MICHELE NORRIS, host:
From NPR News, this is ALL THINGS CONSIDERED. I'm Michele Norris.
Today we conclude our two-part series on ethical issues surrounding reproductive medicine with this question: At what age is a woman too old to have children? That question has become ever more complicated as new technologies allow women to bear children into their 50s and beyond. Doctors at Brigham and Women's Hospital in Boston wrestled with the dilemma recently when two infertile women in their 50s sought the hospital's help in conceiving a child. Both cases were a bit unusual because the women planned to use donor eggs, and instead of carrying the children themselves, both were going to have those eggs implanted into another women's womb, a woman who would serve as a so-called gestational carrier. In a strange twist, the ethics committee at the hospital had to decide whether to impose a cutoff for childbirth even if the woman in question had no biological involvement in the pregnancy.
Dr. ELIZABETH GINSBURG (Brigham and Women's Hospital): In the situation where she would not be carrying a pregnancy, there was really no concern for her health or the health of the baby. So the question really was was she too old to parent and is that a decision we should be making.
NORRIS: Doctor Elizabeth Ginsburg is with Brigham and Women's Hospital. She's the medical director of the Assisted Reproductive Technology program.
Dr. GINSBURG: We really weren't comfortable as clinicians saying, `Well, we have complete control over who's allowed to raise a child and who isn't.' So it's something that we really triaged to our own internal ethics committee, which consists of people in the health-care area in our field. We really couldn't reach a consensus and then brought it to the hospital ethics committee, which is a much broader base of the health-care system and also involves women and men from the community. So we felt that it would be a better representation of what society's feeling was.
NORRIS: Well, without breaching confidentiality, take us into the room. What were some of the arguments that were made for and against this kind of cutoff?
Dr. GINSBURG: Well, I think some of the arguments for having no cutoff was the fact that in our own IVF program, we have no cutoff for the age of a man. Men can have children well into their 60s or 70s or 80s. And if they happen to marry a young woman, then they could get pregnant on their own; they could get pregnant with assisted reproduction. It wouldn't be an issue. But if you flip the situation and there was an older woman, a woman who was past child-bearing age, married to a younger man, we were in that situation not going to offer them care. And that really, for some of the committee, didn't seem fair. It really felt discriminatory.
Other things that were brought up as really fitting into this kind of discussion was kind of flip-flopping about, well, if a woman is older when she raises the child, is it likely that the child will be orphaned at a young age? And it became very clear from the gerontologists that we invited to the committee that, in fact, that wasn't the case, that a woman who's healthy at 50 is very likely to be alive at 80.
NORRIS: I'm wondering if a woman is made aware of the risk, why shouldn't she be able to proceed.
Dr. GINSBURG: Well, the people in the group that felt that she shouldn't be aided to succeed felt that it was a selfish thing for a woman in her 50s to mother a child. Some of the reasons that came up were the fact that as you get older, your parents are more likely to need care. And some of the members of the committee felt that children might feel stigmatized by having parents that were much older. But there's no data. This is really uncharted territory. So it wasn't a situation where we could look at standard of care around the country because there's no standard of care here. There wasn't really anything to help guide us.
NORRIS: It's hard to imagine that this conversation is limited to Brigham and Women's. Is this kind of debate happening in fertility clinics all across the country?
Dr. GINSBURG: It is. And I did call several colleagues around the country. And for most places, they've arbitrarily drawn their cutoff in particular places. Some places use an average age of the couple of a hundred. So if the husband was 20 and the woman was 80, I guess theoretically they would say yes. And obviously that situation seems odd, and you'd be concerned about what social issues underlay that relationship. But I think that's what you run into when you set arbitrary guidelines that aren't based on anything.
NORRIS: So you've heard the arguments for and against this. What conclusion have you reached? At what age is a woman too old to become a mother?
Dr. GINSBURG: Well, I'm a liberal person, and I really felt that if women were well-counseled and healthy and we had no reason to think that she wouldn't be a good parent, that we shouldn't arbitrarily be deciding on a cutoff. I certainly was very comfortable with women using gestational carriers with donor eggs up to age 55. And I personally felt that we should have decided to do it on a case-by-case basis up to 60.
NORRIS: That's Dr. Elizabeth Ginsburg of Brigham and Women's Hospital in Boston.
Her, as she calls it, liberal view about cutoff for motherhood are not shared by all. Dr. Robert Stillman, for one, says the dilemma over age cutoffs at Brigham and Women's is an easy call. He argues that there should be strict age limits for any kind of medically assisted conception.
Dr. ROBERT STILLMAN (Shady Grove Fertility Center): An important cutoff is when medical therapies can be successful. And once they cease to be successful, then medical advice would be that a woman should not conceive.
NORRIS: Dr. Robert Stillman practices at the Shady Grove Fertility Center in Rockville, Maryland. The clinic doesn't offer in vitro fertilization to women older than 44 because that's the age most women stop producing their own eggs. And they don't allow women over the age of 51 to undergo IVF using donor eggs because 51 is the average age of onset for menopause.
Dr. STILLMAN: Most physicians are not interested in extending the reproductive life span, whether that be earlier than puberty--because we can induce ovulation in an eight year old, but no one would ever consider doing that hopefully--and menopausal women after their reproductive life has ended would not come under medical therapy either.
NORRIS: I want to make sure that I understand why you're not interested in extending a woman's reproductive years beyond menopause.
Dr. STILLMAN: Well, as medical practitioners, our goal is to treat patients. And if an individual at 22 or 32 or 42 has difficulty becoming pregnant, then it's our responsibility and honor to play a role in helping them do that. Somebody at 62 who wishes to conceive is not within the purview of medical intervention.
NORRIS: So you're saying as a doctor, you treat medical disorders. And in your view, menopause is not a medical disorder.
Dr. STILLMAN: Precisely. And well-put.
NORRIS: But you could also argue that a woman who is in her 40s, maybe even in her 50s, who's researched this, who understands the risk, who's gone through a process of full disclosure and still wants to move forward--you could argue that it would be unethical to deny her that treatment.
Dr. STILLMAN: Well, I think that's a specious argument. Again, as medical practitioners, not just technicians doing the bidding of an individual with a social goal, as legitimate as the social goal might be--I wouldn't judge a 62-year-old woman who wishes to get pregnant, judge whether that's good or bad. But a patient is an individual with a medically defined disorder, and infertility in menopause is not a medical disorder. So we should stick to what we do, and that's treat people.
NORRIS: Dr. Stillman, should decisions be made on a case-by-case basis?
Dr. STILLMAN: Well, there are always exceptions. But a case-by-case basis, I think, brings up the concerns of a bias with one couple vs. another. On what do we decide? Are they nice? Is their story sadder or less sad? Are they wealthy or less wealthy? Are they one race or another? Or are they one religion or another? I think that raises significant problems for the medical care providers and possibly for the people they're treating. A 55-year-old and another 55-year-old couple, how can I say yes to one and no to another? So if we do it based on biologic grounds and make it fair, then you say anybody over this biologic limit, we wouldn't treat. And anybody under the biologic limit, we would.
NORRIS: That's Dr. Robert Stillman of Shady Grove Fertility Center in Rockville, Maryland.
Childbirth near or beyond those biological limits does carry increased risk for both mother and child. Studies show that older women are more likely to develop high blood pressure and diabetes during pregnancy, and there's a higher incidence of birth defects and premature deliveries. Margaret Janicki LaBarbera was aware of those risks, but true love didn't arrive on a schedule in keeping with her biological clock. She didn't meet her husband until she was in her 50s. At age 54, she had their first child, made possible through in vitro fertilization and a donor's egg. She had a second child 16 months later. And now at 58, she's raising two toddlers.
Ms. MARGARET JANICKI LaBARBERA: I guess I'm not so sure nowadays that we always make choices that honor nature's biological clock. I know I had no difficulties. I belong to a mom's group, and it's interesting that I, in some ways, had less difficulties than a lot of the other younger women. Ethically, a lot of it was about can we be responsible parents for these children that we bring into the world? And I think as an older person, you also bring a certain maturity and knowledge.
NORRIS: We've heard from a group of doctors that are really struggling with this question. If you had a seat at the table, and they turned to you, and they said, `Margaret, what do you think about this?' what would you say?
Ms. LaBARBERA: I guess what I would say is I think it's so personal because you can have somebody at 55 who is physically quite healthy, you can have somebody at 35 who is physically older in many ways and less healthy who is more of a health risk. Do you say to the 35-year-old, `You can't have children because you're a health risk?' but to the 55-year-old, `You can't have children because of your age'? I think it's a complicated issue. I don't think there's one simple answer.
NORRIS: If we can project out a little bit further, you'll be 65 when your children are 10 and 11, 70 when they're 15 and 16. Look into your crystal ball and imagine what life will be like at that point.
Ms. LaBARBERA: Well, I do. And as I look around at other people--my husband has an aunt who's 78. And, I mean, she's able to go places and does things, and she's active. And old age has moved up. You know, you're looking at your 80s and your 90s. And I think I'm also realistic. I mean, I know that things can happen. And I think that's the other reason why we are trying to be responsible in making sure that our kids are not feeling like they only know us. They have family, they have friends, they know other people their age. And I also know that as the kids get older, we're going to have to have some conversations about why Mommy and Daddy look older than the mommy and daddy of everybody else that they know or of many people that they know.
NORRIS: That's Margaret Janicki LaBarbera, who had her first child at age 54.
Around a thousand women in their 50s and 60s have given birth in America over the past decade. And while the debate over postmenopausal motherhood continues, there's more than a bit of irony in one recent statistic from the US Census: 2.3 million grandparents in America are spending their twilight years taking care of their grandchildren.
You can hear the first piece in our series on the subject of egg donation. That's at our Web site, npr.org.
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