Decline in egg quality and quantity

Women over 50 may opt for fertility treatment to expedite conception. It is generally recommended that women over 43 consider donor eggs for better outcomes. As women age, the number of available eggs for recruitment and maturation decreases, with a higher risk of chromosomal abnormalities. Despite ovarian stimulation with high-dose gonadotropin in in vitro fertilization (IVF), the expected egg count in this age group is extremely low, with a high risk of aneuploidy. Preimplantation genetic testing for aneuploidy (PGT-A) is used to select embryos with normal chromosomes for transfer to reduce the risk of miscarriage or unhealthy pregnancy. However, given the low number of good quality embryos expected in this age group, PGT-A is unlikely feasible and will likely yield an aneuploid result. Human Fertilisation and Embryology Authority (HFEA) figures show that birth rates per embryo transferred are above 25% for women under 35, decreasing to 15% or lower for women over 40, and less than 5% for women over 44.

Use of donor eggs and cryopreserved oocytes

Given the high risk of aneuploidy near menopause, donor eggs or cryopreserved oocytes are viable options for women wishing to conceive. Women who have preserved their fertility by freezing eggs can store them for up to 55 years under UK legislation. These eggs, retrieved and cryopreserved at a younger age, are thawed and fertilized via intracytoplasmic sperm injection (ICSI) when fertility is desired. Single embryo transfer is recommended to reduce the risk of multiple pregnancies and associated complications. Women opting to use donor eggs can choose either an altruistic or known donor. In the UK, donor anonymity is limited, as donor-conceived children can request identifiable information about their donor at 18. Criteria for becoming a donor include being under 35 and in good general health. A fertility specialist will assess the donor’s medical, surgical, gynaecological, family, mental health, and social history. They will also conduct a baseline transvaginal scan focusing on antral follicle count and a blood test for anti-Mullerian hormone to determine ovarian reserve. This helps decide donor suitability. Donors will undergo screening for karyotyping, full blood count, cytomegalovirus, infection and genetic conditions like cystic fibrosis and autosomal recessive deafness.

Pregnancy complications

Women of advanced maternal age face much higher risks of obstetric and perinatal complications compared to younger women. For example, the likelihood of preterm delivery, gestational diabetes, pregnancy-induced hypertension, pre-eclampsia, low birth weight, and needing a caesarean section is at least twice as high for women aged 40 and older. Additionally, the use of donor eggs, common in this age group, is an independent risk factor for pre-eclampsia. While donor or cryopreserved eggs may reduce genetic risks, the gestational carrier’s age remains a key determinant of pregnancy outcomes.

The risks become more pronounced when comparing spontaneous pregnancies to those achieved through assisted conception in very advanced maternal age (VAMA), referring to women aged 45 and above. Among this group, pregnancy-induced hypertension affects 5.5% of spontaneous pregnancies but rises to 19.2% in those aged 50+ using donor eggs. In VAMA women, rates of pre-eclampsia, preterm delivery, and low birth weight are 1.1%, 9.3%, and 7.4%, respectively, but rise to 12.6%, 23.3% and 22.1% with donor eggs. Gestational diabetes in VAMA women is also a concern, with rates up to 28% in those aged 50+, and these women are nine times more likely to require insulin compared to younger women.

Child welfare

Clinicians offering fertility treatment have a duty to ensure the welfare of both the child and the mother. An assessment is conducted to determine if a child born via fertility treatment could face serious medical, physical, or psychological harm. In women over 50, this requires additional consideration, evaluating whether their advanced age and other circumstances might hinder their ability to provide adequate care for the child.

Arguments in favour of fertility treatment over 50

There is a reasonable chance of clinical pregnancy and live birth when using donor eggs if they are in good health. Women at this stage often have established careers, stable relationships, and greater maturity. They tend to benefit from emotional and financial stability to support a child. Additionally, gender equality arguments highlight that older men are not denied fertility treatment despite a similar, though less pronounced, decline in fertility, raising questions about the differing treatment of women.

Arguments against fertility treatment over 50

The physical and emotional stress of pregnancy and parenting can be overwhelming for older women. Children may face the burden of caring for ageing parents at a young age and are more likely to endure the emotional impact of losing a parent before adulthood.

Surrogacy as an option

Surrogacy may help bypass the obstetric and neonatal risks associated with pregnancy in older women, especially those with medical comorbidities who are deemed at high risk of carrying a pregnancy. However, this does not prevent the higher likelihood of the intended parent being unable to cope physically with parenting, childcare or dying before the child reaches adulthood.

Responsibility of healthcare providers

Healthcare providers have a moral responsibility to balance the desires of older women to conceive with the potential risks involved. This includes ensuring that patients are fully informed of the risks and benefits and that decisions are made with the mother and child’s best interests in mind. Informed consent is a critical component of this process, requiring transparent communication about the potential outcomes and complications associated with fertility treatments at an advanced age. Providers must also consider the broader implications of their practices, including the allocation of medical resources and the societal impact of promoting fertility treatments for older women.

Pre-treatment evaluations

Comprehensive assessments, including detailed medical histories and thorough physical examinations, are essential. Women aged 48 and above have reported preexisting medical conditions at a rate of 44%, compared to 28% in younger women, highlighting the increased health risks in this age group. Additionally, women over 40 are three times more likely to die from pregnancy-related complications than those in their early 20s. Adhering to guidelines from authoritative bodies is crucial for identifying potential health conditions that could complicate pregnancy. Women above 50 should undergo additional screening for more common age-related conditions. They should see their general practitioner to evaluate cardiovascular and metabolic status, including blood pressure, glucose, cholesterol, thyroid function, and an electrocardiogram, along with a mammogram as a minimum.

Enhanced monitoring protocols

Close monitoring during fertility treatment and pregnancy is vital to manage increased risks. Regular ultrasounds, blood tests, and other diagnostic tests, including gestational diabetes screening, ensure early detection and management of complications. A multidisciplinary approach in a specialized high risk antenatal clinic can enhance care and outcomes. Donor egg treatment is an independent risk factor for developing high blood pressure and pre-eclampsia in pregnancy. It is recommended that women having donor egg treatment should start low-dose aspirin and calcium supplements in early pregnancy to reduce the risk.

Psychological support

Providing psychological support through counselling is crucial for managing the emotional and mental health challenges faced by older women undergoing fertility treatment. Counselling helps address anxiety, stress, and uncertainty, ensuring mental well-being throughout the fertility and pregnancy journey.