ICNE YALE #26 Postmenopausal Pregnancy: An (In)Appropriate Use of Technology?

Sharon Steinberg RN, MS, CS Introduction: During the last decade more than 1,000 American women over age 50 and a few in their 60s have given birth. Health care professionals in various settings such as fertility clinics, ob-gyn offices, labor and delivery rooms and pediatric offices may encounter these older mothers and their offspring. The troublesome outcomes of assisted reproductive technologies (ART) such as multiple births, prematurity and neonatal medical complications are especially concerning when the mother is an older woman. Pregnancies among older women have become a subject of controversy and debate among clinicians, ethicists and the general public. Should a postmenopausal woman whose inability to conceive a child is related to the natural loss of fertility with age, not to disease, be able to utilize ART to bear children. Who should make this decision? Do we need more consensus guidelines? Do we need federal legislation? Is the support of postmenopausal pregnancy a wise use of limited and expensive resources? Women who give birth in their 50s and 60s have been the focus of media attention. The oldest known birth mother is Maria del Carmen Bousada de Lara of Spain, a single woman who became pregnant using anonymously donated oocytes and sperm, and delivered twins in December 2006 at age 66. She was treated in a California IVF program where she said she was 55 and was not asked to document her age. Fertility in women declines with age so that by 45 years ovarian reserve is substantially diminished and there is a decrease in the number and quality of available oocytes.1 Oocyte donation and in vitro fertilization make pregnancy feasible in virtually any woman with a normal uterus, regardless of age and even in the absence of ovaries and ovarian function. Regulations and Guidelines: Currently fifteen states in the US require insurance coverage for infertility treatment and laws vary widely. Insurance company assessments define benefit coverage criteria and determine medical necessity. These assessments can be helpful in clarifying and setting limits for the medically appropriate use of new technologies. However, postmenopausal pregnancies are not covered by insurance in any state.
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In the US there are few federal regulations for ART and no uniformity of regulation between states. The American Society of Reproductive Medicine (ASRM) has assumed an advisory role in developing practice guidelines and preparing ethics reports.2 The ASRM and the Society for Assisted Reproductive Technologies (SART) can refuse to endorse fertility clinics that do not adhere to practice guidelines, but they have no enforcement power Some states regulate clinics but there is no uniformity of regulation at the state level.. Although the Center for Disease Control (CDC) and SART collect, report, and verify data for individual ART clinics, it lumps all outcomes in women over 42 because patient age does not materially affect success with donor eggs.3 The CDC does not collect data on births to women over age 54, resulting in limited availability of data on the number of women over 50 seeking to become pregnant. Ethical Issues: In 2004, the ASRM Ethics Committee report on Oocyte Donation to Postmenopausal Women concluded that there is no compelling ethical or medical reason to judge the practice as unethical in every case if the only concern is the age of the mother.4 Nevertheless, because infertility is the natural concomitant of menopause, and because there are physical and psychological risks involved in pregnancy, the ASRM position is that postmenopausal pregnancy should be discouraged. The ASRM committee report stated that the central ethical question is whether the interests of postmenopausal women who desire to be parents and the resulting children are served by this technology. If cases are to be considered individually a womans health, medical and genetic risks, and the provision for childrearing should all be taken into account. Other countries take different approaches. France prohibited postmenopausal pregnancy and the French Minister of Health stated that the practice was immoral as well as dangerous to the health of mother and child. 5 In Italy, the Association of Medical Practitioners and Dentists is against providing women 50 and over with fertility treatment. In the UK, age restrictions were officially withdrawn in 2005. 6 Postmenopausal pregnancies will remain controversial as long as there are competing interests and divergent national, religious, ethical, and cultural views. One consequence of these divergent views among different countries and religious groups has been a rise in reproductive tourism as women seek out permissive programs in other countries if they are unable to access the services in their own country. An increasing number of Americans travel abroad in search of affordable donated oocytes. Increasing
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numbers of Canadians and Europeans travel to the USA to bypass regulations in their own countries which limit their reproductive options. The baby business has become global.7 In a postmenopausal woman, the inability to conceive a child is normal and not a medical problem; therefore, healthcare professionals do not have an obligation to help an older woman become pregnant. In this regard postmenopausal pregnancy is similar to cosmetic surgery in that it satisfies needs that are not strictly medical. It might be argued that the inability to have a child is psychologically distressing to some older women and that distress demands medical intervention. However, women may be able to satisfy their need to parent by finding alternative ways to bring children into their lives. Psychological counseling may also be helpful. Each fertility clinic determines the guidelines for its practice. Some clinics have set an upper age limit and others decide on a case by case basis and may be more liberal with age limits. If US IVF clinics do not have age limits health care professionals need to carefully consider the specifics of each case. Individual programs should set up guidelines and use ethics committees to provide deliberation of ethically challenging cases so that these cases can be decided fairly, consistently and transparently. The older woman who wants to become pregnant should be adequately informed of potential medical risks. A central repository is needed to accurately record the risks to both the mother and child of postmenopausal pregnancy. At this time, risks sufficient to prohibit postmenopausal pregnancy have not been demonstrated. In considering any individual case the risk to the child not yet conceived becomes a philosophically problematic consideration because you cannot harm an entity that does not exist. Collectively, if harms to the children of postmenopausal women are demonstrated we will confront the difficult question of whether those harms are worse than non-existence. Pregnancy in an older woman may be unnatural, but all IVF is unnatural. A surgically placed artificial heart valve is unnatural. Unless you subscribe to a global philosophy that all things unnatural are bad unnatural cannot be equated with immoral. The high cost of ART makes this option available to only a small subgroup of women who wish to have children later in life. There are competing demands for health care dollars and resources.8 It would be unfair to use resources for post menopausal pregnancy that might otherwise have been used to treat the sick. Older women who want to become pregnant should pay the cost and payment should not come from pooled insurance resources.
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The postmenopausal mother requires a donated egg. If eggs for reproduction were allocated in a manner similar to organs for transplantation, postmenopausal women would not receive priority over younger women who are medically infertile. Most older women will have had a chance to become pregnant at a younger age and for a variety of reasons forfeited that opportunity. Their choice not to conceive a child at a younger age does not give them priority over younger woman who cannot become pregnant because of medical problems beyond their control. Eggs for reproduction are not allocated according to any system of justice and are sold as a commodity. As long as this system prevails older women will have an opportunity to obtain a donated egg. The risks to the egg donor are a serious consideration but those concerns apply equally to both younger and older recipients. Conclusion: The novel use of any technology is risky because the outcome cannot always be predicted and unpleasant surprises are possible. There is nothing absolutely immoral about postmenopausal pregnancies. The goal of having a child is generally considered acceptable if not laudable. The use of technology to create babies is now well accepted. Though more data needs to be collected, no harm sufficient to ban postmenopausal pregnancy has been demonstrated. Healthcare professionals who feel uncomfortable, and I may be one of them, are not obligated to participate in postmenopausal pregnancies. At this time bioethics may not be equipped to decide the fate of postmenopausal pregnancy; perhaps it is better viewed as a matter of public policy. Does society want to accept the possible risks of postmenopausal pregnancy and the discomfort of pushing the limits of biology to satisfy the maternal desires of older women? Clearly, postmenopausal pregnancies widen the scope of reproductive options and challenge conventional values and ideas about motherhood, pregnancy, childbirth and parenting.9

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Heffner LJ, Advanced Maternal Age How Old is too Old? N Engl J Med 2004; 351:1927-1929. Chang WY, DeCherney AH. History of regulation of assisted reproductive technology (ART) in the USA: a work in progress. Hum Fertil (Camb). 2003 May; 6(2):64-70. 3 Clinic Data: 2005 ART Report, CDC Reproductive Health 4 The Ethics Committee of the American Society for Reproductive Medicine. Oocyte Donation to postmenopausal women, Fertility and Sterility 2004; 82: 8254-8255. 5 deWert G. The post-menopause: Playground for Reproductive technology: Some Ethical Reflections. In: Harris J, Holm S, Sren H ed. The Future of Human Reproduction : Ethics, Choice and Regulation, Oxford Press 1998; 221-237. 6 Boggio A. Italy enacts new law on medically assisted reproduction, .Human Reproduction 2005,20:1153-1157. 7 Spar, DL. Reproductive Tourism and the Regulatory Map, N Engl J Med 2005; 352:531-533. 8 Steinberg, S. Ethical Issues of Egg Donation. In: Steinberg D ed. Biomedical Ethics: A multidisciplinary Approach to Moral Issues in Medicine and Biology, University Press of New England, 2007: 120-123. 9 Peterson, MM. Assisted reproductive technologies and equity of access issues, J Med Ethics 2005;31:280-285.