By Mianna Lotz, Macquarie University
Considerable public controversy exists around the question of access to in-vitro fertilisation treatment (IVF) for older women. Some support unlimited, publicly-funded access for all infertile women and couples, irrespective of age. Others beg to differ.
Many people support restrictions on eligibility and access, including increases to the costs borne by individuals. They also oppose the use of tax revenue to fund what is, after all, an expensive procedure drawing on finite health resources.
And many argue that there should be an age limit on IVF access. One such person is the woman who, at 57 years of age, became one of Britain's oldest IVF mothers. Ms Tollefson has called for an age limit of 50 years for women seeking infertility treatment.
Now in her early 60s, Ms Tollefson doesn't regret having had her daughter, but says she struggles with raising a child, and with knowing that she has limited time to see her daughter grow up.
Infertility and current IVF access
Improvements in IVF since it first became available in the 1970s have led to significant increases in both treatment and success rates. Approximately 3% of all Australian births result from some form of assisted reproduction technology (ART) treatment. And, at any given time, approximately 9% of Australian couples are experiencing infertility.
The average age of women using IVF has increased. Data from studies carried out by the Australian Institute of Health and Welfare reveals that the average age of women receiving treatment using their own eggs or embryos, is 36 years, and the average age for women using donated eggs or embryos is 40.8 years. A quarter of all Australian IVF treatment is to assist women who are aged 40 years or over. But only one in 100 women over 44 will deliver a live baby.
There's no national legislation imposing a maximum age for IVF in Australia, and doctors are divided over whether there should be an age limit. Guidelines in some states, such as South Australia, recommend 50 years as the maximum age.
But the government has introduced changes that affect access and affordability. In January 2010, an upper limit was placed on the amount of Medicare reimbursement available to patients undergoing infertility treatment.
While offset to some extent by changes to Medicare rebates, there have also been increases to the up-front costs for IVF. The general net result of these changes was estimated to amount to a doubling of out-of-pocket costs for IVF.
Research conducted by the University of New South Wales' Perinatal and Reproductive Epidemiology Research Unit (PRERU) indicates that this change resulted in a significant 13% drop in use of ART in 2010, a sharp turnaround following the record of 10% increases per year in the period 2004 to 2009.
Ethics of access
So how do these increased costs impact on who accesses IVF? PRERU's figures show that the largest decline in ART use has been among women aged 34 to 37, who are more likely to become pregnant without assistance.
While the reasons for this are complex, it should be noted that the impact of increased up-front and out-of-pocket costs is likely to impose less of a burden on older women and their partners, many of whom have higher earning capacity, more secure careers, and a larger assets base.
Combined with the absence of an age cap and means testing for IVF treatment, it's not unreasonable to expect an increase in the proportion of older women seeking IVF.
But should older women – including those who are menopausal or even post-menopausal – be able to access infertility treatment, especially when access is becoming more expensive and more restricted?
After all, it is well known that success rates for IVF decrease substantially for older women, a fact that typically results in more treatment cycles, for less likely outcomes. Whereas the “live delivery” rate per IVF cycle is about 20% to 26% for women aged 30 to 34 years, it decreases dramatically – to between 1% and 2.4% per cycle – for women aged over 44 years (depending on whether eggs have been frozen or not).
We need to consider the fairness of a system that allows greater access to IVF to those who can afford to pay more, even though, in many cases, their chances of taking a baby home at the end of the process may be very low. If lower success rates per treatment cycle mean more treatment cycles per woman, the potential result is an increased use of what are expensive and scarce resources.
More generally, the absence of means testing amounts to unequal access and opportunity for those who are less well off in our society – yet whose desires for children are no less intense or legitimate. In effect, this amounts to a form of structural inequality that is discriminatory.
The issue of age
But the popular moral debate tends to centre on a different question – whether older women ought to be allowed to access IVF at all? Should women over the age of 44, or 50, or even 60, be able to receive infertility treatment?
Considerable moral angst has been expressed about the welfare of children born to older mothers. There is concern, for instance, that women in their 60s or 70s will be ill-equipped to raise teenage children; and that the child will be “too young” when her parents die, leaving her abandoned and alone, without sufficient financial and emotional support.
But this moral panic is fuelled by overly narrow, ahistorical and culturally blind conceptions of family and child-rearing responsibility. For a start, it's not uncommon in many countries in the world for children to be raised primarily by their grandparents.
Second, this kind of concern depends on the assumption that the responsibility for the material and emotional care of children falls predominantly on one or two (typically biologically-related) parents. But many cultures have more shared and collectivised approaches to raising and nurturing children. There's no research showing that children raised within such communities fare worse than those raised within the two-parent nuclear family prevalent in our society.
While women (and men) who have children late will indeed miss out on the middle to later stages of their child's life, the assumption that such a child will be left isolated and unsupported, is just that: an assumption.
Clearly, there are reasons to be wary of claims that children born to older mothers will necessarily suffer or be worse off than those of younger women.
The supremacy of biology
But there are also reasons to reflect more critically than we commonly do, on our current preoccupation with expanding the opportunities and technologies that allow people to reproduce biologically-related offspring.
While access to adoption is increasingly restricted by institutional barriers, the number of children in desperate need of short- and long-term foster care in Australia continues to grow. These are highly vulnerable children, children who already exist and who have significant unmet needs for family and security.
Their needs go unmet while we, as a society, fixate on the assumed supreme value of having and raising “our own” children. We think of these as children that are more truly “ours” in the sense of being biologically related to us, but also, I fear, in the sense of being “owned by” us – ours to keep, to possess; and for the duration of our lives.
We need to ask whether this supposed need to have our “own” children is legitimate at all. And we need to ask whether it can possibly be more weighty than the substantial needs of already-existing children to be raised with love and security, regardless of their genetic origin.
This is a question that confronts us all. Not just older women who seek to have children, but everyone willing to invest large amounts of money and emotional energy into having a biologically-related child. And all of us who effectively turn our backs on needy children primarily because they are not “ours”, biologically speaking.
This is the third part of our short series on motherhood. Click on the links below for other articles in the series:
Mianna Lotz does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.