'Inconvenient biology:' advantages and disadvantages of first-time parenting after age 40 using in vitro fertilization

"I'm not your grandpa": Experiences of advanced age fathers raising their teenage children in Belgium, an interpretative phenomenological analysis

This study aims to gain more insight in the lived experience of men who became father at an advanced age (40 years or older). Advanced Parental Age (APA) is becoming an increasingly widespread phenomenon as the average age at which people have children has been increasing for decades now. However, the psychosocial dimension of APA-fatherhood in particular remains a highly understudied topic. This Interpretive Phenomenological Analysis presents findings from a qualitative interview study with seven men who fathered their (now teenage) children in their early 40s to early 50s. Interviews were semi-structured and focused on lived experiences of the participants and their normative stances regarding the topic of parenting at an advanced age. Three themes were identified: The fathers in our sample describe their APA as a result of life events rather than an intentional postponement. Second, they managed how they were perceived as APA-fathers by distancing themselves from 'too old' parents. However, these fathers did not perceive fatherhood at a younger age as better than their current APA. Three fathers, who also had an earlier fatherhood experience, provided a rich account of how they made sense of their fatherhood roles in both families. Third, the seven fathers encountered social stigma, leading to various coping strategies. These findings contribute to better understanding the psychosocial dimension of APA-fatherhood.

Sociodemographic Trends and Perinatal Outcomes in Fathers 50 Years and Older

Importance

The age of fathers at childbirth is rising, with an increasing number of births attributed to older fathers. While the impact of advanced paternal age has been documented, sociodemographic data about fathers aged 50 years and older remain scarce.

Objectives

To explore sociodemographic and temporal trends among the oldest US fathers (age ≥50 years) and their associations with perinatal outcomes.

Design, Setting, and Participants

This retrospective cross-sectional study included data from all US births from 2011 to 2022 using the National Vital Statistics System. Data were analyzed from August 2023 and May 2024.

Exposures

Reported paternal age at childbirth.

Main Outcomes and Measures

Outcomes of interest were sociodemographic factors, temporal trends in older fatherhood, and perinatal outcomes, including preterm birth, low birth weight, gestational diabetes, gestational hypertension, assisted reproductive technology (ART), rates of maternal primiparity, and the infant sex ratio.

Results

From 2011 to 2022, the US recorded 46 195 453 births, with an overall mean (SD) paternal age of 31.5 (6.8) years and 484 507 (1.1%) involving fathers aged 50 years or older, 47 785 (0.1%) aged 60 years or older, and 3777 (0.008%) aged 70 years or older. Births to fathers aged 50 years or older increased from 1.1% in 2011 to 1.3% in 2022 (P for trend < .001). Fathers aged 50 years or older were more diverse, with variations in educational achievement and race and ethnicity. Marital status and maternal racial and ethnic and educational backgrounds also varied by paternal age and race. Despite controlling for maternal age and other sociodemographic and perinatal factors, every 10-year increase in paternal age was consistently associated with greater use of ART (eg, age 50-59 years: adjusted odds ratio [aOR], 2.23; 95% CI, 2.19-2.27), higher likelihood of first maternal birth (eg, age 50-59 years: aOR, 1.16; 95% CI, 1.15-1.17), and increased risks of preterm birth (eg, age 50-59 years: aOR, 1.16; 95% CI, 1.15-1.18) and low birth weight (eg, age 50-59 years: aOR, 1.14; 95% CI, 1.13-1.15) compared with fathers aged 30 to 39 years. No significant changes in the infant sex ratio were observed, except among fathers aged 70 years or older (aOR, 0.92; 95% CI, 0.86-0.99) and 75 years or older (aOR, 0.84; 95% CI, 0.73-0.97), who showed a decreased likelihood of having male offspring.

Conclusions and Relevance

In this cross-sectional study of all US births from 2011 to 2022, the percentage attributed to older fathers, while small, increased. Notable variations in paternal and maternal race and education were identified. Older fatherhood was associated with increased ART use, first-time maternal births, adverse perinatal outcomes, and altered sex ratio. Further research of this population is crucial for improving patient counseling and family planning.

Sociodemographic predictors of parenting stress among mothers in socio-economically deprived settings in rural and urban Kenya and Zambia

Parental stress occurs when parenting demands exceed the resources available to cope with parenting. Previous research has identified household wealth, educational level, marital status, age, and number of dependent children as predictors of parental stress. However, limited evidence exists from sub-Saharan Africa. This study investigated the sociodemographic predictors of parenting stress among mothers in Kenya and Zambia. This cross-sectional study utilised baseline secondary data from parenting intervention programs implemented in Kisumu County (rural Kenya), Nairobi County (Urban Kenya), and Chisamba District (rural Zambia). Out of 913 caregivers recruited for the parenting program, 844 with complete data were included in the analysis. The mean age was 1.0 (SD = 0.7) years. Parental stress was measured using the Parental Stress Score (PSS) tool and demographic questionnaires were used to collect demographic information. Mean PSS were compared across study sites, and a multiple linear regression model was used to examine associations between sociodemographic predictors (household income, educational level, marital status, maternal age, child age, and number of children aged < 5 years) and PSS, adjusting for clustering and other predictors. From the results, the mean PSS in rural Kenya was 37.6 [SD = 11.8], in urban Kenya was 48.4 [SD = 4.2], and in rural Zambia was 43.0 [SD = 9.1]. In addition, the significant association between PSS and mothers' income and educational level was only observed in Kenyan study sites (income: Kenya rural β = -0.40, p < 0.001**; Kenya urban, β = - 0.33, p = .02*; Zambia rural, β = - 0.01, p = 0.7) education: Kenya rural, β = - 0.25, p = .005**; Kenya urban, β = - 0.14, p = 0.07; Zambia rural, β = 0.04, p = 0.3). However, marital status, mother's age, child's age, and the number of children below five years were not associated with PSS. The results revealed that mothers' income and education level were negatively associated with PSS, indicating that higher socioeconomic status can buffer the effects of parental stress.Trial registration Pan African Clinical Trials Registry ( https://pactr.samrc.ac.za/ ) database (ID Number: PACTR20180774832663 Date: 26/July/2018; (ID number: PACTR201905787868050 Date: 06/May/2019.

"It was not an accident": Women's experiences of renewing motherhood at 40

In recent decades, there has been an increase in motherhood at an advanced age that has raised several medical and social concerns. We conducted a qualitative interview study, guided by Interpretative Phenomenological Analysis, to focus on the motivations and experiences of Belgian women who 'renewed' their motherhood later in life, meaning they had one or several children and then (at least 10 years later) had another child at the age of 40 or older. We focused on ten women's experiences of motherhood later in life, as well as on the way they managed social norms and expectations regarding family building and the appropriate life course. We identified two main themes. The first theme describes the participants' encounters with social norms that challenged their decision to reproduce and parent later in life, and how they managed and anticipated criticism, surprise, disbelief and incomprehension about their renewed motherhood in various ways. The second theme shows how these women talked about taking responsibility as a (renewed) mother of advanced age. For them, responsible motherhood involved making thoughtful reproductive choices, attending to the range of needs of their children, and making extra efforts to safeguard the social and emotional wellbeing of their youngest children, thereby seeking to reduce potential harm resulting from these reproductive choices. This study provides insight into these women's self-conception and their interactions with prejudiced social views of motherhood and family building.

A longitudinal study of families created using egg donation: Family functioning at age 5

Findings are reported from Phase 2 of a longitudinal study of family functioning in heterosexual-couple families with 5 year olds conceived using identity-release egg donation. Seventy-two egg donation families were compared to 50 in vitro fertilization (IVF) families (ethnicity: 93% White British) using standardized observational, interview, and questionnaire measures. There were no differences between family types in the quality of mother-child or father-child interaction, apart from lower structuring by fathers in egg donation families. Egg donation mothers and fathers reported higher levels of parenting stress and lower levels of confidence and competence than their IVF counterparts. Egg donation mothers reported lower social support and couple relationship quality, greater anger toward their child, and perceived their child as more angry and less happy, compared to IVF mothers. Egg donation fathers showed greater criticism and anger toward their child, less joy in parenting, and were less satisfied with the support they received, than IVF fathers. Children in egg donation families showed higher levels of externalizing problems than IVF children as rated by mothers, fathers, and teachers, whereas they were rated as having higher levels of internalizing problems by teachers only. Externalizing problems were predicted by mothers' lower initial social support, steeper increases in parenting stress and greater concurrent criticism, whereas internalizing problems were associated with poorer initial couple relationship quality as rated by mothers. Both were predicted by fewer gains in reflective functioning. There was a moderation effect such that parenting stress was a stronger predictor of externalizing problems for egg donation than IVF families. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Building a family at advanced parental age: a systematic review on the risks and opportunities for parents and their offspring

STUDY QUESTION

What is the existing empirical literature on the psychosocial health and wellbeing of the parents and offspring born at an advanced parental age (APA), defined as 40 years onwards?

SUMMARY ANSWER

Although the studies show discrepancies in defining who is an APA parent and an imbalance in the empirical evidence for offspring, mothers, and fathers, there is a drive towards finding psychotic disorders and (neuro-)developmental disorders among the offspring; overall, the observed advantages and disadvantages are difficult to compare.

WHAT IS KNOWN ALREADY

In many societies, children are born to parents at advanced ages and there is rising attention in the literature towards the consequences of this trend.

STUDY DESIGN SIZE DURATION

The systematic search was conducted in six electronic databases (PubMed including Medline, Embase, Scopus, PsycInfo, CINAHL, and SocINDEX) and was limited to papers published between 2000 and 2021 and to English-language articles. Search terms used across all six electronic databases were: ('advanced parental age' OR 'advanced maternal age' OR 'advanced paternal age' OR 'advanced reproductive age' OR 'late parent*' OR 'late motherhood' OR 'late fatherhood') AND ('IVF' OR 'in vitro fertilization' OR 'in-vitro-fertilization' OR 'fertilization in vitro' OR 'ICSI' OR 'intracytoplasmic sperm injection' OR 'reproductive techn*' OR 'assisted reproductive technolog*' OR 'assisted reproduction' OR 'assisted conception' OR 'reproduction' OR 'conception' OR 'birth*' OR 'pregnan*') AND ('wellbeing' OR 'well-being' OR 'psycho-social' OR 'social' OR 'ethical' OR 'right to reproduce' OR 'justice' OR 'family functioning' OR 'parental competenc*' OR 'ageism' OR 'reproductive autonomy' OR 'outcome' OR 'risk*' OR 'benefit*').

PARTICIPANTS/MATERIALS SETTING METHODS

The included papers were empirical studies in English published between 2000 and 2021, where the study either examined the wellbeing and psychosocial health of parents and/or their children, or focused on parental competences of APA parents or on the functioning of families with APA parents. A quality assessment of the identified studies was performed with the QATSDD tool. Additionally, 20% of studies were double-checked at the data extraction and quality assessment stage to avoid bias. The variables sought were: the geographical location, the year of publication, the methodological approach, the definitions of APA used, what study group was at the centre of the research, what research topic was studied, and what advantages and disadvantages of APA were found.

MAIN RESULTS AND THE ROLE OF CHANCE

A total number of 5403 articles were identified, leading to 2543 articles being included for title and abstract screening after removal of duplicates. This resulted in 98 articles included for a full-text reading by four researchers. Ultimately, 69 studies were included in the final sample. The key results concerned four aspects relevant to the research goals. (i) The studies showed discrepancies in defining who is an APA parent. (ii) There was an imbalance in the empirical evidence produced for different participant groups (mothers, fathers, and offspring), with offspring being the most studied study subjects. (iii) The research topics studied underlined the increased risks of neuro-developmental and psychotic disorders among offspring. (iv) The observed advantages and disadvantages were varied and could not be compared, especially for the offspring of APA parents.

LIMITATIONS REASONS FOR CAUTION

Only English-language studies, published between 2000 and 2021, found in the above-mentioned databases were considered for this review.

WIDER IMPLICATIONS OF THE FINDINGS

More research is necessary to understand the risks and benefits of building a family at an APA for the offspring when they reach adulthood. Furthermore, studies that explore the perspective of older fathers and older parents from non-Western societies would be highly informative.

STUDY FUNDING/COMPETING INTERESTS

The writing of this manuscript was permitted by financial support provided by the Swiss National Science Foundation (Weave/Lead Agency funding program, grant number 10001AL_197415/1, project title 'Family Building at Advanced Parental Age: An Interdisciplinary Approach'). The funder had no role in the drafting of this manuscript and the views expressed therein are those of the authors. The authors have no conflicts of interest.

REGISTRATION NUMBER

This systematic review is registered in Prospero: CRD42022304564.

Survey assessing policies regarding patient age and provision of fertility treatment in the United States

PURPOSE

To determine what policies exist regarding age and provision of fertility treatment in United States fertility clinics.

METHODS

Medical directors of the Society for Assisted Reproductive Technology (SART) member clinics were surveyed regarding clinic demographics and current policies pertaining to age and provision of fertility treatment. Univariate comparisons were performed using Chi-square and Fisher exact tests as appropriate, with significance set at P ≤ 0.05.

RESULTS

Of the 366 clinics surveyed, 18.9% (69/366) responded. A majority of clinics who responded 88.4% (61/69) reported having a policy regarding patient age and provision of fertility treatment. Responding clinics with an age policy did not differ from those without a policy on the basis of geographical location, (p = 0.5), insurance mandate status (p = 0.9), practice type (p = 0.4), or annual number of ART cycles (p = 0.7). Of all clinics who responded, 73.9% (51/69) had a maximum maternal age for autologous IVF, with a median of 45 years (range 42-54). Similarly, 79.7% (55/69) of responding clinics had a maximum maternal age for donor oocyte IVF, with a median of 52 years (range 48-56). Slightly under half, 43.4% (30/69) of responding clinics had a maximum maternal age for fertility treatment other than IVF (including ovulation induction or ovarian stimulation with or without IUI) with a median of 46 years (range 42-55). Of note, only 4.3% (3/69) of responding clinics had a policy with respect to maximum paternal age, with a median of 55 years (range 55-70). The most commonly cited reasons for having an age-limit policy were maternal risks of pregnancy, lower ART success rates, fetal/neonatal risks, and concerns about patients' ability to parent at an older age. More than half 56.5% (39/69) of responding clinics reported making exceptions to these policies, most commonly for patients who have pre-existing embryos. The majority of medical directors who responded to the survey believed there should be an ASRM guideline regarding maximum maternal age for autologous IVF 71% (49/69), donor oocyte IVF 78% (54/69) and other fertility treatments 62% (43/69).

CONCLUSIONS

Most fertility clinics who responded to this national survey reported having a policy regarding maternal age (but not paternal age) and provision of fertility treatment. Policies were based on risk of maternal/fetal complications, lower success rates at older age, and concerns about patients' ability to parent at an older age. The majority of medical directors of responding clinics believed there should be an ASRM guideline regarding age and provision of fertility treatment.

The psychosocial outcomes of older parenthood in early to mid-childhood: a mini-review

Recent decades have seen a global trend towards delaying parenthood, referred to as the 'postponement transition'. Whilst there is plentiful research regarding obstetric and paediatric outcomes related to delayed parenthood, relatively little is known about the psychosocial outcomes associated with advanced parental age during early and middle childhood. This mini-review examines the current literature regarding the psychosocial functioning of families headed by older parents. First, we give an overview of the literature that examines the psychological wellbeing of older first-time parents. We then review the literature regarding the quality of the parent-child relationship in older parent families. Finally, we discuss the psychosocial adjustment and cognitive development of children of older parents. We conclude with suggestions for future research avenues.

The risky business of advanced paternal age: neurodevelopmental and psychosocial implications for children of older fathers

The last several decades are notable for an increase in the percentage of births attributable to men in their 40s and 50s. There is general recognition of offspring health risks related to advanced maternal age, however, fewer patients and providers are informed about the impacts of advanced paternal age (APA). This review examined the literature investigating the association between APA and offspring outcomes, specifically, neurodevelopmental, psychiatric, academic, and behavioral impairment, the impact of paternal health decline and death, and the influence of age on parenting behaviors. This analysis revealed that children, and even grandchildren, of older fathers face significantly increased incidence rates of psychiatric disease and behavioral impairment. The data do not show evidence of superior parenting behaviors among men with APA. Finally, children of men with APA are significantly more likely to experience early bereavement, which is associated with psychological and developmental consequences. An understanding of the degree to which APA can negatively impact the offspring is imperative for patient counseling and development of practice guidelines.

The role of motherhood schemas and life transitions in reproductive intention formation

OBJECTIVE

This study provides a theory-based snapshot of the processes involved in women's fertility intention formation and decisions regarding the timing of motherhood.

BACKGROUND

The trend to defer childbearing is linked with both empowering and challenging outcomes for women. The cognitive-social (C-S) model suggests that deliberative thinking regarding reproduction occurs following fertility-relevant life transitions, which results in fluctuations in motherhood schemas and fertility intentions. This framework was applied to explore fertility intention formation.

METHODS

Semi-structured interviews were conducted with twelve women who either had children or desired children.

RESULTS

Two overarching themes central to the C-S model are discussed: (a) passive expectations and (b) deliberative intentions. Women's motherhood schemas were often underpinned by schematic structures (e.g. group norms and scripts) and material structures (e.g. observational influences). Life transitions and personal experiences tended to prompt deliberative thinking about motherhood plans.

CONCLUSION

The results were generally consistent with the C-S model, but highlight complexities to consider when investigating fertility expectations and intentions.

An exploration of parental age in relation to parents' psychological health, child adjustment and experiences of being an older parent in families formed through egg donation

RESEARCH QUESTION

Is parental age associated with parents' psychological health, couple relationship satisfaction and child adjustment in egg donation families, and how do parents think and feel about their age in relation to parenting?

DESIGN

Seventy-two families with a child born after IVF egg donation were included. Mothers were aged between 32 and 51 years and fathers between 31 and 61 years when the target child was born. When the child was aged 5 years, parents were interviewed and asked to complete questionnaire assessments of parenting stress, anxiety, depression, marital quality and child adjustment.

RESULTS

Older parents experienced more parenting stress and poorer couple relationship quality than younger parents. No differences were found for child adjustment. Qualitative content analysis of the interviews revealed themes related to 'health and mortality', 'giving and receiving support', 'treatment and age', 'positive aspects of older parenting' and 'other'.

CONCLUSIONS

This exploratory study found that older parents experienced greater parental stress and poorer relationship quality. Some parents had concerns about their older age, specifically in relation to their health and mortality. It would be important to follow up these families as the child grows older to understand the child's thoughts and feelings about having older parents. Furthermore, findings should be replicated in a larger sample of families formed through egg donation, which includes more younger mothers who have used egg donation.

Delaying, debating and declining motherhood

Trends of delayed childbearing have accompanied declining birth rates and increasing numbers of childless adults in the USA. Women may postpone parenting in order to save money, find a partner, and get a 'family-friendly' job, but this reproductive strategy may not always be effective. This paper uses two waves of longitudinal data to track childless women's reproductive decision-making and behaviours. During wave 1, interviews were conducted with 72 childless US women between the ages of 25 and 40 about their reproductive desires and intentions. Approximately four years later, a subset of the original sample participated in surveys to assess consistencies between fertility intentions and outcomes, and in-depth interviews to elicit information about changes in their lives that transpired. Whereas some wave 2 participants had fulfilled their goal of becoming parents, the majority were still employing a delaying strategy or had declined to have children. Delayed childbearing was individually strategic for those who could garner resources to be in a better financial or social position to have and raise children, while others kept facing barriers that prevented them from realising their reproductive goals or changed their mind about their fertility intentions and desires.

From late fatherhood to prenatal screening of monogenic disorders: evidence and ethical concerns

BACKGROUND

With the help of ART, an advanced parental age is not considered to be a serious obstacle for reproduction anymore. However, significant health risks for future offspring hide behind the success of reproductive medicine for the treatment of reduced fertility associated with late parenthood. Although an advanced maternal age is a well-known risk factor for poor reproductive outcomes, understanding the impact of an advanced paternal age on offspring is yet to be elucidated. De novo monogenic disorders (MDs) are highly associated with late fatherhood. MDs are one of the major sources of paediatric morbidity and mortality, causing significant socioeconomic and psychological burdens to society. Although individually rare, the combined prevalence of these disorders is as high as that of chromosomal aneuploidies, indicating the increasing need for prenatal screening. With the help of advanced reproductive technologies, families with late paternity have the option of non-invasive prenatal testing (NIPT) for multiple MDs (MD-NIPT), which has a sensitivity and specificity of almost 100%.

OBJECTIVE AND RATIONALE

The main aims of the current review were to examine the effect of late paternity on the origin and nature of MDs, to highlight the role of NIPT for the detection of a variety of paternal age-associated MDs, to describe clinical experiences and to reflect on the ethical concerns surrounding the topic of late paternity and MD-NIPT.

SEARCH METHODS

An extensive search of peer-reviewed publications (1980-2021) in English from the PubMed and Google Scholar databases was based on key words in different combinations: late paternity, paternal age, spermatogenesis, selfish spermatogonial selection, paternal age effect, de novo mutations (DNMs), MDs, NIPT, ethics of late fatherhood, prenatal testing and paternal rights.

OUTCOMES

An advanced paternal age provokes the accumulation of DNMs, which arise in continuously dividing germline cells. A subset of DNMs, owing to their effect on the rat sarcoma virus protein-mitogen-activated protein kinase signalling pathway, becomes beneficial for spermatogonia, causing selfish spermatogonial selection and outgrowth, and in some rare cases may lead to spermatocytic seminoma later in life. In the offspring, these selfish DNMs cause paternal age effect (PAE) disorders with a severe and even life-threatening phenotype. The increasing tendency for late paternity and the subsequent high risk of PAE disorders indicate an increased need for a safe and reliable detection procedure, such as MD-NIPT. The MD-NIPT approach has the capacity to provide safe screening for pregnancies at risk of PAE disorders and MDs, which constitute up to 20% of all pregnancies. The primary risks include pregnancies with a paternal age over 40 years, a previous history of an affected pregnancy/child, and/or congenital anomalies detected by routine ultrasonography. The implementation of NIPT-based screening would support the early diagnosis and management needed in cases of affected pregnancy. However, the benefits of MD-NIPT need to be balanced with the ethical challenges associated with the introduction of such an approach into routine clinical practice, namely concerns regarding reproductive autonomy, informed consent, potential disability discrimination, paternal rights and PAE-associated issues, equity and justice in accessing services, and counselling.

WIDER IMPLICATIONS

Considering the increasing parental age and risks of MDs, combined NIPT for chromosomal aneuploidies and microdeletion syndromes as well as tests for MDs might become a part of routine pregnancy management in the near future. Moreover, the ethical challenges associated with the introduction of MD-NIPT into routine clinical practice need to be carefully evaluated. Furthermore, more focus and attention should be directed towards the ethics of late paternity, paternal rights and paternal genetic guilt associated with pregnancies affected with PAE MDs.

The Premise and Promise of Activation Parenting for Fathers: A Review and Integration of Extant Literature

Although research on fathers tends to focus on mother-derived conceptualizations of caregiving, such as sensitivity, it has been theorized that fathers play a unique role in opening their children to the world by encouraging exploration and risk-taking. However, extant research on these forms of paternal caregiving is scattered across multiple related but distinct domains, namely rough-and-tumble play, challenging parenting behavior, and the activation relationship. Based on the overlap in theory and operationalizations of these domains, the present review aimed to define and operationalize a new caregiving construct: activation parenting (AP). Fathers who exhibit frequent and high-quality AP behaviors encourage children to take risks, challenge children physically and socioemotionally, and set appropriate limits during stimulating interactions to ensure safety and prevent over-arousal. Using Belsky's (1984) process of parenting model as a foundation, associations between paternal AP and characteristics of the father, his environment, and his child are reviewed, with a focus on early childhood (i.e., ages 0-5 years). The present review found some support for paternal AP occurring more frequently, but not necessarily with higher quality, when fathers had children older than one years old. Unexpectedly, the frequency and quality of paternal AP did not differ much by paternal age or indicators of socioeconomic status, or by child age or gender. In line with underlying theories, higher quality paternal AP in early childhood has been found to be associated with children's self-regulation skills and lower levels of internalizing and externalizing problems. Limitations of the current paternal AP literature are discussed and future directions for research, policy, and clinical work are proposed.

Preconception tests at advanced maternal age

Pregnancies at an advanced reproductive age are increasingly common. However, the safety of pregnancy remains a concern as maternal age is a recognized independent factor for various obstetric complications. Also, age is a risk factor for most systematic health problems and older women are more likely to enter into pregnancy with pre-existing conditions. At the moment there is no separate, structured guidance on preconception tests at advanced maternal age. However, the preconceptual period offers an ideal window to recognize and address underlying health issues, social issues and harmful lifestyle behaviours in order to optimize maternal health ultimately reducing infertility, perinatal morbidity and mortality. Preconception tests should be clinically relevant aiming to identify risk factors and address them to predict and prevent infertility and pregnancy complications. The importance of preconception care is magnified for women of advanced age for whom the risks are higher and the potential benefits greater.

The other face of advanced paternal age: a scoping review of its terminological, social, public health, psychological, ethical and regulatory aspects

BACKGROUND

There is a global tendency for parents to conceive children later in life. The maternal dimension of the postponement transition has been thoroughly studied, but interest in the paternal side is more recent. For the moment, most literature reviews on the topic have focused on the consequences of advanced paternal age (APA) on fertility, pregnancy and the health of the child.

OBJECTIVE AND RATIONALE

The present review seeks to move the focus away from the biological and medical dimensions of APA and synthesise the knowledge of the other face of APA.

SEARCH METHODS

We used the scoping review methodology. Searches of interdisciplinary articles databases were performed with keywords pertaining to APA and its dimensions outside of biology and medicine. We included scientific articles, original research, essays, commentaries and editorials in the sample. The final sample of 177 documents was analysed with qualitative thematic analysis.

OUTCOMES

We identified six themes highlighting the interdisciplinary nature of APA research. The 'terminological aspects' highlight the lack of consensus on the definition of APA and the strategies developed to offer alternatives. The 'social aspects' focus on the postponement transition towards reproducing later in life and its cultural dimensions. The 'public health aspects' refer to attempts to analyse APA as a problem with wider health and economic implications. The 'psychological aspects' focus on the consequences of APA and older fatherhood on psychological characteristics of the child. The 'ethical aspects' reflect on issues of APA emerging at the intersection of parental autonomy, children's welfare and social responsibility. The 'regulatory aspects' group different suggestions to collectively approach the implications of APA. Our results show that the field of APA is still in the making and that evidence is lacking to fully address the issues of APA. The review suggests promising avenues of research such as introducing the voice of fathers of advanced age into the research agenda.

WIDER IMPLICATIONS

The results of this review will be useful for developing policies and preconception health interventions that consider and include prospective fathers of advanced age.

Cognitive and behavioural outcome of children born after IVF at age 9 years

STUDY QUESTION

Do ovarian stimulation (OS) and the in vitro laboratory procedures affect offsprings' cognitive and behavioural outcome at 9 years?

SUMMARY ANSWER

OS and the in vitro laboratory procedures or the combination of both were not associated with cognitive and behavioural outcome at age 9 years.

WHAT IS KNOWN ALREADY

ART is not associated with an adverse short-term developmental outcome of the offspring, but limited knowledge is available on the offspring's long-term neurodevelopmental condition.

STUDY DESIGN, SIZE, DURATION

A 9-year longitudinal, assessor-blinded, prospective follow-up study of 169 out of 215 singletons (79%) born between March 2005 and December 2006 was performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Singletons born following IVF or ICSI with OS (n = 57), born after modified natural cycle IVF/ICSI (MNC-IVF/ICSI; n = 46) and born after natural conception to subfertile couples (Sub-NC; n = 66), were assessed at 9 years. This study design, with two ART groups and a subfertile reference group, allows for disentangling the effects of OS and ART procedures on developmental outcome. Cognitive outcome was evaluated with the Wechsler abbreviated scale of intelligence and the NEPSY-II. Behaviour was assessed with the child behaviour checklist (CBCL) and teacher report form (TRF). Univariable analyses and multiple linear regression models were used.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no significant difference in intelligence quotient (IQ) scores between ART groups (mean IQ (95% CI): OS 114.8 (83.2-142.6); MNC 114.0 (90.2-140.8); Sub-NC 115.4 (87.9-141.2), P = 0.746). Multivariable analyses did not reveal a statistically significant association between ART group and total, verbal and performance IQ. CBCL and TRF scores did not differ significantly between ART groups (P = 0.090 and 0.507, respectively). Multivariable analyses did not demonstrate a statistically significant association between ART group and CBCL and TRF total, or internalising and externalising T-scores. No significant correlations between time to pregnancy (TTP)-a proxy for the severity of parental subfertility-and outcome measures were found (Spearman rho between -0.050 and 0.049, NS), which was confirmed with multivariable analyses.

LIMITATIONS, REASONS FOR CAUTION

The attrition rate of 21% may be considered as a limitation of the study; however, after a follow-up period of 9 years, this rate is generally considered acceptable, and there were no significant differences in background characteristics between children with and without follow-up, making an attrition-related selection bias less likely. Another limitation of the study is the relatively small sample size, which could contribute to selection bias, hamper generalizability to the ART population and lead to false negative findings as a result of underpowering. An a priori power analysis on total IQ indicated that the OS-IVF/ICSI and Sub-NC groups should contain 64 children, confirming that our study including 57 and 66 children, respectively, was slightly underpowered.

WIDER IMPLICATIONS OF THE FINDINGS

Our study indicated that OS and the in vitro laboratory procedures or the combination of both and TTP were not associated with cognitive and behavioural outcome at 9 years. These are reassuring results for both parents and clinicians involved in ART.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financially supported by the University Medical Center Groningen (UMCG), two graduate schools of the UMCG (BCN and SHARE) and the Cornelia Stichting. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. The authors have no conflicts of interest to declare.

Is it time to establish age restrictions in ART?

Providers specializing in reproductive medicine are treating increasing numbers of women pursuing parenthood in their 40s, 50s, and beyond. The rise in later-life parenting can be linked to factors ranging from the advent of assisted reproductive technologies and donor oocytes to the highly publicized pregnancies of older celebrities. We explore the medical and psychosocial implications of this trend for both older parents and their children. We also discuss ethical arguments regarding older parents' access to fertility care, existing professional guidelines, and both public and provider opinions about setting age limits for fertility treatment. Finally, we share preliminary considerations of whether age policies should be established, applied to men as well as women, and standardized or considered on a case-by-case basis.

Psychological well-being of identity-release egg donation parents with infants

STUDY QUESTION

What are the psychological health, relationship quality and perceived social support outcomes of heterosexual couples who have conceived an infant through identity-release egg donation?

SUMMARY ANSWER

Parents' scores on all measures were within the normal range. Egg donation mothers had poorer perceived social support, and egg donation fathers had less optimal psychological health than a comparison group of IVF parents, although these differences were associated with the older age of egg donation parents, rather than being an effect of family type.

WHAT IS KNOWN ALREADY

There is limited understanding of the psychological health and couple relationship quality of egg donation parents, and no empirical data on parents' social support, during the first year of parenthood. No studies have included families who have used an identity-release egg donor. The study offers the first examination of the psychological well-being of identity-release egg donation parents.

STUDY DESIGN, SIZE, DURATION

This study included 57 families created through identity-release egg donation, and a comparison group of 56 families who had used IVF with their own gametes, recruited through UK fertility clinics. Families were visited at home between October 2013 and June 2015. The sample forms part of a larger study examining family functioning in families created following fertility treatment.

PARTICIPANTS/MATERIALS, SETTING, METHOD

All families were heterosexual two-parent families with an infant aged 6-18 months. Mothers and fathers were administered standardised questionnaires assessing psychological health (Edinburgh Postnatal Depression Scale, Trait Anxiety Inventory and Parenting Stress Index-short form), couple relationship quality (Golombok Rust Inventory of Marital State) and perceived social support (Multidimensional Scale of Perceived Social Support).

MAIN RESULTS AND THE ROLE OF CHANCE

Scores from the egg donation and IVF parents were within the normal range on all measures. Significant differences were found between the groups indicating less optimal social support in egg donation mothers compared to IVF mothers, and poorer psychological health in egg donation fathers compared to IVF fathers. These differences appeared to be related to the older age of egg donation parents or to twin parenthood, rather than to egg donation per se. No differences were found between the groups in the parents' relationship quality.

LIMITATIONS, REASONS FOR CAUTION

It is possible that families who were managing the transition to parenthood less well may have been less likely to participate in research. Fewer IVF than egg donation fathers participated in the study, so the statistical power was lower for comparisons between fathers.

WIDER IMPLICATIONS OF THE FINDINGS

The findings are of relevance to UK clinics offering identity-release egg donation. That scores of egg donation parents on measures of psychological well-being were more similar than different to those of IVF parents should prove reassuring to individuals considering this treatment type. As less optimal outcomes were found for egg donation parents on several measures, and these were associated with parental age rather than conception type, it is recommended that clinics discuss with older patients how they may establish a social support network and signpost patients to appropriate post-natal support.

STUDY FUNDING, COMPETING INTERESTS

This research was supported by a Wellcome Trust Senior Investigator Award [097857/Z/11/Z] and a CHESS-ESRC studentship. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Does extreme maternal age still act as a risk factor for adverse perinatal outcome? Evidence from Poland 20 years after the social and economic transformation

It was examined whether positive changes in maternal SES and medical facilities in Poland 20 years after social and economic transformation weakened the role of maternal age in shaping perinatal outcome. Data comprised of 2,979 children born in 2000 and 2,992 – born in 2015. To test the differences between the frequency of indicators of adverse perinatal outcome the chi-square test was applied. The influence of maternal age on the perinatal outcome was estimated using Generalized Linear Models (GLMs), with binomial error distribution and the logit link function. The infants survival was examined using survival analysis. Gestational age and birth weight were influenced by mother’s age and the year of survey. Infants of adolescent and older mothers represented the groups with a risk of adverse perinatal outcome: an increase of preterm births and higher risk of having children with LBW in the group of adolescent mothers than in mothers aged >35, infants born SGA and LGA found in both adolescent and adult mothers. GLMs confirmed the impact of maternal age and the year of survey on perinatal outcome. The Cox proportional hazard models showed that the year of survey was the only factor affecting the risk of infants’ death. The impact of maternal age on adverse perinatal outcome can be counterbalanced by positive changes in social and economic standard of living of women, improvement in neonatal medical care and better equipment of hospital wards in 2015 as compared to 2000.

Mid-life fertility: Challenges & policy planning

This review highlights the challenges, priority areas of research and planning, strategies for regulation of services and the need to develop guidelines and laws for fertility treatments during mid-life. The success rate of all treatments is poor in advanced age women because of declining ovarian reserve and natural fertility. There is often a need of third-party involvement which has its own ethical, legal and medical issues. Welfare of children born to older women and early death of parents are important concerns. Most of the new techniques such as the pre-implantation genetic diagnosis, oocyte augmentation, use of stem cells or artificial gametes, ovarian tissue preservation and ovarian transplantation are directed to improve, preserve or replace the declining ovarian reserve. These techniques are costly and have limited availability, safety and efficacy data. Continued research and policies are required to keep pace with these techniques. The other important issues include the patients' personal autonomy and right of self-determination, welfare of offspring, public vs. private funding for research and development of new technologies vs. indiscriminate use of unproven technology. It is important that mid-life fertility is recognized as a distinct area of human reproduction requiring special considerations.

Families Created by Egg Donation: Parent-Child Relationship Quality in Infancy

Increasing numbers of children are being born through egg donation and thus do not share a genetic relationship with their mother. Parent–infant relationship quality was examined in 85 egg donation families and a comparison group of 65 in vitro fertilization families (infant M = 11 months). Standardized interview and observational measures were used to assess mother–infant and father–infant relationship quality at the representational and behavioral levels. Few differences were found between family types in parents’ representations of the parent–infant relationship. Differences were found between family types in the observational assessment of mother–infant relationship quality, indicating less optimal interactions in egg donation families. Findings suggest that egg donation families function well in infancy overall, but there may be subtle yet meaningful differences in mother–infant interaction quality.

The Best Age for Pregnancy and Undue Pressures

In western countries we assist at the paradox that fertility is socially discouraged by a mindset that depicts fertility as a resource to exploit as late as possible. So, couples have high expectative about the advantages of delayed parenthood, but they are scarcely informed about its risks. Scientific data suggests to anticipate the first pregnancy, but social pressures impose to wait, though delayed childbearing can provoke sterility and a greater gap between generations. The best age to become parents should be autonomously decided by a couple, under the condition of being a free informed choice and not a social imposition, but currently this is not guaranteed to western women and men.

Older maternal age and major depressive episodes in the first two years after birth: findings from the Parental Age and Transition to Parenthood Australia (PATPA) study

BACKGROUND

This study examines whether (1) older maternal age is associated with increased risk of depressive episodes between four months and two years after first birth and (2) the role of subsequent reproductive, social and child factors in vulnerability to later onset depression.

METHOD

592 women were recruited in the third trimester of pregnancy in three age-groups (≤ 30 years; 31-36 years,≥37 years); 434 (73%) completed all assessments at four months and two years after birth. Major Depression episodes (MDE) were assessed at four months and two years using the Mini International Neuropsychiatric Interview (MINI). Maternal (age, mode of conception, prior mood symptoms, health), child (temperament, health), reproductive (subsequent fertility treatment, pregnancy, birth, pregnancy loss) and social contextual variables (language background, paid work, practical support, life stresses) were assessed in pregnancy and postnatally using validated questionnaires and structured interview questions.

RESULTS

Maternal age was not related to prevalence or timing of MDE. Depression symptoms, poor child health, low practical support at four months and a non-English language background predicted episodes of depression between four months and two years, ps <0.05.

LIMITATIONS

Life history risks for depression were not considered, nor symptom profiles over time.

CONCLUSIONS

Findings indicate that despite a more complex reproductive context, older first time mothers are not more likely to report major depressive episodes in the first two years after birth. Prevalence for the whole sample was at the lower end of reported community ranges and was comparable early and later in the postpartum period. Screening for depression after childbirth should not be restricted to the early months.

Infertile men older than 40 years are at higher risk of sperm DNA damage

BACKGROUND

The effect of paternal age on semen quality is controversial. In this retrospective study, the aim was to investigate the effects of advancing age on sperm parameters including reactive oxygen species (ROS), total antioxidant capacity (TAC) and sperm DNA damage in infertile men. We also examined whether paternal age >40 y is associated with higher risk of sperm DNA damage.

METHODS

A total of 472 infertile men presenting for infertility were divided into 4 age groups: group A: patients ≤ 30 y; group B: patients 31- 40 y, group C: ≤ 40 y and group D: patients >40 y. The following tests were performed - semen analysis according to WHO 2010 criteria, seminal ROS by chemiluminescence, TAC by colorimetric assay and sperm DNA damage by TUNEL assay - and the results were compared amongst the 4 age groups.

RESULTS

There was no statistical difference in conventional semen parameters, TAC and ROS with advancing paternal age as well as between different age groups. However, a significant negative association was noted between sperm DNA damage and advancing paternal age. Men >40 y showed higher levels of sperm DNA damage (24.4 ± 18.5%) compared to younger men (<30 y; 16.7 ± 11.2%; p <0.05).

CONCLUSIONS

Infertile men over the age of 40 y have a greater percentage of sperm DNA fragmentation compared to infertile men aged 40 y and below. Advanced paternal age (>40 y) may increase the risk of sperm DNA damage in infertile men.

Predictive value of hormonal parameters for live birth in women with unexplained infertility and male infertility

BACKGROUND

Infertile women might get pregnant sometime after fertility treatment, but today, there is no prediction model on who will eventually have children. The objective of the present study was to characterize hormone levels in an arbitrary menstrual cycle in women with unexplained infertility and male infertility, and to determine the predictive value for long-term possibility of live birth.

METHODS

In this cross-sectional study, with 71 infertile women with diagnosis unexplained infertility and male infertility, blood samples were obtained during the proliferative and secretory phases of an arbitrary menstrual cycle. Serum concentrations of FSH, LH, AMH, inhibin B, estradiol, progesterone, PRL and TSH were determined. The predictive value of ovulation and hormonal analysis was determined by identifying the proportion of women with at least one live birth. Mann Whitney U test, chi2 test and Spearman's correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.

RESULTS

There were no differences in hormone values and live birth rates between women with unexplained infertility and male infertility. The best sole predictors of live birth were age of the women, followed by ovulatory cycle, defined as serum progesterone concentration of greater than or equal to 32 nmol/L, and a serum TSH concentration of less than or equal to 2.5 mIU/L. Combining the age with the ovulatory cycle and serum TSH less than or equal to 2.5 mIU/L or serum AMH greater than or equal to 10 pmol/L the predictive value was close to 90%.

CONCLUSIONS

Age in combination with the presence of an ovulatory cycle and serum TSH or serum AMH is predictive for long-term live birth. The advantage of serum AMH compared with serum TSH is the very little variation throughout the menstrual cycle, which makes it a useful tool in infertility diagnosis.

Age shock: misperceptions of the impact of age on fertility before and after IVF in women who conceived after age 40

STUDY QUESTION

What do older women understand of the relationship between age and fertility prior and subsequent to delivering their first child?

SUMMARY ANSWER

Women who were first-time parents over the age of 40 did not accurately perceive the relationship between age and fertility prior to conceiving with IVF.

WHAT IS KNOWN ALREADY

While increases in women's age at their first birth have been most pronounced in relatively older women, the rapidity of fertility decline is not appreciated by most non-infertility specialist physicians, the general public or men and women who are delaying childbearing.

STUDY DESIGN, SIZE AND DURATION

Qualitative retrospective interviews were conducted from 2009 to 2011 with 61 self-selected women who were patients in one of two fertility clinics in the USA.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All participants had delivered their first child following IVF when the woman was 40 years or older. The data include women's responses to the semi-structured and open-ended interview questions 'What information did you have about fertility and age before you started trying to get pregnant?' and 'What did you learn once you proceeded with fertility treatment?'

MAIN RESULTS AND THE ROLE OF CHANCE

Of the women, 30% expected their fertility to decline gradually until menopause at around 50 years and 31% reported that they expected to get pregnant without difficulty at the age of 40. Reasons for a mistaken belief in robust fertility included recollections of persistent and ongoing messaging about pregnancy prevention starting in adolescence (23%), healthy lifestyle and family history of fertility (26%), and incorrect information from friends, physicians or misleading media reports of pregnancies in older celebrity women (28%). Participants had not anticipated the possibility that they would need IVF to conceive with 44% reporting being 'shocked' and 'alarmed' to discover that their understanding of the rapidity of age-related reproductive decline was inaccurate'. In retrospect, their belated recognition of the effect of age on fertility led 72% of the women to state that they felt 'lucky' or had 'beaten the odds' in successfully conceiving after IVF. Of the women, 28% advocated better fertility education earlier in life and 23% indicated that with more information about declining fertility, they might have attempted conception at an earlier age. Yet 46% of women acknowledged that even if they had possessed better information, their life circumstances would not have permitted them to begin childbearing earlier.

LIMITATIONS AND REASONS FOR CAUTION

Both the self-selected nature of recruitment and the retrospective design can result in biases due to memory limitations or participant assimilation and/or contrast of past events with current moods. The cohort did not reflect broad homogeneity in that the participants were much more likely to be highly educated, Caucasian and better able to pay for treatment than national population norms. As attitudes of older women who were unsuccessful after attempting IVF in their late 30s or early 40s are not represented, it is possible (if not likely) that the recollections of women who did not conceive after IVF would have been more strongly influenced by feelings of regret or efforts to deflect blame for their inability to conceive.

WIDER IMPLICATIONS OF THE FINDINGS

While the failure to appreciate the true biological relationship between aging and fertility may be common and may reflect inaccessibility or misinterpretation of information, it is not sufficient to explain the decades-long socio-demographic phenomenon of delayed childbearing.