The State of Fertility Report 2017

The majority of millennial women consider themselves well versed in fertility and conception, but our survey found that they actually don’t have the important facts straight. Healthline’s survey found that 7 in 10 millennial women believed they understood egg health and fertility, but 68 percent of them weren’t aware that 40-50 percent of women over age 35 will need medical intervention in order to become pregnant. Furthermore, 89 percent of survey respondents were unaware that 80-90 percent of women over 40 will need intervention to have a baby.

With so many millennial women delaying parenthood, the reality is many of these women will face more fertility problems than older generations, and they may also not fully understand the many facets of fertility that affect their chances of becoming pregnant. For example, delaying pregnancy reduces conception chances. According to the Southern California Center for Reproductive Medicine, a woman in her 20s has a 20 to 25 percent chance of conceiving naturally during each menstrual cycle. Women in their early 30s have about a 15 percent chance per cycle. After 35, it slips to 10 percent, and after 40, it’s just 5 percent. By the time a woman is over 45, her chances of getting pregnant during each menstrual cycle are less than 1 percent. That’s all while the risk of miscarriage rises with age. “Women’s most fertile time, unfortunately, is when societally, career-wise, and relationship-wise, it’s not a good time,” Toledo noted. It’s this gap between perceived knowledge and actual fertility literacy that presents an opportunity for millennial women — and their doctors — to talk more openly about their fertility and options before their peak childbearing years have come and gone.

Millennial moms have already significantly affected the cultural acceptance of postponing motherhood, as well as national statistics for maternal age. From 2000 to 2014, the average age of first-time mothers increased 1.4 years, from 24.9 to 26.3. During that same time period, the proportion of women aged 30 to 34 who had a first child rose 28 percent, and the number of women over age 35 who had their first child climbed 23 percent. Deciding to have a baby later in life increases the likelihood that it will be harder getting and staying pregnant. And just as millennial women may be unaware of how many women need fertility treatment, they’re also waiting too late to check on their own fertility health. The Healthline survey found that 58 percent of millennial women believed they should check their fertility health between ages 25 and 34. Only 14 percent suggested they get their fertility tested earlier, between ages 20 and 24. That decade between ages 24 and 34 is later than most doctors recommend, however. Discovering fertility problems in the later years during this time can leave women vulnerable to genetic conditions that could make conception — even in their early 30s — difficult. That’s why most doctors recommend women first test their anti-mullerian hormone (AMH) levels by age 25. The test provides an estimate of a woman’s egg supply, or remaining eggs in her ovaries. “I think every woman should get her fertility levels checked by the time she’s 25 years old,” said Eyvazzadeh. “If, however, she’s had an ovary removed, she has a family history of endometriosis, or her mom went through early menopause, she should check earlier.” You don’t need to see a specialist for this test. During your annual pelvic exam or physical, ask your doctor for an AMH level test. If your level is 1.5 or below, it’s a good idea to check on the number annually. If it begins to fall, you may want to consider egg freezing if you’re not ready to have a child yet, or artificial insemination (IUI) or in vitro fertilization (IVF) if you are. Even with increasing awareness of treatments for infertility, Toledo hasn’t noticed a change in the number of women under age 30 asking to have their fertility checked. “Proactive fertility testing is something we need to engage in and teach to 25- to 30-year-olds,” he said. “But right now, it’s really the 30-plus-year-old ringing the bell. Younger women need to at least be checking on themselves and learning sooner if they have circumstances that decrease fertility, other than just age.” Millennial women in our survey said age 30 was the best time to freeze eggs, which is considered a great time to start the process. Yet 14 percent of women in the survey said they’d wait even longer, until age 35, before they’d freeze their eggs. That, Toledo says, is a bit too late for many women. “I would like to see patients somewhere between 30 and 34, and hopefully they have a good AMH. To me, that patient is more mature than someone in their 20s,” he said. “She’s probably in a better place financially, she’s out of school, and she’s probably had some relationships. She’s got a sense of what she’s looking for in a future mate … or might be putting her career first, then looking to become a single mom.” Brahma echoed Toledo’s reasons for letting women wait until their early 30s to freeze their eggs. “We want to make sure we’re recommending a prophylactic treatment that they may actually use,” she said. “We’re not trying to get people to freeze their eggs and not ever use them, and people can see their future more clearly in their 30s.”

Today, 1 in 8 couples experience infertility, and after a woman turns 35, 1 in 3 couples are infertile. As millennials wait longer to start families, the realities of a delayed pregnancy emerge. Fertility problems, which were once taboo and hidden, are discussed more openly by many women and couples. Frankness about infertility struggles also raises awareness, and that’s encouraging millennials to be more candid about their concerns and more proactive in planning for their futures. In our survey, nearly half of millennial women (47 percent) who wanted to conceive said they were concerned about their fertility and ability to conceive. More than one-third of them proactively tracked their ovulation cycles. Women or couples will likely have to try longer to conceive the later in life they try to have a baby. However, fertility doesn’t drop off a cliff when a woman turns 35. Of those women who experience infertility, 44 percent seek treatment, according to RESOLVE, a national fertility education and support group organization. More than half of those who seek treatment (65 percent) eventually give birth.

“Infertility is heartbreaking. When you struggle with infertility, you experience grief every month looking at the pregnancy test and seeing it’s not positive,” said Stacey Skrysak, who underwent IVF at age 33, and writes about her experience on the blog Perfectly Peyton. Fertility problems fall equally on men and women: one-third of women and one-third of men. The final third is caused by a combination of the two sexes.

Advanced maternal age

As fertility drops with age, the risks of birth defects and pregnancy complications increase. For example, the danger of miscarriage rises, and the risk for developing hypertension, diabetes, and preeclampsia goes up too. It’s also more likely the baby will be born prematurely or have Down syndrome or autism. Most survey participants labeled age 50 as the age at which it’s too late to have a child. That’s the same age the American Society for Reproductive Medicine (ASRM) believes doctors should discourage women from having an embryo transfer. For women, that age nears the beginning of premenopause. For men, however, fertility stretches on for many more years.

The role of male fertility

Three-quarters of the millennial women surveyed knew that many factors affect a man’s fertility. Diet, anxiety, physical activity, and alcohol and drug use and abuse play into male fertility. Only 28 percent of people in the survey knew marijuana use lowers a man’s fertility. In the last decade, marijuana use among adults has doubled, and young adults ages 18 to 29 were the largest consumers of the drug. In fact, a recent study published in Human Reproduction Update found that from 1973 to 2011, there was more than a 52 percent decline in sperm concentration, and a 59 percent decline in total sperm count among men from North America, Europe, Australia, and New Zealand. Unlike women, who reach the end of fertility when they enter menopause, men are fertile longer. But still, becoming a father after age 40 comes with added risks. Advanced paternal age increases a baby’s risk of being born with or developing autism, schizophrenia, and rare genetic disorders. After age 50, the risks climb even higher. With that in mind, Eyvazzadeh said women and men shouldn’t fall into the trap of only focusing on freezing eggs or measuring a woman’s fertility. Couples should focus as much on sperm as they do on eggs. Fortunately for men, preserving sperm is much easier — and cheaper — than freezing eggs. The total for all the fees — plus the storage — for freezing sperm is around $2,500. In comparison, egg freezing costs a woman around $15,000.

Fertility helicopter parenting

Parents and grandparents of millennials seem to be worried about the younger generation’s baby-making prospects, too. According to the survey, almost one-third of women with daughters, nieces, or granddaughters of child-bearing age were concerned these women were waiting too long to conceive. Almost one-fifth (18 percent) were willing to pay for an egg freezing cycle to help preserve their loved one’s fertility. That’s something both Toledo and Brahma have experienced in their practices. “Most of the patients that we’ve dealt with have the financial capability, have some sort of insurance coverage, or have a relative that wants to be a grandparent that’s paying for the procedure,” Toledo shared with Healthline.

The emergence of the intervention generation

The first children born through IUI and IVF are now old enough to be parents themselves. When these intervention methods first began, like egg freezing just a decade ago, they were extremely rare. Today, a third of millennials told Healthline they’re willing to use these fertility options to help them conceive. Donated sperm has been used for decades by women without a fertile partner, but donated eggs are a little newer to the fertility treatment list of options. Still, only 12 percent were willing to use an egg donor, and 15 percent were OK with using a sperm donor. On the other hand, they also said they wouldn’t hesitate to donate an egg to someone else who was having trouble conceiving.

Along with physical and emotional turmoil, people who are struggling with infertility and eager to start their families face shockingly expensive bills. It’s a bitter pill for many couples and single parents to swallow, but in the name of conceiving, almost 200,000 pay up each year. IVF treatments carry one of the heftiest price tags. During this procedure, an egg and sperm are joined in a lab, and a doctor places the fertilized embryo into the uterus. A cycle of IVF costs $23,747, on average, which includes testing on each embryo. Some women require multiple cycles of IVF before they’re able to have a baby. “Choosing to go through with IVF was not an easy decision. We went into it knowing we might need to go through more than one round of IVF. It’s scary that you’re spending $12,000-$15,000 just in hopes that maybe it’ll work,” Skrysak said. Skrysak and her husband went through one round of IVF and she became pregnant with triplets. Skrysak went into labor very prematurely and eventually two of her babies passed away. “It’s not only the physical and emotional burden of infertility. There’s a financial burden. It’s now three years after IVF and we’re still dealing with medical debt because of fertility treatments and a premature birth. We probably still have five years of medical debt left to pay off, and I have a lot of grief over that,” she noted. IUI is another option, and many of the women Healthline surveyed either didn’t know what the procedure was or weren’t aware of the significant cost difference between IUI and IVF. During IUI, sperm is placed inside a woman’s uterus. Directly placing the sperm there increases the chances of sperm entering the fallopian tubes and fertilizing the egg. The average price for an IUI treatment is just $865, but many doctors charge far less, about $350 for a cycle. For everything from the medications to storage of frozen eggs, egg freezing can set you back around $15,000. Testing of fertility levels is often covered by insurance, but is about $200 out-of-pocket. “There’s a paradox where maybe you can’t afford egg freezing in your late 20s when you should really do it based on fertility health, but when you can afford it in your 40s, you have to do it three times more because your quality of eggs has diminished,” Landis acknowledged. “That’s why I want to educate women in their 20s — so that they’ll be able to plan and save for egg freezing like they do their 401(k),” Landis said.

Insurance coverage of fertility

Hopefully, as millennials shape the future of parenthood, they’ll push insurance policy to keep up with their needs. Insurance coverage of fertility issues varies widely. In June 2017, Connecticut became the first state to cover fertility preservation, or egg freezing, through health insurance when the procedures are considered medically necessary. Fifteen states also have mandates for fertility treatment. Insurance companies in Arkansas, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, and Rhode Island are required to cover some infertility treatments. While pregnancy coverage is one of the essential health benefits of the Affordable Care Act (ACA), fertility treatments are not. Companies and individual plans have the freedom to offer fertility coverage as part of a plan, but it’s not required. Fertility IQ’s Best Companies to Work for as a Fertility Patient report found that more than half (56 percent) of people had no fertility benefits, while nearly 30 percent had full fertility benefits. The prospect of fertility benefits is even being used as a recruiting tool for some businesses. Some tech companies offer fertility coverage at a 35 percent higher rate than other similarly-sized companies. That may be in large part because tech companies are in a talent war with one another, and any edge over a competitor can help them win a prized recruit. Whatever the sector, the millennial workforce is seeking more financial help with covering the costs of their fertility treatments. Nearly half (47 percent) of people polled in the Healthline survey believed health insurance companies should cover fertility treatments. Even more millennials (56 percent) who took the survey agreed with this sentiment. Startups like Future Family and Nest Egg Fertility have begun to address the expense of fertility tests, egg freezing, or IVF with radically different pricing models and rates. Americans also believe fertility coverage should be highly inclusive. According to the Healthline survey, 51 percent of adults surveyed and 64 percent of millennials believe all couples or single parents, regardless of their marital status or sexuality, should be eligible for fertility benefits.

Scientists have made huge leaps over the past few decades when it comes to understanding infertility and developing treatments to help individuals and couples become parents. Still, there’s a lot of room left to improve infertility diagnosis, treatment, and embryo selection. The current success rate for egg retrieval in women under age 35 is 48.2 percent. That percentage falls as women get older. By the time a woman is over 42, her chance of getting pregnant from each egg retrieval cycle is 3.2 percent, yet the rate of women 40 or older pursuing IVF is growing six times as fast as for women under 35.

The introduction of IVF led to a steep increase in births of multiples, but recent advancements in IVF efficiency have helped reduce the rates of multiple births. In 1998, new guidelines discouraged doctors from transferring more than three embryos at a time. This was designed to reduce the risk of a multiple birth with triplets or more. And it worked — since 1998, the rate of multiple births fell by nearly 30 percent to just 1 percent of all births. Still, in the United States in 2013, 41 percent of all pregnancies that resulted from IVF were multiples. Soon, doctors hope advancements in infertility treatments will help them make better embryo selections before implanting them in a woman’s womb. Currently, for genetic testing, doctors rely on Preimplantation Genetic Screening (PGS). It started being used around 2008, and women were increasingly choosing to utilize it — for about an additional $4,000 — to make their IVF cycle more successful. “There are so many advances that make IVF more efficient and more successful,” Brahma said. “Back in the ’80s, every fresh IVF cycle probably resulted in one opportunity for a child. Now, many people who do IVF in a prime setting can probably build their whole family off of one cycle. We can do PGS and select the best embryos, and we can minimize miscarriage. The success rate has taken off since we can now select embryos so well.” “It takes the fertility space about five years for trends to finally catch on,” Eyvazzadeh explained. “Genetic testing of embryos took a long time to catch on. Now in the [San Francisco] Bay Area, I’d say most families are using PGS.” Fertility doctors predict there will be more advancements in embryo selection and endometrial (tissue lining the womb) receptivity science in the near future. Brahma gave us an overview of the promising developments: “For embryo testing, we’ll be able to drill down into the embryo at the genetic, mitochondrial, and molecular level to make sure we’re selecting the best embryos. There will also be a lot more work around the endometrial receptivity issue.” Eyvazzadeh predicted that people will start doing the fertility gene tests first, as part of the fertility awareness panel that they’re doing, to see if they can wait to freeze their eggs. That prediction plays into a current trend Eyvazzadeh mentioned to Healthline. “The idea that there’s no such thing as unexplained infertility is gaining speed. We’re at that point now with technology that you can look at someone’s genetic profile and explain to them why it’s so hard for them to get pregnant.”

Most millennial women and couples initially turn to their doctors to talk about fertility options — 86 percent talk to their OB-GYN, and 76 percent talk to their primary care physician. But also, the generation that was born at the dawning of the internet turns to what it knows best: Google. Three quarters (74 percent) use Google search for their fertility questions. They also use health sites like Healthline.com (69 percent) and fertility organization websites (68 percent). But the internet — and its myriad venues — also provides another outlet for these fertility-seeking millennials. Online platforms allow people to connect with one another, and many of these sites and online groups have helped lift the stigma and cloud of shame that once surrounded infertility. According to our survey, 1 in 3 women turn to these online portals to connect with women who are dealing with similar issues and sharing their own infertility stories. Thirty-nine percent of women said they connected via social media channels with fertility themes, such as Facebook, Instagram, and YouTube. Facebook groups and pages like Infertility TTC Support Group (17,222 members), Mommy and Infertility Talk (31,832 members), and PCOS Fertility Support (15,147) bring together women from every corner. Chat rooms and online communities are also used by 38 percent of women, and 32 percent follow fertility bloggers. “During my infertility journey, I found a lot of support through RESOLVE,” shared Skrysak. “Thanks to online message boards, I was able to share the emotional roller coaster that is IVF and realize that I’m not alone in the journey.” Instagram has called attention to many health conditions, from psoriasis to infertility. Searching hashtags allows someone to connect with a community of people from across the world. The most popular Instagram hashtags for fertility issues include:

Healthline proprietary infertility information

For this report, Healthline conducted proprietary traffic and search analysis of fertility topics. Within the search traffic Healthline received for fertility, the largest area of search centered around treatments (74 percent of searches). While 37 percent of treatment seekers were searching for a fertility clinic or doctor. Many people also showed high interest in natural treatments (13 percent). The most popular natural fertility treatment was acupuncture.

Today, the outlook for women and couples facing infertility is more optimistic than for any previous generation. The first IVF baby was born a few decades ago, in 1978. And since then, millions of women have received fertility treatments. “Whether you have a baby through IVF or you adopt, there’s an amazing love that you can’t explain until your baby’s in your arms. Even though we had a bittersweet experience of having a survivor but also losing two children, it is all worth it in the end. We were meant to have a family and we feel like our family is complete thanks to having IVF,” Skrysak told Healthline. Solutions to expanding access to infertility treatments are getting more creative, too. For example, INVOcell is a device that allows a woman to grow embryos inside her vagina for five days instead of in a lab before transferring the best embryo back to the uterus. INVOcell costs about $6,800, including medication — a fraction of the cost of IVF. While more research is being done to evaluate the effectiveness of INVOcell vs. IVF, one clinical trial involving 40 women found the success rates for both methods were not significantly different. Innovative programs with greatly reduced costs will hopefully see larger expansion as millennials look for ways within reach to solve infertility and start families later in life. In addition, as people are recognizing they share in this struggle with many people they know — and millions more they can connect with on the internet or through social media — the “shame” of infertility is disappearing. Waiting to start families may help millennials feel more prepared for parenthood, but it doesn’t change some significant realities. Specifically, waiting increases the chances for complications such as birth defects and difficulty conceiving. While the Healthline survey found that millennials were versed in many aspects of fertility, there’s still a lot left for them to learn. As women near their late 20s to early 30s, their doctors and fertility experts should look for ways to educate and start conversations on the subject. “We want people to feel empowered, not be afraid,” Toledo says. As having children later in life becomes more normalized in our culture, it will be increasingly important to help millennials understand — as early as possible — the benefits and consequences of delaying pregnancy so they can make the best choices for themselves and the families they may want to start — eventually.