Postmenopausal age fertility? Is it too late to become a parent?
This is a difficult question.
As Reproductive Endocrinologists, it seems that the boundaries of acceptability are always changing. In my practice, we do not discriminate on the basis of age. Advanced age patients are informed of the increased risk of pregnancy complications such as hypertension, diabetes, and pre-term birth that are more common as patients age. Patients are treated into their late forties and early fifties. We screen patients very thoroughly and require a cardiac stress test for those over 45. Patients that choose to try to conceive in their mid forties or later are informed that they have to be in optimal health and not have significant “co-morbidities.” The most common one of these is obesity. If a patient wishes to try to become pregnant later in life, she needs to demonstrate that she is not increasing the risk further by being obese.
I try to educate patients about the ethics of advanced age parenting and assess the family structure to make sure kids will be cared for if the older parents become ill.
There was and interesting case a few years ago in Florida when a lady called a Florida IVF clinic and was turned away by the receptionist “because of her age.” It turns out the patient was in the legal profession and sued that clinic for age discrimination.
The article below comments about a terrible event in Italy and suggests that there should be legal age limits imposed upon patients and clinics. Who is to decide what is the proper limit. What about an older man that marries a younger lady or vice versa. It is best to make these assessments on an individual basis instead of making more rules. I hope that U.S. Reproductive Endocrinologists will use good judgement on a case by case basis.
Here is the article as reported in the A.P. by A Vasireddy and S. Bewley
Julio E. Pabon, M.D., F.A.C.O.G.
How Old Is Too Old to Become a Parent?
Tragic Outcome of Postmenopausal age Pregnancy: An Obstetric Commentary
Vasireddy A, Bewley S
Reprod Biomed Online. 2013;27:121-124
Background
Initially, in vitro fertilization (IVF) was offered to overcome the problem of tubal disease. As experience has grown with the treatments and as the technology has improved, IVF has become available to a wider patient population, based on more heterogeneous indications. Nowadays, it is offered to treat male factor, tubal, immunologic, hormonal, unexplained, etc. causes of infertility. Over the years, it also became evident that the treatment can be successfully completed with donated gametes (egg, sperm donation) or when the embryo is implanted into a surrogate’s uterus. This has opened up new areas of use. The availability of such “nonclassic” methods also raises legal and ethical questions.
A trend in delaying childbearing can be observed in the past decades. Women in increasing numbers continue their education and seek a professional career. In modern societies, it also seems more difficult to establish stable relationships that could be the base of a family. The result of these changes is that more and more women start thinking about conceiving once they are already over 30.
The ovaries contain a finite number of eggs. Reduced oocyte availability and poorer egg quality are associated with increased reproductive difficulty as women age. While under 30 years of age, only 5%-10% of couples face infertility problems. By the age of 40, the incidence of infertility is over 40%. Over the age of 45, women rarely conceive on their own or with assisted reproductive technology (ART).
Age-related problems in the woman can usually be overcome with the use of donated oocytes. This commentary article discusses the ethical and biological aspects of oocyte donation at an advanced age in relation to a controversial legal case.
Commentary Summary
According to a 2011 report, an Italian court took a 1-year-old child away from a couple as they were considered too old to be fit parents at the female age of 57 and male age of 70. The child was conceived through ART treatment abroad.
The authors discuss that as women age, the proportion of embryos affected by aneuploidy increases, and this is a major limiting factor in achieving pregnancy in the late 30s and early 40s. The uterus also shows some signs of aging, probably related to suboptimal blood supply, but this seems to be less of an issue because the age factor can be overcome by the use of donated oocytes.
It is also known that pregnancies at the extremes of the reproductive years are associated with a higher frequency of medical complications (hypertensive complications, gestational diabetes, preterm delivery, stillbirth, operative delivery). A pregnancy conceived through egg donation in a woman with advanced age is also associated with an increased incidence of medical complications, so the use of “young” eggs does not prevent these complications.
Even if a pregnancy progresses uneventfully and results in the delivery of a healthy child, one has to consider the chronic medical problems and malignancies that affect women in the fourth through sixth decades of life when they need to raise the child. While one tries to help couples whose last resort is gamete donation, the interest of the offspring also needs to be considered. Should the parents become incapable of fulfilling their parental responsibilities, it will become the responsibility of the society to provide care for these children. Therefore, the authors feel that the fertility treatment of women of advanced age or even in menopause should be regulated to avoid future cases like that in Italy.
Age is probably the single most important parameter affecting reproductive success. A woman’s chance to conceive starts to decline at around the age of 30, and over 45 it is very rare to achieve a successful pregnancy. This is due to the reduced number of eggs available for fertilization as well as to their poorer quality that leads to increased aneuploidy rates with age. Women who delay childbearing can expect a longer time to succeed, more need for ART, and smaller family size. ART may compensate for some of the reduced chance but cannot make up for all of it. Pregnancies that are conceived in women over 35 are complicated by higher miscarriage and stillbirth rates; medical complications during pregnancy are more common too.
Women over 40 are more likely to require donor eggs to achieve a pregnancy when compared with younger women. An embryo that is created from a younger woman’s egg will have a high chance to implant, so women even after reaching natural menopause still have a chance to achieve a successful pregnancy. However, they need to be aware that these pregnancies are still complicated by more hypertensive complications, low birth weight, and need for operative delivery.
A child born to older parents may face relationship or emotional problems with his/her parents due to the big age gap. On the other hand, older parents are more likely to be able to provide the financial needs required to raise a child. The availability of social egg freezing is another issue that will likely result in more pregnancies among women of advanced reproductive age. Freezing eggs at a younger age allows women to study and start a job before they interrupt their professional career with a pregnancy and delivery. These women will probably not have big families that may have consequences to society. These women may also be diagnosed with medical problems or may be affected by undiagnosed medical issues by the time they decide to use their eggs, which may complicate the pregnancies and may lead to a higher rate of maternal morbidity/mortality.
Therefore, care providers have to be very careful when counseling women about pregnancies at an older age. Women should be encouraged to try on their own at a young age. Those who for various reasons cannot complete their desired family size early on should undergo a thorough medical evaluation before their own or donated eggs are used. An upper age limit should also be set to avoid problems like the one discussed in the article and to make sure parents will be there for their children until their children at least reach adulthood.
