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The age factor in family planning

This article first appeared in the St. Louis Beacon: September 5, 2008 - Sarah Palin is a name new to many of us this week, but the situation involving her infant son, Trig, is familiar to many. Trig has Down Syndrome, one of the chromosomal conditions that occur more frequently with a mother's advancing age. Palin, now the Republican candidate for vice-president, was 44 when she gave birth in April to Trig, her second son and fifth child.

Advancing age and pregnancy raise a number of issues for consideration for an expectant couple. "The biggest risk of delaying pregnancy is not being able to get pregnant at all," said Dr. Jill Powell, assistant professor of medicine in the department of obstetrics, gynecology and women's health at Saint Louis University School of Medicine. "We see all these celebrities having babies -even twins- in their 40s and we take it for granted that we will be able to do it too."

But there is a big drop in fertility, starting around age 38, according to Powell, which then falls even more precipitously after the age of 40. And if pregnancy is achieved, whether spontaneously or through in-vitro, there are other medical issues to consider during the pregnancy. "The biggest thing driving risk is any baseline medical risks (of the mother), such as diabetes or high blood pressure."

"It is important to get evaluated and be screened for these conditions," Powell said. "A lot of complications seen in pregnancy in women of later childbearing years are occurring or worsening in part because of the mother's age during the pregnancy. This is because these co-existing medical conditions are more likely to happen the older you are when you become pregnant."

Cancer in Pregnancy

Pregnant women occasionally must deal with cancer - about 1 in 1,000 cases. But a story in the New York Times noted recently that the incidence of pregnancy-associated breast cancer is on the rise.

That isn't surprising, said Dr. Matt Powell, assistant professor of obstetrics and gynecology in the division of gynecologic oncology at Washington University School of Medicine. (Matt and Jill are husband and wife.) "As women are having children at older ages, there are more cases of cancer," he said.

Breast cancer is relatively rare in women under the age of 35, but the rates steadily increase, with most cases occurring in women age 50 and older. While age in itself is a factor, the timing of pregnancy also plays in: Studies show that women who give birth for the first time at younger ages are less likely to get breast cancer than those who delay pregnancy to later years.

The Effects of Therapy

Historically when cancer was diagnosed during pregnancy, the outlook for the baby was not good. Luckily, times have changed. "The trend over the last 20 years has been to treat the patient, and the baby will usually do just fine," Matt Powell said.

Various studies have followed the effects of chemotherapy on a fetus's well-being. And while the treatment, isn't risk-free, the incidence of major birth defects from chemotherapy appears small.

"There is ample evidence that treatment with chemotherapy in pregnancy is safe," Matt Powell said. "The one thing we can't do during pregnancy is radiation; the doses we use would kill the fetus."

For those who worry about the long-term effects of radiation on the future health of the ovaries, uterus and yet-to-be-created offspring: "The uterus can tolerate a fair amount of radiation. And we can move the ovaries out of harm's way, laparoscopically."

And the long-term effects of the chemo? "There don't seem to be many issues," Matt Powell said. "Chemo exerts its effect on rapidly dividing cells; [the cells that would eventually form the fetus] stay dormant and are not likely to acquire a mutation."

In the case of cervical cancer, where treatment may include a hysterectomy, Matt Powell says that there are other fertility-preserving options. "We can do a radical removal of the cervix and reattach the uterus to the top of the vagina. While most (women) will need artificial reproductive techniques, spontaneous pregnancies have occurred."

An Ounce of Prevention

It is a fact of modern life that many women are delaying pregnancy until later on in the course of their reproductive years. An annual physical is always important, and perhaps especially so in men and women in family planning mode.

"Get your mammogram when you know you're not pregnant -- a few days after your period," Jan Powell advised. "Also, make sure you've had your pap, a pelvic exam and your blood pressure checked." When you decide it is time to pursue pregnancy, "immediately start a prenatal vitamin, quit smoking and have your partner quit smoking which will optimize fertility rates."

Dr. Cindy Haines is managing editor of Healthday-Physician's Briefing and president of Haines Medical Communications Inc., a full-service medical communications and consulting firm. As a board-certified family physician, Haines is well-versed in all areas of health care, with particular interest in fitness, nutrition, and psychological health.

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