**1. Introduction**

Dizygotic twin pregnancies are known to increase with age of the mother. Naturally conceived twins are thought to occur in a 0.3% rate in women under 25 years, 1.4% between 25 and 34, 3% between 34 and 39, and 4.1% in women in their 40s or over [1]. We also know that at least 50% of all twin pregnancies are conceived through ART and that this proportion is probably higher for women in their 40s. International guidelines affirm that maternal mortality associated with multiple births is 2.5 times that for singleton births [2]. Since obstetric and obstetricrelated medical complications are amplified in the case of women of advanced reproductive age and also in twin gestations, the combination represents a particularly vulnerable group.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In Spain, for example, according to the 2013th ESHRE registry [3], a total of 56,704 treatments were performed, 18,113 consisting in egg donation, which makes almost 32% of all treatments. The percentage of women older than 40 years undergoing treatment and arriving to egg aspiration was 15.7%, with a pregnancy rate of 29.9%, but a delivery rate of 9.5%. For egg donation programmes, the percentage of women over 40 increased to 66.9%, with a pregnancy rate of 48.4 and a delivery rate of 30.5%. This means that in 2013–2014, 4272 women over 40 carried and delivered a baby in Spain. The proportion of double embryo transfers was 71.5%, with 20.9% of twin deliveries in FIV/ICSI treatments and 24.6% in egg donation: around 982 twin deliveries in women over 40 in Spain in 2013. And this only counts for the pregnancies achieved through ART. This same registry suggests that the overall preterm birth rate for twins was 51%.

**2.2. Counselling advanced reproductive age mothers**

threatening situation.

**2.3. Fertility in older mothers' children**

**2.4. Oocyte donation programmes**

**3.1. Low ovarian reserve**

important to avoid a twin gestation in older mothers.

**3. Reproduction treatment and advanced maternal age**

Autonomy principle involves that appropriately informed patients can decide whether they want to undergo or refuse a diagnostic test or treatment, accepting the benefits and risks of their decision. Following this principle, any woman seeking reproductive treatment after the age of 35, or more appropriately, after the age of 40, should be carefully informed about obstetrical complications and the health implication for them and the child. They should also be informed about preventive and treatment strategies that may be put in place to avoid them. When counselling women with pre-existing medical conditions, their head specialist should review the case and advise for or against pregnancy. It is very important to remember that certain medical conditions do contraindicate pregnancy, as they might lead to a life-

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Although most causes of infertility are not genetic, it has been observed in a US population study that daughters from mothers older than 40 years are more likely to remain childless in their lifetime [4]. However, it is difficult to discern whether this is a "learnt" pattern or a true "inherited" infertility trait. In the same population, daughters from "old" mothers were at double risk for delivering twins than daughters from "young" mothers (OR = 2.1, 95% CI: 0.8–5.4), although this difference was not statistically significant. This may suggest that delay-

Oocyte donation restores pregnancy possibility in women of advanced reproductive age and reduces the chances for implantation failure found among them. Most women seeking this treatment are happily married women, well-educated and high-income, and physically and psychologically healthy [5]. However, oocyte donation recipients experienced a higher risk of pregnancy complications largely due to advanced maternal age, particularly hypertensive disorders and diabetes, and the risk increases with age [6]. The Ethics Committee of the American Society for Reproductive Medicine recommends women of advanced reproductive age undergo a comprehensive medical test to ascertain fitness for pregnancy in order to prevent the rise of obstetric complications during pregnancy [7]. Multiple pregnancy is known to increase obstetrical and neonatal risks in women of all ages; therefore, it is particularly

The effect of age in the ovarian reserve is unavoidable. Although menopause is considered the end of the reproductive age in women, changes in the ovarian cycle take place many years prior to menopause. These changes may lead to a fertility dysfunction in women that decide to get

ing childbirth might be perpetuated and worsen with time in our current society.

But, which age is "too old"? Can we set a threshold? Can we legislate against advanced reproductive age? And, would this legislation only account for women seeking reproductive care? If we already know all these, why is it still happening? Can we, as a society, deny maternity to any woman? Can we afford this? What if maternity age continues to increase in the world? Should not this evolve with society? This chapter will raise many questions that, sorry, we would not probably able to answer.
