I was delighted when asked to write against the proposal to deny women aged 42 years or more the chance of their own genetic motherhood. Indeed, it is challenging to imagine the points that my opposing author will use to try and limit a woman’s reproductive choice! To debate the matter we need to 1) examine the IVF/ICSI livebirth rate for women in their 40s, 2) consider the risks to the health of these mothers and their baby(ies) and what can be done to mitigate any concerns, and 3) contemplate the grounds for denying such treatment, and the offered alternatives (childlessness?).

Most women conceive within the first 12 months of regular unprotected sexual intercourse. Of the 16% that don’t, around half will conceive without treatment during months 12 to 24 [1]. During those first two years of trying the couple should undergo investigations including semen analysis and confirmation of ovulation and tubal patency (by HyCoSy, HSG or laparoscopy). If all tests return as normal then, by definition, the couple have ‘unexplained’ infertility. Impatience by doctor or patient to ‘do something’ can lead to the use of unnecessary interventions such as ovarian stimulation (OS) (for ovulating women?!) and/or intra-uterine insemination (IUI) (for couples with a normal reproductive tract and sperm function?!) as these are often viewed as softer, more natural treatments. But these are certainly not as natural (or as cheap) as conceiving naturally. A number of studies comparing outcomes of OS or OS-IUI versus IVF to ‘treat’ couples with unexplained infertility unfortunately include patients with 12 to 24 months of trying [2]. Unsurprisingly the OS or OS-IUI success rates are high (and therefore falsely close to IVF). I say unsurprising as the woman was likely to conceive anyway even without OS and/or IUI. For couples with less than 2 years of unexplained infertility, full investigation but no treatment is required.