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Women's awareness and perceptions of delay in childbearing

      Objective

      To explore women's awareness of issues associated with delayed childbearing, including its social and medical implications and the limitations of available treatment.

      Design

      Cross-sectional study.

      Setting

      University-based tertiary care clinics.

      Patient(s)

      Three hundred sixty-two women attending a subfertility clinic and 362 pregnant women.

      Intervention(s)

      A precoded questionnaire.

      Main Outcome Measure(s)

      Awareness and perceptions of issues surrounding delay in childbearing.

      Result(s)

      Subfertile women were, on average, 3.3 years older (95% confidence interval 2.5–4.1) and more likely to have tried for their first pregnancy after the age of 30 years (37.3% vs. 24.6%). Despite awareness of the impact of age on fertility, 85% of the subfertile group expected IVF to overcome the effects of age compared with 77% of the pregnant population. Knowledge about age-related obstetric risks, such as trisomy 21, was similar in both groups (86.3% vs. 85%). Almost all participants (94.5%) believed that women should be informed about the implications of delaying childbearing at an early age.

      Conclusion(s)

      Women are largely aware of the risks and complications of delaying childbirth, but erroneously believe that IVF can reverse the effects of age. There is a need to provide accurate information in the community.

      Key Words

      Demographic studies from Europe and the United States (
      • Breart G.
      Delayed childbearing.
      ,
      • Heck K.
      • Schoendorf C.
      • Ventura S.
      • Kiely J.
      Delayed childbearing by education level in the United States, 1969–1994.
      ) have shown that the age at first pregnancy as well as the number of pregnancies in women more than 35 years have been rising since 1980 (
      • ESHRE Capri Workshop Group
      Fertility and ageing.
      ,
      • Bewley S.
      • Davies M.
      • Braude P.
      Which career first? The most secure age for childbearing remains 20–35.
      ). Extensive use of contraception and the growing popularity of assisted reproductive technology (ART) have given women the impression that female fertility may be manipulated at any stage of life. Although this is true in terms of fertility control, the assumption that fertility can be resumed at a more convenient time is erroneous and can result in future subfertility (
      • te Velde E.
      • Pearson P.
      The variability of female reproductive ageing.
      ). Pregnancies in older mothers are also at increased risk of low birth weight, preterm delivery (
      • Tough S.
      • Newburn-Cook C.
      • Johnston D.
      • Svenson L.
      • Rose S.
      • Belik J.
      Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery.
      ), miscarriage, Down's syndrome (
      • Hecht C.A.
      • Hook E.B.
      Rates of Down syndrome at livebirth by one-year maternal age intervals in studies with apparent close to complete ascertainment in populations of European origin: a proposed revised rate schedule for use in genetic and prenatal screening.
      ), and other chromosomal anomalies. Obstetric complications and interventions, such as gestational diabetes, hypertension, placenta previa, operative delivery, and maternal mortality (
      • Temmerman M.
      • Verstraelen H.
      • Martens G.
      • Bekaert A.
      Delayed childbearing and maternal mortality.
      ), are also known to be age linked. Results from the National Heath and Nutrition Examination Survey III in the United States demonstrated enhanced risks of cardiovascular disease, diabetes, hypertension, and congestive heart failure (
      • Alonzo A.
      Long-term health consequences of delayed childbirth: NHANES III.
      ) in women who chose to delay childbirth.
      Epidemiological data have consistently shown that fertility declines as early as the middle of the third decade (
      • Menken J.
      • Trussell J.
      • Larsen U.
      Age and infertility.
      ,
      • Leridon H.
      Can assisted reproduction technology compensate for the natural decline in fertility with age? A model assessment.
      ) and female age remains the most important determinant of success (
      • Templeton A.
      • Morris J.
      • Parslow W.
      Factors that affect outcome of in-vitro fertilisation treatment.
      ) in an IVF program. Although there is no strict definition of advanced reproductive age in women, subfertility becomes more pronounced after the age of 35 years (
      • The Practice Committee of the American Society for Reproductive Medicine
      Aging and infertility in women.
      ). Only half of the age-related decline in fertility that occurs between 30 and 35 years and a third of that between 35 and 40 years can be overcome by IVF (
      • ESHRE Capri Workshop Group
      Fertility and ageing.
      ,
      • te Velde E.
      • Pearson P.
      The variability of female reproductive ageing.
      ,
      • Leridon H.
      Can assisted reproduction technology compensate for the natural decline in fertility with age? A model assessment.
      ,
      • Templeton A.
      • Morris J.
      • Parslow W.
      Factors that affect outcome of in-vitro fertilisation treatment.
      ). With expected live birth rates of 25%–30%, in women in their 20s and 30s, IVF can be seen as an expensive and invasive treatment with a relatively low success rate. Live birth rates are even lower (10%) in women more than 40 years (

      Human Fertilization and Embryo Authority. Guide to infertility and directory of clinics 2005/06. www.hfea.gov.uk/Forpatients/yourguidetoinfertility.

      ) and treatments other than oocyte donation are unlikely to be effective in such cases (
      • The Practice Committee of the American Society for Reproductive Medicine
      Aging and infertility in women.
      ).
      Although postponement of childbirth is common in the postcontraception era, women may be unaware of the implications of this decision such as its potential impact on their own health, the health of any future children, and the possibility of age related subfertility. As early as 1982, it was believed that appropriate information about the consequences of delay should be provided for all women considering having children later in life (
      • DeCherney A.
      • Berkowitz G.
      Female fecundity and age.
      ). However, this is still not common practice and research exploring women's own perceptions of their decision to postpone childbirth is limited. In a recent survey of Swedish students' attitudes toward childbearing, Lampic et al. (
      • Lampic C.
      • Skoog Svanberg A.
      • Karlstrom P.
      • Tyden T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ) found that most were unaware that fertility declined with age.
      The present study was designed to explore women's awareness of issues associated with delayed childbearing, including its social and medical implications, and the limitations of available treatment. We studied two groups of women of fertile age: women attending a subfertility clinic after attempting unsuccessfully to get pregnant and women who were currently pregnant. We expected those who were current users of fertility services to differ from those who were not (
      • Heikkila K.
      • Lansimies E.
      • Hippelainen M.
      • Heinonen S.
      A survey of the attitudes of infertile and parous women towards the availability of assisted reproductive technology.
      ,
      • van Balen F.
      Late parenthood among sub-fertile and fertile couples: motivations and education goals.
      ) in terms of [1] a conscious decision to delay childbearing and [2] awareness of the implications of such a decision.

      Materials and methods

      This was a questionnaire-based study in which participants were required to complete a precoded anonymous questionnaire. The study was approved by the Grampian Research Ethics Committee.

       Participants and Procedures

      Women were recruited from Aberdeen Maternity Hospital (which offers secondary and tertiary level fertility and antenatal services for the Grampian region) between March and September 2006.
      Women were approached in two settings. The first was the Aberdeen Fertility Centre. The second was Aberdeen Antenatal Ultrasound Department where women coming for midtrimester (20 weeks) anomaly scans were approached. Midtrimester anomaly scans are routinely offered to all antenatal women in the region. Recruitment was performed on a part-time basis by A.M., who approached consecutive women at each recruitment session. Those who consented were provided with questionnaires, which were similar for both groups. A precondition to the study was maintenance of participant anonymity and no clinical data were collected from the women's case notes. Investigators had no knowledge about the women's medical, fertility, and obstetric history.

       Questionnaire

      The anonymous questionnaire was developed by the team of investigators (consisting of three gynecologists/obstetricians and a medical sociologist). It was piloted on each study group separately and revised on the basis of observations made by staff as well as patients. The final questionnaire comprised 32 questions covering demographic details, decision to delay childbearing, awareness of limitations of fertility treatment, existing age limits for access to fertility treatment, and tests for prediction of fertility.

       Sample Size

      Our hypothesis was that women attending an infertility clinic were more likely to have postponed their first planned pregnancy than an antenatal population. Local population-based data from Aberdeen Maternity Neonatal Databank (D. M. Campbell, personal communication) suggested that 31% of primigravida were more than 30 years. In contrast, 41% of the women attending the Aberdeen Fertility Centre for the first time were more than 30 years old. We estimated that a sample size of 361 women in each group (a total of 722 women) would provide 80% power at the 5% level of significance to demonstrate a difference of 10% (30%–40%) in the proportion of women who had deliberately postponed their first planned pregnancy until after the age of 30 years.

       Statistical Analysis

      The SNAP software (Mercator, Bristol, UK) was used to design the questionnaire. Data were analyzed using the Statistical Package for the Social Sciences (SPSS version 14 for Windows; Chicago, IL). Parametric tests were used for normally distributed data and χ2 test for categorical data. Confidence intervals were calculated where appropriate.

      Results

      Of a total of 772 women approached in the two clinical settings, three in the pregnant group and five in the subfertile group chose not to participate (overall response rate 98.9%). It took approximately 10 minutes to complete the questionnaire and most of the women filled it in while waiting in the clinic before their consultation. Three hundred sixty-two women were recruited in each group. Women in the subfertile group were on average 3.3 years (95% confidence interval [CI] 2.53–4.07) older than those in the pregnant group (P<.001). The demographic characteristics of the women in both groups are shown in Table 1.
      Table 1Demographic characteristics of each group.
      Subfertile (n = 362)Pregnant (n = 362)P value
      Mean age (y; SD)32.60 (4.94)29.30 (5.57)<.001
      Independent t-test.
      University degree127 (35.1%)129 (35.7%).96
      Continuity correction χ2 test.t-test.
      Previous pregnancy153 (42.5%)218 (60.2%)<.001
      Continuity correction χ2 test.t-test.
      Previous live birth85 (23.5%)173 (47.8%)<.001
      Continuity correction χ2 test.t-test.
      Previous TOP
      Independent t-test.
      38 (10.5%)23 (6.3%)<.001
      Continuity correction χ2 test.t-test.
      Previous miscarriage47 (12.9%)66 (18.2%)NS
      Note: NS = not significant; TOP = termination of pregnancy.
      a Independent t-test.
      b Continuity correction χ2 test.t-test.
      Of the 371 women with previous pregnancies, more women in the pregnant group had a live birth (79.9% vs. 55.5%). A quarter of women in the subfertile group (38/153) had a history of termination of pregnancy compared with 10.6% (23/218) in the pregnant group.

       Delay in Childbearing

      A higher proportion of subfertile women reported trying for their first planned pregnancy after the age of 30 years (37.3% vs. 24.6%; P<.001) (Table 2). Of those women who had delayed their first pregnancy until after 35 years of age, 26/36 said that this decision was influenced by relationship issues.
      Table 2Perceptions of delaying childbearing.
      Subfertile (n = 362)Pregnant (n = 362)P value
      When did you try for your first planned pregnancy
       <30 years227 (62.7%)273 (75.4%)<.001
      Continuity correction χ2 test.
       >30 years135 (37.3%)89 (24.6%)
      Did you use contraception before trying for your first pregnancy?
       Yes316 (88.3%)284 (79.6%).002
      Continuity correction χ2 test.
       No42 (11.6%)73 (20.2%)
      How many years did you use contraception for?
       <5 years118 (37.7%)108 (37.5%).189
      Pearson χ2 test.
       6–9 years91 (29.1%80 (27.8%)
       >10 years104 (33.2%)100 (34.7%)
      Do you feel you postponed trying for pregnancy until your circumstances were different?
       Yes260 (73.2%)193 (53.8%)<.001
      Continuity correction χ2 test.
       No95 (26.8%)166 (46.2%)
      a Continuity correction χ2 test.
      b Pearson χ2 test.
      A higher proportion of women in the subfertile group used contraception in the past compared with the women in the pregnant group. However, when stratified according to the length of time contraception was used, the difference did not reach statistical significance (Table 2).
      More women in the subfertile group indicated that they had postponed their first planned pregnancy (73.2% vs. 53.8%) in comparison with pregnant women (P<.001) (Table 2). This decision to delay childbearing was associated with feelings of regret in 35.5% (91/256) of subfertile women and 11.5% (22/191) pregnant women (P<.01).

       Perception of the Impact of Age on Fertility

      Most women (93.0%) in the subfertile group and 88.3% in the pregnant group indicated that they were aware that age could affect their chances of pregnancy (P=.03); 85.1% of the subfertile women and 76.5% of the pregnant women believed that the chances of pregnancy decreased between the age of 30 and 40 years. Fewer women (53% and 45.6%, respectively) were aware that the chances of having a baby with IVF decreased between ages of 30 and 40 years. More women in the subfertility group (84.6% vs. 76.8%) believed that fertility treatment could overcome the effect of age (P=.015). Figure 1 shows the views of subfertile women on the chances of a spontaneous and IVF-assisted pregnancy. Similar responses were obtained from the pregnant group; 72.8% identified 30–40 years as the age of decline of spontaneous fertility, 45.7% believed that chances of IVF-assisted pregnancy decreased between age 30–40 years. Approximately half of these women (52%) believed that the chances of pregnancy after IVF only declined after the age of 40 years. The majority of women (subfertility = 74.7% vs. pregnant = 69.1%, P=.11) were aware that the chance of having a live baby after a single IVF attempt was less than 40%.
      Figure thumbnail gr1
      Figure 1Perception of subfertile women of age at which chances of pregnancy declines.

       Complications in Pregnancy

      Women were asked to indicate whether they thought perinatal complications were influenced by age. Both groups (subfertile vs. pregnant) were equally aware of the possibility of age-associated complications in pregnancy, including miscarriages (72.7% vs. 65.2%), Down's syndrome (86.3% vs. 85%), diabetes (48.2% vs. 41.3%), cesarean section (45.8% vs. 40.6%), and high blood pressure (71.2% vs. 69.3%). A fifth of all women in each group were aware of an increased incidence of twins with increasing maternal age (20.3% vs. 21.7%).

       Threshold for Embarking on IVF

      A third of all women in both subfertile and pregnant groups were prepared to consider undergoing IVF with National Health Service funding even if the expected success rate was <10% (37.3% vs. 33.4%). A similar proportion was happy to undergo self-funded IVF treatment (30.3% vs. 31.6%) at the same success rate. A small proportion (4% of the subfertility group and 3% of the pregnant group) were willing to undergo IVF even if the predicted success rate was <1%.

       Opinion About Age Limit for Fertility Treatment

      Only more than a third of women (37.1%) in the subfertility group knew that most clinics had age limits for access to fertility treatment, compared with 20% of the pregnant group (P<.001). Of those who were aware, relatively few knew what the local age limit was (20% in the infertility group and 18.1% in the pregnant group). However, most women agreed that there should be an upper age limit for IVF treatment (74.2% in the subfertile group and 70.8% in the pregnant group), especially when funded by the National Health Service (87.3% and 92.5%). Nearly half of them believed that the upper age limit should be between 40 and 45 years (43.5% and 44.9%). Only 15.6% of subfertile women and 9.8% of the pregnant group believed that the upper age limit for fertility treatment should be more than 50 years (Table 3).
      Table 3Opinion on age limit for fertility treatment.
      Subfertile (n = 362)Pregnant (n = 362)P value
      Are you aware of any age limit above which fertility treatment is not provided in your area?
       Yes134 (37.1)72 (19.9)
       No227 (62.9)289 (80.1)<.001
      Continuity correction χ2 test.
      If yes, what do you think the age limit is?
       30–35 years1 (0.7)5 (6.9)
       35–40 years57 (42.2)21 (29.2)
       40–45 years45 (33.3)26 (36.1)
       45–50 years27 (20.0)13 (18.1)
       >50 years5 (3.7)7 (9.7)
      Do you believe there should be an upper age limit for women to be treated in subfertility clinics?
       Yes267 (74.2)255 (70.8)
       No93 (25.8)105 (29.2).359
      Continuity correction χ2 test.
      If yes what do you think the upper age limit should be?
       30–35 years2 (0.7)7 (2.7)
       35–40 years29 (10.8)44 (17.2)
       40–45 years117 (43.5)115 (44.9)
       45–50 years79 (29.4)65 (25.4)
       >50 years42 (15.6)25 (9.8)
      Do you believe there should be an upper age limit for women to receive NHS funding for subfertility treatment
       Yes234 (87.3)236 (92.5)
       No34 (12.7)19 (7.5).066
      Continuity correction χ2 test.
      If yes, what do you think the upper age limit should be?
       30–35 years2 (0.9)7 (3.0)
       35–40 years33 (14.0)50 (21.1)
       40–45 years119 (50.6)112 (47.3)
       45–50 years47 (20.0)55 (23.2)
       >50 years34 (14.5)13 (5.5)
      a Continuity correction χ2 test.

       Perceptions About First-Time Motherhood at an Advanced Age

      When asked their feelings about women becoming first-time mothers at an advanced age, subfertile women were more inclined to find ages 40 and 45 years acceptable. Few were comfortable with the prospect of first-time motherhood at the age of 50 years and older (Table 4).
      Table 4Acceptability of first-time motherhood at an advanced age.
      Acceptable (%)Neutral (%)Unacceptable (%)P value
      Pearson χ2 test.
      40 years
       Subfertile (n = 360)88.310.80.8<.001
       Pregnant (n = 360)73.323.92.8
      45 years
       Subfertile (n = 357)53.839.27.0<.001
       Pregnant (n = 361)39.146.814.1
      50 years
       Subfertile (n = 357)8.444.347.3.005
       Pregnant (n = 361)5.036.059.0
      55 years
       Subfertile (n = 356)2.220.577.2.695
       Pregnant (n = 361)2.218.079.8
      60 years1.48.789.9.253
       Subfertile (n = 355)1.48.789.9.253
       Pregnant (n = 361)1.712.585.9
      a Pearson χ2 test.

       Information About Delay in Childbearing

      Women in both groups (subfertility and antenatal) believed that they should be provided with information about the risks and benefits of delaying childbearing (95% vs. 94.2%). The best time to provide such information was perceived to be the early 20s (54.1% and 53.4%). School age was the second choice (24% and 20.4%).

       Tests of Ovarian Reserve

      Few women (18.1% in the subfertile group and 12.2% in the antenatal group) had heard of any tests of ovarian reserve that might inform a decision to postpone pregnancy without risking infertility. Most of those who had, could not remember either the name or the mechanism of action of any such tests. Only 10 women (7 in the subfertile group and 3 in the pregnant group) were aware that these tests were designed to predict the number of eggs left in the ovaries.

      Discussion

      To the best of our knowledge, this is the first study in the United Kingdom to explore women's perceptions of delayed childbearing. Studying two contrasting groups gives an insight into the knowledge and awareness of different populations of women. The high participation rate (>98%) perhaps reflects women's willingness to complete the anonymous questionnaire, while waiting in the clinic for their appointment.
      Women in the subfertile group were more likely to have tried for their first pregnancy after 30 years of age. Most of the women were aware of the complications associated with maternal age, but were overly optimistic about the ability of IVF to overcome the effect of age on fertility, especially after the age of 40 years. This may reflect the growing popularity of ART and the way in which it is portrayed by the media. It is also possible that pregnancies in older women achieved by means of donor eggs may have perhaps encouraged women to believe that female fertility can be manipulated at will (

      Spanish Women oldest mother. BBC online. Saturday, December, 30, 2006.

      ,

      Doctor defend IVF for woman, 62. BBC online. Thursday, May 4, 2006.

      ,

      Older mums likely to live longer. BBC online. Saturday, December 25, 2004.

      ).
      Fewer subfertile women had a live birth compared with pregnant women, confirming previous findings (
      • Thomson F.
      • Shanbag S.
      • Templeton A.
      • Bhattacharya S.
      Obstetric outcome in women with sub-fertility.
      ) that subfertile women are more likely to encounter problems when they achieve pregnancy. Earlier work has failed to show a link between terminations per se and future subfertility (
      • Lurie S.
      • Levy R.
      • Katz Z.
      • Appleman Z.
      • Insler V.
      The influence of mid-trimester termination of pregnancy on subsequent fertility: four to five years follow up.
      ,
      • Debby A.
      • Glezerma M.
      • Sagiv R.
      • Sadan O.
      • Malinger G.
      • Golan A.
      Reproductive performance following mid-trimester termination of pregnancy.
      ). A relatively high rate of terminations in our subfertile population thus tends to suggest that these women were able to conceive in the past and could favor an association of subfertility with increased age.
      The study has a number of weaknesses. Because the questionnaires were anonymous, no clinical data could be linked to responses. We were thus unable to include causes of subfertility, number of previous visits to the fertility clinic, or any current or past treatment for subfertility in the analysis. This meant that a small proportion of the antenatal population could have experienced subfertility in the past. Prevalence of subfertility in the general population is estimated at 1 in 7 (
      • Thonneau P.
      • Marchand S.
      • Tallec A.
      • Ferial M.
      • Ducot B.
      • Lansac J.
      • et al.
      Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (1988–1989).
      ). Assuming that infertility is resolved in half of all cases (with or without treatment) (
      • Templeton
      • Fraser C.
      • Thompson B.
      The epidemiology of infertility in Aberdeen.
      ) 26 of 362 women in the pregnant group could fall in this category. It is unlikely that responses from this small population would bias the overall results based on a relatively large sample size. We have used a sample of subfertile women who are potentially facing fertility problem at present, and a control group of women who are pregnant. Although used by other studies (
      • Heikkila K.
      • Lansimies E.
      • Hippelainen M.
      • Heinonen S.
      A survey of the attitudes of infertile and parous women towards the availability of assisted reproductive technology.
      ,
      • Kooij L.
      • Bukman A.
      • Hoek A.
      • Heineman M.
      • Tymstra T.
      Women's opinion on the use and offer of ovarian reserve testing: a first step towards a wide ranged social discussion.
      ) this is perhaps not an ideal control group for subfertile women. Women attending a family planning clinic for contraception might have been another choice, but it would have been impossible to rule out the possibility of such women who have not yet tried for a pregnancy having an incidence of subfertility (1 in 7) similar to that of the general population. Women using contraception advice for family spacing could also experience future problems with secondary subfertility. Other studies looking at fertility awareness and intentions concerning childbearing have compared the responses between male and female respondents (
      • Lampic C.
      • Skoog Svanberg A.
      • Karlstrom P.
      • Tyden T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ,
      • Virtala A.
      • Kunttu K.
      • Huttunen T.
      • Virjo I.
      Childbearing and the desire to have children among university students in Finland.
      ).
      A significantly higher proportion of women in the subfertile group believed that they had postponed pregnancy and many regretted this delay (Table 2). This may reflect feelings of remorse or guilt in women who are now experiencing problems with conceiving. This has been reported in a previous study (
      • Friese C.
      • Becker G.
      • Nachtigall R.
      Rethinking the biological clock: Eleventh hour moms, miracle moms and meanings of age-related infertility.
      ) on women using donor eggs because they were too old to conceive using their own.
      It has been suggested that various factors influence women's decision about delaying motherhood. In order of importance they are professional development, financial security, and the presence of an appropriate partner (
      • van Balen F.
      Late parenthood among sub-fertile and fertile couples: motivations and education goals.
      ,
      • Virtala A.
      • Kunttu K.
      • Huttunen T.
      • Virjo I.
      Childbearing and the desire to have children among university students in Finland.
      ,
      • Benzies K.
      • Tough S.
      • Tofflemire K.
      • Frick C.
      • Faber A.
      • Newburn-Cook C.
      Factors influencing women's decisions about timing of motherhood.
      ). In our study, stability of a relationship and the availability of a suitable partner were deemed to be important, although only 36 women who delayed their first planned pregnancy until after 35 years of age, were asked this question.
      A higher level of education is generally associated with delayed age at first-time motherhood (
      • van Balen F.
      Late parenthood among sub-fertile and fertile couples: motivations and education goals.
      ). This was not the case in our study where, despite similar levels of education, the age of first pregnancy was higher in subfertile women than in pregnant women.
      Knowledge about the effects of age on reproductive outcome (with or without IVF), success rates of IVF, and complications of pregnancy were similar in both groups. This contrasts with other studies suggesting that responses from fertile women are different (
      • Heikkila K.
      • Lansimies E.
      • Hippelainen M.
      • Heinonen S.
      A survey of the attitudes of infertile and parous women towards the availability of assisted reproductive technology.
      ,
      • van Balen F.
      Late parenthood among sub-fertile and fertile couples: motivations and education goals.
      ). This difference may be because the subfertile group included some parous women. In addition, awareness of issues associated with subfertility can be influenced by education rather than experience of the condition alone. In a Canadian study (
      • Tough S.
      • Benzies K.
      • Newburn-Cook C.
      • Tofflemire K.
      • Fraser-Lee N.
      • Faber A.
      • et al.
      What do women know about the risks of delayed childbearing?.
      ) a computer-assisted telephone interview survey conducted on 1,044 parous women showed that they were generally unaware of potential consequences of maternal age on reproductive outcome. There are no studies in the literature comparing the responses between parous and subfertile women. However, the population studied in the present group was more aware of potential complications compared with a younger group of university students (
      • Lampic C.
      • Skoog Svanberg A.
      • Karlstrom P.
      • Tyden T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ).
      In this study only a small proportion indicated that an IVF success rate of <1% was acceptable. This is in direct contrast with the results of a Dutch study where 71% women in a subfertile group and 59% of pregnant women (
      • Kooij L.
      • Bukman A.
      • Hoek A.
      • Heineman M.
      • Tymstra T.
      Women's opinion on the use and offer of ovarian reserve testing: a first step towards a wide ranged social discussion.
      ) believed that any chance of conception justified treatment. This difference in attitudes may be due to differences in funding and access to fertility treatment in the two countries. Although access to National Health Service funding is variable, most health authorities do not fund IVF in women more than 40 years old.
      Most of the women in this study found 40 years to be an acceptable age for first-time motherhood. A qualitative study exploring parenting in older mothers found no negative impact of age on parenting. However, the study was limited to women who were less than 40 years old (
      • van Balen F.
      Late parenthood among sub-fertile and fertile couples: motivations and education goals.
      ). There is a scarcity of literature exploring first-time motherhood beyond 45 years, which most of the women in our study found unacceptable.
      In the past there has been a significant emphasis on avoiding teenage pregnancies and relatively little attention has been drawn to possible problems associated with postponement of childbirth. As a result there are misconceptions in the community about the effect of age on natural fecundity and the outcome of fertility treatment. Many women are currently choosing to delay motherhood in the interests of personal and professional development. Although starting a family is a personal preference, free choices cannot be made without full knowledge of their consequences. The results of this and other studies (
      • Lampic C.
      • Skoog Svanberg A.
      • Karlstrom P.
      • Tyden T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ,
      • Friese C.
      • Becker G.
      • Nachtigall R.
      Rethinking the biological clock: Eleventh hour moms, miracle moms and meanings of age-related infertility.
      ,
      • Benzies K.
      • Tough S.
      • Tofflemire K.
      • Frick C.
      • Faber A.
      • Newburn-Cook C.
      Factors influencing women's decisions about timing of motherhood.
      ) suggest that women should be provided with the appropriate information on the possible outcomes of a decision to delay motherhood. However, there are no suggestions from the literature as to how and when this information should be provided. We are also unaware of the impact of providing such information to society at large.
      Most women who are older will conceive spontaneously, and only a handful will need fertility treatment. Unfortunately, as there are no effective means to identify those who will face subfertility later, information may need to be provided to all women. Further work is needed to determine the best way to achieve this.

      Acknowledgments

      The authors thank all the staff at the subfertility clinic and the ultrasound department who helped in this study. We are grateful to all the women who completed the questionnaire.

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