I am a healthy, in-shape 40-year-old. I conceived my first child at 38 after three months on Clomid and progesterone suppositories. My child is now 13 months old and I'd like to try again before it's too late. However, I'm still nursing him and have not started menstruating again yet. My OB/GYN says I must wean him completely as soon as possible, but I was hoping that cutting back to nursing only at naptime and bedtime would be enough to get my periods back. I don't want to miss my opportunity to have another child, but neither my son nor I want to wean completely yet. May I have your opinion?

--Julie

I believe that any breastfeeding would be likely to interfere with your normal ovulatory cycles and hormone production after ovulation. You are in a bit of a Catch-22 here. Although you conceived on clomiphene two years ago, you are now two years older, and those two years are generally associated with a rapid decline in fertility. At age 40, ovarian reserve (your capability of releasing high-quality normal eggs) is diminished. Fertility rates at best are about 4-5 percent per month. Unfortunately, they are not markedly improved by fertility treatment. Generally, the best you can expect with gonadotropin induction and insemination is about 10-12 percent per month, with an increased risk of miscarriage if you conceive.

You did not mention why you required fertility medication for your first pregnancy, but I'm guessing you had some sort of problem conceiving then. Lacking more information, I have to assume that whatever factors necessitated fertility treatment the first time are still present. Another issue here is that the reliability of the clomiphene challenge test to predict ovarian reserve in women who are breastfeeding has not been determined. So, as costly and time-consuming and stressful as this treatment can be, I would recommend that you discontinue breastfeeding, determine ovarian reserve, and actively and aggressively pursue treatment with gonadotropin injections and inseminations.