Age shock: misperceptions of the impact of age on fertility before and after IVF in women who conceived after age 40

study question: What do older women understand of the relationship between age and fertility prior and subsequent to delivering their first child? summary answer: Women who were first-time parents over the age of 40 did not accurately perceive the relationship between age and fertility prior to conceiving with IVF. what is known already: While increases in women’s age at their first birth have been most pronounced in relatively older women, the rapidity of fertility decline is not appreciated by most non-infertility specialist physicians, the general public or men and women who are delaying childbearing. study design, size and duration: Qualitative retrospective interviews were conducted from 2009 to 2011 with 61 selfselected women who were patients in one of two fertility clinics in the USA. participants/materials, setting, methods: All participants had delivered their first child following IVF when the woman was 40 years or older. The data include women’s responses to the semi-structured and open-ended interview questions ‘What information did you have about fertility and age before you started trying to get pregnant?’ and ‘What did you learn once you proceeded with fertility treatment?’ main results and the role of chance: Of the women, 30% expected their fertility to decline gradually until menopause at around 50 years and 31% reported that they expected to get pregnant without difficulty at the age of 40. Reasons for a mistaken belief in robust fertility included recollections of persistent and ongoing messaging about pregnancy prevention starting in adolescence (23%), healthy lifestyle and family history of fertility (26%), and incorrect information from friends, physicians or misleading media reports of pregnancies in older celebrity women (28%). Participants had not anticipated the possibility that they would need IVF to conceive with 44% reporting being ‘shocked’ and ‘alarmed’ to discover that their understanding of the rapidity of age-related reproductive decline was inaccurate’. In retrospect, their belated recognition of the effect of age on fertility led 72% of the women to state that they felt ‘lucky’ or had ‘beaten the odds’ in successfully conceiving after IVF. Of the women, 28% advocated better fertility education earlier in life and 23% indicated that with more information about declining fertility, they might have attempted conception at an earlier age. Yet 46% of women acknowledged that even if they had possessed better information, their life circumstances would not have permitted them to begin childbearing earlier. limitations and reasons for caution: Both the self-selected nature of recruitment and the retrospective design can result in biases due to memory limitations or participant assimilation and/or contrast of past events with current moods. The cohort did not reflect broad homogeneity in that the participants were much more likely to be highly educated, Caucasian and better able to pay for treatment than national population norms. As attitudes of older women who were unsuccessful after attempting IVF in their late 30s or early 40s are not represented, it is possible (if not likely) that the recollections of women who did not conceive after IVF would have been more strongly influenced by feelings of regret or efforts to deflect blame for their inability to conceive. wider implications of the findings: While the failure to appreciate the true biological relationship between aging and fertility may be common and may reflect inaccessibility or misinterpretation of information, it is not sufficient to explain the decades-long socio-demographic phenomenon of delayed childbearing.