Changing the Conversation – Being Proactive with Fertility Support

Silence isn’t golden when an OB/GYN doesn’t include fertility support with reproductive healthcare

The fertility field has long been driven by a reactive chain of events in the lives of reproductive-aged women and couples: A person or couple decide they want to have a baby, they start trying to get pregnant and then if they don’t succeed after a certain period of time, they ask for help from their OB/GYN.

What if we completely changed the conversation with women?

What if discussions about lifelong fertility goals started happening when women are in their 20s to early 30s? What if women learned in their younger reproductive years just how hard it can be for some to conceive in their later reproductive years? Perhaps it would help women be proactive rather than reactive with their fertility, and maybe it would help women have more options for family building throughout their life.

Unintentional missed opportunity

The reason for limited discussions about fertility is complicated.

• Some women have no idea if or when they want children, so it isn’t even on their radar to discuss it.
• Some women have anxiety about the idea of having difficulty having children, so they are scared to ask about it.
• Some women simply don’t know that fertility declines so much in the late 30s and early 40s that they don’t know it’s something they should even worry about.

OB/GYNs are often a great resource to start the conversation. Interestingly, a study by Houston Methodist Hospital notes that many OB/GYNs are uncomfortable talking about infertility with their patients. Lead author Dr. Rashmi Kudesia calls it a missed opportunity when OB/GYNs don’t bring it up, noting that women get conflicting information on fertility (from the internet/media and talking to friends), and many think they won’t ever have a problem.

I agree, it is a missed opportunity, but it’s unintentional. And raising awareness about the importance of having a discussion among both patients and OB/GYNs will help everyone. Each year,  more women are delaying having children for careers or other reasons and the incidence of infertility is growing.

New data from the World Health Organization shows that roughly 1 in 6 people worldwide will be affected by infertility during their lifetime. That’s a considerable jump from previous estimates of 1 in 8 people.

Understanding the different mindsets of patients and OB/GYNs in the difficult conversations of fertility may help us arrive at a solution.

Why a gynecologist might not offer patients fertility support and discussion

The Houston Methodist study found that OB/GYNs are most likely to provide fertility counseling to married women ages 27-40. I believe that having fertility conversations at a younger age would expand knowledge for patients and open doors to conversations they should start to consider in their younger reproductive years.

For example, if someone envisions a lengthy career track and no time to start a family for many years, maybe a conversation about egg freezing would help pause the biologic clock and expand opportunities for success. The study noted that single and lesbian women were less likely to receive fertility counseling, no matter their age.

Discussing the reproductive disease of infertility should be included in reproductive and gynecologic healthcare, particularly since there is so much confusion among women about fertility. The following factors may influence whether or not an OB/GYN routinely discusses fertility support in healthcare.

Patient autonomy on fertility

A primary reason OB/GYNs in the Houston Methodist study said they don’t discuss fertility is because they think that if a patient wanted to talk about it, the patient would bring it up. This can be unintentional or it could be out of respect for patient autonomy, which is the right of patients to make such decisions without undue pressure from their provider. The doctor may be prepared to discuss fertility concerns, but defer to the patient to bring it up.

Many of their patients aren’t ready to get pregnant

Roughly 60% of their patients of reproductive age are using birth control and are not likely to need a discussion on infertility. Doctors are also quite aware that women are purposefully delaying having children.

OB/GYNs could bypass fertility support discussions due to this understanding, potentially sidelining important dialogues out of habit. However, it’s key to remember that individual timelines don’t undermine the significance of open fertility conversations throughout a person’s care.

Lack of fertility support training

OB/GYN training and education primarily focuses on gynecological care, childbirth and prenatal care. Reproductive health is a part of their care and infertility issues are one aspect of that, but understandably not a primary focus. The study notes that OB/GYN reproductive healthcare typically involves more counseling on contraception than fertility preservation, optimal ages for conception and infertility.

Limited OB/GYN appointment time

This is a constraint most doctors face. It can result in not addressing fertility issues, particularly if the patient doesn’t bring them up in a visit. Routine well-woman exams include wellness care prioritizations that may not include fertility planning discussions.

Temporary concern that may resolve itself

OB/GYNs know that conception is not as easy as many think. It can take time, and some issues making conception difficult can resolve over time. When the patient has expressed a desire to conceive, the doctor might want to give natural processes time to work. Sometimes this works in the patient’s favor.

Other times, this can lead to a delay in fertility care if the doctor waits too long to suggest exploring infertility issues. We more commonly see this among younger patients (particularly those in their early 20s). Sometimes doctors will try to reassure patients to “just give it time,” when in reality even a 20 year old with infertility (12 months of lack of conception) deserves an evaluation.

Having a baby is a sensitive topic

The relationship between a woman and her OB/GYN is built on trust and collaboration. Unlike a well-meaning but sometimes intrusive relative who persistently asks, “When are you going to have a baby?” during family gatherings, OB/GYNs strive to create a safe space. However, some OB/GYNs may tread too lightly into this sensitive topic by not addressing concerns or issues head-on.

Why a woman may not bring up fertility support with her OB/GYN

There are several reasons why women don’t bring up the possibility of fertility planning or their individual fertility concerns. Perhaps the biggest reason is that many women are just not well informed about the prospects of infertility, particularly the age factor. It is common for women to think that infertility only affects older women.

Another common reason for not seeking help from a doctor sooner is that many women are under the impression that pregnancy will happen at some point without any help and that it just takes some longer than others. They don’t realize that women under age 35 should typically be pregnant by 12 months of trying (85% of couples succeed by one year), and that after one year, only 8%-10% of couples will succeed in the second year of attempts.

After two years without success, the monthly pregnancy rate drops to about 2% per month. Among women age 35 and older, we want to see most of them conceive within six months: After that the rate of natural success drops, and we recommend an evaluation for treatment.

The celebrity pregnancy trap

Many women are often misled with false hope by glowing stories of celebrity pregnancies at an advanced maternal age. Media coverage tends to suggest conceiving children in later years is easy. Examples include Gena Davis having twins at 48 and Kelly Preston having her third child with John Travolta at age 48.

This makes women think they have lots of time to have children. But celebrities may have used in vitro fertilization (IVF) with donor eggs, details often not included in media reports.

IVF fallback fallacy

As fertility medicine becomes more widely used, some women think they can always fall back on IVF. Many women think that prior to menopause, assisted reproductive technologies can help most women conceive. This is not the case, and IVF – even for a healthy woman of a younger age – is no guarantee of a successful pregnancy.

Many women over age 37 require multiple rounds of IVF to have a child. And for women over age 40, many will try IVF and not succeed, and then have to decide between options of egg donation, embryo donation or adoption.

Stigma of infertility and embarrassment

The social stigma around infertility still exists and can prevent some women from talking to their OB/GYN about their concerns out of fear of it being considered a personal failure. Embarrassment or shame to talk about such a personal issue can prevent others from bringing up conception difficulties with their doctor.

Break the silence: take action to open up discussion on fertility support during your appointment

As the cause for lack of discussion falls on both patients and OB/GYNs, so does the solution. Here’s my advice for both.

Fertility dialog actions by an OB/GYN

Many OB/GYNs who do initiate a dialog on fertility suggest bringing up the topic as part of an overall reproductive health plan. Addressing fertility planning and infertility in a non-directive way can be a part of this approach, and reinforced at each visit.

Our experience is that patients who come to us because their doctor was proactive and had an early discussion about fertility are highly satisfied with their OBGYN care and likely to return to that doctor for ongoing care in years ahead. Doctors can start by simply providing an educational handout that reviews age and fertility and the option of fertility preservation for patients anticipating delaying childbearing for their later reproductive years.

Infertility is a natural aspect of the general discussion on having children, and talking about it at this time is a good way to help patients open up. The risk of genetic disorders and birth defects is another avenue to initiate fertility consideration, as advanced maternal age increases the risk of syndromes in a child.

Patient actions

If your OB/GYN doesn’t bring up fertility support during exams, checkups or other visits, you can help get the discussion going – even if you think you have no fertility issues at all. Be prepared by writing down questions you may have and being ready to be open and honest.

• Be your own advocate and bring up fertility if your OB/GYN hasn’t. If you have serious concerns, you might schedule an appointment just to discuss fertility.
• Talk about your plans for family and make the prospect of infertility part of it. Discuss your timeline and how to know if fertility issues may affect that, as well as what to look for.
• Be direct and ask if there is anything in your health history that might indicate fertility concerns. You may have some information on family reproductive health history that can help your doctor.
• Know your menstrual cycle and if you have irregularities, bring it up. They can indicate infertility or issues that can hamper fertility down the road.