In an excellent review published in the Journal of Assisted Reproduction and Genetics, entitled “Is it time to establish age restrictions in ART?” (assisted reproductive technologies) the authors address a growing modern-day medical and ethical challenge. The increasing social trend (read our article Social Freezing) of postponing having children and the advances in and accessibility of assisted reproduction services have dramatically increased the number of older parents in our society. In the article, the authors explore the medical and psychosocial implications of this trend for both older parents and their children.
We excerpt from the study what we consider of bioethical interest. The article begins by discussing the increasing number of older parents and the lower rate of mothers under the age of 30 in our postmodern societies, remarking that “There has been a dramatic increase in women having children in their 40s, 50s, and even 60s. […] Thus, advanced-aged parents are becoming more common, and possibly more socially accepted. Simultaneously, concerns for the welfare of children of older-aged parents are increasing.” (read HERE).
The authors continue with a reminder that, “It has been demonstrated that a significant linear relationship exists between advanced maternal age and adverse perinatal outcomes, including intrauterine growth restriction, low birth weight, congenital malformations, and perinatal mortality.”
“Additionally, the focus on perinatal outcomes does not address the life-long health risks for children born to older parents or the psychosocial impacts of delayed parenting for both parents and their children”.
They go on to explain the relevance of the study, “Understanding the implications for both parents and children of advanced-age parenting is important in order to provide reproductive health professionals with critical information to guide treatment decisions and to ensure appropriate informed consent” (emphasis added).
What constitutes “great harm” in the reproductive field?
The report gives some positive opinions of specialists about advanced-age parenting.
“Roberson argued that ‘procreative liberty deserves primacy because it is an important aspect of self-determination and well-being’, and “asserted that ‘reproductive choices have such a major impact on a person’s life—on one’s body, and one’s sense of meaning—that we are committed to assigning discretion over them to the individuals directly involved unless great harm (emphasis added) to others from the choice would ensue’. As applied to the issue of advanced-age parenting, the argument would be that older potential parents enjoy the same rights as younger potential parents and that the value of reproduction does not differ across age groups.” The authors then ask a crucial question: “The open question that remains with this argument is what constitutes ‘great harm’?”
Analyzing the risks of children born to older parents based on the latest studies
We prefer to quote the authors on such a delicate matter:
“Children born to older parents are at increased risk for:
autistic spectrum disorders and pervasive developmental disorders. More specifically, children born to fathers 35 to 49 years of age are more likely to be diagnosed with autism. A recent review suggests a 21% increased risk of autism in children with each additional decade of paternal age. The same review suggests an 18% increased risk of autism for each additional decade of maternal age.
Additional data suggest that children born to mothers 35 years old or more are at increased risk for Asperger’s syndrome and children born to mothers 40 years of age or more are at increased risk for pervasive developmental disorder.
Schizophrenia may also be more common amongst children of older parents. Research suggests that children of fathers age 35 and older have higher risks of schizophrenia (pooled estimate 1.33; 95% CI, 1.25–1.42) whereas, after adjustments for paternal age, male children of mothers aged > 45 demonstrate an increased risk of schizophrenia (increased relative risk 1.86; 95% CI, 1.12–3.10).
Furthermore, children born to older fathers are at increased risk for depression and anxiety, whereas children born to older mothers are at increased risk for hyperkinetic disorders.
There are also concerns regarding possible shortened longevity for the children of older parents. German genealogical data for births between 1650 and 1927 suggests that daughters of mothers ≥ 40 years were likely to live nearly 9 years less and sons 5 years less than those whose mothers were 20–29 years of age are more likely than their peers to be in a caregiving role for their parents before reaching adulthood. Children serving as caregivers are at increased risk for depression, anxiety, eating disorders, substance abuse, and behavioral problems.
Further, they can have difficulty emancipating from the home and tend to delay advanced education, dating, and marriage . They can be anxious regarding their parents’ health and risk of death and report fear of parental death. They report an emotional struggle watching parental decline, illness, or pain, as well as fear of finding their parent dead.”
Meanwhile, the authors based their statement in peer review studies they noted that these above-listed referring psychological risks have not been well studied and thus require caution as a basis for the implementation of age policies.
They also ask, “While there are clear risks for both parent and child in advanced-age reproduction, the question that remains is whether the psychological risk of children serving as caregivers or parental death, as well as other potential hazards, is serious enough to support an age limit on assisted reproduction.”
The authors quote ethicist John Robertson who wrote that
“Providers faced with patients who pose a risk of having children with less favorable physical, social, or psychological situations, may not wish to treat them. Precisely because fertility services could produce a child, physicians may reasonably view themselves as having a moral responsibility for causing the existence of the resulting child and choose not to help bring about such an outcome”.
The study continues, “American Society of Reproductive Medicine in his Ethics Guidelines on child-rearing ability affirms that The wellbeing of offspring is an overriding ethical concern that should be considered in determining whether to provide infertility services” and “Physicians may take the welfare of resulting children into account in deciding whether to provide services” (read HERE). In the authors’ opinion. “While these ethical principles and guidelines may help direct decision-making, in practice, it is difficult for physicians to know precisely where the boundaries for responsible and ethical care lie”
They also give a somewhat contrasting view[…]
“ethicist John Harris rejected the argument for restricting access to reproductive technologies based upon potential harm to the resulting child by asserting that the concerns raised are seldom of sufficient seriousness, probability, or proximity to justify a constraint on reproductive liberty.”
IVF age limits. Preliminary professional attitudes
The review begins this section with:
“a recent qualitative study of attitudes, process, and decisions regarding age cutoffs provides some insight into how ART providers grapple with this issue. […] To this end, many practitioners indicated that they were making age limit decisions based on personal feelings and beliefs as well as on perceptions of public opinion, noting further that public opinions are fueled by unrealistic information presented in the media.”
Public views on assisted reproductive technologies restriction
Based on a survey study, the authors say that the public’s view on age limits for fertility care suggests support for age limits:
“A nationally representative sample of 1427 adults was given age groupings to select from when answering the question of what age limit should be placed on women for carrying a pregnancy (i.e., including the possibility of donor eggs). A majority, 67%, felt there should be age limits for women receiving fertility car, 46 % percent of respondents chose the 45–54 age group as an upper limit and an additional 24% chose the 55–64 age group for an upper limit. 59% percent supported age limits for men in reproductive care, with24% feel that the oldest age a man should become a father was 45–54 years and 33% feeling the oldest age should be 55–64. Interestingly, only male respondents were likely to support age limits for women, but not for men.”
The study concluded these last sections, stating the following:
“Considering preliminary information surveyed from the public, as well as from members of the ASRM, it seems that both the professional and the lay public are interested in openly discussing age limits for providing fertility care. Importantly, this dialog should occur with equal consideration for age limits for men and women, given the known health risks incurred by children of older-aged parents of both sexes. But they admit […]that with the growing number of patients of advanced reproductive age entering fertility treatment, consensus, and policy development will not be easily accomplished.”
The review conclusions are that considering medical risk for mother and possibly great harm for the child, a robust discussion of this issue is long overdue.
There is no doubt that for a couple who are having difficulties in conceiving, having a child is an objective good. However, it is also indisputable that assisted reproduction techniques raise clear ethical concerns. In order to begin this bioethical reflection, it should be clearly established that the early embryo, which can be manipulated or destroyed using these techniques, is a living being of our species.
We believe this is unquestionable from a biological point of view, and the embryo, therefore, deserves our full respect. The bioethical assessment of assisted reproduction techniques includes analysis of embryo losses caused by their selection and manipulation through preimplantation genetic diagnosis, ‘social freezing’ or the possible lack of rigor in the information provided by the clinics involved, to which must be added the higher morbidity reported in babies born as a result of these procedures.
In this sense, we support indeed the establishment of age restrictions for this collective as soon as possible.
Julio Tudela y Manuel Zunin
Bioethics Observatory – Institute of Life Sciences