Debate: do upper age limits need to be imposed on women receiving assisted reproduction treatment?

The inability of local National Health Service trusts to uniformly provide assisted reproduction technology (ART) services has resulted in what has come to be known as a 'postcode lottery'. Older women and those with responsibility for children at home, often have to fund their own treatment. Recently, with the birth of babies to much older women, the mass media have debated whether those past menopausal age should be helped to achieve a pregnancy in this way. We argue that the time is right for interested professionals to enter the debate, especially in view of proposed revisions to the Human Fertilisation & Embryology Authority's code of conduct which requires clinics providing ART to consider the 'welfare of the child'. With that change in mind, we set out the case for imposing upper age limits on those receiving ART in the United Kingdom.     

How present ART' results: questions' list to French ART professionals and application on Amiens' ART results

ObjectivesART transparency of results and ways to submit are in centre of present biologists and clinical cares. This work aims at identifying ART results’ presentation pertinent tests.Patients and methodsAt first time, we propose a questions’ list to French ART professionals. Next, we apply results on Amiens’ ART center 2006, 2007 and 2008 IVF parameters.ResultsOne hundred and twenty questions’ lists were analysed. Ninety percent of interrogated people were in favour of the results’ center public communication. Most quoting criterions hold to define a reference population are (percentage of favourable opinions): IVF/ICSI treatment (96%), first of second rank's attempts (71%), women age less than 35 years old (68%), one or two top embryos quality transfer (60%). In 2007, 2008 and 2009, we made 1123 tentative IVF ± ICSI in Amiens’ ART center. Pregnancy rates were analysed for these years with criterions next quoting as most pertinent (women's age and rank's attempt), and in function of puncture retrieval oocytes number and indications.Discussion and conclusionMost of professionals are in favour of ART transparency of results. All would like that results presentation holds to special criterions to allow a fair comparison. Pregnancy predictive factors, which are women age, rank attempt, puncture retrieval oocytes number, seem to be main criterions for evaluation. These criterions pertinence has been shown thanks to Amiens ART center results.     

Prognosefaktoren der assistierten Reproduktion

Previous conceptions are one predictor for the outcome of assisted reproductive technology (ART) procedures. This study analyzes German IVF Registry data to examine the impact of former pregnancies on the outcome of ART procedures. The dataset consists of a total of 174,909 ART procedures performed between January 1998 and December 2000. Multiple logistic regression was used to assess the correlation between spouse/partner change, women’s age, and infertility diagnosis. More than one former pregnancy was negatively associated with ART regarding the woman’s age and duration of infertility. ART success was significantly more likely when a former pregnancy had been achieved through ART than when it was achieved by spontaneous conception. It was also demonstrated that any former miscarriage would increase the treatment-dependant miscarriage rate in ART procedures. A significantly higher impact was shown for one former miscarriage achieved by ART procedures compared to spontaneous conception. Partner change was shown to have no specific impact on the treatment-dependant pregnancy rate. A statistically significant increase of miscarriages in all ART procedures was found among women older than 34 years of age. The highest rate of treatment-dependant miscarriages was seen in ART procedures with cryopreserved embryo transfer. Successful ART procedures ending in a live birth or even a miscarriage predicted the success of subsequent ART procedures. More than one former pregnancy, age factors, and duration of infertility were inversely associated with ART success.     

Depression: Reflection on treatment

Objective: The aim of this study was to explore the influence of age and mode of conception on women’s perceptions of pregnancy-specific daily stressors. Background: The age of childbearing and the proportion of women conceiving with assisted reproductive technology (ART) are increasing. There is little existing evidence about whether older age or ART conception affects women’s perceptions of pregnancy-specific daily stressors. Methods: Approximately equal numbers of nulliparous women who had conceived spontaneously and with ART in three age groups (? 30, 31–36, ? 37) were recruited through ART clinics and nearby hospitals in Melbourne and Sydney, Australia. In the third trimester participants were interviewed and completed questionnaires including questions relating to their socioeconomic circumstances and reproductive history, and standardised instruments of mood, health and the perception of the positive and negative aspects of pregnancy during the third trimester. Results: Participants were 564 women aged 20–51 years of whom 285 (50.5%) had conceived with ART. In univariate analyses older maternal age and ART conception was associated with a more positive experience of pregnancy. However, when controlling for physical health and sociodemographic and psychological factors only, lower scores on the measures of anxiety and not being in the paid work force in the third trimester made independent contributions to more positive perceptions of pregnancy. Conclusion: Pregnancy-specific daily stressors are not influenced by maternal age or ART conception. Not being in the paid workforce in late pregnancy and being less anxious contribute to a more positive experience of pregnancy.     

Cytometric assessment of uterine receptivity via epithelial β3 integrin expression

Research questionMany techniques now exist to assess the receptivity status of the endometrium. Can a simple low-cost flow cytometric technique be used to rapidly assess uterine receptivity via a luteal phase endometrial biopsy?DesignEpithelial β3 integrin (EB3) evaluation was undertaken in 300 women presenting with repeated implantation failure or recurrent pregnancy loss who subsequently underwent 710 assisted reproductive technology (ART) cycles. Endometrial tissue was mechanically dissociated and evaluated using specific antibodies to capture integrin expression. Autologous and donor oocyte embryo transfers were evaluated. A ‘High’, ‘Borderline’ and ‘Low’ grading system was developed based on the pattern and percentage expression of EB3 relative to the total endometrial epithelium. Clinical outcomes of the resulting embryo transfers (n = 559) were analysed according to EB3 grading.ResultsBased on 180 completed transfers, the clinical pregnancy rate (CPR) per embryo transferred in the donor egg cycles was 41.7%. EB3 results from women with a ‘High’ grading showed a superior CPR (54.0%) compared with ‘Low’ (22.2% CPR) or ‘Borderline’ (37.4%) cases (P = 0.024). Similarly, following 379 autologous oocyte transfers, the CPR was 36.1% overall, with major variations between the ‘High’ (43.8%), ‘Low’ (17.5%) and ‘Borderline’ (34.8%) groups (P = 0.0008). Implantation rates showed similar significant trends in the ‘High’ versus ‘Low’ groups of 40.4% versus 16% (P = 0.048) in donor oocyte transfers, and 30.8% versus 16.1% (P = 0.025) in autologous oocyte transfers.ConclusionsThe distribution patterns and percentage expression of EB3 assessed by a flow cytometry grading system shows a significant relationship to implantation rate and CPR success in ART cycles and may thus represent a useful additional tool for the assessment of uterine receptivity.     

Age when learning about mode of conception and well-being among young adults conceived with ART

Objective: To investigate the age at which young adults recalled learning about being assistive reproductive technologies (ART)-conceived and the association with subjective well-being and parental relationship. Background: The use of ART is increasing. Parents are encouraged to tell children about the way they were conceived when they are young. Little is known about whether age when learning about being ART-conceived influences adult well-being. Methods: A structured interview was conducted with women who gave birth as a result of ART in Victoria, Australia 1982–1992 and their young adult offspring. The young adults’ interview included questions about age when learning about ART conception and perceived quality of the parental relationship, and a standardised measure of subjective well-being. Results: 547/594 (92%) young adults agreed to participate. Of these, 10.6% (n = 58) were conceived with donor gametes; 77% had been informed about their ART-conception before the age of 12, 18% when they were between 12 and 17 years, and 5% when they were 18 years or older. There were no statistically significant differences in subjective well-being or quality of the parental relationship between age groups when learning about mode of conception or between those conceived with ART alone and those where donor gametes had also been used. Conclusion: The age when young adults learned that they were ART-conceived, including those conceived with donor gametes, did not influence current quality of life or parental relationship. This is reassuring for those who wish to disclose mode of conception to their children but have not done this at an early age.     

A pot of gold at the end of the rainbow? A spectrum of attitudes to assisted reproductive technologies in Ireland

Objective: New technologies present new ethical dilemmas. Our ethical intuitions may mislead us in relation to new technologies such as nuclear power, vaccines, GMOs and assistive reproductive technologies (ART). Between 1999 and 2008 the number of ART treatment cycles increased by 265% in Ireland. The implications and potentials of such technologies are profound – challenging existing understanding of humans’ relationships to reproduction. Because such technologies are comparatively unregulated, and their use has only been occurring for a single generation, detailed investigation of how awareness of ART influences understanding of personal fertility is needed. Method: Data from a general Irish population of varied ages and both sexes (N = 611) were collected through an online survey which included demographics, knowledge of fertility, knowledge of ART and personal fertility. Results: Latent class analysis revealed a typology of five groups of responders to ART distinguished by their attitudes and knowledge of this technology. These groups are labelled as ‘Worried Yet Willing’, ‘Live and Let Live’, ‘Disengaged’, ‘Judgemental’ and ‘Conflicted’. Conclusion: Responses to the introduction of ART in Ireland fall into at least five distinct groups. Understanding of the distinguishing features of these types of responders is important for fertility healthcare professionals in terms of service development and delivery. Implications for the direction of future related research is discussed.     

Midwife-led care unit for ‘low risk’ pregnant women in a Japanese hospital

Objectives.?To examine the obstetric outcomes of our ‘low risk’ pregnant women under the midwife-led delivery care compared with those under the obstetric shared care.

Methods.?A retrospective cohort study compared outcomes of labor under midwife ‘primary’ care with those under obstetric shared care. The factors examined were: maternal age, parity, gestational age at delivery, length of labor, augmentation of labor pains, delivery mode, episiotomy, perineal laceration, postpartum hemorrhage, neonatal birth weight, Apgar score, and umbilical artery pH. In this study, pregnant women were initially considered ‘low risk’ at admission when they had no history of medical, gynecological, or obstetric problems and no complications during the present pregnancy.

Results.?There were 1031 pregnant women initially considered ‘low risk’ at admission. At admission, 878 of them (85%) requested to give birth under midwife care; however 364 of these women (42%) were transferred to obstetric shared care during labor. The average length of labor under the midwife ‘primary’ care was significantly longer than that under the obstetric shared care. However, there were no significant differences in the rate of prolonged labor (≥24?h). There were no significant differences in other obstetric or neonatal outcomes between the two groups.

Conclusions.?There was no evidence indicating that midwife ‘primary’ care is unsafe for ‘low risk’ pregnant women. Therefore, midwifery care is recommended for ‘low risk’ pregnant women.     

Ongoing support of the infertile couple — Before,during and after assisted conception treatment

Abstract

Assisted reproductive technology (ART) offers patients the hope that they may have a child and provides the primary motivation for treatment. Despite the treatment failure, for many, the hope of conception remains. The decision to abandon treatment is momentous, especially for those couples with a diagnosis of unexplained infertility. The urgency for individuals to pre-empt future regrets and to know they have done enough to do so contributes to a significant amount of pressure. This pressure is further exacerbated by external pressures to conceive. A significant factor intrinsic to the decision-making process is the role of ‘hope’. Hope allows women, in particular, to avoid the reality of potential childlessness. Thus, the necessity for psychological support to be offered at the point of ending treatment is crucial. This paper draws on the author's research completed in 2005 and includes a more recent literature search which finds the original evidence still pertinent.     

Is the wrong question being asked in infertility research?

A persistent finding is that assisted reproductive technology (ART) is associated with compromised birth outcomes, including higher risks for prematurity, low birthweight, and congenital malformations, even among singletons. Over the past decade, our research group, the Massachusetts Outcome Study of Assisted Reproductive Technology (MOSART), has evaluated pregnancy and birth outcomes among three groups of women, those women treated with ART, those with indicators of subfertility but without ART treatment, and fertile women. We have also explored the influence of infertility-related diagnoses on outcomes for women and infants. Over the course of our research, we have changed our perspective from an original focus on ART treatment parameters as the primary cause of excess morbidity to one centered instead on the underlying infertility-related diagnoses. This paper summarizes the research findings from our group that support this change in focus for infertility-based research from a primary emphasis on ART treatment to greater attention to the contribution of preexisting pathology underlying the infertility and suggests directions for future analyses.     

Awareness of the effects of postponing motherhood among hospital gynecologists: is their knowledge sufficient to offer appropriate help to patients?

Purpose

The aim of this study is to ascertain the awareness of hospital gynecologists about the effects of woman’s age on spontaneous fecundity and on the efficacy of assisted reproduction techniques (ARTs).

Methods

One hundred fifty-six gynecologists working in public or private Italian hospitals, without specific experience in reproductive medicine and ART, were administered a multiple-choice answer questionnaire addressing (a) the effect of age on woman’s spontaneous fecundity, (b) the tools to estimate the ovarian follicular reserve, and (c) the outcome of ART in women above 40 years.

Results

Approximately half of the interviewed gynecologists indicated the woman’s age limit for successful reproduction between 44 and 50 years; fertility lifespan was believed to be prolonged by oral contraception, pro-fertility medical treatments, or ART. The correct meaning of serum FSH measurement was known by approximately one third of the interviewed doctors. The effectiveness of ART for women of advanced age was overestimated by half of the gynecologists, especially in case of patients having regular cycles and/or small follicles at ultrasound.

Conclusions

Overall, the survey clearly showed that the knowledge of hospital gynecologists about the effects of age on woman’s fertility and ART effectiveness is largely insufficient to offer scientifically correct, helpful information to patients. Properly targeted corrections to academic and periodical educational programs for Ob/Gyn specialists are warranted.

     

‘Super-mothers’: the meaning of mothering after assisted reproductive technology

Objective: The objective was to explore mothers’ experiences after assisted reproductive technology (ART). Background: The experience of mothering in women after assisstive reproductions has not been fully understood. Study design: An interpretive phenomenology approach was used to conduct the study. Participants: A purposive sample of nine mothers who had babies through ART participated in the study. Data were collected using semi-structured in-depth interviews. Findings: ‘Super-mothering’ was the main theme emerging from the data, describing mothers who wanted to be exceptional by performing all of their mothering responsibilities without fatigue or exhaustion and who were ready to do everything in their power to support the child. This theme incorporates four sub-themes: (1) over-care; (2) over-protection; (3) over-emotional investment; and (4) over-expectation of themselves and others. Conclusion: The challenge to be a mother through ART is a stressful phenomenon, particularly so for the majority who are also first-time mothers. Healthcare professionals need to consider the concept of super-mothering in trying to understand and care effectively for this group.     

Mapping research in assisted reproduction worldwide

Research questionWhat are the current research trends in human assisted reproduction around the world?DesignAn analysis of 26,000+ scientific publications (articles, letters and reviews) produced worldwide between 2005 and 2016. The corpus of publications indexed in PubMed was obtained by combining the Medical Subject Heading (MeSH) terms: ‘Reproductive techniques’, ‘Reproductive medicine’, ‘Reproductive health’, ‘Fertility’, ‘Infertility’ and ‘Germ cells’. An analysis was then carried out using text mining algorithms to obtain the main topics of interest.ResultsA total of 44 main topics were identified, which were then further grouped into 11 categories: ‘Laboratory techniques’, ‘Male factor’, ‘Quality of ART, ethics and law’, ‘Female factor’, ‘Public health and infectious diseases’, ‘Basic research and genetics’, ‘Pregnancy complications and risks’, ‘General – infertility & ART’, ‘Psychosocial aspects’, ‘Cancer’ and ‘Research methodology’. The USA was the leading country in terms of number of publications, followed by the UK, China and France. Research content in high-income countries is fairly homogeneous across categories and it is dominated by ‘Laboratory techniques’ in Western-Southern Europe, and by ‘Quality of ART, ethics and law’ in North America, Australia and New Zealand. ‘Laboratory techniques’ is also the most abundant category on a yearly basis.ConclusionsThis study identifies the current hot topics on human assisted reproduction worldwide and their temporal trends for 2005–2016. This provides an innovative picture of the current research that could help explore the areas where further research is needed.     

Attitudes towards motherhood and fertility awareness among 20–40-year-old female healthcare professionals

ABSTRACT

Objective To explore attitudes towards family formation and fertility awareness among Danish female healthcare professionals.

Methods We collected cross-sectional baseline data from a prospective cohort study of 863 women, ranging in age from 20 to 40 years, working at a hospital in Denmark. Information about participants’ intentions and attitudes towards family formation and fertility knowledge was gathered by means of a questionnaire.

Results Only 2% of the respondents did not want children. Most women believed that motherhood is important, and hoped to have two to three children. About half of the respondents intended to have their last child after the age of 35 years. The most important prerequisites for family formation included: living in a stable relationship, having completed one's studies, a sound financial situation, a job that can be kept when having children, access to public child day care, and the possibility of travelling. As many as 50% of women underrated the impact of a woman's age on fertility, and overestimated the success rates of assisted reproductive technology (ART) treatments.

Conclusions Many female healthcare professionals contemplated giving birth after the age of 35 years. Knowledge of fertility and ART success rates is needed to make well-informed decisions about when to have children.     

Assisted reproduction for postmenopausal women

Abstract

With increasing longevity, an ageing population and advances in assisted reproductive technologies (ART), a greater number of women are deciding to have a child and become a mother in their later years. With this social and demographic change, an important social and ethical debate has emerged over whether single and/or married postmenopausal women should have access to ARTs. The aim of this paper is to address this question and review critically the arguments that have been advanced to support or oppose the use of ART by older women.

The arguments presented consider the consequences for the individual, the family and wider society. They cover the potential physical and emotional harm to the older woman, the possible impact on the welfare and wellbeing of the future child, and the impact on the norms, values, customs and traditions of society. After reviewing the evidence, and weighing the opposing arguments, this paper concludes that there is no moral justification for a restriction on the use of ART by postmenopausal women. Allowing access to ART for postmenopausal women is an extension of reproductive autonomy and procreative rights in an age where the promotion of agency, autonomy, individual choice and human rights is paramount.     

Pregnancy following diagnosis of premature ovarian insufficiency: a systematic review

The aim of this review is to report the occurrence of pregnancies in women with premature ovarian insufficiency (POI), naturally or with different treatments (hormonal replacement therapy, IVF, in-vitro maturation and stem cell therapy). This study involved an exhaustive search of the electronic databases MEDLINE, PubMed and Embase covering the period January 2000 to January 2018. A combination of Medical Subject Heading and text words was used to generate a subset of citations, including studies involving POI (‘premature menopause’ or ‘premature ovarian failure’ or ‘POI’ or ‘hypergonadotrophic amenorrhoea’). This subset of citations was then combined with ‘AND’ to the Medical Subject Heading term ‘pregnancy’. Fifteen studies were included in this review. Two randomized controlled trials, two observational studies, and 11 interventional studies reporting cases of pregnancy in women with POI were included. This review reports pregnancy rates across studies ranging from 2.2% to 14.2%. Mean age in patients who achieved a pregnancy was 30 years, highlighting that oocyte quality in these patients is likely unaffected. No treatment has thus far shown its superiority in improving fertility in women with POI. Recent advances in options such as in-vitro maturation and stem-cell therapy, however, are likely to be the future of treatment and may generate new hope for these patients.     

Female university students' attitudes to future motherhood and their understanding about fertility

Objectives As highly educated women tend to postpone childbearing, the purpose was to explore female university students' attitudes to future motherhood and their understanding about fertility.

Methods Female students (n = 300), visiting a Student Health Centre in Sweden, answered a questionnaire with mainly multiple choice questions and verbal rating scales.

Results The women wanted to have two to three children at the age of 29 for the first birth and 35 for the last. Only 2.7% did not plan to have any children. Six out of 10 would consider having an abortion if confronted with an unplanned pregnancy ‘right now’. The most important circumstances for women's decision to have children were to be sufficiently mature, have a stable partner to share parenthood with, have completed studies and have a good economy. Having children before they got ‘too old’ was only ranked as very important by 18% of women. The women had an acceptable understanding about fertility.

Conclusions It appears that female university students are not very concerned about having children before they get ‘too old’. Therefore, it is important that caregivers, working with contraceptive counselling also include information about fertility, especially to women who intend to postpone their motherhood.     

Systemic delays in the initiation of antiretroviral therapy during pregnancy do not improve outcomes of HIV-positive mothers: a cohort study

ABSTRACT: BACKGROUND: Antiretroviral therapy (ART) initiation in eligible HIV-infected pregnant women is an important intervention to promote maternal and child health. Increasing the duration of ART received before delivery plays a major role in preventing vertical HIV transmission, but pregnant women across Africa experience significant delays in starting ART, partly due the perceived need to deliver ART counseling and patient education before ART initiation. We examined whether delaying ART to provide pre-ART counseling was associated with improved outcomes among HIV-infected women in Cape Town, South Africa. METHODS: We undertook a retrospective cohort study of 490 HIV-infected pregnant women referred to initiate treatment at an urban ART clinic. At this clinic all patients including pregnant women are screened by a clinician and then undergo three sessions of counseling and patient education prior to starting treatment, commonly introducing delays of 2--4 weeks before ART initiation. Data on viral suppression and retention in care after ART initiation were taken from routine clinic records. RESULTS: A total of 382 women initiated ART before delivery (78%); ART initiation before delivery was associated with earlier gestational age at presentation to the ART service (p < 0.001). The median delay between screening and ART initiation was 21 days (IQR, 14--29 days). Overall, 84.7%, 79.6% and 75.0% of women who were pregnant at the time of ART initiation were retained in care at 4, 8 and 12 months after ART initiation, respectively. Among those retained, 91% were virally suppressed at each follow-up visit. However the delay from screening to ART initiation was not associated with retention in care and/or viral suppression throughout the first year on ART in unadjusted or adjusted analyses. CONCLUSIONS: A substantial proportion of eligible pregnant women referred for ART do not begin treatment before delivery in this setting. Among women who do initiate ART, delaying initiation for patient preparation is not associated with improved maternal outcomes. Given the need to maximize the duration of ART before delivery for prevention of mother-to-child HIV transmission, there is an urgent need for new strategies to help expedite ART initiation in eligible pregnant women.     

Why search for a sperm donor online? The experiences of women searching for and contacting sperm donors on the internet

Whilst studies have examined the experiences of women who use clinic donors, to date there has been limited research investigating women’s motivations and experiences of searching for a sperm donor online. A total of 429 women looking for a sperm donor on Pride Angel (a website that facilitates contact between donors and recipients) completed an online survey. Fifty-eight percent (249) saw advantages of obtaining donated sperm online with the most common advantage reported as being able to connect with and meet the donor (n?=?50 (24%)). A third (n?=?157 (37%)) of the participants gave disadvantages, the most common reported was encountering ‘dishonest donors’ (n?=?63 (40%)). Most recipients (n?=?181 (61%)) wanted the donor to be ‘just a donor’ (i.e. to provide sperm and have no further contact). Whilst it was important for recipients to know the identity of the donor, some did not see this as important for the child and thus the level of information that parents have about the donor, and that which the child has, can differ. Finding a donor online blurs the distinction between categories of ‘anonymous’, ‘known’ and ‘identity release’ donations. Whilst the survey had a large sample size, the representativeness of the sample is not known.