Grandmother pregnancies: A medical hara-kiri?

Recently, there started an intense debate with reference to a news item published in the Hindustan Times with a photograph of a 66-year-old proud lady with her newborn triplets sired through in vitro fertilization (IVF) and donor gamete technology [Figure 1]. The picture, with a caption “Bundle of Joy,” generated a rather justified outcry among the doctor–gynec community as they deal with this technology as well as the professional services for pregnancies/deliveries. Their major concerns were:

Figure 1

Bhateri Devi (88) from Hisar, underwent in vitro fertillisation and gave birth to triplets, after 44 years of remaining childless

60+ is too old an age to become pregnant. That is against nature and is likely to be very risky for the mother-to-be.

The child/ren born is/are likely to be orphaned at a very young age and may be deprived of parental love and supervision.

This type of incident and the media attention may be used as a form of undue publicity and may harm unsuspecting couples opting for these techniques in ignorant belief that this is quite safe.

As we exchanged strong opinions and sentiments, some interesting aspects came to the fore, which prompted the editors of the Indian Menopause Society (IMS) journals to include this debate in the current issue and, as the lone protagonist to defend this so-called “Grand Mother Pregnancies,” I am invited to put forth my view!

Pregnancy in the age group of 50+ years is, in itself, a debatable issue and putting arbitrary limits at 55 and 60 is useless as far as the patient's well being is concerned. More than 90% of the women reach menopause by 50 and that is nature's call to say goodbye to reproductive function. With the technology of IVF/intracytoplasmic sperm injection, controlled stimulation of ovaries and using other person's gametes and/or womb, various combinations of joint pregnancies are being achieved. Donor sperms have been used since ages – we read anecdotal references in epics like Mahabharata – which is culturally accepted by all communities across the world. Perhaps because getting donor sperms without any bodily harm to the donor is easier, it makes this acceptable. When we speak of donor oocytes, this entails a mini surgery and, in a bid to harvest large numbers, we need to use medicines that may also harm the oocyte donor both physically as well as emotionally. All these make oocyte donation costlier and may lead to the donor women's exploitation in poorer communities. Donor womb (although temporarily) becomes even more contentious as the donor has to go through a pregnancy with all risks attached to it and spare 9–12 months for the hiring couples. Again, mercenary considerations are likely to lead to women's exploitation in this technology.

When we focus on pregnancy after 50, it will almost always entail donor oocytes. Hence, all the attendant evils are present. In addition, the health risks to a woman whose body clock has passed the natural phase of reproduction make the prospect scary. Because we do not have any data or actual experience of this situation, we feel alarmed beyond realistic worries.

Pregnancy after 50 or 60 is tantamount to scaling Everest or going to the North Pole or landing on the moon! The first few attempts are likely to fail and may have disastrous consequences for the people involved. As a doctor, one would definitely want to avoid this situation. I believe that there is a consensus among the doctor community that any pregnancy after 45 is a high-risk pregnancy and should not be undertaken as long as possible.

But, at the same time, we need reckon with human elements of the whole issue. Curiosity and attitude of taking up challenges into unknown or uncharted territories is a fundamental human trait. The few mavericks who harbor these traits bring about major advances in any field. Coupled with this attitude, a felt need to achieve parenthood at any cost has brought about 50+ pregnancies. Some couples feel that they missed the bus as IVF techniques were not developed during their young days and the realization that they can possibly make use of this now has led to this situation.

For a childless couple in the Indian scenario, especially in the traditional and orthodox regions of North India, a couple opting for pregnancy as late as 60+, although bizarre, seems logical! We may sound alarm bells, but still we need to accept this fact on behalf of the couple in question. The “high-risk” argument, although valid, does not deter these couples in correcting their life's major perceived failure. Let us consider this not as a medical success or achievement but as an example of pushing human limits! Many desperate patients have defied medical logic and opted for risky treatment for various (mostly personal) reasons. I request you to look at this as a rights issue for a fellow human being who has been denied some fulfillment by mother nature (a fulfillment that is made out to be the raison d être of human existence by the neighbors and family members) and feels segregated in the social set within which she lives. Bhateri Devi might have opted for IVF at 30 if it was available in Hissar or if she could have afforded that earlier.

Let us consider the three major concerns voiced by gynecologists that I listed earlier:

1. “60+ is too old an age to become pregnant. That is against nature and is likely to be very risky for the mother to be”:

The “age too old for pregnancy” is a perceived concern, which has changed over time and is very arbitrary. As a student, I do remember that pregnancy in 30+ used to be considered elderly primi and we used to mark the case with a “red dot,” denoting “high risk”! With IVF, we went to 40+ primis! The Indian Council of Medical Research guidelines mentions a limit of 45 years for assisted pregnancy and, now, we accept postmenopausal pregnancies up to 55 from the Indian Society of Assisted Reproduction (ISAR)/IMS platform! I am pretty sure that in the 1990s, you must have felt abhorrent to pregnancies in late 40s and 50s. Today, we are carrying those feelings for 60+! The question is: Where to draw a line? Who is competent to draw the line – a doctor him/herself and for other doctors to follow? What is the logic of a particular deadline? Do we have scientific data about 60+ pregnancies? All our notions are based on a general drift of older age pregnancy, but there is no specific data to suggest a deadline. I believe that we do not have answers to these and desiring couples would only say that we object to this mode of pregnancy out of orthodox obstinacy!

As for the “against nature,” a majority of the medical/surgical procedures may be dubbed “against nature”! The entire gamut of anti-aging medicines, menopause medicines and elective “on demand” cesarean sections are just a few examples.

The concerns that old age pregnancy is “very risky” is a valid assumption, but then pregnancy in diabetics, cardiac disease patients, hypertensive patients and renal disease patients and other severely incapacitated people is also very risky; perhaps riskier than in a healthy 60+ woman! If you read earlier accounts of such pregnancies, they were very dismal. Do we banish these couples from achieving pregnancy?! We counsel such women against pregnancy but, ultimately, do defer to their decision to continue with the pregnancies. I still remember the dictum, “A diabetic woman should not marry and if she marries, she should not become pregnant.” Things changed with newer advances and experiences.

The risks for 50+ pregnancies are not quantified and do not warrant banning pregnancies in this age! If the quantum of risk is the issue (which is notional at best and not scientifically clear yet), many human endeavors would be stopped, like boogie jumping, skydiving or even for that matter going to space (many people lost their lives in the early attempts), where the risk is far greater than the risk in the elderly pregnant lady! We do not prevent such risky endeavors as long as someone else is not jeopardized.

2. The child/ren born is/are likely to be orphaned at a very young age and may be deprived of parental love and supervision:

Loss of parents is an issue, but then all soldiers on forward duty should avoid pregnancies. All HIV (human deficiency virus) positive couples and cancer patients also should be denied this. If we do not raise our voices in these cases, we may be blamed for double standards!

3. This type of incident and the media attention may be used as a form of undue publicity and may harm unsuspecting couples opting for these techniques in the ignorant belief that this is quite safe:

We have seen misuse of publicity and manipulation of media by our professional brethren and, in fact, by almost all people for personal, pecuniary as well as political gains. This is just one way of publicity. But, when we see pictures of large cysts, monster babies or multiple births with the attending doctor posing with a broad smile, we feel equally upset, as handling of these also are no medical marvels!

Now, let us look at this issue from the couple's perspectives. Their life suddenly changed from a social pariah to a celebrity! They would do anything for this attention and limelight. Leave alone the redressal of social stigma, the sense of achievement at a personal level would be tremendous for them. In fact, they would feel vindicated of their life and would die in peace in the society where they live! Unless we change the social systems, unless we change the mindset that there is so much to life then mandatory matrimony and parenthood, these incidences are going to happen. We need to do our duty as doctors and counsel the couple about the medical and social issues and fallouts. We may highlight that this is tantamount to “Medical hara-kiri,” but, ultimately, we will have to abide by their wishes!

Mrs. Devi's husband of 44 years said he was ecstatic at becoming a father for the first time. “Bhateri has fulfilled my dream of having a child and gave my family an heir,” he said. In India, being unable to have children throughout married life can stigmatize women.

From a legal viewpoint also this act may be condoned. We can regulate “surrogacy” as there would be options, and there is the likelihood of exploitation of other individuals. But, how would you regulate a married couple their own child? I solicit you all to think on level, that the couple in doing this is not harming anyone else nor taking any life as a feticide or abortion would, then why do we feel so upset?

I do see a point that doctors giving this treatment should be regulated – i.e., they need to counsel the couple extensively about the risks involved, to the health of the mother to be, to the child to be, genetic issues, child support in the event of death of the parents due to their advanced age and possible options of surrogate uterus. We can think of counseling by two doctors separately (as it happens in II trimester abortion) to take away individual bias.

From an ethical standpoint, I do appreciate the hurdles of old age pregnancy and the mercenary approach of some of our colleagues. But, at the same time, we all have been party to transgress the fine line of true ethics. We need to recognize that ethics are something personal and collective. They are generally above the law. The law always trails the “ethics” and, sometimes, unfortunately, bypasses them in the name of need of the society. The current MTP act is a glaring example of that. We have conveniently closed our eyes to the rights of the fetus to “safe life” in the name of free choice for the women. Almost 80% MTPs are being performed without truly ethical need, but here we turn our faces in the name of rights of a woman!

As I too practice assisted reproductive technology and IVF, I personally would try to dissuade such a couple to the best of my capacity. I may even offer them “surrogacy” as an option. But, if they are steadfast in their decision, I feel that the couple can and should be allowed to opt for the pregnancy even though I would feel very uncomfortable in handling this patient myself, and may not undertake such a case.

We as Gynec doctors are in a unique position. I do wish to know how we all feel as human being toward a fellow being as well as a professional doctor! Although I agree with the majority as a doctor, I may not as a human being! There lies the crux of the matter. I believe that we are prisoners to our set beliefs as to what is ideal or appropriate and when someone dares to think or act differently, we get upset. All our responses and feelings of alarm stem from the fact that we take this as a medical issue and not as a broader social, personal one.