AMA Journal of Ethics^®

Case

Dr. Deans, a fertility specialist, is meeting Lily and her husband Bill for the first time. As Dr. Deans gets to know her, he learns that Lily has wanted to have children since she was a little girl, but work—she lists her occupation as a corporate CEO—always seemed to get in the way. Now, at 53, she and her husband have decided to have a child before it is too late. Lily, who has undergone menopause, realizes that she no longer is able to have a child that will be genetically related to her, but she is willing to use donor eggs and her husband’s sperm to carry the child to term herself.

Dr. Deans carefully takes a complete history and does a thorough workup and physical exam. As he finishes, Lily looks up at him hopefully. “So,” she says, “can you help me to become a mother?”

Under Lily’s expectant gaze, Dr. Deans realizes he has conflicting responses to her request. Pregnancy is always riskier the older a woman is, but, if he’s being honest with himself, there’s really no medical reason why he shouldn’t help Lily get pregnant. Lily is 2 years younger than the age at which the American Society for Reproductive Medicine’s guidelines say IVF should be “discouraged” [1], and she has no comorbidities, such as hypertension or diabetes, that would make her a poor candidate for IVF. Indeed, Lily is in excellent health.

What’s making Dr. Deans uncomfortable doesn’t have much to do with the clinical situation at all—it’s the image of a 63-year-old mother cheering on her 10-year-old during school plays and soccer matches, or a 68-year-old telling her 15-year-old that she’s been diagnosed with cancer, or a devastated 17-year-old sitting on a hard wooden pew at his or her mother’s funeral.

Dr. Deans knows that the future is unpredictable regardless of a parent’s age, and, had Lily become pregnant without ART, he recognizes that he would not have the same hesitation. Still, he can’t help feeling that using ART resources in this case is not quite right, and he finds himself wanting to advise Lily against a procedure.

Commentary

How old is too old to be having a baby? No case illustrates the ethical dilemmas faced by Dr. Dean better than the of case of Maria Bousada, a single mother who conceived and delivered twins using donor-egg IVF at age 66 and died 3 years later, leaving her 2-year-old twins orphaned [2]. Shortly after that, Omkari Panwar, a 70-year-old woman from India, gave birth to twins [3]. Such cases have gotten substantial media attention, bringing to light the ethical issues that surround postmenopausal reproduction.

The central ethical issue is balancing the patient’s interest in reproductive autonomy and the welfare of the children born from that person. Although the decision to provide reproductive services to women of advanced reproductive age in the United States falls to individual practices and clinicians, most infertility doctors use the American Society for Reproductive Medicine’s (ASRM) practice and ethical recommendations as a guide.

Arguments in Favor

The ASRM ethics committee describes the main arguments in favor of making donor-egg IVF available to postmenopausal women: that not to do so would contradict societal values of equality and personal freedom [1].

1. It is not uncommon for grandparents to raise children; according to the ASRM ethics committee opinion, they “often bring economic stability, parental responsibility, and maturity to the family unit” [1]. If our society considers it acceptable for grandparents—postmenopausal women and men of the same age—to raise children, then it follows that for older people (who are not physically or psychologically incapable) to raise their own children should likewise be considered acceptable.
2. It is prejudicial to disallow older women to have children if it is considered acceptable for men to procreate very late in life. One could argue that allowing men and women to have equal reproductive possibility would contribute to a more egalitarian society.
3. Our society recognizes individuals’ rights to make reproductive choices regardless of their life expectancy or age; there is no prohibition placed on people, for example, with terminal illnesses that shorten their life spans or careers that jeopardize their safety. Therefore, it would be discriminatory to deny only older women the opportunity to fulfill their desire to become parents by procreating.

Additional arguments can be made in favor of allowing postmenopausal reproduction. From a consequentialist viewpoint, if no considerable damage is to be expected, the full right to reproductive freedom can justifiably be exercised without limitation even at advanced age. From a macroeconomic perspective, women who conceive later can focus on working and contributing to society for a longer uninterrupted period of time, and the costs of parenting can be postponed until financial security has been achieved.

Furthermore, the societal norm for heterosexual women to marry men of the same age or older is fading, and it is not inconceivable for women to marry men even two to three decades younger. Thus, the concern that children born to postmenopausal mothers would be harmed because they would have two parents who are likely for age-related reasons to die while the children are young may not apply in all cases. Certainly, regardless of gender, when patients have similarly aged partners or are considering single parenthood, thought certainly needs to be given to the support system that will be available until that child reaches adulthood.

Arguments Against

The arguments against postmenopausal reproduction described by the ASRM ethics committee invoke the “natural” limit on reproductive capacity, concerns about the child-rearing ability of older parents and possible harm to their children arising from their age, and the medical risks involved in pregnancy after menopause [1]:

1. Natural reproduction takes place in women in the years between the onset of menstruation and its end. In this sense, because it transcends the natural limit of reproductive capacity, postmenopausal reproduction can be termed “unnatural,” which some view as morally wrong.
2. Despite the social acceptance of grandparents raising children, parenting poses significant emotional and physical demands that some people of advanced age may not be able to handle. Additionally, there is a high likelihood that the children may experience the loss of one or both parents before reaching adulthood [1]. Given the evidence that children who experience the loss of a parent have a greater chance of depression and drug abuse [4], knowingly subjecting children to the probable loss of both parents early in life is to expose them to likely harm.
3. Postmenopausal pregnancy poses a greater risk of obstetrical and neonatal complications to both mother and child [1, 5]. A study that stratified maternal age demonstrated that mothers older than 49 had statistically significantly more maternal morbidity, including risk of diabetes, cardiac disease, and preeclampsia, as well as increased neonatal mortality and morbidity, than mothers 49 or younger [5].

Additional arguments can be made against allowing postmenopausal reproduction. Considerations of a child’s best interests are indicated in matters of reproduction, particularly when those matters require intervention and fall outside societal and biological norms. From the standpoint of the child’s welfare, it can be argued that the possible harm to a child who is likely to suffer the loss of a parent at an early age may outweigh the harm to parents of not being able to exercise reproductive autonomy. And, if resource limitations demand that society make decisions about allocating them, one can argue that it might be difficult to justify denying assisted reproduction technologies to a young woman with premature ovarian failure while granting it to an older woman past her natural reproductive life cycle.

Analysis

Certainly, guidelines provide a framework for physicians making difficult decisions, and the values of an individual physician can differ from this framework, as evidenced by the trepidation of Dr. Deans. In this particular case of caring for Lily, an otherwise healthy 53-year-old woman, after appropriate medical screening and assessment of social support, we would invoke respect for patient autonomy and uphold the ASRM guidelines by offering Lily donor-egg IVF. While physicians should indeed be aware of the greater sociocultural implications of their care, their decisions are made on an individual basis while caring for individual patients, not for society as a whole.

Conclusion

Cases like that of Lily and Dr. Deans bring to light the ethical dilemmas routinely faced by infertility doctors. While the donation of oocytes and embryos to women of advanced age is undeniably a charged issue, compelling arguments exist on both sides. Physicians are bound by ethics to uphold beneficence and nonmaleficence, and they must ensure the welfare of the child and the mother and protect their patients from harm. Women should be extensively counseled about the potential adverse health risks of pregnancy at an advanced age as well as the potential health risks to their future offspring.