Older Women Pregnancy:: CHR Special Contribution

The October 3 issue of New York Magazine features a nude photograph of a pregnant woman of a grandmotherly age, accompanied by the question "Is She Just Too Old for This?" The accompanying article by Lisa Miller explores the issue of older women pregnancy and the question of when and if a woman is ever too old to get pregnant and have a child. As the leading fertility center with special expertise in treatment for older women wanting to conceive, CHR feels compelled to point out that this is simply not the right question to ask.

Special Contribution

Despite the more than enough economic and other policy issues that would warrant front-page coverage, older women pregnancy suddenly appears to have become the topic of the moment.

Recently we commented on a very personal account by Holly Finn in The Wall Street Journal (July 23, 2011), which portrayed her ultimately unsuccessful attempt at achieving older women pregnancy. A recent story on single embryo transfer in the popular online magazine Slate (August 15, 2011) also quickly expanded into maternal age.

Now, New York Magazine's cover of its October 3, 2011 issue features a nude, pregnant woman of a grandmotherly age in the well known Demi Moore pose, accompanied by the question "Is She Just Too Old for This?"

Why the sudden interest in pregnancy in older women?

It is no coincidence that New York Magazine features this story. New York City, with its concentration of career-orientated women, is the quintessential starting point for this seemingly sudden societal development, which in reality has been quietly growing for over a decade.

Already in a publication in 2007 (Gleicher et al. Too old for IVF: are we discriminating against older women? J Assist Reprod Genet 2007; 24:639-644) researchers at CHR pointed out the impending developments, resulting in a significant increase in pregnancy in older women, often for the first time. Based on the National Vital Statistics, since before 2003, women between ages 40 to 45 represent the most rapidly growing age group in the U.S. going through pregnancy. The trend has only accelerated since.

By 2004, 4,709 fresh in vitro fertilization (IVF) cycles, 5% of all U.S. cycles, were performed for women over 42. By 2008, 14,162 cycles (9.6%) occurred in women at 41 and 42, 8,893 (6.0%) in women at ages 43-44, and 6,981 (4.7%) in women above age 44. In four years, the proportion of women above age 42, thus, had more than doubled!

By 2008, less than half of all IVF cycles performed in the US (57,508, 38.8%) involved women under 35 and only 60% occurred in women under 38. When IVF was introduced into clinical practice in the early 80s, age 38 was, for all practical purposes, the upper age limit for the procedure!

The developed world, therefore, is in the midst of a reproductive biological revolution, whose consequences so far have not been registered, understood, discussed or investigated by sociologists and/or the medical profession.

It then should not surprise that Lisa Miller, in her otherwise well balanced and well written story, missed the main point: The question is no longer "is she (a hypothetical woman) just too old for this?" This question has been already answered by thousands of women, with a decisive NO! The real questions to be asked are much more complex. The questions all relate to the multitude of societal consequences arising from so many older women (and some older men) becoming parents.

Evolutionary consequences

Extension of the female's reproductive lifespan has been a topic of primary interest for almost a decade for CHR. Over the years, CHR has developed a worldwide reputation as the leading fertility center in the world when it comes to "older" ovaries. Our patient population has significantly aged in parallel, with the average age of newly presenting patients now at around 40 years (Gleicher and Barad. Dehydroepiandrosterone (DHEA) supplementation in diminished ovarian reserve (DOR). Reprod Biol Endocrinol 2011;9:67). Women in their mid-40s and above now represent a large minority of the center's patients.

Interestingly, CHR researchers have recently identified evidence that evolutionary genetic processes have been working for thousands of years on expanding female reproductive lifespan via genetic mutation of the FMR1 gene. By defining the so-called ovarian genotypes and sub-genotypes of FMR1, CHR investigators demonstrated how, over time, new genotypes and sub-genotypes evolved, and expanded the length of time women are able to conceive, likely by influencing the speed of follicle recruitment and ovarian follicle depletion.

In this sense, extension of female reproductive lifespan must be viewed as an evolutionary process, carrying significant societal consequences at each stage of extension. Our rapidly developing medical abilities means that more and more women, who had absolutely no chance of pregnancy only a few decades ago, will be able to achieve older women pregnancy and and have children. Therefore, dramatic societal changes will take place.

Medical consequences

Extension of female reproductive age and increased frequency of pregnancy in older women will also have major significance for health care, especially in prenatal management. As the age of women who conceive increases, medical complications of older women pregnancy are increasing, as pregnancy is a "stress test" for the whole body and all of its systems. This is why CHR's Founder and Medical Director, Dr. Gleicher, who edited Medical Therapy in Pregnancy and co-edited (with Uri Elkayam, MD) Cardiac Problems in Pregnancy, now a classic, always described pregnancy as a "window into a woman's medical future."

Because of increasing perinatal and neonatal risks with advancing maternal age, many medical colleagues often outright object to older women pregnancy. What they fail to understand, however, is that they no longer have a choice. The boat set sails a while ago, left the harbor and is on the way towards new lands.

Women will have children at progressively older ages, and medical providers better get ready to offer the required levels of medical expertise for pregnancy in older women. Our responsibility as physician is to correctly inform our patients about potential risks. It is not up to us to tell them how to live their lives. The last thing a childless older woman needs is an excessively opinionated health care provider who makes her feel even guiltier about not having attempted childbirth at a younger age. As physician it is not our function to "punish" patients for what we consider "incorrect" decisions. Just as we do not withhold care to smokers who suffer from lung cancer or from obese diabetics, it would appear unethical to withhold care from an older woman, who desire pregnancy.

Once again, not surprisingly, egg donation represents the most rapidly growing form of IVF proportionately. Most recently published national statistics shows that donor egg cycles in 2008 represented 12.3% of all IVF cycles. This percentage can be expected to grow since egg donation further extends a woman's reproductive lifespan beyond her natural abilities with the use of her own eggs.

Perinatology, neonatology and medical sub-specialties in general, therefore, better get ready to take care of pregnancies in increasingly older women. In The Netherlands, a university department recently established a first cardiology section within a perinatal unit to specifically address increasingly frequent cardio-vascular problems in pregnancy. At this point, it may not be exaggerated to expect an evolution of "geriatric" perinatologists in the near future, with special expertise in managing pregnancy in older women.

Societal consequences of pregnancy in older women

So far, the trend towards childbirth at older ages is primarily in the developed world, which also has the lowest birth rates. Most of Europe as well as Japan persistently demonstrate birth rates below what is required for population replacement. Even the U.S., which used to comfortably exceed replacement rates, is now just barely reaching them. Since it is practically impossible to grow economies without expanding populations, governments should welcome the fact that increasing numbers of women are in fact having children in later life.

As pregnancy in older women becomes more common, the societal fabric has to change in their support. Ways to achieve that goal, to accommodate the needs of older mothers and encourage them in their pursuits of forming new family units (often as single mothers), urgently needs to be studied.

To answer New York Magazine's question "whether there is anything wrong with older women pregnancy or being pregnant at age 53," the answer, therefore, is a loud and clear NO (as long as the mother is mentally, physically and socially in appropriate shape, of course). What is clearly wrong is how unprepared the society, academia, government and the medical profession are in serving older mothers.

-The CHR

CHR is a leading infertility center in New York City, with world-wide patient clientele, well recognized for its extensive clinical research program, which over the years contributed a number of major breakthrough to the IVF process.

Last Updated: October 12, 2011