and care were constructed in the organizations she encountered. It sets her own reflections alongside broader observations on the challenges facing women today when planning a family and draws attention to what she perceives to be the misleading myths and misunderstandings concerning reproduction that these women are now subject to. In the light of this, it offers some suggestions for modified public health messages and new approaches to sex education and health screening that may consequently help to empower tomorrow’s women (and men) to take full control over their reproductive lives in the 21st century. The paper takes as its mascot the figure of Cassandra, daughter of King Priam and Queen Hecuba. She was loved by Apollo, but resisted him. In consequence, he rendered useless the gift of prophecy that he had bestowed on her by causing her predictions never to be believed.

      Keywords

      A personal story

      At the age of 32, I suddenly began to suffer considerable, cyclical gynaecological discomfort. By age 37, my weight was inexorably increasing and my menstrual flow became lighter and would begin unpredictably between day 21 and 35. I had the occasional night sweat and hot flush. Trips to the doctor where these symptoms were discussed alongside other things elicited no further comments.
      During this time, I had started trying to conceive because, even though married 5 years before, at age 27, I had earlier lacked the emotional and financial confidence to have a baby. As a school teacher and academic researcher, I had made many sacrifices to gain several higher degrees and professional certifications. By 32, I had a full-time job, a husband and a comfortable home – things that were hard and time consuming to attain – and I felt the conditions were exactly right to begin the family that was always firmly on my agenda, if not for a long time at the top of it. After the first time of unprotected sex on cycle day 14, I looked forward to my forthcoming offspring.
      To my surprise, no baby was conceived. I had assumed, like many of my contemporaries (
      • Edwards K.
      Thirty Something and the Clock is Ticking.
      Mainstream publishing company, Edinburgh2011
      ), that sex without contraception always resulted in pregnancy. This was because since childhood I had been educated to believe that ‘all’ acts of unprotected intercourse would inevitably result in a live birth – which, if it was unplanned, was naturally morally suspect and to be avoided until ‘the right time’, which was always left undefined. Months passed and no baby materialized. Time and time again, pregnancy announcements came from family, friends and colleagues and irritated my profound and unrelenting pain. I forgot what it was like not to be constantly and secretly sad, and carrying the burden of loss of control blanched the colour from every aspect of my life all the time.
      At around age 34/35, I consulted a doctor, who told me that the hormonal imbalances that I informed her I suspected I had (but could not make sense of), would be easily ‘corrected’ by a pregnancy. Another GP told me to ‘wait 2 years’, because women are only assessed as infertile if they have been trying unsuccessfully for that long. Respectful around doctors, I went away, misconstrued his advice and waited for 24 attempts at trying to conceive, which actually turned into three chronological years, possibly because of my unacknowledged reactive depression and busy work schedule.
      During this time, my husband and I also attended a family planning and women’s health clinic because, we assumed, our issues were surely relevant to their mission. Yet we were turned away. At smear tests, nurses in whom I confided told me to ‘have patience’. Another GP consultation at age 37 where I again talked of my lack of pregnancy alongside other issues simply elicited the response ‘go home and relax’. Still no baby resulted. I purchased ovulation sticks which apparently showed I was ovulating. What I was unaware of at the time is that these devices detect merely hormonal surges. They do not prove an egg has been released nor measure its potential to develop into a live birth and therefore they are, in some contexts, misleading.
      I felt ashamed, vaguely and constantly unwell and very confused, especially since the clinicians in whom I placed my trust seemed unconcerned. I disclosed nothing to close family or friends because of the very private nature of my struggles. I assumed it was something I was doing wrong, and given that women are so urgently told to use contraception at the very earliest opportunity to prevent pregnancy, I believed that it must have been my inadequacy alone.
      The reason I felt I had plenty of time for childbirth was also everywhere around me. No one in my wide and international social and professional circle had given birth before about 33. In media reports, numerous celebrities were also getting pregnant for the first time at 40+, often with twins (

      Freedman, M., 2007. Another day, another 47 year old celebrity pregnant with twins. <http://www.mamamia.com.au/weblog/2007/05/another-day-another-47-year-old-celebrity-pregnant-with-twins.html> (accessed 1 Aug 2011).

      ,

      Mamamia, 2007. Another day, another 47 year old celebrity pregnant with twins. <http://mamia.com.au.weblog/2007/05/another_day_ano.html>, (accessed 3 September 2010).

      ,

      Morrell, S., 2008. Nicole Kidman shouldn’t be a fertility role model. Herald Sun, January 10. <http://www.news.com.au/story/0,23599,23031810-007146,00html> (accessed 21 August 2009).

      ,

      Sager, J., 2010. Mariah Carey pregnant with twins – was it IVF? <http://thestir.cafemom.com/pregnancy/113917/mariah_carey_pregnant_with_twins> (accessed 16 Dec 2010).

      ). Some were admitting to the use of IVF treatment, but rarely did they (understandably) disclose how many pregnancies were lost in the process, whether donor eggs from a much younger woman were used, the toll taken on their own or their baby’s bodies, what the total cost was, or the number of attempts needed for a live birth (

      Mail Foreign Service, 2010. Ecstatic Celine Dion pregnant with twins at 42. <http://www.dailymail.co.uk/tvshowbiz/article-1282756/Celine-Dion-pregnant-IVF-twins-42.html> (accessed 24 September 2010).

      ). Therefore I ‘knew’ that IVF would easily ‘cure’ me – if only I had the courage to go to a clinic – and, since no GP had formally referred me, I still assumed all I had to do was wait, and I was also terrified at the prospect of the cost. No one had explained to me how the process would work, how long it might take, how it would be paid for, what tests might be done and what criteria would be used to make me eligible for treatment. As I still menstruated – to me an obvious sign of fertility – I firmly believed my pregnancy was just around the corner.
      Having never been given a diagnosis, I wonder, with hindsight, if my symptoms were those of perimenopause, the transitional period of hormonal shifts that can, in some women, occur years before final menopause (
      • Corio L.
      The Change Before the Change: Everything you need to Know to Stay Healthy in the Decade Before Menopause.
      Bantam, London2000
      ). Tragically, this had been suggested to me by a herbalist I consulted only in desperation. However, because for me she had less authority than a formally-qualified clinician, I doubted her. Aged 42 now, I expect my menopause to happen around age 43–45 – just within the ‘normal’ spectrum. I know this now because late in 2008 at the age of 39 I finally attended a private IVF clinic through self-recommendation. Two quick but expensive blood tests told me I had a raised FSH and low anti-Müllerian hormone. They revealed my ovaries were almost ‘closed down’ and my egg reserve was virtually completely empty. I had nothing to make a baby with, no matter how regularly I had sex. The clinic doctor informed me my menopause was imminent and only the use of donor eggs would lead to pregnancy. He said, ‘Treatment here costs £8000 per cycle including drugs and you’ll probably need three cycles for it to work. Our waiting list is about 2+ years and it costs £1500, refundable against future treatment, to put your name on the list now.’
      Since then, my personal IVF experience means that my husband and I have haemorrhaged money as well as blood. Our life savings are around £18,000 lighter, for the NHS would not treat me because at age 39/40 I was by then ineligible for funding (although no one ever pointed this prospect out to me when I had previously sought advice). I have had two gynaecological operations, endless vaginal scans and blood tests whose results were essentially meaningless as there is currently no formal consensus on what they reveal (
      • Rai R.
      • Sacks G.
      • Trew G.
      Natural killer cells and reproductive failure –theory, practice and prejudice.
      Human Reproduction. 2005; 20: 1123-1126
      ). I managed unexpectedly quickly to get a first attempt at donor egg IVF through egg sharing at a second clinic (where it also cost a non-refundable £450 simply to place my name on the waiting list), but it failed. A second attempt a year later gave a positive pregnancy test. Two weeks afterwards, a missed miscarriage was diagnosed. After this, I was told by a no-doubt well-meaning clinician that all I needed to do was simply ‘try harder’ to get pregnant. This puzzled me, since I had exhausted my life savings to get that far and taken the most powerful drugs I had ever used in order to conceive. I wondered what more I could possibly have done.
      Making sense of my experience was made all the more difficult because staff, perhaps desperate to convince me (and reassure themselves) that the process does work sometimes, bombarded me with anecdotes of unexpected IVF ‘miracle’ babies, who had been born to patients with very poor prognoses. This merely intensified my sense of personal failure. As I passed out during the operation to remove the products of conception, the anaesthetist told me that it was better that the embryo had miscarried because it would not have been viable. I was crying as I drifted into unconsciousness and struggled to tell him that it was a donor egg from some anonymous woman, and I had no more money to pay for another. Becoming conscious one hour later, the nurse by my side told me that miracles do happen as her relative at age 44 gave birth to her first child that year. I was crying even before I had opened my eyes.
      Once recovered from the miscarriage, I was bound to try a third cycle with embryos cryopreserved from the previous attempt (if only to rule out a pregnancy if I subsequently wanted to adopt). Mere ‘shadows of possibility’, treatment with these resulted in an initial negative result, which was subsequently reinterpreted as a ‘weak positive’. I was then instructed to continue medications until another blood test could determine whether there was an ectopic pregnancy.
      To pay for all this, my husband and I took on two jobs each, and for 2 years juggled these with appointments for time-consuming treatments and tests in several different places. Although infertility consumed every element of our lives for what has ultimately amounted to 10 years, I did not confess to a soul outside of my clinics that I was unable to do what I perceived everyone could do effortlessly – get pregnant – and my sense of shame cut into my heart. This was even more so since I personally felt that clinical staff in IVF centres tended to hint the lack of success was my failure rather than that of the science and technology they used. This is probably because from their perspective the treatments work (as they sometimes do), and it is only a deficiency in women’s stamina that makes them withdraw before their goal is achieved (

      Cross, J., 2010. I don’t regret spending thousands to become pregnant. <http://www.dailymail.co.uk/femail/article-1309682/Women-spend-50-000-baby.html> (accessed 26 Oct 2010).

      ). Ultimately I had to resign from work in order to fully recover from my experiences and this merely exacerbated my sense of loss of control.
      This writing describes only my personal truth – a narrative that could be told in many ways. Some may dismiss me as naïve for, as one journalist has said, ‘it would be impossible … to exist in society and not know that having children became problematic in one’s mid-30s’ (

      Williams, Z., 2005. A fertile gesture. The Guardian, 1 October 2005. <http://webcache.googleusercontent.com/search?q=cache:zAC9bb7wzTQJ:www.guardian.co.uk/lifeandstyle/2005/oct/01/familyandrelationships.family3±susan±bewley±contactandcd=2andhl=enandct=clnkandgl=uk> (accessed 12 Nov 2010).

      ). Whilst initially I would have agreed with this, I have reflected at length on my experiences and assumptions and have wondered about just how flawed or unrepresentative they might be and what can be learned from them. Although admitting to ignorance about reproduction in our information-saturated, highly sexualized culture is embarrassing, I am also beginning to suspect that I am definitely not alone and that assuming ‘everybody knows’ may be far too simplistic an explanation (
      • Birrittieri C.
      What Every Woman Should Know About Fertility and her Biological Clock.
      New Page Books, New Jersey2005
      ,
      • Birrittieri C.
      Personal account: how IVF changed my life.
      Lancet, Medicine and Creativity Supplement. 2006; 368: S58
      ,
      • Bretherick K.L.
      • Fairbrother N.
      • Avila L.
      • Harbord S.H.
      • Robinson W.P.
      Fertility and aging: do reproductive-aged Canadian women know what they need to know?.
      Fertil Steril. 2010; 93: 2162-2168
      ,
      • Bunting L.
      • Boivin J.
      Knowledge about infertility risk factors, fertility myths and illusory benefits of healthy habits in young people.
      Human Reproduction. 2008; 23: 1858-1864
      ,
      • Cooke A.
      • Mills T.A.
      • Lavender T.
      Informed and uninformed decision making – women’s reasoning, experiences and perceptions with regard to advanced maternal age and childbearing: a meta-synthesis’.
      International Journal of Nursing Studies. 2010; 47: 1317-1329
      ,
      • Daly I.
      Explaining the trend towards older first time mothers – a life course perspective.
      in: Ebtehaj F. Herring J. Johnson M.H. Richards M. Birth Rites and Rights. Hart Publishing, Oxford2011: 239-254
      ,
      • Peterson B.D.
      • Pirritano M.
      • Tucker L.
      • Lampic C.
      Fertility awareness and parenting attitudes among American male and female undergraduate university students.
      Human Reproduction. 2012; 27: 1375-1382
      ). Indeed, my private tragedy transcends the personal and embraces the political domain, as it speaks for the as-yet unidentified community of women in the developed world who inevitably and sadly will, in future years, trudge the arduous path I have traversed.
      I would argue that what women know and understand and what they relate to and use in their own lives may be subtly different things (
      • Elkind D.
      The Hurried Child. Growing up too Fast too Soon.
      Addison-Wesley Publishing Company, London1981
      ). I did know about fertility ‘decline’ with age; but I did not really understand it in an adequate way, perceiving it merely as ‘risk’ easily managed through excellent prenatal care. I had no idea that late-age pregnancy is ultimately difficult because of a decline in egg quantity and quality – the key building blocks of life. Nor did I really believe the risk especially in the light of media reporting of first babies at age 40+ and the fact that no clinician outside my fertility clinic communicated to me that age was a relevant issue (

      Cohen, E., 2010. Pregnant at 47: can I do that? <http://edition.cnn.com/2010/HEALTH/05/27/late.pregnancy.risks/index.html> (accessed 9 June 2010).

      ). For me, highly educated and ‘well informed’, it was extremely difficult to relate to my own life all the competing, confused and fragmented threads of information that I had gleaned since childhood about pregnancy and fertility from a wide variety of sources and then to step back in order to see that in fact I really was ageing and moving fast towards chronological middle age and reproductive old age. For I still felt young, looked young and perceived myself to be in relatively good health.
      Thus, I feel it is reasonable to claim that I am as much a victim of a deficiency of information as I was solely responsible for my miserable plight. I lacked key information to make appropriate choices about reproduction as a result of the sex education I had received and, despite great effort, I failed to access it from public health agencies. I was also falsely given hope by the oblique reporting of ‘miracle’ babies born through IVF (
      • Jenny Z.
      The baby worth every pound.
      London Evening Standard, 28 July. 2010; : 25
      ). I therefore write because, as a teacher, I have a duty of care to ensure that the next generation of adults, who could be struggling with many of the issues I had to make sense of on my own, are well informed. For, statistics show that there is a global trend for delaying childbearing beyond 30 years of age and by 2007, 20% of British women had waited until after 35 to begin their family (
      • Botting B.
      Reproductive trends in the UK.
      in: Drifte J.O. Templeton A.A. Infertility. Springer-Verlag, London1992: 3-22
      ,

      BUPA, 2009. <http://wellness.bupa.co.uk/for-you/your-health-assessments/ha-forward-planning> (accessed 20 July 2009).

      ,

      Campbell, D., 2010. The best age to become a mother – between 20 and 35. The Guardian, 31 Dec. <http://www.guardian.co.uk/society/2010/dec/31/pregnancy-mothers-fertility-child> (accessed 3 January 2011).

      ,
      • Cooke A.
      • Mills T.A.
      • Lavender T.
      Informed and uninformed decision making – women’s reasoning, experiences and perceptions with regard to advanced maternal age and childbearing: a meta-synthesis’.
      International Journal of Nursing Studies. 2010; 47: 1317-1329
      ). Moreover, infertility issues affect around one in six of the population (
      • Templeton A.
      The epidemiology of infertility.
      in: Drifte J.O. Templteton A.A. Infertility. Springer-Verlag, London1992: 24-32
      ).
      • Gustafsson S.
      Optimal age at motherhood. Theoretical and empirical considerations on postponement of maternity in Europe.
      Journal of Population Economics. 2001; 14: 225-247
      estimates that as many as half of women in their thirties will have some sort of fertility problem and she also comments on the ‘spectacular’ increase in the percentage of women who have not yet given birth by 34 in Europe, of whom many, as a result, will be ‘ultimately childless’.

      Myths and misunderstandings

      A number of misunderstandings and myths may need to be addressed. First, it may be that teens and young adults are genuinely confused about what are, in the developed world, stark dissonances between chronological, reproductive and cultural age. A well-groomed celebrity can be 47, look 32 and be perceived as ‘young’ especially since life expectancy is around 70–80 years. As her egg reserve was fixed at birth and from that point began a slow decline, reproductively she is almost certainly unable to conceive her own genetic child, or indeed any child unless donor eggs from a much younger woman are used. When the journalist Kasey Edwards was told by her gynaecologist that she was approaching infertility, she responded ‘But I’m only 32 … Surely that’s not old’ (
      • Edwards K.
      Thirty Something and the Clock is Ticking.
      Mainstream publishing company, Edinburgh2011
      ). For the girls in schools now, 40 really is the new 20, a phrase increasingly in common parlance (

      Cougar Town, 2010. <http://www.livingtv.co.uk/shows/cougar-town/video.php> (accessed 24 Sept 2010).

      ).
      Second, such is the entrenched potency of the ‘family planning’ rhetoric and so extensive is contraceptive use in developed societies that anything to do with baby making carries with it a strong sense of personal control, as if implicit in every act of contraception is a guaranteed conception and live birth that we simply choose to defer (
      • Marks L.
      Sexual Chemistry. A History of the Contraceptive Pill.
      Yale University Press, New Haven2001
      ). This may drive men and women to ‘delay’ families precisely because they partly assume that starting them is their decision alone. Posters in GP surgeries talk of ‘planning’ (not ‘hoping for’) a baby; ovulation monitors indicate when sex should occur to conceive; the habit of The Pill allows you to control when you will menstruate. As Kasey Edwards has written, ‘in sex-education classes in school, it’s implied that there is a one-to-one relationship between unprotected [intercourse] and getting knocked up’ (
      • Edwards K.
      Thirty Something and the Clock is Ticking.
      Mainstream publishing company, Edinburgh2011
      ) and similar assumptions are not uncommon (

      Kardashian, K., 2011. I never knew about ovulation and the limited amount of time that you have to get pregnant… No one ever taught me that. <http://www.usmagazine.com/momsbabies/news/khloe-kardashian-i-never-knew-how-hard-it-was-to-get-pregnant-2011410> (accessed 16 Oct 2011).

      ). Yet, in clinical reality, if 100 ova are exposed to spermatozoa at ovulation, only around 31% will become a live birth (
      • Leridon H.
      University of Chicago Press, Chicago1977
      ,
      • Macklon N.S.
      • Geraedts J.P.
      • Fauser B.C.
      Conception to ongoing pregnancy: the ‘black box’ of early pregnancy loss.
      Human Reproduction Update. 2002; 8: 333-343
      ). As one author has pointed out, these discourses mean that for some women reproduction is viewed as so inevitable it is relegated to the lowest point on their ‘to do’ list. She admitted ‘I didn’t consider motherhood as any sort of accomplishment, because … anybody could do it … that’s hardly an achievement’ (
      • Edwards K.
      Thirty Something and the Clock is Ticking.
      Mainstream publishing company, Edinburgh2011
      ).
      Third, it seems that there exist key misunderstandings of what IVF treatment can actually achieve (
      • Adashi E.
      • Cohen J.
      • Hamberger L.
      • Jones H.
      • de Kretser D.
      • Lunenfeld B.
      • Rosenwaks Z.
      • Van Steirteghem A.
      Public perception on infertility and its treatment: an international survey.
      Human Reproduction. 2000; 15: 330-334
      ,
      • Hashiloni-Dolev Y.
      • Kaplan A.
      • Shkedi-Rafid S.
      The fertility myth: Israeli students’ knowledge regarding age-related fertility decline and late pregnancies in an era of assisted reproduction technology.
      Human Reproduction. 2011; 26: 3045-3053
      ). It may be that many perceive it (before they try it) as a failsafe ‘cure’ for infertility (

      Parkin, J., 2007. Why I believe IVF actually causes childlessness. <http://www.dailymail.co.uk/news/article-459101/Why-I-believe-IVF-actually-CAUSES-childlessness.html> (accessed 8 Dec 2010).

      ). As one journalist admitted, ‘I honestly thought that you start to worry at 38 and then you go to doctors at 39 and then you would have treatment to help you get pregnant’ (
      Bewley S. Ledger B. Nikolaou D. Reproductive Aging. RCOG Press, London2009
      ). Thus, many do not view it as a treatment that must work in harmony with one’s own body and that relies on viable eggs or spermatozoa being available. Furthermore, it is in reality a treatment with a rate of ‘success’, which, overall, currently hovers around the 20–30% mark worldwide (
      • Bewley S.
      Which career first? The most secure age for childbearing remains 20–35.
      BMJ. 2005; 331: 588-589
      ,

      Throsby, K., 2001. No-one will ever call me mummy: making sense of the end of IVF treatment. London School of Economics, Gender Institute, New Working Paper Series, issue 5, November. <http://www2.lse.ac.uk/genderInstitute/pdf/noOneWillEverCallMeMummy.pdf> (accessed 24 September 2010).

      ). For the 39,879 women who had IVF in the UK in 2008, there were only 12,211 successful live births resulting from 50,687 cycles of treatment (

      HFEA, 2011. <http://www.hfea.gov.uk/> (accessed 8 August 2011).

      ). Therefore, it is also reasonable to describe it as an unreliable and unpredictable process which does not work for the majority trying it and when it does, its success is often the result of multiple, time-consuming, expensive attempts. It is a stark ‘truth’ that, if around 4 million IVF babies were born since treatment first began, many more millions of couples who were treated were left empty handed (
      • Brown L.
      • Brown J.
      • Freeman S.
      Our miracle called Louise.
      Paddington Press, London, A parents’ story1979
      ,

      Groskop, V., 2010. IVF: the uncomfortable truth. The Guardian, 3 July. <http://guardian.co.uk/lifeandstyle/2010/ju;/03/ivf-fertility-infertility-gedis-grudzinskas> (accessed 14 August 2010).

      ,

      Nobel Prize, 2010. <http://nobelprize.org/nobel_prizes/medicine/laureates/2010/press.html> (accessed 8 Aug 2011).

      ). Indeed, as one clinician has admitted, ‘We would probably have said 20 years ago that by 2008 we will be able to pick the best embryo to transfer but it is still beyond our grasp’ (
      Bewley S. Ledger B. Nikolaou D. Reproductive Aging. RCOG Press, London2009
      ).
      Moreover, IVF is regularly perceived by the lay person as a treatment specifically for older women. As one woman has reported ‘… with all these medical breakthroughs women can have children later and later … it means I can put off having children until my forties. It’s such a relief’ (
      • Hewlett A.
      Baby Hunger. The New Battle for Motherhood.
      Atlantic Books, London2002
      ). As the Princeton-educated actress Brooke Shields exclaimed when told she would need IVF, ‘Isn’t that for older women? I’m only thirty-six’ (
      • Shields B.
      Down Came the Rain: My Journey Through Postpartum Depression.
      Hyperion Books, New York2005
      ).
      Hewlett S.A. High Achieving Women. Centre for Work Life Policy/National Parenting Association, New York2001
      ,
      • Hewlett S.A.
      Creating a Life: Professional Woman and the Quest for Children.
      Hyperion Books, New York2002
      reported that 90% of women aged 28–40 who participated in her 2001 study stated that they believed that reproductive technologies would allow them to get pregnant into their forties. IVF does tend to be used more by older women because it is precisely that group that struggles most to conceive. Yet after around 36/37, ‘success rates’ plummet and by the age of 40 they are almost negligible for patients using their own eggs (

      HFEA, 2011. <http://www.hfea.gov.uk/> (accessed 8 August 2011).

      ). Thus, it is possible to argue that IVF is in reality a treatment that usually works best on younger people and it cannot be the guaranteed, failsafe back-up plan for older women as two recent movies imply (
      • The Back-Up Plan
      Directed by Alan Poul.
      CBS films, USA2010
      ,
      • The Switch
      Directed by Josh Gordon, Will Speck.
      Bona Fide Productions 2010, USA2010
      ).
      Similarly, it is quite possible that miscarriage rates are also greatly misunderstood. Unfortunately, these can occur in one in four or five pregnancies overall and in one in two women over 40 years old (
      • Holman D.J.
      • Wood J.W.
      • Campbell K.L.
      Age-dependent decline of female fecundity is caused by early fetal loss.
      in: Velde E.R. Female Reproductive Aging. The Parthenon Publishing Group, London2000: 123-137
      ,
      • Kluger-bell K.
      Unspeakable Losses.
      Norton, London2000
      ,
      • Leridon H.
      University of Chicago Press, Chicago1977
      ,

      Miscarriage Association, 2010. Pregnancy loss and infertility, the miscarriage association. p. 2. <http://www.miscarriageassociation.org.uk/ma2006/downloads/Pregnancy%20loss%20and%20infertility.pdf> (accessed 26 September 2010).

      ). Although seldom discussed, upon disclosure a woman can often find that they are far more common than she originally anticipated. Such an experience can delay pregnancy plans and, whilst waiting for recovery from them, fertility still continues its inexorable decline.
      Moreover, many women may be uncertain of the wide individual variation in levels of fertility across the population and the fact that it is not something fixed and unchanging, but a characteristic that briefly blossoms and then declines in females and males (although comparatively ‘slowly’ in the latter) (
      • Faddy M.J.
      • Gosden R.G.
      • Gougeon A.
      • Richardson S.J.
      • Nelson J.F.
      Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause.
      Human Reproduction. 1992; 7: 1342-1346
      ). For example, analysis of school curriculum materials reveals that it is often unhelpfully characterized as something ‘without an end’ and universally guaranteed, rather than something that is, for all women, finite (
      • Kisby Littleton F.
      Fertility, the reproductive lifespan and the national curriculum in England: a case for reassessment.
      Sex Education: Sexuality, Society and Learning. 2012; 12: 483-497
      ). Neither are women aware that some members of the medical community have suggested that subfertility and infertility can occur at least a decade or more before menopause, which can vary widely between about 40 and 60 years (
      • Lobo R.
      Early ovarian aging: a hypothesis.
      Human Reproduction. 2003; 18: 1762-1764
      ,
      • te Velde E.R.
      Age-dependent changes in serum FSH levels.
      in: Fauser B. FSH Action and Intraovarian Regulation. Parthenon Publishing Group, London1997: 145-155
      ). Whilst some women do give birth easily in their late thirties and beyond, what many of them (or those ‘planning’ to emulate them) will probably not really understand is that it is ultimately biological serendipity that permitted this and that personal volition only plays a secondary role.

      New directions for education

      In Greek mythology, the beauty of Cassandra (daughter of Queen Hecuba and King Priam) caused Apollo to grant her the gift of prophecy. When his love was not returned, Apollo placed a curse on her so that no one would ever believe her predictions until they had come to pass (
      • Harvey P.
      The Oxford Companion to Classical Literature.
      Oxford University Press, Oxford1986
      ). She thus possessed a combination of deep understanding and powerlessness and I know how she must have felt. Although positive reproduction experiences are thankfully common, similar stories to mine have been, and will continue to be, replayed around the developed world as women are educated to expect fulfilling careers, may have to work for economic reasons, anticipate meeting the perfect partner and continue to struggle with work–life balance and the decision to have a baby whilst they are still enmeshed in career structures suffused with patriarchal values (
      • Barker I.
      ‘Have it all’ girls told to keep it real.
      Times Educational Supplement, 13 November. 2009; : 12
      ,
      • Harris A.
      Future Girl: Young Women in the 21st Century.
      Routledge, London2005
      ,
      • Hewlett S.A.
      A Lesser Life: the Myth of Women’s Liberation.
      Sphere, London1988
      ). Although in the short term we cannot change many of the very complex issues that lead to this situation, we can modify the subsequent public health message that the women of the future experience at the school and adult level – if we have the will to do it.
      Twenty-first century culture tells women that they can ‘outsmart Mother Nature’ (

      Tampax, 2011a. <http://www.tampax.co.uk/en-GB/home/home.aspx> (accessed 28 July 2011).

      ,

      Tampax, 2011b. <http://www.youtube.com/watch?v=9kDT3xmj9bU> (accessed 27 July 2011).

      ). At present, a ‘two-dimensional’ version of reproduction is also disseminated in schools – man + woman + unprotected sex = guaranteed baby – and, until some discover otherwise, most carry this notion into adulthood (
      • Skoog Svanberg A.
      • Lampic C.
      • Karlström P.-O.
      • Tydén T.
      Attitudes toward parenthood and awareness of fertility among postgraduate students in Sweden.
      Gender Medicine. 2006; 3: 187-195
      ). Most adults know the options for dealing with unplanned parenthood; most know how to nourish a developing baby in utero and we mostly have complete faith in the medical profession to care for our baby and young child. Most dangerously, many feel a strong moral sense that, if a family should be ‘delayed’, it is simply personal choice, a lack of a suitable partner and is no-one else’s business. Most harbour a vague notion that, if they are so unlucky as to experience a problem conceiving, an IVF clinic can provide a ‘cure’ (
      • Dickson J.
      The patients’ viewpoint.
      in: Drifte J.O. Templeton A.A. Infertility. Springer-Verlag, London1992: 381-388
      ).
      These beliefs have validity, but together they may not make up the whole story that couples need to know now. Thus although my account does not have the epistemological authority of a formal study, it is still possible to make some suggestions on the basis of it (
      • DasGupta S.
      • Charon R.
      Personal illness narratives: using reflective writing to teach empathy.
      Academic Medicine. 2004; 79: 351-356
      ). While it should not be necessary to cause anxiety around reproduction, it may be that now more balanced and honest information needs to be disseminated, first in schools and then later also supported by official public health messages disseminated at the grassroots level and directed at young adults – not through media headlines, ill-informed TV documentaries or websites of dubious quality (
      • Marriott J.V.
      • Stec P.
      • El-Toukhy T.
      • Khalaf Y.
      • Braude P.
      • Coomarasamy A.
      Infertility information on the World Wide Web: a cross-sectional survey of quality of infertility information on the internet in the UK.
      Human Reproduction. 2008; 23: 1520-1525
      ).
      This information should be designed to empower the women who will grow up in cultures very different from those in which ‘developed’ society’s original messages about sex education were first formulated (
      • Hall L.A.
      In ignorance and in knowledge. Reflections on the history of sex education in Britain.
      in: Sauerteig L. Shaping Sexual Knowledge. Routledge, London2009: 19-36
      ). It may be that these women should be encouraged to take adequate notice of their natural menstrual patterns if they have used chemical contraception for a long time (

      Grigoriadis, V., 2010. Waking up from the pill. <http://nymag.com/print/?/news/features/69789/> (accessed 1 Dec 2010).

      ), and also be sensitively warned of the relative frequency and potential disruption of early miscarriage (
      • Tough S.
      • Tofflemire K.
      • Benzies K.
      • Fraser-Lee N.
      • Newburn-Cook C.
      Factors influencing childbearing and knowledge of perinatal risks among Canadian women and men.
      Maternity Child and Health Journal. 2007; 11: 189-198
      ). They need to be briefed about the wide spectrum of ages of menopause and the fact that a woman’s egg supply is fixed at birth and the implications of the decline in quantity and quality of eggs should be made crystal clear to them in a timely fashion. The telling changes that may occur in the transitional phase before a woman’s final period should be clearly outlined, lest women walk into perimenopause with their eyes closed before their family is complete (

      Feinmann, J., 2008. Too young for the menopause? Daily Mail, 2 January. <http://www.dailymail.co.uk/health/article-505447/Too-young-menopause.html> (accessed 8 Aug 2011).

      ). It may be that, at the same time, honest, more balanced and easily accessible accounts (beyond statistics or abridged stories of straightforward patient success) of the current limitations of the fertility industry (including egg-freezing technology) would be helpful so that these women do not assume they can fully rely on it to conquer Nature’s plan if the need should arise (

      Extend Fertility, 2011. <http://extendfertility.com/why/promise.php> (accessed 8 Aug 2011).

      ,

      Parkin, J., 2007. Why I believe IVF actually causes childlessness. <http://www.dailymail.co.uk/news/article-459101/Why-I-believe-IVF-actually-CAUSES-childlessness.html> (accessed 8 Dec 2010).

      ).
      Most crucially, it may be that for these women the debate about ‘delayed childbearing’ needs to be moved from the moral sphere where it usually sits (

      Frostrup, M., 2006. Stop scaring older mums. Evening Standard, 15 Aug. <http://www.thisislondon.co.uk/showbiz/article-23363674-stop-scaring-older-mums.do> (accessed 6 March 2011).

      ) and be repositioned within the biological one too. Whether it is desirable or not for older women to bear children, because fertility potential varies and ultimately ceases in women, and to a lesser extent men, not all couples can have the choice. Indeed, it may be that women cannot avoid ‘delayed’ childbearing until they are made more fully aware of the true concept of it and are (re)introduced to the basic notion of ‘optimum time for birth’ (
      • van Noord-Zaadstra B.M.
      • Looman C.W.N.
      • Alsbach H.
      • Habbema J.D.F.
      • te Velde E.R.
      • Karbaat J.
      Delaying childbearing: effect of age on fecundity and outcome of pregnancy.
      British Medical Journal. 1991; 302: 1361-1364
      ,
      • Maheshwari A.
      • Porter M.
      • Shetty A.
      • Bhattacharya S.
      Women’s awareness and perceptions of delay in childbearing.
      Fertility and Sterility. 2008; 90: 1036-1042
      ). These basic notions could also be set forth alongside the traditional warnings about teenage pregnancy currently disseminated at the school level (
      • Allen L.
      Doing ‘it’ differently: relinquishing the disease and pregnancy prevention focus in sexuality education.
      British Journal of Sociology of Education. 2007; 28: 575-588
      ,

      Boseley, S., 2008. Sex education ‘should teach about infertility’. The Guardian, 28 May. <http://www.guardian.co.uk/society/2008/may/28/health.sexeducation/print> (accessed 22 April 2009).

      ,
      • Dickson J.
      The patients’ viewpoint.
      in: Drifte J.O. Templeton A.A. Infertility. Springer-Verlag, London1992: 381-388
      ;
      • Kisby Littleton F.
      Fertility, the reproductive lifespan and the national curriculum in England: a case for reassessment.
      Sex Education: Sexuality, Society and Learning. 2012; 12: 483-497
      ,
      • Peterson B.D.
      • Pirritano M.
      • Tucker L.
      • Lampic C.
      Fertility awareness and parenting attitudes among American male and female undergraduate university students.
      Human Reproduction. 2012; 27: 1375-1382
      ). They could also be reinforced carefully in nurse-led fertility support sessions offered to women who have not conceived by age 29/30, where current fertility myths are also challenged (

      Asthana, A., Hill, A., 2009. Women urged to test for fertility at 30. The Observer, 9 Aug. <http://www.guardian.co.uk/lifeandstyle/2009/aug/09/fertility-mot-children-nhs> (accessed 10 Aug 2009).

      ). These information sessions would be a modified form of the ‘fertility MOTs’ already suggested, for they would avoid the potential complacency, expense and possible inaccuracies that could result from the formal assessment of ovarian reserve through blood testing (
      • Hussell J.
      In the News. New blood test could predict early menopause.
      The Daisy Network Newsletter (Update 54, Summer). 2010; : 10-11
      ,

      Macrae, F., 2009. Fertility MOT at 30: women should know how fast their clock is ticking, says IVF doctor. <http://www.dailymail.co.uk/health/article-1205357/Fertility-MOT-30-Women-know-fast-clock-ticking-says-IVF-doctor.html> (accessed 8 Aug 2011).

      ,
      • Visser J.A.
      • de Jong F.H.
      • Laven J.S.E.
      • Themmen A.P.N.
      Anti-Mullerian hormone: a new marker for ovarian function.
      Reproduction. 2006; 131: 1-9
      ).
      How can people be expected to properly ‘know’ what appears to be currently formally untold? Clearly, what are considered to be ‘our’ reproductive choices are to some extent cultural illusions divorced from the reality that human reproduction is ultimately dependent on biology’s plans. In the light of all this, it is important this paper is not interpreted as yet another piece telling women at what age to have a baby, nor a judgement on those that delay childbirth, or even a criticism of the fertility industry. It is none of these. Rather, it is a call for appropriate education so that people become fully empowered to make reproductive decisions for themselves. It is also a hint that perhaps infertility clinics could further integrate medical, social and psychological models of care and learn from palliative care. Relentless positivity and descriptions of others’ success does not always assuage emotional pain; but sensitive validation of that pain is usually reassuring to its sufferer. Perhaps, at the beginning of the third millennium, women who consider themselves ‘emancipated’ should be helped to re-engage in a more respectful dialogue with Mother Nature alongside the one they have with Science, and all of us should be made to listen more carefully to Cassandra as well. For, reproductive health and rights are not only about the choice not to have a baby, but they are also about the choice to have one too.

      Acknowledgements

      I am grateful to Professor Susan Bewley, Professor Bill Ledger, Antonia Rodriguez, Irenee Daly and Kate Bentley for their sensitivity during preparation of this article.

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      Article info

      Publication history

      Published online: April 22, 2013
      Accepted: March 7, 2013
      Received: January 22, 2013
      Declaration: The author reports no financial or commercial conflicts of interest.

      Identification

      DOI: https://doi.org/10.1016/j.rbmo.2013.03.023

      Copyright

      © 2013 Published by Elsevier Inc.

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