There is a tradition that during Succot, Hannah, though past child-bearing and a barren woman, prayed at Shiloh for a child. Her prayer was answered. But today, as Israeli women start families later, doctors increasingly publish warnings about fertility and age. So what's an older woman to do?
Sarah Rosenblum of Ramat Beit Shemesh was 41 when she got married and conceived spontaneously, delivering a healthy boy.
"I got pregnant the very first month we started trying. My pregnancy was a breeze," she says. "To be honest, it had never entered my mind that I wouldn't fall pregnant."
Through the course of history, in literature and in historical population studies, women were bearing children very young, but also continuing and occasionally starting well after 35.
Indeed, some 3,000 years ago in ancient Israel, women were giving birth at all ages, some naturally and some after profound efforts. Hannah, according to tradition, made the pilgrimage to the Shiloh Tabernacle at this time of year, and moved her lips in silent and intense prayer for a child. Despite her very advanced age, it is written, "she was remembered," and indeed, she gave birth to the prophet Samuel.
Yet today, gynecologists and fertility specialists say that despite advances and a long history of success stories, older women who have children are better thought of as exceptions, not role models. The best strategy, they say, is to plan to finish childbearing when it's easier to get pregnant - before 35.
"After 35 there's a big decrease in fertility that will end in a normal delivery," says Dr. Yuval Gielchinsky, a Hadassah University Medical Center gynecologist. "The miscarriage rate is also very high after 35. You never know when your fertility will end."
Women need to understand that postponing childbirth creates risk factors for infertility, concurs Hadassah fertility specialist Prof. Ariel Revel. "Age is the No. 1 factor. In my opinion childbirth shouldn't be postponed beyond the early 30s."
Still, Israeli women are not heeding the warnings. Should they?
STATISTICS show that every year women are starting families later and delivering children at older ages. In 2006, according to the Central Bureau of Statistics, there were 148,170 live births. The average age of mothers delivering a child was around 30 - 43 percent of mothers were between 30 and 39. About 29% of the babies were born to women 30 to 34, and 14% to women 35 to 39.
Statistics don't measure the youngest and oldest ages of the mothers but do reveal that fewer than 4,000 women under 19 gave birth in 2006; nearly 5,000 women 40-44 had children; and fewer than 500 women older than 45 delivered. Those aged 25 to 29 contributed the largest number of births, delivering 31% percent of all the children born last year.
"In Israel, as in almost every developed society, there have been pretty large recent increases in the fertility rates of older women. If you look at the 35-39 and 40-44 age groups in all developed societies, we are seeing increases in the fertility rates over the last 25 years or so. At the same time fertility rates are going down in younger age groups, 15-19 and 20-24, reflecting, in part, delayed childbearing," says Hebrew University demographer Dr. Barbara S. Okun.
"Since many women are choosing to have smaller families, they can 'afford' to wait a little later before starting childbearing. Women are also studying longer, marrying later, and therefore starting families later."
In fact, says Okun, prior to the mid-19th century, women were routinely having children in their late 30s and early 40s. "It is quite true that in historical populations in Western Europe [where record keeping was good and women didn't use birth control], the average age at last birth was a little over 40. That means that about half of women continued childbearing after 40, which would be considered very late by today's standards.
"That is striking if you consider that in the past, many women were rendered sterile at young ages, following complications of pregnancy and childbirth, so that the average age at last birth would have been higher had there been better maternal medicine at the time.
"It's also the case that age at last birth started declining when fertility fell, for the most part in the late 19th century in Western Europe, because women stopped having such large families."
Demographers and doctors agree that fertility declines with age, starting slowly in a woman's late 20s and early 30s, more rapidly after 35 and very rapidly after 40. It's just not a precise science.
"Beyond these generalities, we don't have an exact knowledge of how fertility changes with age - there is no exact equation or mathematical formula for this," says Okun. "Moreover, what could be true for one woman or couple could be very different for another woman or couple of the same age. For example, some couples have high fecundability - the monthly probability of conception in the absence of contraception. Others of the same age have lower fecundability [but] that doesn't mean that [they] are sterile and will never have children, but rather that it will take them longer on average to get pregnant.
"We call this heterogeneity because there is so much variation across couples in their probabilities of conception. One primary determinant of this heterogeneity is, not surprisingly, coital frequency, for which accurate data is, unfortunately, very difficult to collect.
"What makes it tough it that there is heterogeneity, but a woman or couple cannot know in advance how high their own fecundability is. The age of sterility - beyond which the probability of conception is zero - also varies from person to person and is unobservable."
So how old is too old to conceive?
FERTILITY VS FECUNDITY
Technically speaking, "infertile" is only a general medical term, used to describe a woman who fails to conceive in one year. While fertility refers to the outcome of trying to conceive within a certain period, fecundity is the biological capability to conceive, regardless of the time frame.
A woman who considers herself as trying to conceive, but doesn't have relations frequently enough, on the right days or who takes longer to conceive may be labeled "infertile," even if she is fecund. The same is true for women who can biologically conceive, but may have trouble getting pregnant because of their weight, medications or other health problems that can possibly be rectified.
At the basis of female fertility - or more accurately fecundity - it's all about ovarian reserve, explains Dr. Revel: "From the time the fetus develops, there are 5 million-6 million eggs; not one is produced a woman's whole life after. By 20 weeks [into the pregnancy], 80% are already lost. A baby [girl] is born with about 1 million eggs."
What happens to the other 4 million-5 million? "Planned cell death," says Revel. "It's called apoptosis. Every cell in the body has a system to dispose of itself in a clean way to avoid debris and infection in the body. It's a natural process. Apoptosis should last about five decades. A girl starts about 10 to ovulate, and by 50, most of the eggs have been exhausted. Apoptosis could also be called cell suicide. One egg is needed for ovulation; about 999 will jump off a cliff."
Why most eggs become damaged or die by a certain age is not known, nor is it known at what age that will happen for each individual woman, despite the general averages.
What we do know, says Revel, is that "if a woman smokes, egg quality will be poorer, and a woman will have menopause three-four years earlier. Before menopause, women have a window of about 13 years [of decreasing fertility], as egg quality starts to deteriorate."
The fertility rate for older smokers is lower, and says Revel, a 44-year-old egg is poor quality: "There are much more chromosomal problems and miscarriages in older women."
"By 44, only about 3% of women can conceive naturally," estimates Gielchinsky.
There are exceptions in both directions. Women with Turner's syndrome have premature ovarian failure, often by 35. And occasionally women at 45 conceive spontaneously without a problem. Still, even women with "late fertility" into their 40s, will experience a decline in fertility.
GOVERNMENT POLICIES on fertility treatments are considered the most liberal in the world and the rights of and benefits to Israelis trying to conceive are the same regardless of race, religion or ethnicity.
Initial concerns for helping Jews compensate for the six million who died in the Holocaust did likely influence a policy of encouragement of and benefits to those that want to have children, as did later concern about increasing the Israeli population for security and self-preservation reasons besides hostile Arab states, says Prof. Eitan Lunenfeld, president of Ayala, the Israel fertility society, and chairman of the obstetrics and gynecology department at Soroka University Medical Center in Beersheba. Fertility treatments were first subsidized through the government-sponsored health clinics' basic health services basket, and later the basket of services was adopted by the national health insurance company, which today spends vast amounts of taxpayer money for heavy subsidies of fertility treatments to citizens.
Today, all women younger than 44 with no children or with one child are eligible for subsidized IVF and other fertility treatments using their own eggs, according to the universal health insurance law and its amendments. "There is very little success [with IVF] after age 43," says Revel. "Most countries that have a 5% [birth] rate won't do IVF at this age; instead they use egg donation."
An older woman who want to get pregnant with her own eggs can reduce risks associated with an older pregnancy by using IVF with embryo screening, otherwise known as preimplantation genetic diagnosis.
From 45 to 51, Israel only subsidizes single or married women to undergo fertility treatments with ova donations, up to the birth of two children. The law can be reapplied to a woman who marries more than once, so that she can have two children from each marriage.
Women who want to try for additional children after the first two, and struggle with infertility, are not fully subsidized by the state, but can often receive around 50 percent subsidies from the state-sponsored health clinics. In all cases, patients pay co-payment for medications that accompany any treatments, depending on the regulations of the clinic and the cost of the medicine.
These fertility policies help explain why Israel has the highest per capita number of fertility clinics in the world, and why women here purportedly undergo more cycles of treatment than anywhere else.
IT'S IN THE GENES
In 2004, Israelis found the first proof of genetic traits that may help explain the heterogeneity of fertility. Researchers from Hadassah University Medical Center on Mount Scopus, Shaare Zedek Medical Center and Bikur Holim Hospital, all in Jerusalem, published a study looking at 250 Ashkenazi women older than 45 who conceived naturally. It found a shared genetic predisposition that protects them from DNA damage and cellular aging of the ovaries. A year later, researchers at Hadassah University Medical Center at Ein Kerem and Soroka University Medical Center ran a similar study of Beduin women who conceived after 45 and found similar results.
The latest study, says one of the principal researchers, Hadassah gynecologist Dr. Yuval Gielchinsky, will be published in two months. "In a genetic study... with Hadassah researchers and scientist Michal Lineal from [the Hebrew University at] Givat Ram, we found women with a group of genes that are differently expressed compared to the rest of the population," he says. There are also a few studies checking the correlation between longevity and late fertility, he added. "There is a part of the population that preserves fertility at an extreme age."
How many women have late fertility and a genetic advantage for late childbearing and how can these women know who they are? The answer, says Gielchinsky, is not yet known.
For now, he says, "you never know when your fertility will end. There is no test and menstruation is not a sign. We just use the statistics, that after 40 it's really hard."
As for sensational newspaper accounts of women in their 50s and 60s "miraculously" delivering a healthy child, Gielchinsky winces. "It's only in the fine print that she uses someone else's eggs - that the child is not biologically her own," he says. "Women should know and consider that. There is nothing positive to say about waiting until age 45 to have children."
Some women older than 35 say they didn't worry about becoming pregnant.
Yehudit, 45,from Jerusalem, conceived naturally at 37 and 43. "I am closer in age to the grandmother of a boy who used to play with my son in the park than to the mother. She is 28 and her mother is 48. That brought some laughs," she says.
"At the time I didn't think anything of [my age when I got pregnant the first time], though I was a bit nervous about being able to conceive with my second son. I was lucky to have a doctor who was very relaxed and did not pressure me or get all panicky because of my age. He was very reassuring and calm. In the end, his method proved to be the right one for us."
Since at least the 1990s, researchers have been looking for links between infertility and stress or depression, after earlier studies analyzing links between stress hormones and the immune system. Several recent studies continue to bear out a relationship between fertility and mental health.
In a 2004 Soroka study, hypnosis doubled the success rate of IVF treatment. A 2006 study at Assaf Harofeh Medical Center in Tzrifin found that IVF success rates for women entertained by clowns after the procedure go up from 19% to 35%. At Emory University in the US, Dr. Sarah Berga has led several studies on stress, the stress hormone cortisol, and infertility. She now encourages patients to undergo cognitive therapy while trying to conceive naturally or during IVF.
Women say they are not surprised by mind-body links.
"It was only after I had given birth [at 41] that I began to realize, after listening to people around me, that I should have been worried," said Sarah Rosenblum of Ramat Beit Shemesh. "My advice to anyone wanting to have their first baby in their 40s is: Go for it. Don't allow any negative comments to hamper you from trying; don't sweat over it, just relax and be positive."
Today they are many solutions and options for infertility struggles. And despite the warnings of doctors about starting early, government policies, variety of treatments, anecdotes, population and case studies and personal stories continue to offer encouragement to women of all ages.
Ofra Balaban was seeing spots. "I was sweating; I tried not to faint," she says. "It was the longest silence of my life." She could hear her nurse at her health center breathing, but she wasn't saying anything. "Eventually she said 'Mazal tov; I guess you're pregnant.'"
Balaban almost passed out from the good news, after she had been trying to conceive for nearly seven years. When she started trying just short of her 30th birthday, she waited a few months, and then went to see a doctor.
"We found I wasn't ovulating. I had been taking a medication for Crohn's disease and didn't realize it could interfere with ovulation. It wasn't until I was 31 that this was discovered and my medication changed so that I could ovulate," she says.
Because at that time women with Crohn's disease were not allowed to undergo IVF, Balaban started to undergo artificial insemination. She had 20 treatments over more than six years. Finally, she asked her doctors about egg donations. After four tries with donated ova, she got pregnant at 36 and delivered a healthy son.
After finding out about her pregnancy, she played the piano - Beethoven and Mozart - for two hours. "And then I phoned every person I had ever met. I know that's the opposite of every one else, who keeps it a secret. I had to talk, to keep myself sane. The frustration of fertility treatment is so high, you wait for something to be possible and it's negative, again and again and again. You run to the hospital for hormone shots, ultrasounds, blood tests. It's really hard work. You feel occupied all day long and finally it's negative, you have to wait another month. All these people 'escorted me' all the way and now I wanted to tell them and make them happy.
"It took me seven years to hug a baby."
At 40 she tried again and had her second son, also with egg donation.
In the years since, Balaban has been busy. Shortly after her second son was born, she founded an organization for women and couples who need fertility information, support and advocacy. She named the organization Chen, after her father, who passed away a few weeks before her first son was born.
Chen, together with the support of the Ministry of Tourism, launched an outreach program for fertility tourists in which women and couples from anywhere in the world can benefit from Israeli fertility centers, whose treatments are at least one-third the cost of those in Western countries.
Chen is also lobbying the state to revise some IVF policies. Sometimes Israel spends too money on "useless" pregnancy tests and overdoing IVF, says Balaban. "Sometimes they do 15 rounds of IVF that fail, instead of checking after the eighth round for chromosomal abnormalities. The money could be better directed."
It is also fighting for grown offspring born from egg donations to be able to go to court to get legal access to check if they are genetically related to someone they want to marry. Currently, the law will allow them to appeal to see the records only if it is an issue of saving their life.
Chen is also working on a bill with a more liberal ova donation policy. Israeli law currently allows only women undergoing IVF treatments to donate their ova, without compensation, if they are younger than 32 and if they do so anonymously. Restricting women who want to donate healthy ova, says Balaban, leaves 5,000-6,000 women a year on a waiting list for up to three years at a time.
In her crusade, Balaban looks back sometimes and is so grateful that she was lucky to find ova donations when she needed them.
"My first son is now 10. We have no secrets," she says. "I told him about the egg donation. He thought about it and said, 'Mom, what that woman did was really noble. But her role is finished. The important thing is that I was born from your body and I have a loving mother and father.'"
While fertility rates and issues of fertility and age are fairly consistent throughout the West, Israel has its own special circumstances because of religious and political issues.
In Modi'in Illit, a haredi community, a considerable number of women being treated at the Maccabi Health Services' women's health center and fertility clinic are not medically infertile.
Dr. Ronit Kochman, a Hadassah University Medical Center infertility and menopause specialist who runs the clinic, explains that the halachic rules of purity that religious Jewish women follow may cause the monthly window of fertility to close before a couple resumes relations.
According to Jewish law, sexual activity is prohibited during menstruation and for seven days afterward. The prohibition is called nida. The period of menstruation is counted as a minimum of five days and lasts until the end of the bleeding. A woman's total nida period usually lasts for approximately two weeks, and is followed by immersion in the mikve or ritual bath.
Sometimes the abstinence period last much longer than two weeks, says Kochman. "In practice, any minute bleeding or spotting, regardless of the timing during the menstrual cycle [or] physiological occurrences such as midcycle ovulatory bleeding or spotting renders the woman zava and prohibits sexual intercourse at the optimal time for conception."
The status of women missing their fertile days solely because of rabbinic prohibitions on the number of days she must wait after menstruation and any monthly spotting is described as "halachic infertility." For 60% of women of childbearing age, the menstrual cycle lasts 25 to 28 days, says Kochman. And women having longer cycles tend to ovulate later - after the mikve when the couple is permitted to have relations freely - so religious women with longer cycles are less likely to miss their fertile days.
But 20% of Kochman's patients, she says, ovulate before they can go to the mikve and before marital relations can be resumed. This problem occurs even more frequently with women in their mid 30s to early 40s, as menstrual cycles tend to get shorter and ovulation earlier for women around age 35.
Religious patients of all ages who miss their fertile days are frequently treated with hormones that delay ovulation until after the mikve. "Because one fifth of our patients are not really infertile, our pregnancy success rate is very high," says Kochman. "We know how to delay ovulation until after the mikve. It's ethically hard for caregivers to give treatment for something that is medically 'normal.' But it's a way of life the woman chooses and I respect that."
Not every doctor will agree to prescribe hormones to delay ovulation for non-medical reasons, but this is - for the time being - a common practice in Israel. In some haredi communities, not only doctors but rabbinic authorities will "provide" the hormone treatments needed to delay ovulation, says Kochman. "Rabbis don't give prescriptions, but they recommend which medication to take and send the women to the gemach [charitable society] - there are several organizations - and she gets it." (It is illegal and a criminal act for any gemach to give prescriptions for potentially dangerous drugs.)
The issue of imposed infertility has been debated recently in the religious newspaper Hatzofeh, with some calling for rabbinic changes to ease the severity of the nida restrictions.
In addition to the issue of halachic infertility, other common reasons for female infertility are less prevalent in the religious communities. Because premarital contacts are strictly forbidden, the frequency of infertility due to inflammatory diseases like gonorrhea and chlamydia is exceptionally low. The major factors of infertility in the haredi community, across all ages, says Kochman, are anovulation, short menstrual cycle and male infertility, all of which are often treatable.
Prof. Benjamin Bartoov, head of the male fertility clinic at Bar-Ilan University, sees up to 1,500 men a year. "Fifty percent to 60% of couple infertility is caused by male infertility," he says.
Many men who are labeled with infertility are biologically capable of producing children, but have lifestyles or conditions that damage the structure of the sperm cells.
Sperm, unlike eggs, is produced throughout a man's life, approximately each three months, though quantity and quality vary dramatically. Men's fertility also declines with age, but at a significantly slower rate.
The very slow decline in male fertility is still being analyzed to discover how meaningful it is, though several recent studies have shown that some men over 40 father less-healthy children than their under 30 counterparts.
Last year, researchers at New York's Mount Sinai School of Medicine found an increased risk for autism and related disorders in children of men over 40. In 2004, researchers at the Karolinska Institute in Stockholm found an increased risk of schizophrenia in children born to fathers over 50. In 2003, scientists at Columbia University Medical Center found that men over 40 and especially over 50 are serious contributors to the risk of having a child with Down syndrome, and that the age of both parents contributes to the overall risk.
"We used to think that because of spermatogenesis [ongoing process of sperm development] that aging would not be a problem [for fathering]," says Prof. Eitan Lunenfeld, president of Ayala, the Israel fertility society, and chairman of the obstetrics and gynecology department at Soroka University Medical Center in Beersheba.
Despite the growing evidence that men over 40 contribute to certain disorders in offspring, it's still too early to know if the risks are always due to normal cell aging of male sperm or if there are also health, lifestyle and environmental factors. "It's probably both," he says. "But we don't know yet, even though studies try to account for confounding factors."
What doctors do know is that one of the biggest problems with men's fertility is sperm damaged by heat. "One or two degrees elevated in the testicle envelope can make the difference," says Bartoov. Men facing fertility problems because of heat can be truck or bus drivers, kitchen workers or serious bicyclists. And some doctors claim that tight pants, hot baths and Jacuzzis can also be factors. The heat issue is easily treated, he says. "They have to take a vacation or change their hours or their situations."
Other treatable conditions and substances, according to Bartoov, that hurt male fertility include smoking, bacterial infections, obesity, varicocele (an abnormal enlargement of the scrotal veins caused by faulty valves), drug and medication use, zinc, exposure to pesticides, heavy metals and chemicals. Other hospitals, like The Mayo Clinic, also look at levels of vitamins C and E, selenium, folic acid, testosterone levels and stress.
"Miscarriages are also connected to sperm quality," says Bartoov.
He adds, sometimes older couples think they are facing infertility, and that is not always the case. At times they are easily helped with adjustments to health or lifestyle. When that fails, there are treatments such as surgery to correct varicocele or micromanipulation to implant only healthy sperm during in-vitro fertilization.
"I have been working for many years with both partners over age 40 that got pregnant. We don't have statistics but we have enough successful cases in which the woman is over 40."