Discuss Fertility Now.

Ob.gyns. need to do a better job of educating patients about the risk factors for infertility such as age, smoking, sexually transmitted diseases, and extreme body weight well in advance of their efforts to conceive. Decisions and choices that your patients make in their teens and 20s can affect their fertility for years to come.

Infertility affects about 6.1 million people in the United States alone; 10% of the reproductive-age population--both men and women. If you're a generalist ob.gyn., you may not practice infertility at all, but fertility specialists like me are seeing an epidemic of infertility that is solely due to ovarian aging.

Women are pushing the limits of their fertile age, primarily as a result of a demographic shift within the baby boom generation. Now, for the first time in history, a majority of women in this country have college educations. The age of first marriage has gone from 18 years to 24. That is a huge demographic shift, even though 24 sounds pretty young. There's also effective contraception, so it's possible to delay child bearing. And then there are the demands of careers and being successful outside of the home that eat up a number of years.

All of these forces have led the baby boom generation to delay childbearing like no other generation in history. The baby boom ended in 1964, so in 2004, the last of them will turn 40. We're in the middle of this late reproductive age phenomenon, and when older women try to get pregnant, they often have problems.

Physicians are more apt to talk to patients about contraception and ask whether they are being physically abused than about fertility and their intent to have children. It's usually left to the patient to bring up.

Patients may say they don't plan to get pregnant because "I don't have a partner" or "I feel bad that I'm taking the job promotion instead of trying to get pregnant." It's sensitive, so it's often avoided.

You can address fertility with a patient by opening the conversation with a phrase like, "I see you have been or have not been pregnant in the past. Do you have any plans to get pregnant in the future?" Wait for their response. If they say never, that's fine. But what you usually hear is "Yes, I want to get pregnant sometime, but not yet." In that case I would say, "You have to be careful that you don't get to the point where you could have trouble getting pregnant just because you're much ...