Mid-life Low Fertility is Not the Same As No Fertility!

by Lauren Streicher, MD

Young women are well aware that a possible consequence of having sex is pregnancy. It’s the woman who is perimenopausal who often thinks she does not need to worry about inadvertently conceiving.

Most of my patients assume that the further they are on the other side of 40, the less the need for contraception. It’s correct that fertility dramatically declines as time marches on: just ask any 40-year-old who is trying to get pregnant. But “declines” is not the same as “disappears.”

While pregnancy is a lot less likely after 40, it can, and does, happen.Roughly 40 percent of pregnancies in the United States are unintended. Not surprisingly, the highest rate of unintended pregnancy is among women aged 24 and younger. Surprisingly, the second-highest rate is among women over 40. In fact, unplanned pregnancies in women over 40 have recently increased because so many women in that group assume they are no longer fertile.

While the number-one predictor of fertility is age, there is a significant variability in ovarian aging: some women are infertile at 35, while others are still going strong at 45. That’s why contraception is still needed, unless an unplanned pregnancy would not be the end of the world.

Contraception for the midlife woman is tricky. Low-dose, oral hormonal contraception not only prevents pregnancy, but also has the bonus of easing symptoms from perimenopausal hormonal fluctuations. Many women think that the pill is not an option for the over-35 crowd, but contrary to popular belief, healthy, normal-weight women who are nonsmokers can safely use hormonal contraception, such as the pill or vaginal ring, up to age 55. The newest pills contain minuscule amounts of estrogen compared to earlier birth control pills and therefore have a much lower risk of complications such as blood clots or stroke.

In addition to preventing pregnancy, hormonal contraception has a number of noncontraceptive benefits that are particularly relevant to woman over 40. These include less pain with periods, lighter periods, and, best of all, a significant decrease in ovarian and uterine cancer. In addition, taking a low-dose birth control pill is an excellent way to regulate the erratic periods and crazy mood swings that are part of the perimenopausal hormonal roller coaster. But many midlife women have medical conditions that eliminate estrogen based contraception as an option.

Non-Estrogen Birth Control Options

Intrauterine devices (like Mirena, Skyla and Paraguard) and implants (like Nexplanon) are excellent long-acting, reversible non-estrogen options. In addition, intrauterine devices that have a progestin component have non-contraceptive benefits such as lightening heavy periods (very common in perimenopause!) and reducing uterine cancer.

But if you’ve given your maternity clothes to Goodwill and used the crib for firewood, you may be considering permanent sterilization.

Since the 1970s, outpatient tubal interruption has been performed laparoscopically using a small incision in the belly button, and one or two other tiny incisions in the lower abdomen. The surgeon uses clips, rings, or cautery (the use of a heated instrument) to seal the fallopian tubes. No matter the method, the result is the same: An egg can no longer rendezvous with a sperm. Some women opt to have the tubes completely removed- not only pretty much a guarantee that even the most motivated sperm will not meet up with an egg, but has also been shown to reduce the risk of ovarian cancer.

What’s the Best, Safest Contraception?

The obvious perfect solution for the midlife woman is not female contraception, but vasectomy. The obvious barrier, however, is a willing spouse or partner. If you are single and looking — and not interested in having kids — consider adding “has vasectomy” to your perfect-guy wish list, along with “great sense of humor” and “likes pets.”