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

When Sylvia Ann Hewlett’s book, Creating a Life: Professional Women and the Quest for Children, was published last year, it caused a furor. Her premise that, “at mid-life, between a third and half of all high achieving women in America do not have children” and that the majority desperately want children, was thought by some to be anti-feminist. Critics felt she was telling young women that they’d be happier and healthier if they got married and had children before 35. However, the point of Hewlett’s examination of fast-track careers, trade-offs women are forced to make between work and motherhood, and statistics about fertility and infertility was to expose the reality so that young women could take a long view of their lives, figure out what their priorities are, and plan accordingly. Citing figures from the Mayo Clinic, Dr. Hewlett says women’s fertility peaks between ages 20-30, drops 20 percent after age 30, 50 percent after age 35, and 95 percent after age 40. Despite the promise of assisted reproductive technologies such as in vitro fertilization (IVF), only 3 percent to 5 percent of women over 40 succeed in having a child. Yet in the Journal of the American Medical Association in November, Dr. Richard J. Paulson, chief of the Division of Reproductive Endocrinology and Infertility at the University of Southern California Keck School of Medicine, published a study on pregnancy in postmenopausal women ages 50-63. Of 121 women attempting to get pregnant, there were 45 births, all accomplished through egg donation. “There are really two biological clocks,” Dr. Paulson says. “One for the ovary, which seems to run out, and one for the rest of the reproductive system, which seems to go on.” Healthy women over 50, he says, can successfully become pregnant via egg donation and have pregnancy rates similar to those of younger women.

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, 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.”

One woman’s story Like many older women with infertility problems, Rena*, a 53-year-old Manhattan lawyer, arrived at egg donation step by painful step. After getting married for the second time at age 40, she tried to become pregnant, but went through miscarriages, intrauterine insemination, injectable drugs, and three cycles of IVF with her own eggs. “Every stage was devastating because I couldn’t believe or accept that it wasn’t working. But if you want to have a child, you have no choice except to go on to the next step. And yet you may not be psychologically ready to move to a more aggressive step or adoption….the chances of success are so small and there is so much stress on your marriage,” she confides. At age 46, Rena finally decided to get on an egg donor list and had to wait about a year. Her first attempt at egg donation ended in a miscarriage. The second attempt resulted in a healthy pregnancy and the birth of her now 4-year-old daughter. Rena counts herself unusually lucky because with frozen embryos from the second donor, she was able to have another daughter, at age 51, so that her daughters are full siblings. When egg donation was first proposed to Alice*, now a 50-year-old patient at the Montefiore Institute for Reproductive Medicine and Health, she was unwilling to consider it. Married, at 36, with a successful career in sales, Alice had always wanted children and never thought she would have a problem. In her late 30s, she suffered from fibroid tumors and hemorrhaging, had several fibroid surgeries, and discovered that she had severe endometriosis. As a result, she was not able to try IVF when she might have been able to use her own eggs. At age 42, Alice was told that she should consider egg donation, but was so angry that she had wasted years, she could not accept the idea. Alice then discovered she had a cyst on her ovary and thought she might have cancer. After it was removed, she told herself, “I don’t have cancer and I still have my uterus, so I’m going to try to have a baby.” She is currently taking hormones to get into sync with the egg donor, and has her first IVF procedure scheduled.

Other kinds of costs Egg donation may offer hope to some, but it is not without drawbacks. Insurance does not cover the costs, so each recipient must pay for the egg donor’s medical tests and procedures, as well as $5,000-$7,500 for her participation, according to Dr. Witt. A single attempt at egg donation can run $25,000 unless it is shared. Alice and her husband are sharing the cost of the procedure with another couple who will use eggs from the same donor. There can also be a long wait of up to one-and-a-half years in any egg donation program, so older women may run out of time, especially in programs where there is an age ceiling. Then there are the unique emotional challenges of egg donation because the child’s genetic background can create more complicated family relationships. Rena was at first distraught not to be able to have a child genetically related to herself. She admits: “When my daughter was born, there was a kind of sadness because I couldn’t see anything of myself in her. But now that she’s 4, she actually has my personality and I have realized that I leave my imprint on her in other ways. It’s wonderful how that happens.” But Rena worries, “I hope I live to see my kids graduate from college.” “The struggle of a lifetime” Indeed, being a mother at 50 is not the end of the road, but rather the beginning of a different kind of journey, cautions Dr. Rosen. Sylvia Ann Hewlett, who had a third child through IVF, at age 51, after two children and four years of escalating infertility treatments, says, “It can be an enormously joyous journey. It is great to have my 5-year-old Emma at a time when I’m comfortable with my identity and not struggling. I feel I’m a more experienced and relaxed mother.” On the other hand, Dr. Hewlett is very careful about taking care of her health and looks because she doesn’t want to be taken for Emma’s grandmother or to stick out in Emma’s social milieu, and most of all because she wants to be around for a long time. The financial considerations are pressing as well. “By the time she’s ready for college, I’ll be deep into retirement and not earning money, so I have to think about paying for her college and saving for it now,” Dr. Hewlett says. She says she also faced disapproval from colleagues who wondered why she wanted to get pregnant again at 50. “This thing has terrible power. If you’re over 40, the desire to have a baby before it’s too late can kick in with ferocious intensity,” she wrote in Creating a Life. For some women, she says, it becomes “the struggle of a lifetime.” For older women who desperately want to have a baby, egg donation might be the answer. “If you have the desire, it doesn’t go away until you experience it, even if you can’t get pregnant on your own,” Alice says. “I’ve always wanted to experience giving birth and this is the only way it could happen….If you have a dream, don’t give it up until you’ve tried everything you possibly can.”

*Names have been changed for confidentiality.

Resources: • Creating a Life: Professional Women and the Quest for Children, by Sylvia Ann Hewlett, published by Talk Miramax Books, 2002 • Resolve, the National Infertility Association dedicated to providing education, advocacy and support for men and women facing infertility. • Montefiore Institute for Reproductive Medicine and Health, Hartsdale. (914) 997-1060 • The Center for Reproductive Medicine and Infertility at the Weill Medical College of Cornell University at New York Presbyterian Hospital, New York City. (212) 746-1762 or • Reproductive Medicine Associates of New York. (212) 744-1855 Reproductive Medicine Associates of New Jersey. (973) 971-4600


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