Advances in reproductive technology mean that - provided she has a uterus and money to spare for treatment - a woman can carry a child whatever her age. But has our society been so seduced by our clinical powers, that we can no longer perceive when we are transgressing the boundaries of…
…well, of what? Nature? Ethics? Social expectation? One of the difficulties is that, while there is undeniably lots of concern, it can be hard to pin down the problem. Viewed from one angle, postmenopausal motherhood is unnatural. But then, so are insulin injections for diabetes. So are heart transplants. It is hard to demonstrate that, while postmenopausal motherhood is unnatural, other aspects of modern medicine aren't.
Perhaps it is the ethics of postmenopausal motherhood that is most worrying. We tend to think medicine should improve people's health. But a postmenopausal pregnancy, with all the risks it entails, is surely a threat not an improvement to health. Offering treatment to such women might thus be seen as transgressing the ethical boundaries of medicine, rather than of nature per se.
But again, this will not work. All reproduction is risky, as are many of the activities and choices we favour. It is safer to use contraception than become pregnant, and safer to undergo an early abortion than undergo childbirth (1). If the goal of medicine is to minimise health risks, all women should be denied treatment that increases the chances of pregnancy and childbirth.
Of course, for many people, it is not the woman's health, or the risks she undergoes, that give cause for concern. Rather, it is that she imposes these risks on an innocent child who has no choice in the matter. Can risks to offspring form a better basis for a conclusive rejection of postmenopausal motherhood?
The children of older mothers may be at increased risk of complications caused by the accumulation of genetic defects in eggs as they age. However, postmenopausal women can circumvent this risk by using eggs from younger donors.* Because of this, a child conceived with donated eggs and born to a woman of 60 might be at less risk than a child conceived naturally by a woman of 40.
Nevertheless, postmenopausal reproduction is somewhat riskier than reproduction at the 'optimal' time. But reproduction, even at the optimal time, is never risk-free. Given the huge array of factors that can adversely affect offsprings' health - low parental income (2) and low parental IQ (intelligence quotient) (3) among other things - it's not evident that advanced age in itself is so dangerous as to merit special attention. Older women who give birth are still likely to survive and take home a healthy child (4).
However, in addition to health risks, the child of an elderly mother may risk losing his/her mother early in life. How should this possibility affect decisions about access to treatment? Of all the psychological traumas a child can undergo, the loss of a mother must be among the most severe. If the early loss of a mother is to be avoided, perhaps life expectancy should play a part in determining who has access to treatment.
But where should the line be drawn? Lifespans are increasing. A woman of 60 may reasonably expect to live beyond the age of 80. Also, younger women who seek fertility treatment may do so precisely because their health has been impaired by cancer or other illnesses. Women who seek fertility treatment after life-threatening illnesses do not seem to be castigated by the media, and queries are seldom raised about their life expectancy. It is surely just as terrible for a child to lose her young mother to cancer as it is for a child to lose her older mother to age-related illness. If the risk of losing a parent in infancy is to be minimised, it seems reasonable that the life expectancy of all fertility patients should be ascertained.
I identified three broad categories of concern above: nature, ethics and social acceptability. I have suggested that postmenopausal reproduction is no less 'natural' than many other modern medical interventions. I have also argued that the ethical importance of avoiding clinical and psychological risks to children does not seem to justify a specific focus on postmenopausal mothers, though it might justify a broader concern about life expectancy for fertility patients.
Yet postmenopausal motherhood continues to generate extreme reactions. The problem seems to be the final item in my list: social acceptance. We are not used to the idea of reproduction in older women, and it makes us squirm. With the passing of time, this may change. In the meantime, we need to decide whether our dislike of squirming is a reasonable basis for establishing a maximum age for fertility treatment.
* It is not within the scope of this article to explore ethical questions associated with egg donation itself, although I acknowledge this is an important consideration.