Improvements in IVF have led to significant increases in both treatment and success rates, but at what cost?
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.
We need to consider the fairness of a system that allows greater access to IVF to those who can pay more, even though their chances of taking a baby home may be very low
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 for women seeking infertility treatment.
Britain's oldest first-time mum ... Susan Tollefsen became a mother after receiving IVF treatment at 57.
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 have led to significant increases in both treatment and success rates. Approximately 3 per cent of all Australian births result from some form of assisted reproduction technology (ART) treatment. And, at any given time, approximately 9 per cent 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 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 per cent drop in use of ART in 2010, a sharp turnaround following the record of 10 per cent 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.
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's well known that success rates for IVF decrease substantially for older women. Whereas the “live delivery” rate per IVF cycle is about 20-26 per cent for women aged 30 to 34 years, it decreases dramatically – to 1-2.4 per cent 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, culturally blind ideas 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, or extended family members.
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.
The supremacy of biology
There are also reasons to reflect on our preoccupation with expanding the 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 idea 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, 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, 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 article first appeared on The Conversation.