01.02.2009

Having It All

Don't be fooled by the celebrity mums. As Lisette Kaleveld finds, the odds are lengthening on being fertile when we want to be and it's time to heed the wisdom of our bodies.

Don't be fooled by the celebrity mums. As Lisette Kaleveld finds, the odds are lengthening on being fertile when we want to be and it's time to heed the wisdom of our bodies.

Once she hits 35, the decline is rapid. Although there are enough older women with bumps and babies to challenge the facts, a woman's fertility decreases with age. Nicole Kidman had her first child at 41 years, Madonna gave birth to her second at 42. Demi Moore, at 46, is supposedly hoping for another baby, and with her striking good looks, that thick, silky hair, and a younger husband at her side, why not?

If fertility means abundance, these women have it. They've been able to join men in the world outside the domestic sphere, find empowerment, self actualise, and still come out the other end firmly grounded in their femininity - glamorous and sensual, with rounded bellies. If these are our modern day fertility goddesses, then it's not the young nubile body we're celebrating here, but the post-feminist promise that women can have it all.

In nature, fertility is a wetness, a potentiality, the source of life. It's hard to define an invisible force. We cannot know easily who is fertile and who is not, or how this secret quality changes in our bodies over time. So we hedge our bets and assume we'll be ready when we're ready. Like older celebrity mums, Assisted Reproductive Technologies (ART) such as IVF, promise to extend for a woman her fertile years - as she understands them. In 1995, the average age of first time mothers in Australia was 26.5 years, now it's over 29 years (1).

But here I am making that tired old fashioned link between fertility and maternal age. There's nothing new about that - but what is new is that it's no longer such a focus for fertility experts. Reproductive health comes down to more than the age of the mum.

Firstly, for too long, men have tended to wriggle out of the fertility equation. But the facts are in - men are 40 per cent responsible for fertility, as medical scientist Ann Vlass will confirm. A healthy pregnancy requires good quality sperm, and this starts to decline when men reach their mid thirties. Last year, The Guardian reported that men who wait until their forties to start a family face a greater chance of their partner having a miscarriage (2).

Of more concern, is the dramatic fall in male sperm counts, well documented in Australia and overseas. "At least 90 per cent of men who come to my [natural fertility] clinic have a low sperm count," says Ann. "The trend line is so distinct now, this decline in fertility and increase in abnormalities. Some sperm cannot even identify the egg."

Jane Bennett, natural fertility specialist and co-author of The Pill: Are you sure it's for you? agrees. "You need a healthy swarm for conception to take place. The dramatic decline in sperm counts is really interesting, it's almost at epidemic proportions. But the change is a slow creep...there has been no major event to report, it slips past the radar," says Jane. "Yet sperm counts are continuing to fall, and have halved in the last few decades."

The take home message for men and women in their fertile years is not to be dazzled by IVF miracles and celebrity birth happy endings, because the reality is that more couples than ever before are experiencing, or can expect to experience, infertility or subfertility. This basically means diminishing odds when it comes to conceiving easily, conceiving at all, conceiving unassisted and/or conception leading to a full term healthy pregnancy.

Fertility crisis in the baby boom?

"One for him, one for her and one for the country," former treasurer Peter Costello told the nation in 2004. His appeal to the masses to breed was not exactly elegant, but I will give him this: he brought to federal politics a truth as old as civilisation itself - that without a growing population and the birth of healthy children, society (and, um, the economy) would cease to thrive, even grind to a halt.

After two decades of birth rates at below replacement levels (and declining), the Howard Government was quick to offer incentives to would-be parents: maternity payments, family benefits, a childcare rebate and that controversial baby bonus. In 2007, 285,000 births were registered. It was an all time high; a baby boom was declared. We could at last look forward to a prosperous future, a growing population to counterbalance an ageing one.

Yet behind the big picture statistics are lingering doubts. "Yes, there has been a mini baby boom and the number of babies being born has risen a little," Jane Bennett says. "But more couples than ever are having trouble conceiving. One in six couples trying to conceive is having problems. Twenty years ago it was half that - about one in 10."

Australia's recent spike in births turns out to be, in fact, largely demographic. In the 1950s, "baby boom" meant larger families everywhere, but this is not the case today. It's more a second wave boom - meaning Generation X, the abundant offspring of the Baby Boomers, are now having children after postponing them, while at the same time younger women are starting families at a younger age.

Medical Director Dr Angela Cooney of Family Planning WA Sexual Health Services says there have always been people with reduced fertility, but this proportion of the population is higher than it was two generations ago.

The fertility crisis is evident in the sudden demand for reproductive technologies. Between 2002 and 2006, there was a massive 47.4 per cent increase in initiated ART treatment cycles in Australia and New Zealand (3). And success rates are not huge. "You hear of women having babies through IVF in their mid and late forties, but the truth is that they are usually giving birth to someone else's child by ovum or embryo donation," says Angela. "People think IVF can fix everything, but it can't.

"The biggest and increasing areas of preventable infertility in Australia are increasing age, and obesity. Couples trying to conceive," she says, "are getting older and fatter."

She is frank and to the point, and that's exactly how Kath Mazzella, Secretary of the National Gynaecological Awareness Information Network, urges women to be with regard to their fertility.

Getting frank about fertility

"In our day we all just went on by accident," is how Kath describes family planning of yesteryear. Her kitchen table is well polished, her home welcoming and warm. She's older than me - I imagine grandkids playing at her feet, running around her country kitchen - and she's happy to brew tea for us and chat. "We didn't really have to make a decision," she says.

I'm imagining a time when young women could go out into the world with a kind of "que sera sera" (what will be will be) wistfulness, and still somehow end up a mother of four. But now having children is much more of an "opt into" than an "opt out of" thing. Accessibility to contraception, delayed marriage, women's participation in the workforce - and many couples rely on that double income - mean that for children to be born, decisions need to be made.

As a 32 year old woman, you'd think I would have a clue, or a biological clock, or at least a plan. Maybe I'm atypical, but I haven't thought too much about it. "What's that about?" Kath quizzes me. She has a point. When it comes to my career, study, interests and travel, I am able to plan and plot with clarity, energy and enthusiasm, while for my partner and I, having children remains a fairly sketchy dream. It's for someday, or when the time's right, or maybe never.

Then I meet Caroline. She's 35 and has just been diagnosed with cervical cancer (the sneaky kind that resists even pap smear detection). With treatment she can survive the cancer, but it's almost certain that she will never be able to have children.

Caroline is spirited and attractive, a pillar of strength, with blonde hair and flushed cheeks. "I didn't know if I wanted kids," she tells me. "I have a boyfriend, but I've never been married - I hadn't even been mentally gearing up to consider the idea. There's social pressure to have kids, but I never thought it was a 'be all and end all' issue."

Many women fear their own fertility, says Kath. They think, "I'll worry about all this when I'm 35." But according to Kath, reproductive health should be an ongoing concern, something to think about years before we actually have children. "Women have got to be more streetwise," she says, explaining the vigilance needed in detecting and treating conditions like endometriosis, polycystic fibrosis and chlamydia, all of which can lead to infertility.

From contra-ception to conception

Fertility experts like Ann Vlass (who works as a fertility specialist at natural fertility clinic Helping Nature Heal) and Jane Bennett say reproductive health is all that and more. Even when all the equipment is working, there is still unexplained infertility. It's a subtle thing, which, in their view, can be addressed through healing the mind/body divide. "When you think about it, for most of adult life women treat their reproductive ability as a burden. We take the Pill religiously, then suddenly at 34.5 years of age, we want to conceive and get in touch with our fertility. We expect it to all flow when it's been repressed for 20 years," says Jane.

"We spend too much time on contra-ception. We almost need retraining to accept the idea of conception," suggests Ann.

I remember sex education at high school. It was a defensive kind of learning, its focus on how to avoid pregnancy and disease. It's heartening to know Jane runs workshops for schoolgirls to help them at least acknowledge positively their ability to create life. "It's a gift, this awesome capacity that we have," she says.

GPs are also looking at how sexual education can affirm fertility, helping young people see it as a miracle rather than fear it as a danger and burden. "Positive family planning is when, in consultations, doctors discuss with patients their long term plans for a family, encouraging young women to think about it earlier," says Jane. The Family Support Act, too, recognises the need to better educate young people about fertility.

Hopefully, new approaches to family planning will help young people be grounded in their bodies, and more proactive about what they want.

Now that Caroline cannot have children, she says she does feel a loss. But with a thriving career underway it's not an overwhelming loss: "I also have lots of friends in a similar state - they don't want to leave it too late, but they don't yet have the right partner - that's a different kind of infertility."

"There will be many who will remain childless," says Angela. "Some are ignorant of the fact they will run out of time for babies, but I also know there are plenty of women in their early to mid thirties who would love to be pregnant but can't find a committed bloke."

Despite all obstacles, babies are still made. Many wouldn't be here today if it weren't for contraception failures and other such mysteries. Fertility experts come to know the "magical elements" well. They see couples do all the right things and still not conceive. On the other hand, for all the information and technologies we have at hand, about one in two pregnancies is unplanned (in Australia 64 per cent of these are contraception failures). Other couples "go through three or four IVF cycles then spontaneously conceive on their own. There's a lot we don't understand about this stuff," Angela admits.

Fertility experts just work as best as they can with the subtleties and secrets of the body. They learn to respect fertility for what it is: a complex dance of timing, conscious decision making and general health, all mixed up in the energetics of our relationships and that dynamic, internal pharmacy of hormones and hormonal surges. In the end, there must be a portion of self flattery in any control we assume to have. Maybe, in approaching the mystery, a little bit of "que sera sera" isn't so foolish after all.

References

1. Australian Clearing House for Youth Studies

http://www.acys.info/youth_facts_and_stats/pregnancy__and__parenthood/2007_and_earlier/2004-2006

2. Campbell, Ian. "Scientists warn that biological clock affects male fertility" The Guardian, July 7 2008. http://www.guardian.co.uk/society/2008/jul/07/health.children

3. Assisted reproduction technology in Australia and New Zealand 2006 Report http://www.aihw.gov.au/publications/per/artiaanz06/artiaanz06.pdf

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