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Advanced Maternal Age: Ethical and Medical Considerations for Assisted Reproductive Technology Journal name: International Journal of Women’s Health Article Designation: Review Year: 2017 Volume: 9 International Journal of Women’s Health Dovepress Running head verso: Harrison et al Running head recto: Maternal age and reproductive technology open access to scientific and medical research DOI: 139578 Open Access Full Text Article REVIEW Advanced maternal age: ethical and medical considerations for assisted reproductive technology Brittany J Harrison1 Objectives: This review explores the ethical and medical challenges faced by women of Tara N Hilton1 advanced maternal age who decide to have children. Assisted reproductive technologies (ARTs) Raphaël N Rivière1 make post-menopausal pregnancy physiologically plausible, however, one must consider the Zachary M Ferraro1–3 associated physical, psychological, and sociological factors involved. Raywat Deonandan4 Methods: A quasi-systematic review was conducted in PubMed and Ovid using the key terms Mark C Walker1–3,5 post-menopause, pregnancy + MeSH terms [donations, hormone replacement therapy, assisted reproductive technologies, embryo donation, donor artificial insemination, cryopreservation]. 1 Faculty of Medicine, University Overall, 28 papers encompassing two major themes (ethical and medical) were included in of Ottawa, Ottawa, ON, Canada; 2Division of Maternal-Fetal the review. For personal use only. Medicine, University of Ottawa, Conclusion: There are significant ethical considerations and medical (maternal and fetal) The Ottawa Hospital, Ottawa, ON, complications related to pregnancy in peri- and post-menopausal women. When examining the Canada; 3Ottawa Hospital Research Institute, The Ottawa Hospital, ethical and sociological perspective, the literature portrays an overall positive attitude toward Ottawa, ON, Canada; 4University pregnancy in advanced maternal age. With respect to the medical complications, the general of Ottawa Interdisciplinary School of Health Sciences, Ottawa, ON, consensus in the evaluated studies suggests that there is greater risk of complication for spon- Canada; 5Department of Obstetrics, taneous pregnancy when the mother is older (eg, .35 years old). This risk can be mitigated Gynecology and Newborn Care, The by careful medical screening of the mother and the use of ARTs in healthy women. In these Ottawa Hospital, Ottawa, ON, Canada instances, a woman of advanced maternal age who is otherwise healthy can carry a pregnancy with a similar risk profile to that of her younger counterparts when using donated oocytes. Keywords: maternal age, medical, ethical, assisted reproduction, menopause Introduction International Journal of Women's Health downloaded from https://www.dovepress.com/ by 54.70.40.11 on 12-Dec-2018 Recent advances in assisted reproductive technologies (ARTs) have made it more possible for older couples to conceive. With the advent of ARTs, it is now physiologi- cally possible for post-menopausal women (PMW) to become pregnant; as well, ARTs are being used with increased frequency for women of advanced maternal age (AMA).1 In parallel with technological advances, a cultural shift has seen greater societal accep- tance of women having children later in life. Consequently, a post-menopausal state is no longer a barrier to gestation in areas of the world where this social viewpoint is shared, and where ARTs are available. However, AMA and pregnancy after physiologic menopause, can give rise both to Correspondence: Brittany J Harrison a number of medical complications and to a series of ethical challenges.1,2 This review McMaster University, Faculty of Medicine, 100 Main St West, Hamilton, ON L8P 1H6, aims to critically appraise and evaluate the existing literature surrounding this phenom- Canada enon, and give recommendations concerning pregnancy complication risks, as well as Tel +1 905 220 5617 Email [email protected] to discuss some of the practical aspects of post-menopausal pregnancy (PMP). submit your manuscript | www.dovepress.com International Journal of Women’s Health 2017:9 561–570 561 Dovepress © 2017 Harrison et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/IJWH.S139578 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Harrison et al Dovepress Methods with pregnancy. The remaining 34 papers were read in detail Search strategy by two reviewers and eliminated if they did not pertain to PubMed and Ovid were searched to identify relevant lit- either the ethical or medical challenges that accompany a erature pertaining to PMP and the associated ethical and PMP; this left 28 papers for review. This is demonstrated in medical challenges. To complement the comprehensive the flow chart of Figure 1. Ovid search, a PubMed search was conducted using the search terms “post-menopausal AND pregnancy + MeSH Synthesis strategy Terms [donations, hormone replacement therapy, assisted The remaining 28 papers were first divided into two broad reproductive technologies, embryo donation, donor artificial categories for review: those pertaining to primarily ethical insemination, cryopreservation]” with no filters applied. discussions and those encompassing medical complications. This broad search, which was completed in November 2016, Key details pertaining to our objectives and inclusion criteria ensured we captured all relevant literature and yielded were extracted and tabulated (Tables 1 and 2). 144 papers in total. These titles and abstracts were then For the ethical section, review of 12 papers was done screened and included if they met the following inclusion equally by two reviewers. Key arguments were extracted out criteria: written in the English language and contained any of the text, combined into themes, and summarized according discussion of the ethical and medical (maternal and fetal) to argument in Table 1. complications of pregnancy in AMA. For our purposes, For the medical complications section, 16 papers were AMA is defined as .35 years. There were no exclusions reviewed equally by two separate reviewers. Descriptive based on type of article. information including patient characteristics, sample size, All abstracts were reviewed for content relevance and study design, and the fetal and maternal medical complica- 110 papers were excluded as they were out of scope and had tions associated with AMA were extracted from the papers, an alternate focus such as hormone replacement, neoplasms and summarized in Table 2. These reviewers split the papers For personal use only. caused by exogenous estrogen, and disorders not associated and screened for qualitative and quantitative content in full. ,QLWLDOVHDUFK³SRVWPHQRSDXVDO$1'DGYDQFHGPDWHUQDODJH$1'SUHJQDQF\0H6+7HUPV>GRQDWLRQVKRUPRQHUHSODFHPHQW WKHUDS\DVVLVWHGUHSURGXFWLYHWHFKQRORJLHVHPEU\RGRQDWLRQGRQRUDUWLILFLDOLQVHPLQDWLRQFU\RSUHVHUYDWLRQ@´ SDSHUV 7LWOHVDQGDEVWUDFWVZHUHH[FOXGHGLIRXWRIVFRSHRUKDGDOWHUQDWHIRFXVVXFKDVKRUPRQHUHSODFHPHQW QHRSODVPVFDXVHGE\H[RJHQRXVHVWURJHQRUQRQSUHJQDQF\DVVRFLDWHGFRPSOLFDWLRQV SDSHUV International Journal of Women's Health downloaded from https://www.dovepress.com/ by 54.70.40.11 on 12-Dec-2018 6HFRQGDU\VHDUFKSDSHUVZHUHHDFKUHDGLQGHWDLODQGLQFOXGHGLIWKH\SHUWDLQHGWRHWKLFDOFRQVLGHUDWLRQVRU PHGLFDOFKDOOHQJHVDFFRPSDQ\LQJDGYDQFHGPDWHUQDODJHSUHJQDQF\ SDSHUV 3DSHUVZHUHGLYLGHGLQWRWZRFDWHJRULHVIRUUHYLHZ SULPDULO\HWKLFDOGLVFXVVLRQVDQG WKRVH HQFRPSDVVLQJPHGLFDOFRPSOLFDWLRQV SDSHUV HWKLFDO SDSHUV PHGLFDO Figure 1 Flow chart demonstrating selection of papers. 562 submit your manuscript | www.dovepress.com International Journal of Women’s Health 2017:9 Dovepress Powered by TCPDF (www.tcpdf.org) 1 / 1 Dovepress Maternal age and reproductive technology Table 1 Ethical arguments: post-menopausal pregnancy Author, year Overarching theme Conclusion Benshushan and Post-menopausal women (PMW) possess many qualities which enhance their parenting abilities. For Schenker,1 1993 Time and experience is needed to fully understand the effect on children. Edwards,14 1993 Patient autonomy must not be violated. For Paulson and Individualized care and decision-making is required. For Sauer,17 1995 Broad categorical exclusions are not fitting for in vitro fertilization (IVF) in PMW. Mori,23 1995 Patient autonomy must not be violated. For However, to protect child welfare, the procedure should be limited to women below 60 years of age at present. Parks,6 1996 Equality must not be violated. For Ageism and sexism underlie most arguments against IVF in PMW. Eisenberg and Patient autonomy must not be violated. For Schenker,8 1997 However, to protect child welfare, the procedure should be limited to women below 55 years of age at present. American Reproductive Infertility is natural among PMW and nature should not be violated. Against Medicine,24 2004 Landau,7 2005 The risks and costs outweigh the benefits and success associated with IVF in PMW. Against IVF in PMW has the potential to increase human suffering. Cutas,9 2007 Patient autonomy must not be violated. For It cannot successfully be shown that
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