There is currently a lively media debate raging on whether a woman’s age, sexual orientation, marital status or economic strength should influence her eligibility to undergo advanced fertility treatments such as IVF. Perhaps not surprisingly, the most vociferous opposition has come from those who already have children of their own, from women who in spite of (often repeated attempts at) fertility treatments have failed to conceive and from those who for whatever reason have chosen not to have children.

Discrimination on the basis of the woman’s age:
Those who speak out against older women (over the age of 50 years) embarking on a quest for parenthood usually parents use two arguments to support their position. The first is that pregnancy carries with it such significant, incremental age-related medical risks to both mother and baby that it is inordinately dangerous for older women to conceive and accordingly that any medical interventions aimed at propagating conception would verges on being morally and ethically reprehensible.

The second argument relates to parenting risks. The argument advanced is that with progressive aging, older women will lack the physical ability to share in the common formative physical activities with their offspring, and that the emerging generation gap would ultimately become so wide as to compromise child rearing and finally, that there would be a greater risk of the child being orphaned at an early age without having fully benefited from parenting.

1. Age-related medical risks: It is indeed indisputable that in general, pregnancy in older women is associated with increased risk to both mother and baby. Pregnancy-induced complications (e.g. preeclampsia, gestational diabetes, intrauterine growth retardation, premature separation of the placenta, preterm delivery, low birth weight, dysfunctional labor and caesarean section) are all far more likely to occur in older women. However, this risk can be mitigated by in advance identifying those older women who are most predisposed to developing such complications.

The following assessments in advance of pregnancy would allow for screening out those women who for medical reasons should not undergo fertility treatments:

• Tests of cardiovascular status include physical examination, effort EKG , blood lipid-profiling and Chest X-ray
• Predicting the risk of gestational diabetes through glucose tolerance testing and blood insulin levels
• Assessing the risk of preeclampsia by testing liver enzymes, blood BUN, electrolytes and creatinine and through advance evaluation for hereditary blood clotting; tendencies (thrombophilia)
• Evaluation of the integrity of the woman’s reproductive apparatus through physical and pelvic ultrasound examinations
• Tests for blood diseases such as severe anemia, lymphoma and leukemia include a complete blood and platelet count, measurement of the blood sedimentation rate, iron and folic acid levels as well as selective evaluation of women of African extraction for Sickle Cell disease and those of Asian and Mediterranean extraction for Thalassemia
• Psychological screening

When women so deemed to be at risk are selectively precluded from proceeding, the physical risk of age-related complications can be minimized.

2. Parenting risks: The common argument made is that the mother might either not live long enough or because of age-related maladies, might not be able to afford her child all the benefits of parenting. I would argue that less than 5 decades ago the average lifespan of women was in the mid-70. Today through women commonly live into their eighties. While it is true that advancing age might well compromise the ability to fully participate in some physical activities with their children, other advantages that age brings to child rearing such as enhanced wisdom, and a greater likelihood of financial and marital stability as well as preservation of the nuclear family, would in my opinion more than offset any disadvantages. Rather such age-related benefits might better prepare children for the real challenges of life in the 21st century. But surely the same parenting concerns should apply to men becoming fathers at an older age. Singling out women in this regard represents a double standard and is somewhat sexist, in my opinion.

Discrimination on the basis of sexual preference:
Over the last 29 years I have been instrumental in assisting more than 100 same sex couples have IVF babies and I can truly testify that in my experience they have usually turned out to make exemplary parents. This has especially been the case with same-sex female couples who often have more stable and lasting relationships than do male counterparts. Frankly, in my opinion, same-sex couples who decide to have a family together often give the issue much more sober consideration than is the case for many heterosexual couples. It is almost as if, given the hitherto non-legally binding relationship that “gay couples” have to live with, they recognize the complexity and gravity of the road they are embarking on and as such, take the step to IVF (or other forms of fertility enhancement) much more seriously.

I recently had the great privilege of attending the Bar and Bat Mitzvahs sponsored by the parents of a set of IVF twins. Also attending the festivities was single gay gentlemen whom I had helped have a daughter through use of an egg donor and gestational carrier. With him was his beautiful 11 year old daughter. He and I spoke about his relationship to her and I also spent time talking to his daughter, the love of his life. The joy that these two beautiful people had brought into each other’s lives was obvious. His love and adoration for her and hers for him was absolutely indisputable. Similar encounters that I have had with many same-sex IVF parents and their children over the years has left me realizing that sexual orientation is irrelevant when it comes to parenting. It does not leave the children confused about their own sexuality. An individual’s sexual identity and orientation is probably well established in early childhood. In the final analysis what matters is love and commitment between two people choosing to have a family. Not their sexual orientation.

Discrimination on the basis of marital status:
While there can be little doubt that children born to single parents are often disadvantaged through absence of a nuclear family setting. In addition, it is a reality that in these harsh economic times, it often takes two bread winners in a family to get by…let alone provide the where with all to support the needs of a child. This having been said, the fact remains that the modern institution of marriage is under siege, with more and more couples choosing to cohabit without “tying the legal knot”. This inevitably has led to a steady rise in the number of babies being born out of wedlock as well as ever increasing number of unmarried individuals and couples being diagnosed with infertility and seeking medical assistance to have a baby….and the number is expected to continue to rise. This is a reality that cannot be ignored or wished away. To turn our backs on such women/couples would be unthinkable, in my opinion.

Discrimination on the basis of Economic status:
I strongly protest the notion that anyone has the right to deny an individual or couple the right to have a family through medically assisted reproduction purely on the basis of the economic status of the prospective parent(s). After all, this never comes into the equation with natural, non-assisted reproduction. So why should it apply when it comes to assisted reproduction. Needless to say, there is a need and an obligation to counsel the economically disadvantaged who seek infertility treatment as to the short and long term financial consequences of having a child. Of course a legitimate question arises as to who should pay for the often expensive advanced fertility treatment needed in such cases. That is a different matter altogether. It is up to individual societies to determine how far the obligation to subsidize such medical benefits should go.

I have long held that it is not the role of a physician to dictate medical treatment to patients. I also believe that we have no right to deny access to advanced fertility treatments purely on the basis of a woman’s age, marital status, sexual orientation or the size of her pocket book. Rather, it is our role is to provide sufficient information to allow patients to make their own informed choices. Thereupon, provided that doing their bidding does not conflict with our own ethical/moral stance, and ever conscious of the tenant of the “Hippocratic Oath”, that binds physicians to “do no harm”, we are obligated to provide optimal medical care.