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Reproductive ageing and conflicting clocks: King Midas’ touch

Published:September 25, 2013DOI:https://doi.org/10.1016/j.rbmo.2013.09.012

      Abstract

      The population attempting pregnancy and having babies is ageing. Gynaecological and obstetric complications worsen with age. Maternity services are struggling. Increasing rates of infertility and complications are not matched by the marvels in the laboratory. This paper argues that assisted reproduction treatment has had a damaging social impact. Despite its public acclaim, it helps few and fails many more. The assisted reproduction industry could take a new and revolutionary direction towards empowering men to experience pregnancy, producing babies from artificial gametes, with a final goal being the liberation of both women and men from the burdens and dangers of pregnancy through the development of artificial wombs.
      This paper seeks to give a brief explanation as to why women are having children older and discusses how reproduction technologies have contributed to this trend. It argues that reproduction technologies is not a panacea for this problem and has in fact contributed to it. We suggest that as a means of promoting reproduction equality between the sexes, science needs to extend the reproduction experience to men, as well as developing artificial gametes and wombs.
      VIDEO LINK: http://sms.cam.ac.uk/media/1401028

      Keywords

      Introduction

      Women are born already experiencing the age-related loss of primordial follicles that started in utero. Their fertile pot flourishes cyclically for a limited time before the inevitable demise of reproduction capacity (i.e. replication of offspring) approximately a decade before the menopause. Pari passu with the age-related loss of egg numbers and quality are the fall in fertility and rise in miscarriage, captured in Figure. 1, Figure. 2. The same, rising J-shaped curve seen for miscarriage is found for virtually all complications of pregnancy, whether ectopic pregnancy (Figure 3), pre-eclampsia, Caesarean section, stillbirth and neonatal death (Figure 4) or maternal death (Figure 5), varying only in incidence and impact on the mother and baby.
      Figure thumbnail gr1
      Figure. 1(A) Age-related loss of primordial follicles (symbols indicate four different sources of data from 1952 onwards; n = 110; from
      • Faddy M.J.
      • Gosden R.G.
      • Gougeon A.
      • Richardson S.J.
      • Nelson J.F.
      Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause.
      ; reproduced with permission). (B) Age-related loss of fertility (from

      NICE, 2013. Clinical Guideline 156. Fertility: Assessment and Treatment for People with Fertility Problems. Available from: <http://www.nice.org.uk/cg156>.

      ; reproduced with permission of the Royal College of Obstetricians and Gynaecologists).
      Figure thumbnail gr2
      Figure. 2Age-related rise in miscarriage (from
      • Nybo Anderson A.-M.
      • Wohlfahrt J.
      • Christens P.
      • Olsen J.
      • Melbye M.
      Maternal age and fetal loss: population based register linkage.
      ;
      • Menken J.
      • Trussell J.
      • Larsen U.
      Age and fertility.
      ; reproduced with permission).
      Figure thumbnail gr3
      Figure. 3Effect of age on ectopic pregnancy (from
      • Nybo Anderson A.-M.
      • Wohlfahrt J.
      • Christens P.
      • Olsen J.
      • Melbye M.
      Maternal age and fetal loss: population based register linkage.
      ; reproduced with permission).
      Figure thumbnail gr4
      Figure. 4Effect of maternal age at delivery on stillbirth rate and neonatal mortality rate. Upper line = stillbirth rate per 1000 total births; lower line = neonatal mortality rate per 1000 live births (from

      CEMACH, 2006. Perinatal Mortality Surveillance, 2004: England, Wales and Northern Ireland. London: CEMACH; 2006. Available from: <http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/43.-March-2006-Perinatal-Mortality-Surveillance-Report-2004.pdf>.

      ; reproduced with permission).
      Figure thumbnail gr5
      Figure. 5Effect of maternal age on the rate of maternal death in the UK, 1985–2002 (from

      CEMACH, 2004. Why Mothers Die 2000–2002. Available from: <http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/33.-2004-Why-Mothers-Die-2000–2002-The-Sixth-Report-of-the-Confidential-Enquiries-into-Maternal-Deaths-in-the-UK.pdf>.

      ;
      • Alexander S.
      • Wildman K.
      • Zhang W.
      • Langer M.
      • Vutuc C.
      • Lindmark G.
      Maternal health outcomes in Europe.
      ; reproduced with permission).
      A Royal College of Obstetrics and Gynaecology (RCOG) expert study group did not find any pregnancy complications that lessen with age (
      ). As women enter their thirties and forties, the child-bearing population starts to intersect with the early onset of diseases of middle age. Again, few medical labels disappear with age, and so pregnancies in older women are attended by more medical complexity and complications. Even uterine receptiveness, a necessary precursor for older women to receive oocyte donations, declines after the age of 45 (
      • Soares S.R.
      • Troncoso C.
      • Bosch E.
      • Serra V.
      • Simon C.
      • Remohi J.
      • Pelliver A.
      Age and uterine receptiveness: predicting the outcome of oocyte donation cycles.
      ). Overall, age has an impact on the need for maternity services (Figure 6) and drives up costs.
      Figure thumbnail gr6
      Figure. 6Births with complications by maternal age from a representative sample (26,870 births) of London’s maternity hospital birth episodes in quarter 1 2009/2010 (from

      NHS, 2011. Improving Maternity Care in London. A Framework for Developing Services, March 2011. Retrieved from: <http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Improving-maternity-care-in-London_A-framework-for-developing-services.pdf>.

      ).
      While women should not be bullied into having children if they do not want them or do not feel ready, they should be under no illusion about biological fitness diminishing with age. Unfortunately, this basic fact and its timing is not well known and understood (e.g. see
      • Everywoman J.
      Cassandra’s prophecy: why we need to tell the women of the future about age-related fertility decline and ‘delayed’ childbearing.
      ,
      • Johnson M.H.
      • Franklin S.
      A patient perspective.
      ). The limited academic literature that has investigated women’s, and men’s, knowledge of age-related infertility all points to the need for education about the absolute and relative risks and benefits of waiting until one is older to have children (
      • Bretherick K.L.
      • Fairbrother N.
      • Avila L.
      • Harbord S.H.A.
      • Robinson W.P.
      Fertility and aging: do reproductive-aged Canadian women know what they need to know?.
      ,
      • Cooke A.
      • Mills T.A.
      • Lavender T.
      ‘Informed and uninformed decision making—Women’s reasoning, experiences and perceptions with regard to advanced maternal age and delayed childbearing: a meta-synthesis.
      ,
      • Daly I.
      MISCONCEPTIONS: women’s knowledge of age-related fertility decline in the context of a trend towards older motherhood, PhD.
      ,
      • Daniluk J.C.
      • Koert E.
      The other side of the fertility coin: a comparison of childless men’s and women’s knowledge of fertility and assisted reproductive technology.
      ,
      • Daniluk J.C.
      • Koert E.
      • Cheung A.
      Childless women’s knowledge of fertility and assisted human reproduction: identifying the gaps.
      ,

      Lampi, E., 2006. The Personal and General Risks of Age-related Female Infertility: Is There an Optimistic Bias or Not? Working Papers in Economics (online), vol. 231. Retrieved from: <http://www.frisch.uio.no/firstnordic/Lampi-paper.pdf>.

      ,
      • Lampic C.
      • Svanberg A.S.
      • Karlström P.
      • Tydén T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ,
      • Maheshwari A.
      • Porter M.
      • Shetty A.
      • Bhattacharya S.
      Women’s awareness and perceptions of delay in childbearing.
      ,
      • Peterson B.D.
      • Pirritano M.
      • Tucker L.
      • Lampic C.
      Fertility awareness and parenting attitudes among American male and female undergraduate university students.
      ,
      • Schmidt L.
      Should men and women be encouraged to start childbearing at a younger age?.
      ). Currently, school-based reproduction education is the only time in young people’s lives that they get a concerted message about fertility, which is usually directed towards understanding how not to get pregnant. This myopic focus has overshadowed other conversations on the topic. This approach does not account for how a woman’s fertility needs change across her life. Lisa Jardine, the current Chair of the UK Human Fertilisation and Embryology Authority (HFEA), has said, ‘instead of all the teaching at school being about how to stop getting pregnant, someone had better start teaching about how you do get pregnant, because there are going to be a lot of extremely disappointed people out there’ (
      • Tibbetts G.
      Sex education must include infertility lessons.
      ; see also
      • Dixon H.
      Cassandra’s prophecy: a response from a sex education perspective.
      ).

      More than just a woman’s issue

      It is too easy to suggest that if women want to have children, they should ignore the economic and socio-cultural factors influencing their decision making and just ‘get on with it’. Such a view would allow age-related infertility to be too easily dismissed as nothing more than an individual ‘woman’s issue’ – implying that it has little social consequence or impact (see also
      • Franklin S.
      Conception through a looking glass: the paradox of IVF.
      ). Nothing could be further from the truth.
      Family formation is more than just the choices made by individual couples. Such choices are influenced and modified by political, economic and social change (
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ). Yet, as a result of the childbearing choices made by couples, European populations are shrinking and the age demographics are changing (
      • Hoorens S.
      Trends in fertility: what does the 20th century tell us about the 21st?.
      ). There are many reasons why this is problematic. A growing population provides more young people to maintain the workforce after their aged dependents retire, which is necessary for economic growth (
      • ESHRE Capri Workshop Group
      Europe the continent with the lowest fertility.
      ). As such, low fertility is currently causing concern regarding labour market supply and governments’ expenditure on pensions, health and welfare services across Europe (
      • Dey I.
      • Wasoff F.
      Another child? Fertility ideals, resources and opportunites.
      ). In the UK for example, state benefits and the NHS accounted for just under half of government expenditure in 2009/2010. Much of this spending was directed at the elderly and, as their numbers increase, providers will face further challenges (

      Cracknell, R., 2010. The Ageing Population. Key Issues for the New Parliament 2010; Retrieved from: <http://www.parliament.uk/documents/commons/lib/research/key_issues/Key% 20Issues%20The%20ageing%20population2007.pdf> (accessed 12.1.13).

      ). Clearly, women’s decision to have children (or not) is much more than a ‘woman’s issue’, with broader, long-lasting social implications.
      The total fertility rate (TFR) is a demographic measure of fertility indicating the average number of children a woman would have if she experienced the age-specific fertility rates for a particular year throughout her childbearing life (
      • Botting B.
      What has happened to reproduction in the 20th century?.
      ). Currently, in Western and Northern Europe, TFR has stabilized between 1.7 and 2.0, which continues to be below replacement level (2.1) but only moderately so in comparison to the lowest low fertility rates seen in southern and German-speaking countries in Europe (e.g. 1.4 in Spain and Germany;
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ,

      Worldbank, 2013. Retrieved from: <http://data.worldbank.org/indicator/SP.DYN.TFRT.IN>.

      ).
      In early 1970s Europe, the average age of a woman when having her first child was 24–25 years, which increased to 28–29 by 2000 (
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ). European populations are shrinking partly due to couples waiting until an older age to start their families (
      • Bongaarts J.
      • Sobotka T.
      A demographic explanation for the recent rise in european fertility.
      ,
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ). This is not the only reason for population decline, but it has been described as an ‘obvious’ cause (
      • ESHRE Capri Workshop Group
      Europe the continent with the lowest fertility.
      ) and as playing a ‘crucial’ role in explaining low fertility (
      • Sobotka T.
      Is lowest-low fertility in Europe explained by the postponement of childbearing?.
      ;
      • Billari F.C.
      • Kohler H.P.
      Patterns of low and lowest low fertility in Europe.
      ). However, the transformation of sexuality, marriage, contraception and family life also interact with fertility timing to create this trend (
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ). Although this is a complex subject, it is noteworthy that
      • te Velde E.
      • Habbema D.
      • Leridon H.
      • Eijkemans M.
      The effect of postponement of first motherhood on permanent involuntary childlessness and total fertility rate in six European countries since the 1970s.
      determined that, in six European countries, delaying motherhood has resulted in an increase in permanent involuntary childlessness from 2–3% in 1970/1985 to 6–7% in 2007.

      The UK picture

      In the UK in 1970, 47% of births were to women under the age of 25, which, by 2008, had dropped to 25% (
      • Office for National Statistics
      Social Trends 40: How UK Life has Changed Since the 1970s.
      ). In 2009, 48% of all babies were born to women aged 30 and over. One in five births were to women aged 35 and over, which was an increase of 15% since 1999. The conception rate for women aged 40 and over has seen the most spectacular rise. Its current rate is 12.8/1000 women in 2010, twice what it was in 1990 (

      Office for National Statistics, 2012. Births in England and Wales by Parent’s Country of Birth, 2010. Newport: The Office for National Statistics. Retrieved from: <http://www.ons.gov.uk/ons/dcp171778_230307.pdf>.

      ). These figures demonstrate the continued and increasing trend towards older first-time motherhood that exists in the UK as it does in the rest of Europe (

      Braude, P., 2013. Are the ‘best’ embryos being selected and what prospects for improvement? Reprod. Biomed. Online 27, 644–653.

      ,
      • Martin F.
      • Preston J.
      Ageing: what is it and why does it happen?.
      ,
      • O’Leary L.
      • Natamba E.
      • Jeffries J.
      • Wilson B.
      Fertility and partnership status in the last two decades.
      ).

      Increasing fertility policy options

      Despite the trend towards older childbearing in most European countries, some countries have maintained (or recovered) a relatively high TFR. This has been achieved through a variety of government policies aimed directly or indirectly at increasing the birth rate. Evaluating the exact impact of such policies is notoriously difficult (
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ). However, there seems to be consensus that the effectiveness of such policies depends on whether one is looking to influence the total number of births in a cohort (‘quantum’ effect) or the mean age at each successive parity (‘tempo’ effect). Quantum effects require a longer time frame to take effect, while tempo effects are more short-lived (
      • ESHRE Capri Workshop Group
      Europe the continent with the lowest fertility.
      ).
      In countries such as France (TFR = 1.98) and Sweden (TFR = 1.85), analysis of their policies indicate that they have systematically nurtured gender equality in both the public and private sphere over an extended period of time as well as garnering societal support for childbearing (
      • Frejka T.
      • Sobotka T.
      • Hoem J.M.
      • Toulemon L.
      Summary and general conclusions: childbearing trends and policies in Europe.
      ).
      However, in countries with stubbornly low fertility, policies have targeted structural measures alone – such as baby bonuses and paid parental leave. Such policies appear to be less effective when embedded in a society that has not fostered gender equality nor understood the need for systematic support of the family (
      • Hoem J.M.
      Overview chapter 8: the impact of public policies on European fertility.
      ). For example, in Poland (TFR = 1.3) there is a sense that women have ‘confused priorities’ (
      • Mishtal J.
      Irrational non-reproduction? The ‘dying nation’ and the postsocialist logics of declining motherhood in Poland.
      ). The vast and complex literature in this area (beyond the scope of this paper) has been summarized by
      • McDonald P.
      Sustaining fertility through public policy: the range of options.
      as showing ‘the effectiveness of any policy will depend on the broader setting... it is not so much the individual policies that matter as the nature of the society as a whole’.
      Despite the fact that tempo effects can be quickly achieved via specific policies, these have not been enough to reduce the trend towards older motherhood. Despite the high TFR in France and Sweden, the mean age for first births in both countries has risen from 24.4 and 25.9, respectively, in 1970 to 27.8 and 28.8 in 2006 ().

      Can IVF make up for the decrease in national fertility rates?

      There is a public perception that fertility can be restored via IVF (
      • Daly I.
      MISCONCEPTIONS: women’s knowledge of age-related fertility decline in the context of a trend towards older motherhood, PhD.
      ,
      • Eriksson C.
      • Larsson M.
      • Skoog Svanberg A.
      • Tyden T.
      Reflections on fertility and postponed parenthood-interviews with highly educated women and men without children in Sweden.
      ,
      • Maheshwari A.
      • Porter M.
      • Shetty A.
      • Bhattacharya S.
      Women’s awareness and perceptions of delay in childbearing.
      ;
      • Skoog Svanberg A.
      • Lampic C.
      • Karlstrom P.O.
      • Tyden T.
      Attitudes toward parenthood and awareness of fertility among postgraduate students in Sweden.
      ). For example, a participant in the study of childless women over thirty by
      • Benzies K.
      • Tough S.
      • Tofflemire K.
      • Frick C.
      • Faber A.
      • Newburn-Cook C.
      Factors influencing women’s decisions about timing of motherhood.
      said: ‘Women are having babies later because of technology. Fertility technology that allows us to kind of extend our fertility period, where before we couldn’t you know?’
      • Bewley S.
      • Davies M.
      • Braude P.
      Which career first?.
      have argued that this type of thinking can ‘lull women into infertility’. Although IVF has brought joy to millions of people, it was not developed with the intention to encourage older motherhood. Assisted reproduction treatment may be able to assist a man with a low sperm count or overcome the problem of a woman with blocked Fallopian tubes, but unfortunately it is not designed to overcome egg degeneration. The link between IVF success and a woman’s age is starkly represented by the HFEA-published success rates. The live birth rate per cycle started using a woman’s own fresh eggs is 32.2% for women aged 18–34, 27.7% for women aged 35–37, 20.8% for women aged 38–39, 13.6% for women aged 40–42, 5.0% for women aged 43–44 and 1.9% for women aged 45 and older. The aggregate success rates in the UK for all ages is 25.6% (). There is no doubt that the existence of IVF has enabled some women to have the child they desired and would not have had without. In this sense, IVF ‘works’, but there is a real question as to how well it works and for whom. Many more women have become or remained childless despite IVF. IVF cannot overcome the effect of age, which is why so much ‘successful’ IVF in older women relies on egg donation.
      • Leridon H.
      Can assisted reproduction technology compensate for the natural decline in fertility with age? A model assessment.
      determined assisted reproduction treatment could not fully compensate for the natural age-associated decline in fertility. Specifically, if a woman of 30 postpones children until she is 35, her absolute chance of conceiving naturally is reduced by 9%. According to Leridon, assisted reproduction treatment can only restore 4% of this loss. Again, if at 35 she waits until 40, her absolute chances of a natural conception are reduced by a further 25%, and only 7% can be made up for via assisted reproduction treatment. It is fair to speculate that outcomes may have improved in the intervening years. A pharmaceutical company-funded report by the RAND Corporation even suggested that a more widespread provision of IVF should be considered as part of any future population replacement policy (

      Grant, J., Hoorens, S., Gallo, F., Cave, J., 2006. Should ART be Part of a Population Policy Mix? A Preliminary Assessment of the Demographic and Economic Impact of Assisted Reproductive Technologies. Paper Presented at the 22nd Annual Meeting of the European Society of Human Reproduction and Embryology, Prague.

      ). However, the excellent recent study by
      • te Velde E.
      • Habbema D.
      • Leridon H.
      • Eijkemans M.
      The effect of postponement of first motherhood on permanent involuntary childlessness and total fertility rate in six European countries since the 1970s.
      , using data from six European countries, found that the impact of IVF on permanent involuntary childlessness was small at the current rate of utilization (∼25% based on 2007 data); even hypothetically projecting that all eligible couples used IVF did not completely counterbalance the effects of postponement. The authors cautioned against assuming that IVF is the answer to population decline. First, for this effect to take place, it would require three full cycles of IVF and it is well established that a high proportion of couples drop out before completion due to cost or the psychological stress involved with invasive treatment (
      • ESHRE Capri Workshop Group
      Europe the continent with the lowest fertility.
      ). Secondly, many people who are having trouble conceiving do not come forward for treatment (
      • Boivin J.
      • Bunting L.
      • Collins J.A.
      • Nygren K.G.
      International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care.
      ).
      • te Velde E.
      • Habbema D.
      • Leridon H.
      • Eijkemans M.
      The effect of postponement of first motherhood on permanent involuntary childlessness and total fertility rate in six European countries since the 1970s.
      conclude that the impact on population levels of IVF to overcome the effects of women waiting until they are older to conceive is ‘almost negligible’ at present (p. 1182).
      By contrast, some countries use IVF to enhance population. For example, Israel’s stated pronatalist stance provides free, unlimited IVF procedures for up to two children for women under 45 and unsurprisingly Israelis are the highest per capita users of IVF globally (
      • Collins J.A.
      An international survey of the health economics of IVF and ICSI.
      ,
      • Gooldin S.
      Cultural competence and ethical incompetence: notes from a study of the new reproductive technologies in Israel.
      ,
      • Sperling D.
      Commanding the ‘be fruitful and multiply’ directive: reproductive ethics, law and policy in Israel.
      ). In Denmark also, assisted reproduction plays an increasing role in fertility rates (
      • Sobotka T.
      • Hansen M.A.
      • Jensen T.K.
      • Pedersen A.T.
      • Lutz W.
      • Skakkebaek N.E.
      The contribution of assisted reproduction to completed fertility: an analysis of Danish data.
      ,
      • Skakkebaek N.E.
      The contribution of assisted reproduction to completed fertility: an analysis of Danish data.
      ). Denmark, however, may be unusual as this trend is suspected to be due to a worrying increase in testicular problems and poor semen quality among young men (
      • Andersson G.
      • Rønsen M.
      • Knudsen L.B.
      • Lappegard T.
      • Neyer G.
      • Skrede K.
      • Teschner K.
      • Vikat A.
      Cohort fertility patterns in the Nordic countries.
      ,
      • Jørgensen N.
      • Asklund C.
      • Carlsen E.
      • Skakkebaek N.E.
      Coordinated European investigations of semen quality: results from studies of Scandinavian young men is a matter of concern.
      ).

      Why women are having children older

      Just as we have to stop considering age-related infertility as ‘merely’ a woman’s problem, we also have to start examining why women are waiting to have children. While both demographers and sociologists have found correlations between many different variables and delayed parenting, they cannot imply causation. However, the popular representation of such research has done so. For example, the well-established fact that education and involvement in the labour force are related to women having children at an older age has been commonly interpreted as educated women postponing motherhood because they are prioritizing their career (e.g.
      • Theodosiou A.
      Cassandra’s prophecy: medic or mother? Exploring the relevance of age-related fertility decline to women in medicine.
      ). This is not to say that career formation and educational ambitions are not influential; it is merely to suggest that they are part of a myriad of influences that conjoin to create the socially and historically unique environment in which women now live and make life choices. The reality is that there have been many profound changes in young people’s lives in the last half-century which affect reproduction decision making.
      First, the switch to a knowledge economy has increased the need for university-level education, which means that both men and women spend longer in formal education. Thus the traditional view that people will have established a viable occupational identity and will have embarked on the initial phase of a lifelong career from their early twenties no longer holds, especially in the context of increased life expectancy (
      • Arnett J.
      Conceptions of the transition to adulthood: perspectives from adolescence through midlife.
      ,
      • Elder G.H.
      The life course paradigm: social change and individual development.
      ,
      • Mortimer J.T.
      • Zimmer-Gembeck M.J.
      • Holmes M.
      The process of occupational decision making: patterns during the transition to adulthood.
      ).
      Secondly, the ‘job for life’ model has been eroded. For contemporary men and women, developing a career entails building a stock of experience that will, in time, add up to a portfolio of skills, which might help in securing a permanent job. With increased workplace competition, individuals are counselled that they need to stand out as candidates in order to progress. Getting ‘work experience’ is one way to achieve this. Without this experience, employees can be forced to work unpaid for extended periods of time in ‘internships’. This cycle can consume many years of the mid- to late-twenties. Add this to the extended time spent in education and the timetable for having children is pushed further back (
      • Joshi H.
      Production, reproduction, and education: women, children, and work in a British perspective.
      ).
      Thirdly, even when an individual becomes settled in the workplace, the labour market has changed to such an extent that family is now supposed to be fitted around one’s job, rather than vice versa.
      • Kemkes-Grottenthaler A.
      Postponing or rejecting parenthood? Results of a survey among female academic professionals.
      suggests that women are ‘facing a historically unique conundrum’ in trying to decide if they should become mothers at all. Postponement or delayed motherhood can thus be described as a ‘third way’, relieving a person from having to make an either/or decision between work and family.
      • Kemkes-Grottenthaler A.
      Postponing or rejecting parenthood? Results of a survey among female academic professionals.
      suggests that postponement is a conflict-solving strategy; people who postpone starting a family do so with the intention of catching up later. And herein lies the problem. Many women find that ‘catching up’ is not necessarily easy; what starts as merely postponing children can turn into involuntary childlessness.
      Thus the perception created by the media and taken up by the medical community – that women are trying to carve out amazing ‘high-voltage’ careers at the expense of everything else – is misleading. Women who work outside the home have often been portrayed as doing so for some sort of self-aggrandisement, rather than the grimmer reality, which is the basic human need of being able to provide for one’s self. Furthermore, society has developed in such a way that two-income households are becoming a financial necessity. Trying to live off one income has become increasingly difficult for many couples, in a way that it was not for previous generations.

      ‘Delay’ is inadvertent: non-synchronous clocks

      While the context described above provides structural difficulties in having a child, it also impacts on women’s perceptions of their psychological readiness for motherhood through the disintegration of age norms. Age norms and structures are important for a number of reasons: age is a natural part of the way we understand ourselves, others and the world around us; chronological age is thus a convenient administrative gauge, for both individuals and society, as it is easy to measure and has universal attributes. Age underlies much of how we organize our families, educational system, leisure time and work (
      • Settersten R.A.
      Age structuring and the rhythm of the life course.
      ,
      • Welles-Nystrom B.
      The meaning of postponed motherhood for women in the United States and Sweden: Aspects of feminism and radical timing strategies.
      ). Therefore, age makes it easy to map social and cultural expectations related to experiences and roles—for example, the ‘right’ or suitable age to have a child (
      • Wrosch C.
      • Heckhausen J.
      Being on-time or off-time: developmental deadlines for regulating one’s own development.
      ).
      • Neugarten B.L.
      • Moore J.
      • Lowe J.C.
      Age norms, age constraints, and adult socialization.
      found that individuals are aware of what these age norms look like across the lifespan. In other words, we have a sense of when we should leave home, when we should be in education or when we should marry. Individuals ‘use their age-linked “mental maps” to organize their own lives, the lives of others, and their general expectations about the life course’
      • Elder G.H.
      • O’Rand A.
      Adult lives in a changing society.
      . The term ‘social clocks’ was coined to capture the idea that there are ‘internal indicators’ to people that they are ‘on-time’ or ‘off-time’ for life events (
      • Neugarten B.L.
      • Datan N.
      Sociological perspectives on the life cycle.
      ,
      • Neugarten B.L.
      • Moore J.
      • Lowe J.C.
      Age norms, age constraints, and adult socialization.
      ). Neugarten argued that the existence of social clocks can be seen in the fact that ‘men and women compare themselves with their friends, siblings, work colleagues or parents in deciding whether they have made good’, and that this social comparison is done ‘always with a time-line in mind’ (
      • Neugarten B.L.
      Time, age, and the life cycle.
      ). Thus, one can see how a 28-year-old childless woman looks to her peers to determine if she is on-time or off-time. When she sees that her peers are not yet married or do not have children, she can self-reflect that she’s on-time and comfort herself that there is no reason to be concerned. Therefore, women have normalized only starting their families at a time when reproduction is becoming increasingly difficult and risky. This has created a conflict between biological and social clocks.
      Fundamental to understanding how these clocks are now in conflict is to see how the normative path to adulthood has changed. Due to the upheaval and uncertainty that exists as early adult life unfolds, age norms are becoming increasingly unstable (
      • Settersten R.A.
      Age structuring and the rhythm of the life course.
      ). It takes the current younger generation longer to reach adult milestones which were more easily attainable for previous generations. These include moving away from home, financial independence, getting married and starting a family. In the USA in 1960, 70% of 30-year-olds had achieved all these milestones. By 2000, only 40% of 30-year-olds could say the same (). A similar trend is taking place in the UK. One of the key markers of the transition to adulthood is moving out of the parental home. However, Britain has twice as many adult children moving back into the family home after a time away (usually university) as anywhere else in Europe. The

      Office for National Statistics, 2011. Births, Deaths in England and Wales, 2010. Newport: The Office of National Statistics. Retrieved from: <http://www.statistics.gov.uk/>.

      reported that nearly three million adults aged 20–24 were living in their parental home, an increase of 20% from 1997.
      • Berrington A.
      • Stone J.
      • Falkingham J.
      The changing living arrangements of young adults in the UK.
      found that young people said they were still living with their parents out of financial necessity and 35% of both men and women expressed a desire to buy or rent but said they could not currently afford it. Other reasons included precarious careers and the growing gap between capital costs and incomes.
      This inability to move through the milestones of adulthood results in many young people feeling as if they are in a state of suspended animation, that they are not yet truly adult. Interestingly, a Swedish study found that young people continue to look at such traditional accomplishments as indicative of having achieved grown-up status – a status that it is desirable to achieve prior to becoming a parent (
      • Lampic C.
      • Svanberg A.S.
      • Karlström P.
      • Tydén T.
      Fertility awareness, intentions concerning childbearing, and attitudes towards parenthood among female and male academics.
      ). Passing through adult milestones at a later age has itself now become normalized. Given this, it is no wonder that many women no longer think in terms of a normative age to have children. Instead they focus on feeling psychologically ready to have children, a status attained by moving through these milestones (
      • Daly I.
      Explaining the trend towards older first time mothers – A life course perspective.
      ).
      This paper has so far focused on proposing a rationale to understanding why women are having children later: structural difficulties impact on women psychologically, and together these inhibit having children at a younger age. However, there are also many problems that arise once a woman gets pregnant and after she has had a child, primarily financial. Having children has been described as the beginning of the great divide between men and women’s pay in the UK (
      • Woodroffe J.
      Not having it all: how motherhood reduces women’s pay and employment prospects.
      ). Other European countries, most notably France (
      • Toulemon L.
      • Pailhe A.
      • Rossier C.
      France: high and stable fertility.
      ) have ensured that the financial impact of childbearing is limited. By comparison, the UK has lower child benefits and is characterized as a nation where government is reluctant to intervene in the labour market (
      • Sigle-Rushton W.
      England and Wales: stable fertility and pronounced social status differences.
      ). Relatively high fertility has been maintained through a combination of immigration and high rates of teenage pregnancy (although declining year on year), which distinguishes the UK from the rest of Europe (
      • Sigle-Rushton W.
      England and Wales: stable fertility and pronounced social status differences.
      ).
      The Fawcett Society and the Equal Opportunities Commission (EOC) have both catalogued the UK experience for women which indicates that: ‘motherhood has a direct and dramatic influence on women’s pay and employment prospects, and typically this penalty lasts a lifetime’ (
      • Woodroffe J.
      Not having it all: how motherhood reduces women’s pay and employment prospects.
      ). In

      Equal Opportunities Commission, 2005. Greater expectations: summary final report EOC’s investigation into pregnancy discrimination. Retrieved from: <http://www.equalityhumanrights.com/uploaded_files/eoc_pregnancygfi_summary_report.pdf>.

      reported nearly half of the 440,000 working pregnant women in the UK experienced some form of pregnancy discrimination including an estimated 30,000 women annually being fired, made redundant or forced to leave their job due to pregnancy. As Professor Bill Ledger said of women delaying motherhood: ‘if it is because they make the choices to live life to the full as a single person, to travel the world and enjoy themselves, then that is fine. But if the reason is that they are worried about stepping out of their career, because they fear losing their job or being demoted, then perhaps society could be kinder to young mothers with children’ (
      • Asthana A.
      • Hill A.
      Late Motherhood: Time for a Vital Wake-up Call.
      ).

      Egg freezing: solution or distraction?

      Paradoxically, the very availability of IVF requires women to continue taking personal responsibility for a problem that might be better served if it were considered a social concern, making IVF an ‘oppressive weight’ (
      • Franklin S.
      • McNeil M.
      Reproductive futures: recent literature and current feminist debates on reproductive technologies.
      ). Oocyte cryopreservation has now been added to the burden. This is the most recent reproduction technology being suggested by many as a possible preventative to involuntary childlessness. The unique selling point is one of ‘insurance’. It is said to allow women to freeze their eggs (e.g. while at university), live their lives and have children at a time that is socially convenient, thus removing the biological clock from reproduction decision making. While this is the best that science currently has to offer as a means to address age-related involuntary childlessness, it is far from perfect. Only 900 babies have been born worldwide via frozen eggs, of which 15–20 were in the UK (

      HFEA, 2013. In vitro Derived Gametes. Retrieved from: <http://www.hfea.gov.uk/in-vitro-derived-gametes.html>.

      ,

      HFEA, 2013. Freezing and Storing Eggs. Retrieved from: <http://www.hfea.gov.uk/46.html#1>.

      ). Despite its acknowledged experimental status and uncertain outcomes, egg freezing has captured the imagination of the media who are guilty of presenting it as a settled and sure-fire way to bypass all the structural and psychological issues (
      • Hodgekiss A.
      Egg freezing should be every father’s graduation present to his daughter, claims leading fertility expert.
      ,
      • Sample I.
      Have Your Eggs Frozen While You’re Still Young, Scientists Advise Women.
      ).
      The difficulty is that, even as a fledgling technology, the rhetoric continues to place the onus for reproduction on the individual, particularly the woman. As results improve, the social structures that presently impede women from having children younger may vanish from critical gaze. Thus egg freezing may (inadvertently) maintain or even legitimize the current status quo: it’s OK to be unable to settle down, fear job loss and financial insecurity, etc. as there is always egg freezing to fall back upon!
      Furthermore, the purported genius is that eggs are frozen while they are still young thus overcoming the adverse medical implications of age. As
      • Martin L.J.
      Anticipating infertility: egg freezing, genetic preservation, and risk.
      points out, this technology creates a new ontological category of ‘anticipated infertility’, given that it is to be used by healthy women in anticipation of a future diagnosis. However, little attention has been paid to the fact that the woman’s body is not frozen. Her cardiovascular, respiratory and metabolic systems continue to age. Her uterus, which hosts and nourishes the pregnancy, continues to age, especially after age 45 (
      • Soares S.R.
      • Troncoso C.
      • Bosch E.
      • Serra V.
      • Simon C.
      • Remohi J.
      • Pelliver A.
      Age and uterine receptiveness: predicting the outcome of oocyte donation cycles.
      ). These biological factors are involved in, and explain, the associated complications and worsened outcomes which women will suffer and must be dealt with and paid for by health services.
      Society appears enthusiastic about the development of technologies whose very existence authorizes postponement and reproduction-based social inequality. This begs the question ‘who benefits from women becoming unfit to reproduce?’ Many good, talented people are committed to helping women and men who might otherwise not have had children. Yet, regardless of the care and time taken by treating clinics, they are rarely responsible for care during pregnancy (if there is one) and birth when the litany of age-related complications are seen. There is a paucity of aftercare services and research on life-long impacts for the large numbers of women who do not become pregnant. Furthermore, it is important, albeit uncomfortable, to acknowledge that individuals and organizations inevitably have financial and reputational interests. Reproduction has become a profit-based industry, whereby doctors, nurses, scientists, embryologists, counsellors, regulators, the pharmaceutical industry, alternative therapists and lawyers make a good living from women’s increasing reliance on assisted reproduction. Coalface clinicians deal every day with women who find themselves involuntarily childless. The assisted reproduction community has a unique insight into the burden that is currently carried by individual women that might be better placed on the shoulders of society as whole, and is in the perfect position to agitate for change.

      The need for blue-sky thinking

      There is little doubt that reproduction technologies will continue to develop in ways as yet unimagined. Those already developed may become more effective. But do we want assisted reproduction treatment to be the only option that women feel they have available and the future mainstream? The alternative is to address how the issues outlined above can be changed. How can we create a society which supports motherhood and childrearing and where others don’t feel harried for working? How do we use science, knowledge and wisdom to create a society that allows women to have children when they want to and are healthiest, rather than when they feel pressurized?
      The remainder of this paper will suggest that (in the absence of other societal compensation for biological inequity) the application of assisted reproduction needs to be extended to men. It is not original to suggest that gender inequality is linked to reproduction. Forty years ago, Shulamith Firestone argued that women’s childbearing and childrearing role was the cause of their oppression. She suggested that women’s liberation would only come if accompanied by a biological revolution. Regardless of educational, occupational, legal, or political equality, fundamentally nothing would change for women as long as they were responsible for bearing children (
      • Tong R.
      Feminist thought-a more comprehensive introduction.
      ). She went so far as to say that women should be freed from the ‘tyranny of their reproductive biology’ by any means available (
      • Firestone S.
      The Dialectic of Sex: The Case for Feminist Revolution.
      ). Thus if we are to pursue a future whereby reproduction technologies are considered a means by which to circumvent structural inequalities, surely we must push for the full biological revolution she outlined? In keeping with Edwards’ pioneering spirit, should we not use science to pursue male pregnancy, artificial gametes and artificial wombs?

      Male pregnancy

      Male pregnancy may be speculative, but is worthy of discussion if we are to envisage a future where assisted pregnancies can be used to create a more equal society. Precedence and ‘proof of concept’ have been set for such a development by virtue of a small number of successful abdominal pregnancies occurring in women. Given this, it is plausible that an embryo could be implanted via a surgical procedure into the abdominal cavity, in such a way that a placenta would form safely (e.g. on the mesentry or appendix). Men could gestate the child, which would then be delivered via laparotomy (planned Caesarean;
      • Gosden R.
      Designer Babies: The Brave New World of Reproductive Technology.
      , cited in
      • Sparrow R.
      Is it every mans right to have babies if he wants them? Male pregnancy and the limits of reproductive liberty.
      ). Although tubal ectopic pregnancies are considered very dangerous (due to rupture) and abdominal pregnancies are usually terminated, success stories have been recorded dependant on the implantation site. Following an unrecognized abdominal pregnancy, one author (SB) safely delivered a healthy child at term via laparotomy. Currently, the risks associated with assisted reproduction pregnancies, which are especially high post menopause, have been considered acceptable for women to shoulder (
      • Becker G.
      The Elusive Embryo: How Women and Men Approach New Reproductive Technologies.
      ,
      • Vasireddy A.
      • Bewley S.
      IVF is safe over 50 if it is not fatal.
      ). Men often valorize the uniqueness of pregnancy and women’s joy but could now go beyond ‘the final frontier’ to share and experience this themselves. Following a phase of animal work, fully consenting subjects could be carefully monitored to minimize the reasonable risk that is acceptable to achieve male pregnancy, especially during the experimental phase.

      Artificial gametes

      Although artificial gametes that can be used in the treatment of human infertility are thought to be at least a decade away (

      HFEA, 2013. In vitro Derived Gametes. Retrieved from: <http://www.hfea.gov.uk/in-vitro-derived-gametes.html>.

      ,

      HFEA, 2013. Freezing and Storing Eggs. Retrieved from: <http://www.hfea.gov.uk/46.html#1>.

      ), proof of principle has been established in experiments with mice, where gametes have been derived from stem cell lines. (
      • Hayashi K.
      • Ogushi S.
      • Kurimoto K.
      • Shimamoto S.
      • Ohta H.
      • Saitou M.
      Offspring from oocytes derived from in vitro primordial germ cell-like cells in mice.
      ,
      • Hubner K.
      • Fuhrmann G.
      • Christenson L.K.
      • Kehler J.
      • De Reinbold R.
      • La Fuente R.
      • Wood J.
      • Strauss 3rd, J.F.
      • Boiani M.
      • Scholer H.R.
      Derivation of oocytes from mouse embryonic stem cells.
      , cited in
      • Jackson E.
      Degendering reproduction?.
      ,

      Gosden, R., 2013. Programmes and prospects for ovotechnology. Reprod. Biomed. Online 27, 702–709.

      ). There are many problems to solve before the creation of sperm cells from female stem cell lines, and vice versa, becomes a reality. However, its radical contribution would be to make the ‘trade’ in eggs and so-called ‘egg-sharing’ no longer necessary. Furthermore, women would also be freed of having to host genetic surrogacies (i.e. be egg providers) for male same-sex couples who could have a child genetically related to both parents via artificial gametes.

      Artificial wombs

      Artificial wombs may currently seem the stuff of science fiction, but some scientific developments lend themselves to suggesting they could be possible. As technologies and treatments evolve that ensure the survival of premature babies, the ability of a child to survive outside the womb for an increasing proportion of the normal human pregnancy is demonstrated. Jackson, in her 2008 review of the literature of ectogenesis, points out that successful animal experiments have demonstrated different aspects of what would be required for the creation of artificial human wombs. For example, Kuwabara removed goat fetuses at 17 weeks of gestation, which then survived for 3 weeks in extrauterine incubators which contained warm amniotic fluid and delivered nutrients and removed waste via an artificial placenta (
      • Knight J.
      Artificial Wombs: An Out of Body Experience.
      ).
      The development of an artificial womb that supports life from embryo to full term has the potential to radically impact reproduction-based gender discrimination. Women who wished to gestate could still do so, but the option would be available to forego pregnancy. It would also put an end to surrogacy. Artificial wombs allow women to be completely separated from reproduction. As such, they would prevent women from work-based pregnancy discrimination as outlined by the 2005 EOC investigation and allow them to rear children over a much wider age range, as men do, without the high mortality and morbidity risk that pregnancy over 50 entails (
      • Vasireddy A.
      • Bewley S.
      IVF is safe over 50 if it is not fatal.
      ).
      This blue-sky discussion points to something greater. At one time IVF was little more than a pipedream. Yet, with consistent top-quality scientific research by Bob Edwards and the many others who followed, this remarkable technology is now a permanent part of the reproduction landscape, for better or worse. Would Bob have wanted science to give up on developing reproduction technologies further just because it seemed to be in the realm of science fiction or upset the status quo?
      This paper wishes to suggest that we are at a potential crossroads. Certainly, continued focus on developing ‘traditional’ reproduction technologies might make them marginally more effective. They might help some more people have the children they desire. However, should this be the only focus? Currently assisted reproduction treatment fails most of the time and its harms are underplayed. It cannot close the gap of childlessness and population change. Nor does it contribute appreciably to alleviate or eliminate reproduction-based social inequalities, which make it increasingly difficult for women to have children at the safest time. We have outlined that an exciting new path of discovery could exist. The expansion of reproduction technologies to facilitate men’s increased embodied involvement in pregnancy and/or making pregnancy an extracorporeal event would transform present reality and contribute to greater social equality between the sexes.

      Who can afford child rearing?

      Undoubtedly the realization of male embodiment of pregnancy would be controversial, but it is likely that it would precipitate a reassessment of a number of values related to gender, intimate relationships and children. Nevertheless, enabling male pregnancy or laboratory-grown babies would still not solve practical post-natal issues such as childcare. An

      OECD, 2011. Doing Better for Families. Retrieved from: <http://www.oecd.org/social/soc/doingbetterforfamilies.htm>.

      report found the UK has the second highest costs of childcare for any country; 26.6% of average family income is spent on childcare compared with an OECD average of 11.8%. This represents 40.9% of the average UK wage. Why have successive UK governments found affordable childcare so insurmountable, where its near neighbours France have had effective measures in place since the Second World War (
      • Toulemon L.
      • Pailhe A.
      • Rossier C.
      France: high and stable fertility.
      )?
      The Big Society was a flagship policy idea in the UK Conservative Party’s 2010 general election manifesto. Its stated aim was to create a climate where local communities are empowered to build a society around social enterprise, volunteerism and localism. This could be the perfect vehicle by which to provide affordable childcare, via the ethos and emphasis on volunteerism and localism. Creating schemes to ‘adopt a local grandparent’ means the ageing ‘baby-boomers’ could provide cheap, or free, childcare. They have the time, life experience and do not need payment. This provides a perfect opportunity to give something back to the younger generation who are paying for generous pensions that they themselves will never access. It also has the added potential benefit of reducing social isolation among the elderly. It is beyond the scope of this paper to fully explore and cost such ideas.

      Conclusions

      There is an expectation for many in the assisted reproduction industry that, like King Midas, anything they touch will turn to gold. However, Midas discovered the dangers of his magic touch when he turned his daughter into gold, thus ‘freezing’, petrifying and destroying what he loved. What do fertility practitioners want for their daughters? This paper argues that, although ‘miraculous’, too little importance has been placed on the broader and damaging social impact of assisted reproduction treatment, which has contributed to gender inequality. It is time to focus on the causes of ‘delayed’ parenting and for this industry to once again be revolutionary via deeper enquiry into present harms and future scientific ingenuity. Asking practitioners to campaign for social change against financial vested interests is not realistic. As long as women are burdened by reproduction and child rearing, there seems to be little impetus for change. We argue that more equitable sharing of reproduction between the sexes would lead to the disappearance of issues such as unaffordable childcare and pregnancy-based discrimination. This can be achieved by becoming more ambitious and innovative and directing scientific research to the goals of male and extracorporeal pregnancy. In this way, assisted reproduction can influence social change in a positive and equal way.

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