The reasons for female infertility in the forties vary. Women may no longer ovulate on a regular monthly schedule, which lowers our odds of conceiving. Some women conceive but miscarry very early, often before they have even missed their period. Jayne felt sure she was pregnant, although her period was only three days late. She had been trying to have a baby for nearly three years. She looked sorrowful as she described forcing herself to wait three days, then rushing to the drugstore for a home pregnancy test. “I got home and ran into the bathroom, but my period had started,” she said. “I was crushed. I have a feeling I miscarried, because my period was so heavy and I had so much cramping that month. Besides, in all the years I’ve been trying to get pregnant, my period has never been three days late.”

It’s hard to know if Jayne indeed had a very early miscarriage. Some women have a condition called “late luteal phase defect,” when their bodies do not produce enough progesterone during the second half of their menstrual cycle, the luteal phase. Because progesterone is vital in order to implant and sustain a fertilized egg successfully, its absence may be implicated in infertility. This may be particularly true as we age and our production of progesterone and other hormones declines.

I suggested that Jayne consider having her hormones measured to determine if low progesterone could be a variable in her inability to conceive. If her progesterone level was low, I explained that natural progesterone supplementation is benign and noninvasive and can be taken while a woman is trying to conceive. Some infertility specialists use progesterone supplementation during the first trimester of pregnancy to help sustain a fetus once a woman is pregnant. It turned out that Jayne’s progesterone level was fine. She still wanted to conceive and intended to continue with her fertility specialist.

The older we get, the less viable for fertilization the eggs produced by our bodies may be. In some cases, no direct cause for the inability to conceive can be found. A woman in her forties who is dealing with infertility may decide that reproductive technology is appropriate and affordable. Others who try these highly sophisticated and very expensive methods to conceive may have to stop, either because they can’t afford any more treatments or a certain number of attempts have failed. Gabrielle reached that point after her second attempt at in-vitro fertilization using donor eggs was unsuccessful. She was 42, and the fertility specialist she and her husband were working with said there was no clinical reason not to try a third time if they wanted to. But after many tears, she and her husband decided not to go through the cycle again, which taxed them physically, emotionally, and financially.

“We could have kept going, because there’s always the hope that conception and full-term pregnancy will happen next time,” said Gabrielle. “But we had to look at what it would do to both of us if we had another unsuccessful attempt. Also, the third attempt would have depleted our financial reserves completely. I’m glad we went as far as we did to have a biological child,” she continued, “because at first I wasn’t going to have any treatment. I didn’t think I could take the stress. But I found strength I didn’t know I had.”

The escalations of hope followed by the sharp descents into disappointment had placed a great strain on her marriage, Gabrielle said. “I thought I was going to end up without a husband too. We’ve weathered the shakiest times. We’ve come through the experience of infertility with the realization that we are committed to this marriage, with or without children.”

For some women who want to build a family, adoption is a viable option, but if they are married to men who prefer to remain childless rather than adopt, these differing goals are not simple to resolve. Beth said, “I know my husband and I could be loving parents. I think our purpose in that role is larger than replicating our DNA, but my husband feels strongly about having biological children. We went through a period where neither of us was listening to the other about this issue. I thought he was being completely egotistical and selfish, and he saw my feelings as a highly romanticized view of what it would really be like to adopt a child.”

Beth is 41 and her husband is 44. Finally they sought help from a counselor, who guided them to a point where they were going to explore adoption step by step, making a decision at each point. “This approach really works for me,” Beth said. “We’re not saying we’re going to go full steam ahead and adopt, but we’re not ruling it out either. We’ve both agreed that our overarching goal is to be a loving family, whether that’s two of us or eventually more. With that goal in mind, we can evaluate all of our options. If any part of the adoption process feels like too much of a threat to our family stability, we’ll reassess.”

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3. The Basics of the Relationship Between Progesterone and Perimenopause

4. The Basics of The Menstrual Cycle During Perimenopause

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