Are You Ever Too Old to Have a Baby?

Are You Ever Too Old to Have a Baby?
The Ethical Challenges of Older Women
Using Infertility Services
Art L. Caplan, Ph.D.,1 and Pasquale Patrizio, M.D., M.B.E.

ABSTRACT
Older parenthood raises a variety of important factual and ethical questions. None
of the questions have received sufficient attention despite the rapid expansion in the United
States and other nations in the numbers of older parents. We do not know much about the
safety, economic, and psychosocial impact of these emerging practices on children or
parents. Nor have there been many analytical considerations of the ethical issues raised. We
argue in this article that there are reasons for concern when older persons seek to utilize
fertility treatments, including the safety of pregnancy for older women, risks posed to
children delivered by older mothers, issues around what constitutes safe conditions for
having a child relative to the age of parents, and the importance of guaranteeing that
someone will serve in the parental role should an older parent or parents become disabled or
die. To protect the best interest of children created by technology in new familial
circumstances, internationally recognized and enforced standards for fertility clinics to
follow ought to be enacted in making decisions about treating older parents seeking
infertility services.

KEYWORDS: Older parents, age limits, right to reproduce, best interest of children,
postmenopausal reproduction

Programs offering fertility services in the United
States and other nations are increasingly faced with
requests from women of advanced reproductive age
seeking assistance in becoming pregnant. Oocyte donation,
new drugs, the technique of single intracytoplasmic
sperm injection, and in vitro fertilization (IVF) afford
older women the opportunity to give birth well beyond
the natural limit imposed by menopause, and more and
more women are taking advantage of this opportunity.1–
4 With egg freezing transitioning rapidly into a therapeutic
option, it can be anticipated that more and more
younger women will freeze their eggs for future use
either in old age or even after their deaths.

Older parenthood does and should raise a variety
of important factual and ethical questions. None of the
questions have received sufficient attention despite the
expansion in the numbers of older parents. We do not
know much about the safety, economic, and psychosocial
impact of these emerging practices on children or parents.
Nor have there been many analytical considerations
of the ethical issues raised. Although it is
imperative that more be done to monitor and evaluate
1Director,Center for Bioethics, University of Pennsylvania, Philadelphia,
Pennsylvania; 2Professor, Obstetrics andGynecology, andDirector, Yale
University Fertility Center, Yale University, New Haven, Connecticut.
Address for correspondence and reprint requests: Pasquale Patrizio,
M.D.,M.B.E., Professor, Obstetrics andGynecology, andDirector, Yale
University Fertility Center, Yale University, New Haven, CT 06511
(e-mail: pasquale.patrizio@yale.edu).
Ethical Controversies in Reproductive Medicine;Guest Editor,Mark V.
Sauer, M.D.
SeminReprodMed 2010;28:281–286.Copyright#2010 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0030-1255175.
ISSN 1526-8004.
281
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older parenting, which uses infertility technology including
postmortem birth, this article will focus on the
key ethical questions raised.

One core ethical question is how to describe older
parenting (and postmortem) fertility treatment. Are
these instances of human experimentation and should
doctors providing these services be held to the standard
ethical requirements governing clinical research? If new
technologies are being tried in novel ways where the risks
and benefits are not well known, there may be a case for
insisting that infertility interventions for patients who
are very old only be done by doctors who have constructed
research protocols and had them approved by
appropriate peer review bodies.

Other questions abound. Should infertility programs
discourage, tolerate, or encourage pregnancy in
old age? Or, instead, should ethical programs try to
discourage and constrain who it is that can bear a child
in their later years? Should restrictions be in place on
advertising and marketing in magazines, the Web, and
other forums for fertility services that target older
persons? And should governments, private insurance
companies, and other third-party payers pay for fertility
treatments for older patients?

GROWTH IN OLDER PARENTING
There is no question that the phenomenon of postmenopausal
women seeking to become pregnant through
egg donation has increased greatly in the past decade.6 In
the United States between 1996 and 2006, the birth rate
for women ages 40 to 44 increased by 50% and for those
37 to 39 years of age by 70%. Although a very small
number of these births occurred spontaneously, most are
attributable to egg donation and the utilization of IVF.
In 2003, there were 263 births reported in women
between the ages of 50 and 54.
Among the oldest women to give birth
using IVF in the past decade are:

1999: Harriet Stole of Southgate, North London,
who gave birth to a son in April 1999, at the age of
66. She had agreed to be a surrogate mother for her
infertile daughter-in-law, Lucy Handerson. Lucy and
her husband, Harriet’s son, Ross Stole, had Lucy’s egg
fertilized with Ross’ sperm and then implanted into
Harriet’s womb. The child was born prematurely at
8 months, weighing 4 pounds, 5 ounces, but survived
and has had no further known medical problems as he
has grown up.

2003: SatyabhamaMahapatra of Nayagarh, Orissa,
India gave birth to a son on April 9, 2003, at the age of 65.
The baby, weighing 6 pounds, 8 ounces (2.95 kg), was
born by caesarean section. Mahapatra became pregnant
through the help of IVF, using an egg donated by her
26-year-old niece and sperm from her husband, Krishnachandra.
This was their first child after 50 years of
marriage. Doctors had attempted to persuade her and
her husband not to undergo IVF due to the risks involved.
Mahapatra was hospitalized for the last trimester of her
pregnancy.

2005: Adriana Iliescu gave birth to two daughters
at a hospital in Bucharest, Romania on January 16,
2005, at the age of 66. After undergoing IVF using
donated eggs, Iliescu became pregnant with triplets.
One of the fetuses died in utero. The surviving two
were delivered by caesarean section. One baby died
shortly after birth.

2006: Maria del Carmen Bousada de Lara is the
oldest woman known to have given birth. She had twin
sons at Sant Pau Hospital in Barcelona, Spain on
December 29, 2006, at the age of 66—1 week shy of
her 67th birthday. The babies were delivered prematurely
by caesarean section and weighed 3.5 pounds
(1.6 kg) each. Bousada became pregnant after receiving
IVF treatment using donor eggs at the Pacific Fertility
Clinic in Los Angeles, California. She had no job, no
husband, and had sold her home to pay for the infertility
treatment. Doctors at the clinic claimed that Bousada
lied about her age, saying that she was 55. Her family
was unaware that she had gone to the United States to
undergo fertility treatment until she returned pregnant
to Spain. Bousada’s older brother criticized her decision,
expressing concern over whether she would be able to
raise children at her age. In response to such concerns,
Bousada stated, ‘‘My mother lived to be 101 and there’s
no reason I couldn’t do the same.’’ Maria died on July 11,
2009 from stomach cancer.

2007: An Austrian woman gave birth to her third
child in March 2007 at the age of 66. She had previously
given birth to another child, a girl weighing 6 pounds
(2.72 kg), in the middle of December 2002 at the age of
61. Her oldest child, a daughter, is 30. IVF was used in
both pregnancies. The Italian IVF specialist S. Antinori
oversaw the second. This is the only known case in the
world of two pregnancies and births involving the same
woman over the age of 60.

2008: Seventy-year-old Omkari Panwar gave
birth to twins, a boy and a girl, in India via emergency
cesarean section. The babies weighed 2 pounds each.
Omkari became pregnant through IVF treatment,
which she and her husband pursued to produce a
male heir. Omkari has two adult daughters and five
grandchildren. In response to hearing that she’d possibly
broken the record for world’s oldest mother, Omkari
stated, ‘‘If I am the world’s oldest mother it means
nothing to me. I just want to see my new babies and
care for them while I am still able.’’

2009: Elizabeth Adeney, aged 66, gave birth to
a 5 pound 3 ounce son in Addenbrooke’s Hospital,
Cambridge, England. The child, who was conceived
through IVF treatment in Ukraine from donor egg and
sperm, was delivered by caesarean section on May 28th.
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WHY HAVE CHILDREN AT LATER AGES?
Why do women of later reproductive age want to have
children? Their motivations vary.

One reason is that new technology exists that
permit the creation of children, and it is widely available
in all parts of the world. For example, there are at least 20
infertility programs operating in nations in the Middle
East. Some are operated in collaboration with British,
German, Australian, or other non–Middle Eastern infertility
programs. There are also programs operating in
Pakistan, India, Bangladesh, Malaysia, and Egypt.8 And
there are programs operating in many nations including
Britain, India, Canada, Singapore, the Netherlands,
Australia, France, Brazil, Argentina, Israel, Spain, the
United States, and Germany.

In America, part of the explanation for woman
giving birth later in life involves the fact that women in
America are marrying later in life, often due to pursuit of
their careers or due to economic necessity and, consequently,
postponing motherhood. American women are
also bombarded by media messages that suggest that
technology can extend the age at which a woman can be
fertile with little difficulty.

‘‘Forty may be the new thirty,’’ but fertility drops
drastically after the age of 35. Despite media suggestions
that women can have a child at any age, some women do
not realize the low odds of having their own biological
child or what is involved in terms of cost and time using
infertility services to have a child after age 35.9 The aging
of the eggs is a well-known biological phenomenon, and
it is rarely emphasized that even with IVF the chances of
a successful pregnancy and a live birth are extremely low
(less than 5%) for women 43 or older.

During IVF, it was recently reported that only 1%
of the eggs collected in women between the age of 41
and 42 result in the production of a live-born baby.
The risk of a miscarriage during the first trimester
of a pregnancy for women older than 40 is also higher
(double) than the risk at age 35 or younger, 50% versus
22%, respectively.

Some older women have been involved in prolonged
infertility treatment for many years with no
success and have been referred to egg donation at older
ages. Others are divorced and remarried and want to
have children with their new husbands.

In other cases, women who never married are
deciding they wish to have a child even without a man
acting as a father. And in some cases, the death of a child
prompts a woman to attempt to have another child.

Less is known about the extent to which woman
are seeking to use technology to have children at older
ages in other nations. But the phenomenon is certainly
present and growing. Many couples who suffer from
infertility want to remove the shame of being childless or
to honor the desire to continue the family lineage and,
thus, seek infertility treatments. Some older couples will
use techniques such as sperm, egg, or embryo donation
but keep that fact a secret.

WHY IS OLD AGE AN ETHICAL PROBLEM?
The decision of women to have children later in life
using donor eggs and other forms of reproductive technologies
raises important ethical questions. Central
among these is whether there is an age at which a
woman should be viewed as ‘‘too old’’ to have a child.10
Why should this be? There may be risks associated with
pregnancy in an older woman that are simply too great
for mother or potential child to face.

If there is an age at which reproduction is simply
too risky, then should formal legal restrictions be placed
on access to infertility treatment based on age? Is that
consistent with national and international codes of
human rights that recognize a right to reproduce?
Should religious advisors and doctors not connected to
fertility clinics support the desire of older women to
reproduce, create that desire, tolerate it, or discourage it?

And why pick on women? Haven’t men been
having children in their old age since the reports offered
in the Bible down to the present day?

It is true that men have been able to father
children in their later years albeit in recent times not at
the ages attributed to the biblical sages. There is a report
of one man having his twentieth child at age 90. Some
see sexism when issues of older parenting are raised since
most questions arise about older women. However,
there are huge differences medically and ethically between
men and women having children at very old ages.

Men are not placed at any serious risk by the
process of generating sperm. And although there is some
evidence that older men are at risk of creating children
with a higher incidence of genetic problems and diseases,
15 the risk to children is far greater in women than
it is in men.

When older men historically had children, they
had younger wives who were still capable of giving birth.
This meant that the child would in all likelihood have at
least one biological parent available to play that key role.
That historically has not been true of most older woman
situations. Single older moms may not have the energy,
resources, or health to act as competent parents to
teenagers.

Also the biological facts are asymmetrical when
men and women of older ages seek to reproduce. Older
men do pass on genetic dangers at a higher rate to their
offspring.16 But women having babies at older ages put
themselves at serious risk and increase the risks faced by
their babies, especially when multiple embryo transfers
are involved.17 Pregnancy complications in older women
(women over 40) are well known. They include pregnancy-
induced hypertension, premature rupture of the
membranes, preterm delivery, vaginal bleeding, and
ETHICAL CHALLENGES OF OLDER WOMEN USING INFERTILITY SERVICES/CAPLAN, PATRIZIO 283
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gestational diabetes.8 Pregnancy exposes older women to
physical risks wholly different from those that younger
women face—risks to the cardiovascular system, along
with a much greater chance of postpartum hemorrhage
and cesarean section.

Those who favor allowing older women to
parent argue that studies on older mothers are misleading
because they include spontaneous pregnancies,
women who have not been prescreened prior to
pregnancy, women who are socioeconomically disadvantaged,
and women who were in poor health prior
to pregnancy. They contend that women over age 40
entering oocyte donation programs are typically rigorously
screened prior to acceptance into fertility programs.
But there are no data showing this is so.18 And
there are little data showing that older ‘‘fit’’ women
fare better than other older women when they have
children.

PROGRAMS LEFT TO MUDDLE THROUGH
IN MAKING DECISIONS ABOUT AGE
Without clear guidelines, concern about the ethical
propriety of the technologically driven extension of the
normal reproductive age is a matter of the marketplace.
If you can pay, you can probably find a clinic or a doctor
who will do what you want. And because the issue is
parenting and childbirth, many are reluctant to comment
or become involved in the ethical assessment of the
practice, much less suggest the imposition of limits
upon it.

As a result, thoughtful doctors and clinics not just
seeking a payday from women to pursue their goal of
having a child must struggle with the following questions:
How should the risks of pregnancy in older
women be weighed against the rights of women to
control their own reproductive lives? How should a
woman’s age and life expectancy factor into a clinic
policy concerning access to services? How hard should
a clinic try to establish what parenting arrangements
have been made in the event of the death or severe
disability of the would-be mother or father? What do we
know about the capacity for postmenopausal women to
parent infants and toddlers? What do we know about the
development of children resulting from such services and
how they fare as the children of comparatively aged
parents?

The last question has not been answered because
the long-term consequences of pregnancy in older
women are unknown. There are no mandatory registries
following older mothers or their children. Still, some
nations, notably the United Kingdom, have decided to
err on the side of caution and impose age limits on single
mothers seeking infertility treatment.4 This has led to
some women from the United Kingdom going overseas
to seek care in countries that lack restrictions.

Concerns about the children of older mothers
seem to fall into two categories: one is about the life
expectancy of the mothers and the fear that children will
be orphaned at an early age. The other is about the
health of the older mothers and the fear that they will
not have the energy and the stamina to care for children.

Those arguing in favor of allowing oocyte donation
for postmenopausal women say that society is
accepting of older men marrying younger women and
having children, so to deny treatment to older women
would be ageist and sexist. They also argue that grandparents
often take on the parenting role and ‘‘bring
economic stability, parental responsibility, and maturity
to the family unit.’’

There are also those who argue that each clinic
should figure out its own policy about age restrictions.
But is this consistent with patient rights to reproduce
and not to be discriminated against in using medical
services? And given the lucrative nature of fertility
treatments, how hard will clinics try to actually screen
much less enforce any age restrictions? Much publicity
follows from having the ‘‘oldest mom’’ in the world give
birth and that translates to prestige, prominence, and
profits.

RESTRICTIONS AND LIMITS ON ACCESS
TO TREATMENT DUE TO AGE
Disciplinewide guidelines are inconsistent or entirely
lacking, so American programs have no generally accepted
standards to provide guidance in making decisions
about these patients. For example, the American
Society for Reproductive Medicine (ASRM) in Practice
Guidelines recommends that all recipients of oocyte
donation over the age of 45 undergo thorough medical
evaluation including cardiovascular testing and a highrisk
obstetric consultation before treatment. The guidelines
do not include recommendations for age restrictions,
however.

A statement from the ASRM Ethics Committee
asserts that oocyte donation to postmenopausal women
‘‘should be discouraged.’’ ASRM also holds that patients
and programs should determine on a case-by-case basis
whether a woman’s health, medical and genetic risks,
and provision for child rearing justify proceeding with
treatment.

Italy enacted a very restrictive policy governing
eligibility for infertility services in 2004. Heterosexual
couples—whether married or living together—in which
both persons are of potentially fertile age have access to
treatment. Homosexual couples, minors, and singles
(i.e., individuals who are not in a heterosexual relationship)
are not. Postmenopausal women cannot undergo
treatment. In fact, the Ministry of Health Guidelines
require that embryos that have been produced at the
request of women who are not ‘‘of potentially fertile age’’
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shall not be implanted but rather collected in a central
repository. An unmarried couple in what the law terms
a ‘‘de facto’’ relationship qualities for treatment. However,
the law avoids defining in any detail what a de facto
relationship is, specifying only that it occurs whenever a
man and a woman live together.

Under the new Italian law, both parents-to-be
must be alive at the time the treatment begins. However,
if the man’s death occurs between the time of fertilization
and implantation, the process is not interrupted and
all fertilized embryos must be transferred.

The Human Fertilisation and Embryology Authority
law enacted in 1990 in the United Kingdom, one
of the few nations to address older parents, determined
that recipients of donor oocytes should not be over age
45, based on the view that it is in the best interest of the
child to be parented into young adulthood.17 Another
clinician used the same argument—that children need an
adult to raise them until they can live independently—
but recommended that the treatment should be limited
to women under the age of 60.

IS THERE A BASIC RIGHT TO REPRODUCE
IN INTERNATIONAL LAW AND ETHICS?
In 1948, the United Nations Universal Declaration of
Human Rights declared in article 16 that ‘‘men and
women of full age, without limits due to race, nationality
or religion, have the right to found a family.’’22 In 1950,
the European Convention for the Protection of Human
Rights and Fundamental Freedoms in article 12 made
essentially the same statement (‘‘Convention for the
Protection of Human Rights and Fundamental Freedoms’’).

These documents are important, but if one looks
at them more closely, they do not and were not intended
to create a right for each person to reproduce. Rather,
they were intended to respect the right of persons to be
left alone and not coerced with respect to reproductive
choices.

There is a difference between negative rights—
the right to be left alone—and positive rights—the right
to claim entitlement to a service or a means to obtain
something. Nothing in these international covenants
and treaties recognizes the duty of the state or government
to supply single persons with mates much less
access to reproductive technologies.

Although governments can and do adopt pronatalist
stances encouraging people to marry and have
children by means of money, housing, or other perks,
there is no fundamental positive right to reproduce.
Moreover, some nations, such as China, have clearly
felt that even the negative right to be left alone can be
infringed if there is a grave danger posed to the state by
uncontrolled population expansion. Although that position
is certainly open to debate, there is no doubt that
nowhere is the positive right to reproduce recognized in
international law, treaties, covenants, or legislation. So
there is no legal obligation to provide older persons with
the technology requisite for them to reproduce.

CONCLUSIONS
There are many reasons why older parents having children
might be a commendable moral act. But there are
also a host of reasons for concern based on the safety of
pregnancy for older women, risks posed to children
delivered by older mothers, issues around what constitutes
safe conditions for having a child relative to the age
of parents, and a lack of data on the impact of older
parenting within and outside of marriage on children. It
would seem prudent in terms of trying to advance the best
interest of children to have some internationally recognized
standards that fertility clinics must follow in making
decisions about older parenting. And given the
uncertainties of how well very old parents can parent
and the known risks to mothers and children of pregnancy
in old age, it would seen morally appropriate to
demand thorough medical assessments of older candidates
for IVF; extensive examination of the precautions in
place to ensure a parent in the case of single, older
women; and the setting of restrictions on both the age
of women eligible to use infertility services as well as on
the number of embryos that ought be transferred per
cycle to older women.

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