1. Blossoming After 40 Years Old: So You Want to be Parents Now? Alice D. Domar, Ph.D Domar Center for Mind/Body Health, Boston IVF Harvard Medical School

2. Main Focus Points During Initial Patient Visit 1. Probability/possibility of pregnancy 2. Psychological risks of pregnancy 3. Benefits of parenting at an older age 4. Risks to the child of having older parents

3. Probability/Possibility of Pregnancy Most societies in the western world are rethinking the concept of age Many people perceive themselves as being younger than they are Nearly half of 50 year olds “feel” at least 10 years younger than they are* *Pew Research Center, June 29, 2009

4. It is likely that your patients will have an unrealistic view of their own fertility. Most patients overestimate their chances of treatment success Most women are unaware that children are not associated with happiness or overall satisfaction with life Many women believe if they look and feel more youthful, they will be fertile longer

5. Media reports of celebrities having healthy children, and even twins, into their 50’s, with no mention of donor gametes, lulls the average women into believing that fertility lasts far longer than it does

6. In the United States and many other countries, birth rates in women 40 and above are growing far higher than in women under 40

7. *Martin at al, National Center for Health Statistics, 59 (1), 2010 Births to Women in the US: 1996- 2008* All Ages Ages 40-44 Ages 45-49 Ages 50-54 9.15% increase 47.6% increase 133% increase 276% increase

8. Age and Fertility Treatment In Switzerland, since 2000, average age of women receiving treatment increased from 34.9 to 36.3* Percentage of women over 40 increased from 17.2% in 2007 to 19.6% in 2011 Women over 40 had poorer results on all aspects of IVF including pregnancy rates “ART does not succeed to improve reduced fertility” *Leeners et al, Gen Comp Endocrinol 2013; 188: 166-74

9. Age is not consistently associated with more distress during infertility treatment – some research shows that age is associated with more distress, but some studies show no difference One study showed that female infertility patients over 35 had a higher quality of life than patients under the age of 35* *Heredia et al, Eur J Ob Gynecol 2013; 167: 176-180

10. Psychological Risks of Pregnancy The research is reassuring about the general psychological well-being of women pregnant over the age of 35

11. In a study of 791 pregnant women in Australia, maternal age was not associated with differences in psychological health* In a study of 541 women in Australia who conceived either naturally or via ART, neither age nor mode of conception was associated with postpartum depression** *Fisher et al, BMC Preg Child 2013; 13 **McMahon et al, Fertil Steril 2011; 96: 1218-24.

12. In a study of pregnant nulliparous women in Australia who conceived via ART, older women scored higher on a measure of psychological hardiness/resilience, and lower on an identification with motherhood than younger women* * McMahon et al, Hum Reprod 2007; 22: 1168-74.

13. In a study of 45 pregnant women with a mean age of 37 years, when compared to 42 women with a mean age of 27 years*: – There were no differences in career goals, family incomes and reasons for delaying pregnancy – The older women were more independent, held less traditional values, were less troubled by the pregnancy and were better adjusted in their last trimester *Robinson et al, Am J Obstet Gynecol 1987; 156: 328-33

14. Benefits of Parenting at an Older Age In a study of 642 successful ART patients, the children, ages 4-11, were assessed based upon the age of their mother when she conceived* Higher maternal age had no negative impact on the wellbeing of the children *Boivin et al, Soc Sci Med 2009; 68: 1948-55

15. However, couples in the older age group were less likely to show warmth to each other and the older mothers were more likely to express depressive symptoms

16. Risks to the Child of Having Older Parents Numerous studies indicate that older parents provide greater financial stability However, their lifespan and their ability to caretake are important factors A 65 year old woman is estimated to live an additional 18.8 years; however, only 13.4 of those years are likely to be of good health* *Zweifel et al, Sex Reprod Menop 2012; 10: 1-8.

17. Child’s Expected Age at Time of Mother’s Death* Mother’s Age at Birth 20 30 40 45 50 55 Child’s Age at Death 61 51 42 37 32 28 *Arias E United States Life Tables, 2006

18. Interviews with children born to mothers older than 35 report advantages such as: – Devotion and attention from parents – Parents are wise and patient – Secure financially and emotionally

19. However, children born to older mothers also report*: – Fear of parental illness and death – Generation gap – Feelings of being different – Feel old for their years – Loss of not knowing grandparents *Zweifel et al, 2012

20. These children are at risk for becoming caretakers to their parents at an early age Higher risk of depression and anxiety, social exclusion, and interruption of educational and social activities

21. The impact of parental death during childhood can be catastrophic Risk of behavior problems for at least two years Vulnerability greatest < 5 years or during adolescence Maternal loss is more significant than parental loss

22. Discussion Questions for Older Infertility Patients Current age and health Thoughts/concerns about being an older parent Thoughts about siblings/half siblings Financial and guardianship planning Availability of extended family and friends Impact on child to be an only child

23. Cassandra’s Prophecy A personal story on the impact of age on fertility* – Age 35, told hormonal balance would be cured by a pregnancy – Told by physician to try two more years – Age 37, told to go home and relax – Assumed ovulation = fertility – Belief that at any point, IVF would “cure” her *Jane Everywoman Reprod Biomed Online 2013; 27: 4-10

24. – Age 39, finally had blood work which revealed elevated FSH and low AMH. – “I did know about fertility decline with age but I did not really understand it in an adequate way, perceiving it merely as risk easily managed through excellent prenatal care. I had no idea that late-age pregnancy is ultimately difficult because of a decline in egg quantity and quality… no clinician outside my fertility clinic communicated to me that age was a relevant issue”.

25. Cassandra’s Points Confusion about the differences between chronological, reproductive and cultural age The focus on birth control brings with it a sense of guarantee that unprotected intercourse produces a baby There are huge misunderstandings about what the ARTs can really achieve Most women don’t know about the increased risk of miscarriage with age, ie pregnancy=baby

26. Goals for the Future Women need to know they can’t outsmart Mother Nature Information about the impact of age on fertility needs to be disseminated far more widely The limits of the success of treatment, even IVF, in women over 40 needs to be discussed more freely

27. Just because a women can conceive a baby no matter her age (with donor oocytes), does not mean this is in the best interest of the patient or her child(ren)