When Professor Robert Edwards, the Nobel winning scientist who pioneered IVF treatment, died In April 2013, the tributes poured in from scientists and families for the positive impact his work has had for millions [Ref: BBC News]. Since the birth of Louise Brown in 1978, the world’s first IVF baby, advances in Assisted Reproductive Technology (ART) have been substantial; one of the latest developments being the use of new ovarian tissue transplant techniques to allow a small number of women treated for cancer to naturally ovulate and conceive subsequent to their cancer treatment [Ref: Bionews]. However, with these advances controversy has also ensued. Some now see the biggest call on IVF to be age related fertility problems, caused by women delaying motherhood for too long, leading to concerns that IVF lulls women into a false sense of security. High on the agenda is the question of older mums through high profile cases such as Carole Hobson, the 58 year-old first time single mum who gave birth to twins in 2011 [Ref: Daily Mail], or the Spanish mother, María Carmen del Bousada, who died in 2009 leaving behind two-year old twins she gave birth to aged 66. This has raised questions about whether women determined to have a child late in life are putting their own interests above that of the child and whether IVF clinicians should exercise greater responsibility and restraint with regard to who they agree to treat. Whilst some fertility clinics have been accused of unscrupulous behaviour and irresponsibly marketing false hopes to people desperate to have children, advances in the field led NICE to update it’s guidance on what treatments should be made available on the NHS in February 2013, including an increase in the age at which women should receive some treatment on the NHS from 39 to 42 [Ref: Guardian].

What are the regulations?
In the UK, there is no legal age limit at which a woman can receive fertility treatment, and no limit that is specified or enforced by the regulatory body the Human Fertilisation and Embryology Authority [Ref: HFEA]. Clinicians are required to meet the clinical best practice standard – that the patient’s health will allow them to go through the treatment and the potential pregnancy. They are also required by law to carry out a Welfare of the Child assessment before starting any treatment. This looks at factors which are likely to cause serious harm, either to the child to be born or to any existing child of the family, possibly including the eventuality that a mother might die before her child reaches adulthood or become unable to care for the child. Whilst many UK clinics will not treat women over the age of 50, 141 women over that age gave birth in 2010 – treble the number that did so a decade earlier [Ref: Daily Mail]. Other women, including many of the ‘oldest mums’ hitting the headlines, have obtained treatment from other countries. In the United States, where there is no legal restriction on the age at which women can receive treatment, the American Society for Reproductive Medicine changed its guidance in spring 2013 from ‘discouraging’ treatment of women over 50 to arguing ‘particularly in the age range of 50–54’ that treatment is not ‘such a significant departure from other currently accepted fertility treatments as to be considered ethically inappropriate in postmenopausal women’ [Ref: ASRM]

Bad for the mother or bad mums?
It is now widely accepted that younger women should be able to use ARTs to overcome the barriers that nature has placed in their way, so why deny post-menopausal women the same chance? Whilst some concerns have been raised about greater risks to women giving birth later in life, especially in relation to pre-eclampsia and diabetes [Ref: BBC News], greater concerns have been expressed about post-menopausal mothers struggling to cope with the demands of bringing up young children and being out of kilter with their peers [Ref: Telegraph]. Others argue that the proportion of IVF babies born to women in their forties is rising, so these older mums might not be as abnormal as we think, and there is no clear place to draw the line. From this viewpoint, decisions should be made on a case-by-case basis, and the choice should be down to the woman and the doctor who treats her [Ref: Guardian]. However, the death in July 2009 of María Carmen del Bousada [Ref: The Times] reignited debate about the ‘selfishness’ of post-menopausal women who have children and the irresponsibility of some IVF clinicians. Much commentary focused on the problems caused for children by having mothers who were statistically more likely to die, or become ill or infirm, before their children reached adulthood. In this view, concern about the welfare of the child born as a result of fertility treatment should provide a clear reason why much older mothers should be denied treatment. Indeed, Janet Maslin-Bosher, who gave birth to twins at the age of 58 in 2002, was reported ten years on, to now be in favour of an age restriction for IVF treatment of around 50, despite her ten year old twins being her ‘joy and salvation’ [Ref: Daily Mail]. Others point out that there is a double standard in the debate, in that older men are able to father children naturally and talk positively about the experience [Ref: The Times], so why should such a fuss be made when women do the same thing? No parent, whatever their age, can guarantee that they will not become ill or die before their children are grown up, and some women are healthier in their 60s than others in their 20s. If it is assumed that children love their parents whatever age they are, can being born to an older mother actually damage the child?

False hope or better options for 21st Century mothers?
Whilst much of the debate has focused on post-menopausal women, broader concerns have been raised about the IVF industry offering false hope to women and fuelling an unhealthy approach to parenthood as another lifestyle choice.  Advances in techniques for egg freezing have brought this aspect of the debate into sharper focus. Until recently egg freezing was primarily offered to young women in extreme situations, such as those requiring cancer therapy. But recognition of the importance of the age of the eggs to the success of IVF, coupled with the development of vitrification techniques with success rates comparable to the use of fresh eggs of the same age, has led some clinics to offer egg freezing services to healthy women [Ref: The Times]. The purpose of the service is to allow women to improve their chances of having children later in life, if that turns out to be desirable or necessary for them. According to Dr Gillian Lockwood, Medical Director of Midland Fertility Services, so-called ‘social egg freezing’ could come to have as positive an impact on women’s lives in the future as the introduction of the contraceptive pill in the 1960s. [Ref: Focus on Reproduction]. However others, such as the IVF pioneer Lord Robert Winston, argue that there is a danger in over-emphasising arguments around choice and individual autonomy and that some fertility clinics are playing an ‘expensive confidence trick’ on women by failing to underline the low success rates associated with egg-freezing,  and IVF more broadly. [Ref: Daily Mail]. In the context of competing demands for women of an education and a career, alongside the difficulties of finding Mr Right, advocates argue that advances in ART are offering more and better options to women with regard to their choices about motherhood. Critics fear turning parenthood into just another lifestyle choice, to be fitted around the demands of a career and busy social life, and encouraging a generation of selfish ‘Bridget Joneses’ tying to ‘have it all’ [Ref: Daily Mail]. Some, such as journalist and writer Liza Mundy argue that it is an unforgiving work culture that doesn’t see childbearing for female employees as convenient that is driving the growth in late motherhood, not a widening ‘exercise of choice’ [Ref: New Atlantis]. But champions of older mums dismiss such concerns as paternalistic, arguing that women are capable of weighing up such risks, costs and benefits for themselves. With further scientific and technological advances to be expected, such as those potentially opened up by successful ovarian transplants [Ref: Telegraph], is it time to applaud the possibilities of late motherhood opened up by IVF or to draw a line under attempts to defy the female biological clock and wake up to the necessary constraints and responsibilities of parenthood?