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Women in their late 30s to early 40s who have difficulty conceiving are often unaware that success rates of fertility treatment decline with age, most commonly due to declining ovarian function. Counseling about the high prevalence of infertility and miscarriage may be met with surprise and sadness. Reports of children born to high-profile women older than 50 years may contribute to misconceptions, but these births highlighted in the media were likely achieved with donor oocytes from a younger woman or with oocytes or embryos that were previously cryopreserved. Consistent with declining fertility rates worldwide,1 the fertility rate in the US has declined from 70.9 births per 1000 women in 1990 to 56.1 per 1000 in 2022.2 Simultaneously, the 2019 US Census reported that age at first birth had risen from 27 years in 1990 to 30 years in 2019 as more women postponed first birth.
Reasons for these trends may include lack of a partner, economic insecurity, career aspirations, and long work hours. Concerns about childbearing discrimination, including lack of pregnancy and postpartum support, and childcare challenges also likely influence decisions to delay pregnancy. Results of a questionnaire completed by 5692 US general surgery residents reported that more female than male residents delayed pregnancy because of training (46.8% vs 32.7%; P < .001) and experienced pregnancy/parenthood-based mistreatment (58.1% vs 30.5%; P < .001).3
Uterine fibroids are sex–steroid responsive benign tumors primarily composed of smooth muscle cells and extracellular matrix that develop in the wall of the uterus.1 They are one of the most common neoplasms in reproductive-aged women. Lifetime prevalence estimates in premenopausal women range from 40% to 89%, depending on the method of detection, the study population, and the ages of those studied. Fibroids can range in size from less than 1 cm to more than 20 cm. Although not all individuals with fibroids have symptoms, typical symptoms include abnormal uterine bleeding/heavy menstrual bleeding (AUB/HMB), pelvic bulk symptoms (protruding abdomen, pressure on bladder and bowels), pain, and reproductive morbidity (ie, infertility). Due to their high prevalence and associated symptoms, fibroids are the leading cause of hysterectomy in the US and account for up to $34 billion annually in direct and indirect costs.
Polycystic ovarian syndrome (PCOS) is a chronic disorder associated with infertility; miscarriage; adverse pregnancy outcomes; and cardiovascular, metabolic, psychological and neoplastic risks.
DIagnosis of PCOS can be made based on the presence of any 2 of menstrual irregularities, clinical or biochemical hyperandrogenism or polycystic ovarian morphology on transvaginal ultrasonography.
Treatment of PCOS may target anovulation, androgen excess, hyperinsulinemia and weight management.
Patients with PCOS should have regular monitoring of their body mass index, blood pressure and metabolic parameters, and should be regularly screened for depression, anxiety and obstructive sleep apnea.
Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.
