THE TWO BIOLOGICAL CLOCKSDoes time run out at 40 … or can you keep on trying?

What’s involved The procedure is not without risks, however. Of the 55 successful pregnancies in the study, an unusually high 78 percent who gave birth had Cesarean sections; 20 percent developed gestational diabetes (two to five times higher than the rates for younger women); and 35 percent developed pregnancy-associated hypertension (10 times greater than the rates for younger women). But the study concluded that a “favorable maternal and neonatal outcome may be expected with contemporary obstetric surveillance and management…there does not appear to be any definitive medical reason for excluding these women from attempting pregnancy on the basis of age alone.” Dr. Paulson recognized that while his series of tests is the largest in the world’s literature, there were still only 45 births. “Having a baby after the age of 50 continues to be an unusual desire, but it’s nice to have the option to offer to women,” Dr. Paulson says. Patients who come to Dr. Paulson must first undergo thorough medical tests, meet with an egg donor coordinator, review health risks with a high-risk obstetrician, and undergo psycho-social counseling for any socio-emotional problems. Once recipient couples are approved, they select egg donors, who are, on average, around age 27, through egg donor agencies. The egg donor, who has also gone through extensive medical and psychological screening, is given follicle-stimulating hormones for two weeks to stimulate egg production while the recipient’s uterus is prepared with estrogen and progesterone to receive the eggs. The collected eggs are fertilized in a laboratory with the husband/partner’s sperm, grown in a culture dish for three to five days, then several fertilized eggs are implanted in the uterus. “The tricky part,” Dr. Paulson says, “was figuring out how to stimulate the donor eggs in synchronization with preparation of the recipient’s uterus.” Fifty-five percent of the women had a baby after up to three cycles. The others decided it was too emotionally taxing and dropped out. However, Dr. Paulson adds, “Most would have been successful had they persevered.”

Dr. Barry Witt, medical director of the IVF Program of the Montefiore Institute for Reproductive Medicine and Health, in Hartsdale, has had two patients over 50, one of whom became pregnant through egg donation. For women over age 45, he says, the chance of becoming pregnant with their own eggs is around 2 percent. The egg is usually the problem with women over 35, as older eggs are more likely to have genetic abnormalities. “However, with egg donation from a younger woman, women over 50 have an even better success rate than younger women of getting pregnant because the eggs are selected for quality. The success rate is almost 50 percent. Although it’s often the last resort for women with infertility, it’s more successful than anything else we do,” Dr. Witt says. “However, because there is a higher incidence of preeclampsia, Cesarean deliveries and gestational diabetes, we carefully screen the candidates. No one who is really high-risk participates.” Because of the risks, many IVF clinics have a cut-off age. Dr. Owen Davis, associate director of IVF at the Center for Reproductive Medicine and Infertility at the Weill Medical College of Cornell University, in Manhattan, reports that they will not treat patients over age 50. But Dr. Davis is quick to add: “I’ll be the first to admit that 50 is an arbitrary age since you can have a 52-year-old in excellent health who could successfully become pregnant, and someone, at 38, who should not.” The Center is concerned about the increased risk in women over 50 of hypertensive disorders, gestational diabetes, a higher incidence of multiple births which bring more risk of gestational diabetes and preeclampsia; as well as the combination of pregnancy with the risk of diseases such as cardiovascular disease, hypertension, and adult onset diabetes, which occur more often in all aging women and men. “There have been so few deliveries to women over 50 up until now,” Dr. Davis says. “We really need to observe hundreds or thousands to see if there are significantly increased risks and to be able to determine what really constitutes adequate baseline testing for these pregnancies.” In an interview with Fertility Newswire on the website FertilityWorld.org, Dr. Zev Rosenwaks, director of IVF at the Center for Reproductive Medicine and Infertility, says: “Is it ethical and good medical practice to help a 65-year-old woman get pregnant when it may put her life at risk or when her placenta may fail to nourish the fetus? …How far do you go even if the technology is available? At the end of the day, you must adhere to the fundamental tenet of medicine: first, do no harm.”

The emotional side Beyond the physical risks, there are a host of psychological and emotional considerations couples must weigh when embarking on pregnancy over 50. Allison Rosen, Ph.D., a specialist in the psychological issues surrounding reproductive medicine at Reproductive Medicine Associates, in New York and New Jersey, and former director of New York Resolve, a national infertility association, counsels recipient couples and individuals, gestational carriers (surrogate mothers) and egg donors. She screens potential recipient couples for substance abuse, lack of the financial or emotional resources necessary to go through the procedure and care for the child, marital conflict, and health problems. “My goal,” she says, “is to make sure they know what’s involved in terms of medical procedures, what pregnancy at 50 feels like, what changes in life to expect with parenthood, and to ensure that they have social support in case of death.” On the West Coast, Dr. Paulson also requires his older patients to have a support system (i.e. a partner), or he will not treat them. “Parenting is difficult enough, but if one’s health gives out, you have to be prepared to provide for the child,” he says. Egg donors must also undergo extensive screening: a personality assessment, a medical and blood workup to make sure they have no substance abuse history or reproductive trauma. Dr. Rosen explores their motivations for being an egg donor. “They must be doing it for altruistic reasons and not for money. And they have to feel that it’s OK that there is a child in the world of their making.” She also informs egg donors that the extent of risk for future ovarian cancer stemming from the use of fertility drugs to stimulate egg production is unknown at this time because there have been no long-term conclusive studies. An important aspect of Dr. Rosen’s work is helping recipient couples figure out how to eventually tell the child how he was conceived. “If they tell the child ‘you are a miracle’, and, therefore, a very special person, it puts a lot of pressure on the child. Some kids just can’t live up to the expectations,” she points out. The question of telling a child about his origin is a complex one. “Most people in America feel there’s a stigma attached to egg donation,” Dr. Rosen observes. “ I would say 50 percent to 60 percent of couples lie about having done it. Most will come up with a cover story, such as, ‘We went on vacation and got lucky!’” As with adoption, couples may lie because they feel a child’s genesis is private and they want to have the opportunity to choose how and when to let the child know about his conception. “Couples often feel judged,” Dr. Rosen explains. “Other people think they are narcissistic and wonder why they can’t just adopt. But people choose egg donation over adoption for emotional reasons — to have one parent’s genes is better than none. And with egg donation, you have more control over the prenatal care of your child as well as the immediate experience of pregnancy and bonding.”