Perimenopause and Infertility

Making choices, managing emotions, and figuring out what's happening with your body

Until she turned 40, Debbie wasn't interested in having children. "Then my brain went haywire, and I suddenly wanted a baby so badly," says the Brooklyn-based singer songwriter. Knowing her age might make it difficult to get pregnant, she saw a fertility specialist and started taking fertility drugs right away. Debbie had a son just before her 42nd birthday.

When her son turned 2, Debbie started trying for a second child. This time the drugs didn't work, even after a year. Tests showed she had a low ovarian reserve, meaning she didn't have a lot of quality eggs left. Now 50, Debbie hasn't yet reached menopause, but she knows it's very unlikely she will conceive another child – even with IVF or another type of assisted reproduction.

What is perimenopause?
A woman's transition through her reproductive years is complex and often misunderstood, says Nanette Santoro, MD, a reproductive endocrinologist and professor of obstetrics and gynecology at the University of Colorado-Denver. Technically menopause is when a woman hasn't had her period for a full year. But the two to 10 years before that – when she may experience hot flashes or irregular periods – is known as perimenopause.

Endocrinologists mark the beginning of perimenopause when a woman first notices her menstrual cycle is consistently early or late by at least seven days. This early stage begins around age 47 and typically lasts about two years, says Santoro. Late-stage perimenopause (going more than 60 days without a period) typically lasts another two years. By age 51 most women have reached menopause.

But some fertility specialists say perimenopause often starts much earlier. It can even begin before a woman notices any symptoms or has reason to think she may have trouble getting pregnant.

"Egg quality begins to decline more rapidly starting around age 35," says Sarah Berga, MD, chair of obstetrics and gynecology at Wake Forest University. "By 42 or so, eggs just don't work so well," says Berga. "It doesn't mean you're not ovulating or you can't conceive, but sometimes it takes longer or might require some assistance."

This can be a very frustrating time, says Santoro, because doctors don't have easy answers. "It can drive women nuts because we only know that their fertility is compromised. We can't give them a straight answer whether they will get pregnant or not, and we can't tell them whether treatments will definitely work."

The maddening unpredictability of perimenopause
Wendy Moorhouse, a nonprofit operations specialist in Alameda, California, started trying to get pregnant in her early 30s. After a year, she visited a fertility clinic and learned that her levels of follicle-stimulating hormone (FSH) were high for her age – an indication that she had a low ovarian reserve and that her body was working harder than normal to trigger ovulation each month. "They told me I was in perimenopause and that this could take a while."

Moorhouse was still having regular periods, so she was shocked. She tried oral fertility drugs every other month for a year, then injectable hormones, then intrauterine insemination (IUI). Nothing worked, and after three years her fertility specialist suggested she consider either adoption or using a donor egg.

Moorhouse and her husband digested the news over a dinner and a lot of wine. "We told ourselves we had to move on to other options, and then we came home and had sex," she remembers. She missed her next period and soon after that discovered she was pregnant.

Moorhouse gave birth to her son at age 37. She had another surprise pregnancy two years later, and her daughter was born just before her 40th birthday. By 44, she'd stopped getting her period completely.

Every woman's reproductive timeline is different, and Berga recommends seeing a specialist as soon as you have trouble conceiving – even if you're in your 30s. "We can test for egg quality and FSH levels, and that will give us a better idea of whether the problem is related to aging," she says. "And if that's the case, it's always better to find out early rather than later, when your options become much more limited."

Understanding your fertility treatment options
Even for women in late perimenopause, there's a chance that they can still get pregnant, Berga says. But it's important to understand that it's unlikely, she says, especially without help. Fertility treatment options depend on several factors, including age and hormone levels. Women in their early 30s often still have good quality eggs, says Berga, and usually have several options, including intrauterine insemination or in vitro fertilization.

But if a woman's FSH levels are high – as they often are in her late 30s or early 40s – IVF may not help because it's likely her egg quality is compromised. That can mean IVF isn't a good option for many women, like Moorhouse.

In this case, fertility specialists often recommend using either an oral medication such as Clomid (clomiphene citrate) or an injectable hormone. These treatments increase FSH levels, prompting the body to release more than one egg each month. These drugs also help regulate the timing of ovulation, Santoro adds, which is helpful for perimenopausal women whose periods have become less regular. 

These medications help about half of the women who use them to get pregnant, and they're safe and relatively inexpensive, says Santoro. "My philosophy is to keep these women in the game for as long as they are still ovulating," says Santoro. "[If] I can help someone with a treatment that's not costing her thousands of dollars, it certainly makes sense to try."

But what if a woman's cycles are already irregular? "If they're in that early perimenopause stage, we can still try," says Santoro. "Unfortunately, the only way we know how to stimulate eggs is with FSH, and in these women it's already high. So it may or may not work."

Dealing with the emotions of perimenopause and infertility
Having difficulty conceiving can be extremely stressful. And the increased pressure to do so before "time runs out" means it can easily become overwhelming. Moorhouse remembers how "every other month I'd go to the clinic for treatments, and then I'd be sad and depressed when they didn't work and didn't want to talk about it with anyone." She and her husband sought emotional help through Resolve, a nonprofit organization that offers support for infertility around the country. Eventually a therapist helped them weigh the pros and cons of alternatives like adoption.

"Women who are unable to conceive and are nearing the end of their fertility window often have to face difficult decisions,” says Patricia Harteneck, PhD, a senior psychologist at Seleni who specializes in working with women and couples experiencing infertility. These choices can include how much time and money to spend on procedures with no guaranteed results, or pursuing other options such as egg donation or adoption.

For women facing these choices, it's very normal to mourn the loss of their fertility and their chance to be a biological mother, says Harteneck. On top of that, they may start experiencing symptoms of perimenopause, which means they can feel depressed, tired, and moody. "It's a very, very tough time."

During this transition, it's extremely important for women to have the support of her partner and loved ones, says Harteneck. A therapist who specializes in infertility can also offer a safe place to explore all the emotions and choices that come with infertility and this period of transition.

Debbie, who has spent the last three years unsuccessfully trying to have a second child, has conflicting thoughts about what lies ahead. "I had a very sad transition last fall when my son started kindergarten, giving up the dream of having a second child," she says. "People would say, 'You're so lucky to have one [child],' but at the time that didn't help. It was on my mind 24/7, and it was rough on my husband as well. It was hard to talk about with people, especially the other moms – all younger – who were still able to get pregnant easily."

But she is grateful to have one healthy child and is finding a silver lining in her situation. "Last year we sent my son to summer camp, and for the first time I realized, 'Wow, I'm starting to get my pre-mom life back.' I'm feeling more at peace with the reality every day, and I'm feeling better and better about the next stage in my life."