Feature Archive

Planning a Family

Family Planning

By Richard Trubo
WebMD Feature

Reviewed By Charlotte Grayson

As Jeanne Meyers was growing up, she always assumed she'd have children someday. But when she got married in her 30s, at a time when both she and her husband had successful careers, they decided to postpone starting a family for a couple more years. A family, they felt, could wait a little while longer.

But before long, their plan of having children was turned upside down. In her mid-30s, when Jeanne and her husband had finally made the decision to become parents, she had difficulty becoming pregnant, month after disappointing month. Finally, a reproductive specialist broke the news that had seemed inconceivable to Jeanne earlier in her life: Her eggs had deteriorated in quality as she had aged, presenting a major obstacle to pregnancy.

"We tried in vitro fertilization (IVF) when I was 37, and while I did get pregnant, I miscarried, probably due to the egg quality," says Jeanne (whose last name has been changed in this article at her request). "I used to work as a nurse in the fertility field, but I never thought I'd be on the other side. I never imagined that I'd have difficulty having children myself."

Jeanne, who now does medical-legal consulting in Atlanta, says that she and her husband faced the facts: While she could probably get pregnant again through IVF, the odds were good that she would miscarry. So they stepped back, and decided to adopt children. Today, at age 40, she and her husband have two sons who were born in the Ukraine.

For millions of Americans like Jeanne, the family life they've given birth to isn't exactly the one they may have envisioned years earlier. In fact, in America today, terms like "family planning" have taken on new meaning, with couples often moving in unanticipated directions as they respond to the hand they've been dealt.

Waiting Too Long?

As part of their family planning, more women than ever are choosing to postpone childbearing into their late 30s and early 40s, due to careers and late marriages. But as with Jeanne, many may have miscalculated their ability to become pregnant. According to the American Society for Reproductive Medicine, a startling two-thirds of women will not be able to conceive spontaneously by age 40 due to factors such as changes in their eggs and the way their ovaries function.

"Ultimately, age matters," says Ruth Fretts, MD, obstetrician/gynecologist at Harvard Medical School and Brigham and Women's Hospital in Boston. "Women tend to not want to hear this. But the large, well-designed studies show that women who delay significantly are going to have an increased risk of infertility. Biology is sexist," adds Fretts. "Biology just doesn't care."

At New York University Medical Center, obstetrician/gynecologist Steven Goldstein, MD, says career women often come into his office at age 38 or 39, perhaps having just gotten married, and announce that they plan to wait a couple more years before having a baby. "I find myself gulping," he says. "Particularly in women over age 40, physicians are nervous as hell that these women are flirting with disaster by having waited. They may not get pregnant when they want to, not because they aren't ovulating, but because the quality of their eggs has diminished."

So how long is too long to wait? "Unfortunately, there's no test doctors can conduct that will tell you, 'You have two years,' or 'You have four years,'" says Goldstein.

According to Fretts, women who delay childbearing often have "more education, good jobs, and perhaps more money -- so they're socially advantaged but biologically disadvantaged. The optimal time to have children is really in the 20s."

Gayle Peterson, PhD, MSSW, a family therapist in Berkeley, Calif., says that the challenge of balancing work with the desire for parenthood is becoming very intense for many women. On the one hand, as their biological clock ticks, they understand the need to start their family, she says. "But lately the work environment has moved toward demanding more overtime, especially in certain professions, and it's almost impossible for these women to find balance."

New Birth Control Alternatives

Ironically, when it comes to contraception, couples have more options today, and thus greater control over at least one component of family planning. In about the last year, the pharmaceutical industry has spawned a wave of new alternatives for women, which include:

  • A new type of intrauterine device (IUD), called Mirena, which can be left in place for up to five years. It contains the hormone levonorgestrel, which is gradually released over the life of the T-shaped device.
  • Lunelle is a once-a-month injection of synthetic estrogen/progesterone hormones. Despite the convenience of not taking a birth control pill each day, Lunelle does require a visit to the doctor every 28 to 30 days for a new shot.
  • The first contraceptive patch, called Ortho Evra, delivers a steady stream of estrogen and progestin through the skin, and is replaced every seven days. Worn under the clothes on the buttocks, upper torso, or abdomen, it will become available sometime in 2002.
  • A vaginal ring, called NuvaRing, is a small, flexible ring that will soon come on the market, and provides a low dose of estrogen and progestin over a 21-day period.

Does Size and Spacing Matter?

The trend toward women starting families later (or not at all) -- along with the availability of more birth control methods -- does not seem to have made much of a statistical impact on family size in the U.S. According to a recent CDC report, analyzing data from 2000, the average number of offspring born to women over a lifetime was 2.1, compared with fewer than two children per woman during most of the 1970s and 1980s.

With the help of contraceptives, some parents continue to try to space out their children in what they consider the most appropriate intervals, although Mother Nature doesn't always cooperate with their family planning. Many child psychologists advise that three to three-and-a-half years between children is optimal.

"While a 2-year-old child is very insecure, and thus a new baby in the family is more likely to cause competition and sibling problems, a child by age 3 is better able to share a parent successfully," says Peterson, author of Making Healthy Families and An Easier Childbirth.

A study at the CDC, published in The New England Journal of Medicine in 1999, concluded that newborns are healthiest when the gap from birth to the next conception is 18 to 23 months, with less prematurity and low birth weight in babies conceived in this time frame.

Meanwhile, Peterson says that more women are telling her that as they plan their families in the new millennium, they no longer want to be supermoms," and are trying to direct more energy toward enjoying life and making their families a priority. More than ever, she says, "Women are recognizing that there's no such thing as 'having it all.' You can't burn a candle at both ends and still have a candle; it's just not going to be there."

Originally published May 27, 2002.

Reviewed by Charlotte E. Grayson, MD.

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