ASRM PAGES Oocyte or embryo donation to women of advanced reproductive age: an Ethics Committee opinion Ethics Committee of the American Society for Reproductive Medicine American Society for Reproductive Medicine, Birmingham, Alabama Advanced reproductive age (ARA) is a risk factor for female infertility, pregnancy loss, fetal anomalies, stillbirth, and obstetric com- plications. Oocyte donation reverses the age-related decline in implantation and birth rates of women in their 40s and 50s and restores pregnancy potential beyond menopause. However, obstetrical complications in older patients remain high, particularly related to oper- ative delivery and hypertensive and cardiovascular risks. Physicians should perform a thorough medical evaluation designed to assess the physical fitness of a patient for pregnancy before deciding to attempt transfer of embryos to any woman of advanced reproductive age (>45 years). Embryo transfer should be strongly discouraged or denied to women of ARA with underlying conditions that increase or exacerbate obstetrical risks. Because of concerns related to the high-risk nature of pregnancy, as well as longevity, treatment of women over the age of 55 should generally be discouraged. This statement replaces the earlier ASRM Ethics Committee document of the same name, last published in 2013 (Fertil Steril 2013;100:337–40). (Fertil SterilÒ 2016;106:e3–7. Ó2016 by American Society for Reproductive Medicine.) Key Words: Ethics, third-party reproduction, complications, pregnancy, parenting Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/ 16110-fertility-and-sterility/posts/10968-oocyte-or-embryo-donation-to-women-of-advanced-reproductive-age-an-ethics- committee-opinion KEY POINTS Prospective ARA patients should be embryos to women over 55 years of counseled about the increased medi- age, even when they have no under- Oocyte and embryo donation is an cal risks related to pregnancy, and lying medical problems, should be established standard of practice for that many of these risks are poorly discouraged. the treatment of age-related infer- characterized due to lack of data. Multiple pregnancy significantly in- tility and is associated with high The counseling process should creases the risks associated with rates of pregnancy success. involve the participation of a physi- pregnancy and delivery; therefore, Adverse obstetrical events and out- cian familiar with managing high- elective single embryo transfer comes are associated with advanced risk pregnancy. (eSET) is the preferred method of reproductive age (ARA), particularly Oocyte and embryo donation should treatment in ARA women. related to operative delivery, hyper- be strongly discouraged if underly- Prospective older parents should be tensive disorders, gestational dia- ing medical conditions that could counseled regarding short- and betes, and perinatal mortality. further increase the obstetrical and long-term parenting and child- Women of ARA considering oocyte neonatal risks are present, particu- rearing issues specific to their age. or embryo donation should undergo larly hypertension or diabetes. The age and health of the partner, if comprehensive medical testing In view of the limited data regarding present, should also be considered focused on ascertaining cardiovas- maternal and fetal safety, as well as in this discussion. fi cular and metabolic tness, as well concerns related to longevity and It is ethically permissible for pro- as a psychosocial evaluation to the need for adequate psychosocial grams to decline to provide treat- determine if adequate supports are supports for raising a child to adult- ment to women of ARA based on in place to raise a child to adulthood. hood, providing donor oocytes or concerns over the health and well- being of the patient and offspring. Received July 1, 2016; accepted July 1, 2016; published online July 20, 2016. The reported success of oocyte Reprint requests: Ethics Committee, American Society for Reproductive Medicine, 1209 Montgomery Hwy, Birmingham, Alabama 35216 (E-mail: [email protected]). donation to women in their 50s (1, 2) and early 60s (3, 4) suggests that Fertility and Sterility® Vol. 106, No. 5, October 2016 0015-0282/$36.00 pregnancy may be possible in Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc. http://dx.doi.org/10.1016/j.fertnstert.2016.07.002 virtually any woman with a normal VOL. 106 NO. 5 / OCTOBER 2016 e3 Downloaded for Anonymous User (n/a) at University of Alabama at Birmingham NAAL from ClinicalKey.com by Elsevier on April 17, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. ASRM PAGES uterus, regardless of age and even in the absence of ovaries are not prohibited from reproduction because of their short- and ovarian function. A woman's reproductive lifespan, ened life expectancy. Given the possibility that postmeno- once a dictate of nature, now can be artificially extended pausal reproduction may satisfy the strong desire of a using hormone therapy and oocyte or embryo donation, or couple or individual for offspring, it would be wrong to in other cases using autologous cryopreserved eggs or deny women the use of donated oocytes or embryos solely embryos procured from earlier treatment cycles. In the because of their age. United States nearly 20,000 embryo transfers using either fresh or frozen donated eggs or embryos occur annually, ARGUMENTS AGAINST OOCYTE AND and often to women of ARA. EMBRYO DONATION TO WOMEN OF Oocyte donation to younger women with primary ovarian ADVANCED REPRODUCTIVE AGE insufficiency, gonadal dysgenesis, poor oocyte quality, or diminished ovarian reserve falls into the conventional realm Arguments against oocyte and embryo donation to ARA of medical treatment addressing the needs of individuals women are based on ideas about natural limits to reproduc- suffering from pathological conditions. However, the practice tion, concerns about childrearing, longevity, and medical of oocyte and embryo donation is more ethically challenged risks. Biologic naturalism contends that oocyte and embryo ‘‘ ’’ when it is used as treatment for women who have experienced donation to older women breaches the natural limit to natural menopause. The average age of spontaneous meno- reproductive capacity in humans and that limited reproduc- fi pause in the United States is about 52 years, an age at which tive abilities de ned by aging is intrinsic to being human. ‘‘ ’’ most women neither desire nor expect to have children. None- Thus, to transcend this limit is unnatural. According to theless, circumstances may lead some women beyond the nat- this view, the fact that some grandparents successfully raise fi ural age of menopause to request oocyte or embryo donation. children would not necessarily be suf cient to justify using For example, women with no children may find life partners assisted reproductive technologies to establish pregnancies in their 50s and desire to start a family, or older couples in sec- after menopause. ond marriages may wish to have children together. In other Another concern relates to the belief that ARA women cases, the loss of a child may motivate couples to seek fertility and their partners may be unable to meet the emotional, fi care. Women may wish to transfer cryopreserved embryos nancial, and physical demands of raising a child and main- from a prior in vitro fertilization (IVF) cycle performed years taining a long-term parental relationship. In addition, there is before menopause occurred. Is the use of a technology that a greater likelihood with older parents that the children will extends women's reproductive life beyond the age of natural suffer the loss of one or both parents before reaching adult- menopause so unreasonable as to be denied, and, if not, hood (6). Data on obstetrical and neonatal outcomes associ- should a recommended standard of practice for its application ated with pregnancy after age 50 remain preliminary and be defined? concerns have been raised that the risks to mother and child are too great to justify the provision of oocytes or embryos to ARA women. Opponents to providing oocytes or embryos ARGUMENTS IN FAVOR OF OOCYTE AND to women in their 50s and older argue that pregnancy at EMBRYO DONATION TO WOMEN OF this age serves neither the interests of older women, nor the ADVANCED REPRODUCTIVE AGE interests of the children they bear. Arguments in favor of oocyte and embryo donation to ARA womenarebasedonmedicalefficacy and safety, societal MEDICAL AND OBSTETRICAL ISSUES practices, gender equality, and reproductive freedom. Live- The medical and obstetrical risks associated with oocyte or birth rates per embryo transfer in women undergoing egg embryo donation to women following natural menopause and embryo donation are generally above 50% (5). Practices are still largely preliminary because of the limited amount throughout the United States offering assisted reproduction of published data. It is well established that medical and typically provide donor oocytes and embryos, making ser- obstetrical complications are significantly increased in preg- vices readily accessible. In our society, it is not unusual for nant women over the age of 45 years, especially regarding children to be raised by grandparents who take on most of adverse events occurring as a result of hypertensive disorders the parenting role and often bring economic stability, and diabetes (7, 8). One report on the US experience with parental responsibility, and maturity to the family unit. donor oocyte cycles from 1996–98 included 440 cycles with There is, therefore, no reason to assume that society will be recipients aged 50–54 (9) but did not assess maternal harmed by allowing ARA individuals to procreate, or that complications of pregnancy. High rates of pregnancy- older women and their partners lack the physical and psy- induced hypertension, gestational diabetes, and cesarean sec- chological stamina for raising children. Also, older men tions in recipients over 50 years old have also been noted (2, may naturally father children and are not restricted from as- 10–13).