Guest Column by Dr. Daniel Shapiro
I fondly remember sitting at my Grammy Lee’s table in Miami in a dining room without air conditioning every Sunday morning after religious school — unless, of course, the Dolphins had a home game.
The menu was always the same, but we never tired of the bagels, lox, cream cheese, whitefish, peanut butter and guava jelly mini-sandwiches, or the ham and cheese (we were very Reform). Grammy had an endless supply of stories and smiles, but we knew she was never listening to any of us carefully. Her response to everything we said was “That’s nice, dear” or “Ooh, is that good for the Jews?”
We learned growing up that despite the trials and tribulations our people face, there are in fact many things that are good for the Jews. The list of attributes modern Jews have is considerable, but the one I think has the greatest impact is the value we place on education.
From an early age we are socialized to do our best (maniacally perhaps) and excel academically. It is no accident that a Jewish fetus is not considered viable until it graduates from Harvard Medical School.
That said, one unintended consequence of all this time spent in school is that we tend to delay marriage and childbearing. Among Reform and Conservative Jews, birthrates have declined significantly the past 50 years, and one good reason is that we simply start our families later than nature intended.
The average age of first birth among Reform and Conservative Jews is now over 30. The socio-biological impact of this recent and drastically different phenomenon cannot be underestimated.
This is not true for strictly Orthodox families, whose first birth still typically occurs in the mid-20s, but the link between education and delay to childbirth may not be as strong as it is among more secular denominations.
The later a woman starts procreating, the fewer babies she will have. Sadly, eggs have expiration and “use by” dates. About 23 percent of 27-year-old women can expect to achieve pregnancy per month, while a 40-year-old can expect only a 7 percent pregnancy rate per month of trying. At 44 it is 1 percent, and beyond that pregnancy occurs only anecdotally.
One in eight couples will be infertile before age 30, one in six between ages 31 and 35, one in four between 36 and 40, and about half above age 40.
So what is a nice Jewish girl to do? And if she is already married or chooses single motherhood, how should she plan for a family?
To the best of one’s ability, the best place to start is to ask oneself how many children one would like to have. For people who want only one or perhaps two, a delay into the 30s is usually not a problem. For those who want large families, “the early bird gets the worm” applies.
Sixty percent of women under age 35 and 40 percent of women ages 36 to 40 can expect to conceive within six months of trying. Women under 35 can wait as long as a year before they are assigned a diagnosis of infertility, while women over 35 should seek medical help if they are not pregnant within six months.
Though fertility medicine has changed dramatically since the era of in vitro fertilization began in 1978, the basic work-up for infertility and pregnancy loss hasn’t changed much in 40 years. All evaluations have the following elements: assessment of egg number/quality, a semen exam, and a radiologic evaluation of the uterus and fallopian tubes.
Patients who have recurrent pregnancy loss will be advised to obtain additional bloodwork for certain immune markers, blood clotting factors and genetic assessment of both parents. To check the eggs, a blood test called an AMH (anti-Mullerian hormone) will be drawn. Standard semen analysis is usually enough to determine whether the sperm is OK, and an X-ray called a hysterosalpingogram is the remaining basic test.
The results of these tests tell the doctor what is likely to happen with the options of nothing, reproductive surgery, intrauterine insemination and IVF. Therapies other than IVF have much lower rates of success but are typically less expensive than IVF.
IVF has several advantages over other therapies. Patients who go through IVF can limit the risk of multiple birth by replacing only one embryo per attempt, can eliminate the risk of a serious condition known as ovarian hyper-stimulation syndrome, and, most important, can freeze extra high-quality embryos.
The ability to freeze embryos and eggs has changed the answer to the question “What is a nice Jewish girl (or couple) to do?”
For women or couples who want to capitalize on modern reproductive technology so they can delay childbearing without compromising either the chance of pregnancy or the hope for a large family, IVF for fertility preservation can be accomplished safely and for less expense than a full IVF treatment cycle.
Patients who choose this approach in their late 20s or early 30s can bank eggs or embryos for future use at any age. The age of the egg determines the chance of pregnancy, so a frozen 27-year-old egg will always behave like a 27-year-old egg, even if it is placed into a 47-year-old uterus.
The goal of egg or embryo freezing is obvious, but the process is basically an insurance policy against the negative impact of time on fertility. For all women, Jewish women included, fertility preservation provides the ability to continue education or delay motherhood for any reason.