Thursday, March 25, 2010

"AMA- Advanced Maternal Age"

Dear MiM,
What things did you wish you had considered before having a baby during residency? Are there any moms out there who had children after residency or who were unable to get pregnant after residency (b/c of advanced maternal age) that have regrets?

Ob-gyn resident from the Bay Area, California

Dear OB/Gyn resident:

Let me start off by stating a simple truth that we all refuse to accept. We are not in control. This was made painfully clear to me only following the dismantling of my perfect plan for having a baby.

Married a week after med school graduation, my husband and I chose not to start a family during residency. We struggled with the initial adjustments to marriage and work, and instead of having a baby had a fantastic time eating out, drinking and traveling. Looking next toward cardiology fellowship, time for baby needed to be in the plan. My first year focused on survival. The second year I volunteered to make the master fellow schedule. A small sacrifice of negotiation + mediation to have control of my own schedule. I stacked my call and cath lab months in the first half of the year. I found a research mentor and agreed to a extra year research fellowship. It would be perfect. November was my last month in the cath lab. Pregnant in December. Start research in July. Have project off the ground, maternity leave in September. With some luck I could extend my research a third year and have number 2!

In reality I was diagnosed with anovulation due to PCOS in April. I then became a fanatic triathlete. By the time I started my research fellowship I was exercising 3 hours a day and was skinny as a rail. I figured I could be the 'best' PCOS patient ever (so it seems PCOS is NOT all about adipose/obesity after all). Fertility drugs in the fall leading up to my first miscarriage. Then a freak accident leading to a broken arm, ORIF in January. Crazy girl running on the treadmill with my arm in a sling. Hip pain, months of physical therapy. Diagnosis of acetabular tear, second to underlying congenital hip dysplasia. MDs doubtful I could walk during a pregnancy. Hip surgery the next January. So by the time I spent 2 years trying to get pregnant and 6 weeks on bedrest following my hip reconstruction I finally said, I give! I get it. I am NOT in control and I cannot make what I want to happen- happen. Not even with a superwoman effort bordering on obsession!

And well, as it turned out it is not too hard to get pregnant. Not hard at all when you are not working, resting, reading, watching TV all day- all while on *bed rest*!

Finding the right time to have a baby is difficult for Mothers in Medicine. You have read on this blog about the challenges of managing maternity time off and negotiating with colleagues the pre-occupations of a mother. The consensus is that no time is the perfect time. In my experience, finally understanding/ appreciating the amazing gift of a healthy pregnancy made all accommodations more palatable. My story is not unique, the complicated world of the female reproductive system has it's quirks. My practical advice to you: take care of your marriage, take care of yourself. When both feel good have a baby. Because in reality we are not in control. Letting go is often required for us to find the future we desire.


  1. I had all 3 of my kids in the first half of my 30s after residency (2 in fellowship at ages 31 and 33, 1 as an attdg at age 35). I have loved this timing and wouldn't change a thing. I didn't feel I shortchanged myself or my family during my training or my subsequent career. I have tried to tame some of the advanced maternal age hysteria on this blog in the past. Check out:

  2. Thanks for sharing your story, JC.

    Many assume it is easy to get pregnant and are disappointed. I assumed it would be difficult and convinced husband we needed to get started stat. (After residency, first years as an attending, early 30s).

    I was pregnant 2 weeks later.

    With our 2nd, also convinced husband it could take years, I was older now and there's so much out there about infertility...I was pregnant 2 weeks later.

    No regrets about timing at all - it was ideal for us if there could be such a thing. Waited until after husband's intern year since that would have been difficult, as much as I wanted to start trying already. Good decision for us.

  3. I'm a nontraditional student who married and had my 2 children at a very young age. I'm still an undergrad student working on my premed requirements, but I hope that having older children by the time I am in med school/residency will make things easier on our family, but we'll see! You are right that there is never a perfect time, we all just do the best we can to try and balance it all.

  4. For me, I can't imagine having been married/been pregnant/been a parent during medical school and/or residency, I found it tough enough such that any additional responsibilities would have made it near-impossible for me to finish. My (non-physician) husband and I were going out from just before med school, got married two years after I finished my family med residency (when I'd joined a practice that seemed like it would be a long-term job for me), and decided to start a family a couple of years after that when I was 33. The timing was perfect for me - except that I couldn't get pregnant (or get really pregnant). 5 years later, after an ectopic, a miscarriage, a job change (more flexible schedule to allow for fertility treatments), and a heterotopic pregnancy thanks to fertility meds/IUI - I made it to the top of the IVF waiting list but had to postpone IVF because my brother was getting married. And then I ended up pregnant without any intervention.

    I didn't want an amnio regardless because termination wasn't an option for me - but I did have a nuchal translucency screen at 12 weeks which showed low risk. My daughter was born 10 months ago and she was fine despite my mild hypertension at the end of my pregnancy.

    I wouldn't have changed my planned timing at all, but I do try to point out to my patients that they need to be aware that things don't always go as planned, ie they might not get pregnant right away (or at all) if they wait too long, and that they can be at higher risk for other complications such as hypertension/pre-eclampsia, gestational diabetes, or Down syndrome. Even though I knew this previously, I don't think it really registered for me (probably because I thought *I'd* never have problems getting pregnant). My husband and I joke that it would be so much easier coping with sleep deprivation etc if we weren't so "old" - but I think that our life experience of going through all this has brought us together more, so in the end there's pros and cons to having kids either earlier or later.

    I like the stats provided (ie. the chance of *no* problem versus the chance of a problem as usually presented) and will probably use that in my practice to help explain - thanks!

  5. I had my son during my PGY2 year. I can say it has been the hardest year of my life, but honestly I wouldn't change it for anything. It is incredibly difficult to have a baby during residency if you don't have a wide support network (like grandparents and friends willing to throw in a helpin hand), but it is do-able. I sometimes, when I'm extremely tired, wish I had waited until the residency, but then I wouldn't have the joy of my son to help me through the hard days. I think you just have to let life happen. If it feels right, start your family.

  6. I second the above post. A month in REI as a (29 yr old) 4th year med student was enough to convince me to have a baby before residency. We knew we wanted to have children at some point but seeing all the women in their 30s having problems conceiving made me realize just how much more difficult it can be can be as we age.

    I'll never forget a REI attending saying, "If they're coming to me trying to get pregnant and running into problems at age 35, they're WAY behind the 8 ball."

    Moreover, the older women just seemed to have so many more problems with their pregnancies and deliveries and I wanted to keep my risk of c/s as low as possible.

    For me, I know I'll never lose if I invest in my family. I love medicine and I'm excited to start residency (my hubby will be an R2 and our baby 1 yr old). My husband and I agree that taking some time to start a family was one of the best decisions we ever made. With all the intensity of career pressure, it could have easily slipped through our fingers.

  7. Wow JC. I feel like I really got to know you here. And your story was so familiar to me - one of my best friends was diagnosed with PCOS on a fertility work-up (she is a drop-dead gorgeous natural beauty and a marathon runner/biker - so there's another example for you). She had her first after IVF and second natural when she was done breast feeding #1.

    You are so right about not being in control. Bad things happen when you ignore that. Good things happen when you let go.

  8. And remember, for most of us, having a baby is like breaking your leg. There is just no good time to do it.

  9. I remember that post Tempeh! I was just pregnant with my 4th child (in the comments), and now that foetus is 2 week old baby Annabel :) (and I am an ancient 36). I managed to not get swine flu and survived the 4th caesar. I have printed those "healthy baby stats" for future reference.
    I have been wondering how your family is going Tempeh. Your last post was about how your nanny was leaving and your husband was going to Haiti, and I hope things are going well for you.

  10. I had 4 kids before starting medical school - I am a 30 year old finishing up my MS1 year now. I am still planning on having a couple more - but definitely before residency. Perhaps between year 2 and 3, and 4th year.

    I am really glad I had my children already because I never had to worry about colleagues feelings when I took time to nurse babies and sleep late and enjoy my newborns. This advice might be too late for many of you - but if you are a pre-med - consider having your children before starting school. I am really glad I did.

    I should mention I have a super duper husband who takes good care of everything now that I am a medical student, so maybe don't try this at home unless you can grab one of those too.

    (For some of you, this post is repetitive, I apologize)

  11. thanks for the advice. JC, I love the reminder that there is much we cannot control. I forget that. And I feel like I am constantly reminding my patients (i.e. 38 year old with twins and mild pre-eclampsia who was hoping for spontaneous labor) to remember that they cannot control it all.

  12. I agree with the general sentiment to have children earlier, but also that there needs to be more flexibility in medicine to ensure parenting time, etc.

    Nevertheless, as a new mom to a 3.5 week old beautiful, content daughter at age 52 and able to put my academic career on hold for a time, it is all worth it. Fortunately, I am very healthy, and remained so throughout the pregnancy and have a mom who began working outside the home in her late 50s and is still working - feels responsible to her clients! My point? even if it is late, if you are healthy and have support, e.g. I am fortunate to have a loving husband that I married a few years ago, you may still want to go ahead later in life.


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