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4.3.1 Access to reproduction technologies

Chantal Rivard, MD, FRCPC

*Updated March 1, 2014 by Dr Arthur Leader, MD, FRCPC

Learning Objectives

  1. Discuss the factors that limit access to reproductive technologies
  2. Reflect on the question of age as a factor limiting access to reproduction technologies

Case

Ms. Boulanger is a 51-year-old civil servant. She has been in a stable relationship for one year with her 43-year- old spouse.

She has never had children. She was previously in relationships with 2 men, the first of whom had fertility problems. They discussed adoption but the partner in question was strongly opposed, so she did not pursue this option. They lived together for 5 years.

The second partner had a vasectomy after fathering two sons, whom Ms. Boulanger helped raise. However, she found it quite difficult to be "step-mother" to these children. She and this man were a couple for more than ten years. Since their separation, three years ago, she has had little contact with these children.

Her current partner does not have children but has always wanted to. As she explains, she has always wanted children, but life circumstances did not offer her the occasion.

Ms. Boulanger is in good health. She has no relevant medical or surgical antecedents. She reports no substance habits, nor does she take medication. She has no known allergies. Her family history is unremarkable.

Her gynecological history is unremarkable. She has regular check-ups, which are always normal. She has been in menopause for approximately 2 years, and is taking hormone therapy, which has been well tolerated.

She has heard about the possibility of egg donation and pregnancy in menopausal women. She is very enthusiastic about this idea, as is her spouse. They have come to you for help.

Questions

  1. How do you feel about such a request?
  2. Is age alone sufficient cause to refuse a patient access to reproductive technologies?
  3. Is access to reproductive technologies a right or a privilege?
  4. What are the physician's obligations to this patient?
  5. Is there Quebec or Canadian legislation regarding age and access to reproductive technologies?

Discussion

With the arrival of new reproduction technologies, we are faced with requests for care from individuals who would not have had access to these options just a few years ago. Consider for example homosexual couples, single women, transsexuals, or patients affected by serious hereditary diseases or diseases such as AIDS. Today, egg donation makes it possible for menopausal women to conceive as well.

These new possibilities may be off-putting at first sight. Yet it is important to reflect on these issues, which are made possible by technology. Must we necessarily meet the requests of these patients simply because technology makes new options available?

Several cases have already been published of menopausal women who underwent in vitro fertilization with donor eggs. We count approximately 100 cases to date, with the eldest individual aged 63 years1. Nonetheless, certain people are strongly opposed to these manipulations of the natural reproductive lifetime.

On the basis of what criteria can we accept or refuse a request for infertility treatment? Can age be the sole criterion? Should we consider infertility treatment for menopausal women as the resolution of a medical problem, or as an improvement of the reproductive capacity of women?

Reproductive freedom
As many infertile couples can attest, life without children can seem incomplete to certain individuals. Why, then, should we refuse couples access to available reproduction technologies?

The feeling of failure or an imperfect life that affects certain people without children is a complex concept involving various psychological factors. As Landau notes, children are not a treatment or therapy, and should not be used as a means to an end. Having a child is not necessarily the solution to a woman's problem in every case.2

For certain people, reproduction is a right and, given this context, an older woman should not be treated differently from other women. Restricting this freedom would be failing to respect her autonomy3. Meanwhile, Antinori believes that it is not the role of the physician to decide for parents whether they are capable of carrying a pregnancy and the responsibilities associated with a child. This choice belongs to the parents, and physicians are to respect the decision of the parents, when the circumstances permit and the risks are acceptable in the given case4.

For others, reproduction is not considered a right. The well-being of the child to be born is placed at the centre of all decision-making. According to Pennings, parenthood is not to be seen as a right, but rather as a commitment. Parents should weigh the various factors influencing their desire to have children, then make a responsible decision5. Landau adds that we have obligations, not only toward the children that already exist, but also toward the children we wish to have6. Thus, it is not simply a matter of our rights as parents; the notion of responsibility must remain at the centre of our decisions.

Why delay childbearing?
Let us review some reasons why women decide to conceive later in life. Certainly, education and career are major factors. Fertility problems also can delay the age at pregnancy. Not having had a stable enough relationship, or having had conflicts to resolve are other reasons sometimes cited for considering pregnancy after the age of 40. Thus, pregnancies later in life could be seen as selfish choices by women (after doing other things, establishing a career, etc.) or, on the contrary, as a careful choice, where the woman has waited to be perfectly ready in her social, psychological, and material spheres7,8.

For Landau, it is important to pay attention to the message being given to women. The fact that IVF and egg donation exist could lead certain women to believe that they can easily wait to have children. Yet these treatments are complex and costly, and carry risks for the patients and their children. In addition, they are far from being 100% effective. Belief in the omnipotence of medicine to help conceive a child could lead to increased rates of infertility for the next generation9.

Duration of the natural reproductive life
Opponents of infertility treatment in menopausal women typically invoke the argument that it is not "natural". Thus, egg donation would not be acceptable unless used in women of child-bearing age, and menopause would be a natural limit to the right to procreate. Using reproductive techniques in menopausal women would be an attempt to "improve upon" nature, not correct a health problem10.

For some individuals, this notion of the duration of reproductive life is merely a social construct. We expect a woman above 50 to fill the role of grandmother, not mother, because - according to a society with highly defined structures - the woman has reached that stage. This therefore presupposes a set reproductive life.

The principal that holds that the acceptability of certain goals, activities, or plans is a function of the average life expectancy forces us to re-evaluate certain plans, given the increase in average life expectancy11. The idea of a woman having a child at 50 might once have seemed irresponsible. Now that female life expectancy is approaching 90 years, it is unlikely that such a woman would be unable to raise her child to adulthood.

According to Pennings12, the growing life expectancy makes it possible to pursue multiple careers and change paths at a certain age, deciding for example to have children. It would be difficult to condemn those individuals who try to accomplish one of the possibilities life offers them if the occasion presents itself, especially if doing so does not hurt others.

In addition, the duration of the natural reproductive life cannot be a sole argument in support of accepting a pregnancy, because it does not perfectly coincide with the age when pregnancy is morally and socially acceptable. For example, most people believe that adolescence is not the best time to be pregnant, although it falls within the period of natural reproduction13.

Parental capacity
One question that every parent should ask before having a child is this: Will I be able to take proper care of it? For certain people, the factors that play into answering this question are so difficult to quantify that the only absolutely essential precondition for having a child is that the parent can love the child, thus providing it with a favourable environment14.

According to Pennings, parental capacity is based on two main factors for older parents: time and the environment. Time is a primordial factor in decisions about any project. We have to estimate the time we can devote to a project, as well as the time for the project itself, in order to see whether it is feasible. In the case at hand, life expectancy with good health can be estimated from current averages (minus influencing factors, such as smoking), and easily falls into the seventies. The time needed for the "project", in other words for the child to become autonomous, is probably more than 20 years, though Pennings suggests calculating 25 years, to be on the safe side15.

Finally, we need to estimate the age when the parent will still have the physical and mental capacity to take care of the child, not just the full life expectancy. Taking care of offspring can demand abilities that may escape certain older people. So, when do we lose this capacity? According to Pennings, we lose it in our seventies, which gives a maximum age of 50 for conception16. Others believe that, once we accept that childbearing with its difficulties and responsibilities is not too difficult a role for a menopausal woman, there should not be any arbitrarily determined age limit17.

Given the duration of this project, certain people estimate that there could be discordance between the capacities needed at the start and at the finish. Taking care of a baby at 55 may be easier than taking care of an adolescent at 65. Certain studies suggest that delaying the age of becoming parents brings more difficulties in adolescence18.

One aspect that is sometimes forgotten is the dual responsibility that the future parents will have to assume. Specifically, many people in their sixties will have to look after their own aging and infirm parents. This task, in addition to raising a child, can prove daunting. With smaller family sizes, elder care can wind up falling to one person alone19.

Shared responsibility
Is the child's well-being the responsibility of the parents alone? This question may seem incongruous within the traditional vision of the North American family. Yet if child care were shared, the fact that the parents might some day no longer be capable of meeting the child's needs would be less stressful and thus would not prevent an older couple from undertaking such a course.

The unique bond between parent and child is difficult to transfer to a third person. By contrast, a child raised in a more extended "family" than the nuclear family we are more familiar with might suffer less from the loss of one or both parents. Nonetheless, this would require adjusting our concept of parent-child relations and the basic family structure20.

Gender equality
The discussion surrounding post-menopausal childbearing could be classified as sexist. Indeed, are the same objections and prejudices voiced when discussing men of that age group? For some, the discussion cannot be compared, because we do not need to intervene actively as a third party to enable conception in the case of older men, which may make a difference in terms of moral considerations. Some might even impose a limit on men if they had recourse to reproductive technologies.

For others, this is not the issue. The discrimination comes from the unique relation between the mother and the child, which causes the role of the mother in the child's life to be perceived differently. The degree of investment to become a mother is not the same as that required of the father, and the presence of the mother is indispensable and irreplaceable. If fathers are playing an increasingly important role, with greater participation that departs from the traditional role as provider of money and security, it is possible that the father could be blamed for becoming a parent at an older age.

To be sure, the mother's involvement also involves physical factors tied to pregnancy and delivery, which will be discussed below.

The success of IVF
In vitro fertilization (IVF) was first used successfully in 1978. Women who elect IVF at age 42 or older require donor eggs, because their own eggs have ›50% risk of aneuploidy. Currently, the average success rate in Canada for IVF for women 40-42 years who use their own eggs is 10% live births per cycle. For women who use donor eggs, the live birth rate is 50% per embryo transfer. Thus, the predicted success rate for a donor egg IVF cycle depends largely on the egg donor's age21.

There are some who feel that post menopausal reproduction is so dangerous after age 49 that it should not be offered. Those who defend this point of view think that other choices should be proposed to these women who wish to have a child to fill a void in their life, for example adoption, working with children through charitable organizations, or enriching their lives in other ways altogether (e.g., studies, travelling, etc.)22.

For others, in well selected cases, a menopausal woman is perfectly capable of carrying a pregnancy to term23.

Given that fresh eggs are a limited resource, it has been suggested that a lack of this resource should lead us to restrict access for menopausal women. With the advent of vitrified (frozen) egg banks, egg supply is no longer as big a problem. Still it could seem fair to give eggs to those women who have the greatest chances of bearing a healthy full-term infant. Thus, there is a conflict between the principle of justice (access for all) and the principal of utility (access for those with the greatest chances of success)24. According to Goold, the universality of the desire for reproduction is a sufficient basis to consider infertility an illness, and all reasons for infertility are valid. Therefore, we must offer all women equal access to reproductive techniques25.

The medical risks
The medical risks associated with pregnancy are also much higher after age 49. The risks for the mother are of several kinds: vascular complications, multiple pregnancies (due to the reproductive technologies), diabetes, postpartum hemorrhage, pregnancy induced , hypertension and eclampsia, congestive heart failure and stroke. An elevated rate of Caesarean sections as well as an increase in placenta abruptio have also been observed26,27. Could these complications have consequences for the future health of the mother?

Children born of post-menopausal mothers are also at greater risk of premature birth, small for gestational age and low birth weight. Though certain risks are due to IVF28 (multiple pregnancies and their consequences), even in their absence studies show a risk associated with maternal age alone29. Thus, the long-term risks for a child born of a menopausal mother also needs to be considered.

One author has also noted that we may be exposing a potential child to these risks without its knowledge or consent. We would need to be able to determine whether a child would have deemed this to be a reasonable risk for his or her own life. This poses a problem, because it involves granting rights to a child that has not yet been conceived, and we would be basing this reasoning on what would be, according to use, the child's choice. Yet from a legal standpoint, such an argument does not hold, because an unborn child does not have rights30. From a moral point of view, this argument could approach the discussion on the well-being of the future child.

By contrast, other authors, including Antinori believe that in well selected cases, the risks for the menopausal woman are not considerably greater than those for the general population31.

The psychological risks
Landau underscores the fact that the risk is still greater of a child being orphaned if the mother is older, and posits the view that the death of this "social" mother could result in a second "loss" for the child, the first being the loss of the "biological" mother, or egg donor.

Furthermore, Landau notes that the social network of these older parents tends to be older as well and perhaps less apt to look after the child should the parents die or become incapacitated32.

For others, it would be discriminatory to refuse childbearing to women solely because they have greater chances of dying. Younger women can also be affected by deadly conditions, and factors other than age also influence longevity, notably genetics, smoking, extreme sports, high-risk professions, etc.33.

Finally, the fact of knowing the egg donor can also pose problems. Post-menopausal women who wish to become pregnant could pressure younger women in their circles to help them with this process. As for younger women, the fact of knowing the donor, and that she is present in the family dynamic could cause problems.

Legal aspects
The United Nations defines reproductive health as a state of physical, mental, and social well-being and not merely the absence or reproductive disease or infirmity34. Hence their 1994 resolution, which stipulates that individuals have the right to be informed of and have access to methods for managing fertility in a safe, effective, affordable, acceptable, and legal manner35.

According to the United Nations, individuals should have the capability to reproduce and the freedom to decide if, when, and how often to do so36. But does this mean that there is no age limit for reproduction? The question is what is in the best interest of the child.

On this point, Canada has not regulated the practice of egg donation in the case of menopausal women, and thus there is no age limit for its use.

In the Assisted Human Reproduction Act, Canada makes no mention of a maximum age for access to reproductive techniques37. Nonetheless, several principles derived from this Act could guide us in our decisions. Among other things, the Act stipulates (Article 2a) that "the health and well-being of children born through the application of assisted human reproductive technologies must be given priority in all decisions respecting their use". Article 2c adds that "the health and well-being of women must be protected in the application of these technologies". Finally, Article 2e states that "persons who seek to undergo assisted reproduction procedures must not be discriminated against, including on the basis of their sexual orientation or marital status". Should age be added to this list?

Conclusion

The case of Ms. Boulanger raises a number of controversial points: access to reproductive techniques, parental capacity, and reproductive freedom, for example. This discussion also calls into question our traditional ways of understanding family, and our ideas of what constitutes a "normal" age for becoming a parent.

Decisions about whether to accept pregnancy in menopausal women should probably be made on a case-by-case basis, given the complexity of the data and the risks, which can differ in each situation. It is also important to highlight the importance of discussions with these patients before conception, so that they can make an informed choice that takes into account all the issues, from the point of view of the future mother, the family, and the child to be born. It is only in this way that the ethical principles involved can be fully respected.

References

  1. Check, J.H. et al. "Successful Pregnancy after the Age of 50: A Report of Two Cases as a Result of Oocyte Donation", Obstetrics and Gynecology, 1993, vol. 81, p. 835.
  2. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, p. 63.
  3. Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, pp. 33 and 35.
  4. Antinori, S. et al. "A Child is a Joy at Any Age", Human Reproduction, 1993, vol. 8, no 10, p. 542.
  5. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, p. 532.
  6. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, p. 61.
  7. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, pp. 536-537.
  8. Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, pp. 37-38.
  9. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, pp. 62-64.
  10. Kluge, E. "Reproductive Technology and Postmenopausal Motherhood", Can Med Assoc J, 1994, vol. 151, no 3, p. 354-5.
  11. Pennings, G. "Postmenopausal Women and the Right of Access to Oocyte Donation", Journal of Applied Philosophy, 2001, vol. 18, no 2, p. 172.
  12. Ibid pp. 172-173.
  13. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, pp. 531-541.
  14. Benagiano, G. "Pregnancy After Menopause: A Challenge To Nature?", Human Reproduction, 1993, vol. 8, no 9, p. 1344-45.
  15. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, p. 534.
  16. Ibid p. 536.
  17. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, p. 58.
  18. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, p. 535.
  19. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, p. 60.
  20. Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, p. 536.
  21. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, p. 56.
  22. Ibid p. 63.
  23. Antinori, S. et al. "A Child is a Joy at Any Age", Human Reproduction, 1993, vol. 8, no 10, p. 1542.
  24. Pennings, G. "Postmenopausal Women and the Right of Access to Oocyte Donation", Journal of Applied Philosophy, 2001, vol. 18, no 2, pp. 174-175.
  25. Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, p. 39.
  26. Dollberg, S. et al. "Adverse Perinatal Outcome in the older Primipara", J PerinatolM, 1996, vol. 16, no 2, p. 95-96.
  27. Salihu, H. S. "Childbearing Beyond Maternal Age 50 and Fetal Outcomes in the United States", Obst Gynecol, 2003, vol. 102, no 5, pp. 1006-1012.
  28. Addor, V. et al. "Impact of infertility treatments on the health of newborns", Fer and Ster, 1998, vol. 69, no 2, pp. 210-215.
  29. Salihu, H. S. "Childbearing Beyond Maternal Age 50 and Fetal Outcomes in the United States", Obst Gynecol, 2003, vol. 102, no 5, pp. 1006-1012.
  30. Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, p. 36.
  31. Antinori, S. et al. "A Child is a Joy at Any Age", Human Reproduction, 1993, vol. 8, no 10, p. 1542.
  32. Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, pp. 60-61.
  33. Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, p. 34.
  34. United Nations. International Conference on Population and Development (ICPD). Guidelines on Reproductive Health, 1994.
  35. General Assembly of the United Nations. Resolution 49/128, 1994.
  36. United Nations. International Conference on Population and Development (ICPD). Guidelines on Reproductive Health, 1994.
  37. Government of Canada. Assisted Human Reproduction Act (An Act respecting assisted human reproduction and related research), 2004.

Further Reading and Resources

  • Addor, V. et al. "Impact of infertility treatments on the health of newborns", Fer and Ster, 1998, vol. 69, no 2, pp. 210-215.
  • Antinori, S. et al. "A Child is a Joy at Any Age", Human Reproduction, 1993, vol. 8, no 10, p. 1542.
  • Benagiano, G. "Pregnancy after Menopause: A Challenge To Nature?", Human Reproduction, 1993, vol. 8, no 9, p. 1344-1345.
  • Check, J.H. et al. "Successful Pregnancy after the Age of 50: A Report of Two Cases as a Result of Oocyte Donation", Obstetrics and Gynecology, 1993, vol. 81, p. 835.
  • Dollberg, S. et al. "Adverse Perinatal Outcome in the older Primipara", J Perinatol, 1996, vol. 16, no 2, pp. 93-97.
  • Goold, I. "Should Older and Postmenopausal Women Have Access to Assisted Reproductive Technology?", Monash Bioethics Review, 2005, vol. 24, no 1, pp. 27-46.
  • Government of Canada. Assisted Human Reproduction Act (An Act respecting assisted human reproduction and related research) assented to on 29 March 2004.
  • Kluge, E. "Reproductive Technology and Postmenopausal Motherhood", Can Med Assoc J, 1994, vol. 151, no 3, p. 354-355.
  • Landau, R. "The Promise of Post-Menopausal Pregnancy", Social Work in Health Care, 2004, vol. 41, no 1, pp. 53-69.
  • United Nations. International Conference on Population and Development (ICPD). Population Information Network (POPIN). Guidelines on Reproductive Health, Resolution 49/128, 1994.
  • Pennings, G. "Age and Assisted Reproduction", Med Law, 1995, vol. 14, pp. 531-541.
  • Pennings, G. "Postmenopausal Women and the Right of Access to Oocyte Donation", Journal of Applied Philosophy, 2001, vol. 18, no 2, pp. 171-181.
  • Salihu, H. S. "Childbearing Beyond Maternal Age 50 and Fetal Outcomes in the United States", Obst Gynecol, 2003, vol. 102, no 5, pp. 1006-1014.