All too often, we don't think twice about our fertility until we're ready to have a baby. In fact, many of us spend years of our lives studiously trying to avoid pregnancy. Then, if and when we decide that the time is right, we're suddenly inducted into a world of ovulation kits, fertility monitors, and sometimes anxiety.
Reproductive specialist Lubna Pal, MBBS, believes that women shouldn't wait until they're trying to conceive to learn about their fertility. "A 20-year-old, in my opinion, should have a candid conversation with her mom about maternal health history," Dr. Pal tells Refinery29, "about whether Mom had irregular periods when she was young, whether there is a family history of endometriosis, fibroids, [or early] menopause" — all factors that may influence your own ability to get pregnant.
But talking with Mum isn't all you should do to prepare. We spoke with Dr. Pal about what women in their 20s, 30s, and 40s should know about their ability to conceive — click through for the key takeaways. (In this particular story, guidance applies primarily to cisgender men and women.)
First, a menstruation refresher: In the first half of your menstrual cycle, an egg in one of your ovaries is maturing while your uterine lining is thickening, getting ready to nourish an embryo if the aforementioned egg joins forces with a sperm cell. Ovulation occurs when the egg leaves the ovary through the fallopian tube to reach the uterus, around the 14th day of an average 28-day cycle. If the egg isn't fertilised (your chances of conceiving are highest in the three days before and on the day of ovulation, since sperm typically live for three days), it won't attach to the thickened uterine lining; instead, it will break down and exit your body along with the uterine lining via your vagina. Voilà: your period. So, if your period isn't happening regularly, neither is ovulation.
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"When menses are irregular, rather than a girl thinking, Gosh, I’m relieved I don’t get periods every month, one needs to be thinking, Why am I not getting my period every month? " Dr. Pal says. " I may have a delay getting pregnant, so let me just understand what’s going on now."
Irregular or absent periods could be a sign of anything from stress to a medical condition that's messing with your hormones, such as an underactive or overactive thyroid, polycystic ovary syndrome (PCOS), or hyperprolactinemia, which is caused by increased production of the hormone prolactin. In the case of thyroid issues, blood tests can reveal what's going on, and your doctor can prescribe medications to regulate things so your period returns to normal. Although hyperprolactinemia is caused by a different hormonal issue, it's also often treated with thyroid medications. Finally, PCOS is a syndrome caused by increased androgens or male hormones, and doctors aren't exactly sure what causes it. The first line of treatment for PCOS is birth control pills, which isn't helpful if you're trying to conceive. In that case, your doctor may prescribe medications that induce ovulation instead. Other causes of absent or irregular periods include certain medications, eating disorders, overexercising, or extreme weight loss.
The bottom line: A variety of issues can mess with your period, so it's good to keep track of it and see your doctor if things change suddenly.
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Your lifestyle now could affect your ability to get pregnant years in the future. "[You] should avoid exposure to things such as tobacco and excessive alcohol that have direct implications for ovarian function," Dr. Pal says. She also urges us to manage conditions such as chronic stress, depression, and anxiety, which may also impact fertility (not to mention your quality of life). Dr. Pal also warns against "absolute extremes of body weight," whether too low or too high. While your size is a function of much more than your behaviour, caring for your body by exercising regularly and eating well can up your chances of conceiving when you're ready.
STIs can affect fertility, too, so prioritise safe sex. Chlamydia and gonorrhoea can damage your fallopian tubes; while HPV won't, it can lead to pre-cancerous cells on your cervix that call for treatments that, in turn, can make it harder to get pregnant right away. "Pap smear abnormality, when it’s dealt with by cone biopsy or LEEP, may actually impact fertility," Dr. Pal explains. The best way to avoid HPV is by getting vaccinated.
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This sounds ominous, but it's important to remember that you're born with all the eggs you'll ever have, and good health doesn't offset their natural decline in number as you age. "We can do a lot in terms of medical management," Dr. Pal says. "The effects of ageing on egg biology cannot be undone." Fertility ends roughly five to 10 years before menopause, and while it's impossible to predict exactly when that will happen for you specifically, we do know that in general, fertility declines in a woman's 30s, especially after age 35. A healthy, fertile 40-year-old woman has around a 5% chance of getting pregnant in a given cycle, while a 30-year-old has a 20% chance.
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According to Dr. Pal, the first step is to go off birth control and start listening to your body. "You can use ovulation predictive kits to get a sense [of] when [you are] ovulating," she says. "If I have irregular periods...I’m not ovulating; when I’m not ovulating, my chance of pregnancy is low. I don’t have to wait one year to approach a doctor. I should be doing that sooner."
If a woman is menstruating regularly, however, she can hold off on consulting a care provider. "You don’t need to be checking your ovarian reserves" right away, Dr. Pal says. "There are many caveats to that test, and I see so so many referrals where young women who happen to get this test done and have a low number are completely concerned [when they might not need to be.]" What's more, a woman who has been on hormonal birth control for a while will have a "falsely low test because her ovaries are relatively quiet," meaning they've been inactive, Dr. Pal points out.
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"[In] a healthy, young couple under 30 years of age (where there’s no history of STIs, [the woman is] having regular menstrual cycles [and] they’re having timed intercourse), infertility is said to be when they have had one year’s worth of trying without success," Dr. Pal says. "But if that under-30-year-old [woman] comes from a family where there [are] fibroids, pelvic pain, or if there is a history of STIs, I think [after] six months she should...have a conversation with her provider." Dr. Pal recommends that women above 35 who have been trying for six months or more speak with a care provider, regardless of other factors. "I’m not saying people should initiate fertility treatment," she adds. "I’m saying people should initiate evaluation."
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Generally, "women who are in their 20s should not worry about egg-banking," says Dr. Pal. "Women in their early 30s may start considering... Between 30 and 35 is a good-enough age; 35 to 37 also is a reasonable scenario. Beyond age 38, the egg quality is going down." She estimates that women under 35 may need to freeze six to 10 eggs, while by the time a woman is 40, she may need to freeze 20, 30, or even 40 because the majority of the eggs will likely result in abnormal embryos, if they achieve them at all.
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As Dr. Pal points out, "Fertility is a team sport: A woman cannot bear the burden of this whole thing." The American Society for Reproductive Medicine reports that infertility affects women and men equally, and that in 40% of opposite-sex, cisgender couples experiencing infertility, the male partner's sperm is the partial or full reason. That's not to cast blame — infertility is no one's fault. It's only to remind you that your eggs aren't the only players on the conception stage.
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