**2.1. Setting a threshold for treatment**

In most countries, there is no legislation restricting maternal age. Some countries would not include women of advanced age in their public reproduction schemes, but the same restrictions usually do not apply to the private sector. And more importantly, in many countries, there is no restriction in the number of embryos being transferred to these women. Not only access cannot be denied but two and three embryos can also be transferred freely.

Classically, advanced maternal age has been defined as any woman conceiving after 35 years of age. Given the late reproductive trends, this threshold should now be reconsidered, as in developed countries it might include a high percentage of the pregnant population. Advanced maternal age nowadays might be considered as a woman conceiving after 40–43 years of age, which is the approximate age in which ovary ageing may have almost completely prevented spontaneous conception. However, although rare, spontaneous conception over 40s is possible, so is it fair to deny reproductive treatment to a woman whose same-age neighbour might have conceived spontaneously?

In this environment, most clinics set their own thresholds (or not at all) without much governmental support. Very few clinics would accept to perform reproductive treatment on a woman older than 50, which represents an age in which more or less half of the female population is menopausal. However, peri- and postnatal risk for the mother and the babies start increasing progressively much earlier than that. But when a clear guidance does not exist, decision making becomes somehow subjective, mainly considering our previous experiences. Can we impose our own personal opinion over a woman's family desire?

## **2.2. Counselling advanced reproductive age mothers**

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

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

In most countries, there is no legislation restricting maternal age. Some countries would not include women of advanced age in their public reproduction schemes, but the same restrictions usually do not apply to the private sector. And more importantly, in many countries, there is no restriction in the number of embryos being transferred to these women. Not only

Classically, advanced maternal age has been defined as any woman conceiving after 35 years of age. Given the late reproductive trends, this threshold should now be reconsidered, as in developed countries it might include a high percentage of the pregnant population. Advanced maternal age nowadays might be considered as a woman conceiving after 40–43 years of age, which is the approximate age in which ovary ageing may have almost completely prevented spontaneous conception. However, although rare, spontaneous conception over 40s is possible, so is it fair to deny reproductive treatment to a woman whose same-age neighbour

In this environment, most clinics set their own thresholds (or not at all) without much governmental support. Very few clinics would accept to perform reproductive treatment on a woman older than 50, which represents an age in which more or less half of the female population is menopausal. However, peri- and postnatal risk for the mother and the babies start increasing progressively much earlier than that. But when a clear guidance does not exist, decision making becomes somehow subjective, mainly considering our previous experiences.

Can we impose our own personal opinion over a woman's family desire?

access cannot be denied but two and three embryos can also be transferred freely.

rate for twins was 51%.

100 Multiple Pregnancy - New Challenges

would not probably able to answer.

**2.1. Setting a threshold for treatment**

might have conceived spontaneously?

**2. Ethical issues in the reproduction clinic**

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 lifethreatening situation.
