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Normal pregnancy with living children in women past the age of fifty
Normal pregnancy with living children 1n women past the age of fifty LAWRENCE R. WHARTON, M.D. Baltimore, Maryland
I N D A r L y gynecologic practice, one of the questions most frequently asked by the menopausal woman is when she can stop using contraceptive measures. In medical jurisprudence, the courts are interested in the same problem for a different purpose. Wondering women have raised the question since the time of Abraham and Sarah, several thousand years ago and in the intervening centuries, very little has been added to our ability to answer the question. Recently, more profitable avenues of investigation have been opened and more information has been and will continue to be obtained. On the basis of the present study, however, it may be said that it is impossible to fix a definite upper limit to human fertility and that dogmatic assertions in the literature probably would not have been made if present information had been available. In studying this problem, four different sources of information have been used. 1. The medical literature from 1860 to thP nrPsent time and some contemnorarv sources. 2. Hospital statistics of obstetrical and gynecological departments in this country and also the Near and Far East. 3. Vital statistics published in this and other countries. ~
.
-
.1.
4. Court decisions m Great Britain and the United States. Women who have had normal, living babies after 50 according to the literature and contemporary sources
The staff of the Welch Library made a thorough search of the medical literature back to 1860, obtaining copies of almost every relevant article. There proved to be infrequent articles on this subject and very few authentic cases, especially before 1900. Certain records of the past 10 to 15 years, obtained by personal investigation, are much more illuminating and, possibly, more accurate than those of the preceding years. Table I gives the essential data on 26 apparently authentic cases of women who had normal living babies after the age of 50 years. These 26 cases have been collected from various sources. The first 6 were single case reports which appeared in the medical literature years ago. The modern student 'vi!! probably be more impressed \vith the reports of more contemporary physicians, which were the source of the last 7 cases in the list. In contrast with the first 6, not one of these later authors published his case as an individual report. Some, such as Berkley, Bonney, and McLeod 7 and Greenhill" mentioned them rather casuaiiy in their textbooks. Others reported their cases in collections from various sources and published in articles such as those by the editors of Lancet. 8 Koren, Zuckerman, and Brzezinski1" discovered their 5 cases in a study of
'
From the Department of Obstetrics and Gynecology, Johns Hopkins Hospital. Presented at the Eighty-seventh Annual Meeting of the American Gynecological Society, Hot Springs, Virginia,
May 25-27, 1964.
672
Pregnancy in women past fifty
Volume 90 Number 5
pregnancy in women over 40 in Jerusalem. Bickers' 11 case was described to the author in a personal letter from Beirut. The cases of Wykr 1 ~ and Wharton are unique in that they were derived from the first efforts to analyze general vital statistics on this point. These 2 cases will be discussed later in the section on vi tal statistics. It is perhaps noteworthy that between 1860 and 1900 only 2 apparently authentic cases are recorded in the literature, whereas since then 24 cases have been described by sources that seem unimpeachable. Also, as we have noted, not one of these 24 recent cases was reported individually in the literature. One may doubt whether the paucity of individual reports is a fair index of the actual incidence of the condition. In assembling these cases, the author encountered numerous others some of which were probably authentic but which for various reasons were not included in the present review. Among these are some interesting, almost fantastic, obstetrical experiences. Certain of the cases, as that presented to the Royal Academy of Sciences in London by a
673
bishop of the Church of England 13 had little or no medical confirmation. The bishop merely thought it worth reporting that one of his parishioners had a healthy baby when she was more than 80 years old. The Royal Academy accepted the statement and included his report in its proceedings. Other cases, such as those reported by Valentin 14 and Kennedy15 have long been quoted and have become almost classic. They are almost surely authentic, although in the last few years interest in them has been replaced by that of more recent material. Most of the women who had healthy children after age 50 were "grand multiparas," the highest number of those children being 11. There were only 2 primiparas in the collection and both were delivered without complications of healthy children. Hospital statistics
A review of the statistics of our large lying-in hospitals and obstetrical departments might suggest the conclusion that no woman past the age of 50 ever has a child, for, as Table II shows, not one of the reporting hos-
Table I. Apparently authentic cases of full-term healthy children born to women more than 50 years of age
Reference
Date
No. of cases
Mother's al(e
Father's age
Para
Taylorl Ha!P
1890 1903
54 51
64 24
Depasse3
1891
59
28
Buckle4
1910
63
7
Gilbertson 5 Woelingas
1917 1958
50 52
11
Berkley, Bonney, and McLeod7 Editorial, Lancets Greenhill9 Koren, Zuckerman, and BrzezinskilO
1938
2
1905 1960 1963
1
Bickersll Wyler 12 Author
1962 1957 1964
7
5
1 3 1
51 52 51 52 53 54 52 51 52
(2 cases) ( 1 case)
( 1 case) ( 1 case)
0
Years since last pregnancy (No.)
Comment
11
19 13 5
Five years postmenopausal Nine years since last menstrual period Amenorrhea of 11 years before pregnancy at 63 Last child, at 4 7, a Mongoloid idiot
674 Wharton
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Table II. Incidence of viable births after 46 in relation to age (Stanton 17 ) Hospital Chicago Lying-In Hospital Johns Hopkins Hospital Boston Lying-In Hospital Jersey City Medical Center Lenox Hill Hospital ~ew York Lying-In Hospital New York City Statistics 1940-1950
Age
Total No. of cases 50:000 65.000
2
42,000
10 6
5o:ooo 27,273
65,880 1,427,106
25
48
49
50
2
50+
0 2
0
0
(J
()
1 1
0
()
()
0
4
3
0
()
5 5
1 2
0 1
u
0
(J
(I I)
25
-----------------------------------------------------------------------
pitals records such an event. In 1961, Eastman reported that in 65,000 full-term deliveries, not one mother was 50 years old. Some smaller hospitals have reported the same findings. In 1959, Calk and Cofer 18 of the Georgia Baptist Hospital in Atlanta, reported that 18,037 women were delivered of normal full-term children, the oldest mother was 48 years of age. The statistics of New York City, during the decade 1940 through 1950, as cited by Stanton, duplicate similar data obtained from every governmental unit that has been investigated by us. In practically every census, a certain number of women have reported that they had borne normal children after they were 50 years old. Stanton's comment was simply that New York City contained a great many unfortunate people of almost every nationality, displaced by war or persecution and completely separated from their families, who simply had no idea of their correct age. This comment might be applied to every large city. Reports from foreign hospitals
By personal correspondence, reports have been obtained from several hospitals in the Near and Far East. Among the obstetricians in charge of these departments were Dr. William Bickers 11 of the American Hospital in Beirut, Lebanon; Dr. Abdel Fattah Yousse£19 in Cairo, Egypt; Dr. A. D. Engineer 20 from the K. G. Medical College in Lucknow, India; Dr. Daphne Chun~ 1 from Queen Mary Hospital in Hong Kong; and Dr. Vishnu Sarma~~ in Madras, India. Not one of these obstetricians reported the delivery of a
healthy, full-term baby in a woman as old as 50 years. Dr. Bickers, however, reported that one of his colleagues had delivered a woman just preceding her fifty-second birthday of a healthy child. This woman already had 5 children, the last pregnancy having been 12 years previously. Vital statistics
In every nation or municipality that has been investigated the vital statistics allow somewhat different conclusions for in almost all census records a certain number of women have had normal babies when they were more than 50 years old. Nor is this a recent tendency, as is shown by the records of Germany as far back as 1861. In 1903, Strassmann 2 " published a study of the problem of Fertility in the German Empire on the basis of vital statistics from 1861 to 1894. In the city of Berlin, for example, in the year 1898, there were 50,510 live births. Among these, + women stated that they were 50 years of age or older, when they gave birth to healthy, living babies. Almost universally, these reports have been completely dismissed on the assumption that the women who made such reports were ignorant of their age. In 1957 Wyler"" decided to check the situation in Switzerland and, as has been indicated in Table I, found that in the years 1946 and 1947, there were 3 women who had healthy babies after they were 50 years old. Wyler corroborated these claims. Wyler also obtained the Vital Statistics from Scotland, which showed that in the years 1939 through 1946, seventeen women older than the age of 50 years reported that
Volume 90 :\umber:>
Pregnancy
they had given birth to healthy, living children. In the United States, the records have been about the same. The effort of a member of the staff of the National Vital Statistics Division, Dr. Grove, to find out more about the "vvomen v;ho report pregnancies after the age of 50 or 55 years alone will be
reported. Dr. Grove was skeptical about the accuracy of the ages of the older women, whose pregnancies were listed in Table III. He therefore ''queried" these mothers, in the group prior to 1943, with the result that many reduced their stated age and consequently dropped into the next lower age, i.e.~ the 50 to 54 group. ~~everthelcss, a certain number still insisted that they were 55 years old or more. Dr. Grove did not make a detailed analysis or publish a report on these remarkable cases, and apparently no other attempt has been made to study these women who insist that their ages were above 50 or 55 at the time of their delivery. The Commissioner of Health for Baltimore, Dr. Huntington Williams, and his entire staff were also found by the author to be cooperative and anxious to help. In the census for 10 years preceding 1961, they found that 2 women, residents of Baltimore, had reported that they had borne living babies after the age of fifty. One of these could not be traced, but the Health Department of Baltimore City soon found the second. She was, fortunately, an intelligent, educated person, a full-blooded Cherokee Indian, married to an employee of one of our large construction corporations. Her husband was 15 years her junior. This couple has lived in Baltimore 25 years. This woman has had 2 healthy full-term children, after her fiftieth year, both delivered at the North Charles General Hospital in Baltimore. The first, a healthy daughter, was born on April 5, 1957; the second in the mother's fifty-third year, a healthy, fuil-term son on April 30, 1959. The hospital records of both admissions are complete and well kept. It has not been possible to obtain a birth certificate of this mother, but her birth was recorded in the family Bible. The Baltimore City Health 24
1n
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women past fifty
Table III. Live births to mothers 50 years and over (United States, 1937-1946)-1{Age of mother 50 to 54 Years Year
White
1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936
84 119 112 109 118 96 122 148
129 131 J(J:j
I
55 Years and older
iNonwhitel H'hite
47 ~2
22
++
51 40 54 51 46 50 59
52 48 41
+fi
jNonwhite
12
19
u
q
0 0
0
0
I)
()
I)
1
2
:l
1
---·--·-····-· *Personal communication frmn Dr. Robert D. Gro\·e, Acting Chief, National V.itai Statistics Division.
Department considered the evidence furnished by their long residence in Baltimore, and former hospitalization sufficient to establish the responsibility of this couple and the accuracy of the stated age. It is thus apparent that the vital statistics of a country or municipality contain valuable information, if one can only obtain the interest of the various health departments.
Medicolegal aspects The problem of the upper age limit of female fertility has been of legal concern for many years. In English courts, it has been important in suits concerning legitimacy, the inheritance of titles, and property. In American courts, the question has arisen chiefly in cases involving legitimacy, wills, and trusts. The decisions of both the English and American courts have been uniform, consistent, and clear. The opinion of the English courts of law was summarized many years ago by Taylor~:; in his textbook, Medical Jurisprudence, the first edition of which appeared in London in 1843. The fifth American edition of this standard text appeared in 1861, and contains a searching study of this question. Decisions of many courts arc cited, trials are quoted and medical records now inaccessible are presented. In conclusion, Taylor stated that the Eng-
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676
Am.
lish courts have long maintained that "we cannot pretend to fix the age at which pregnancy ceases to be possible, and beyond which it cannot occur." The same opinion is repeated in subsequent editions of this book. The Common Law in the United States of America concurs with the English. This was summarized by Leach 26 in 1938 in the Harvard Law Review as follows: a woman "is conclusively presumed to be capable of having children until death." In discussing this, the American reviewer states that this presumption is "silly," on various grounds. Nevertheless, he concludes that "no court, English or American, has failed to follow the presumption." Conclusion
In conclusion, what answer can be given to women soon after menopause who want to knovv "vvhen they can discontinue contraceptive measures? It is impossible to fix definitely an upper limit since there have been too many authentic cases of women who have had healthy babies after the age of 50 or 55. In discussing this problem with women, the physician will be wise to present the
2. Hall, F.
J.
V.: Midland M.
3. DePasse, E.: 1891. 4. Buckle, L.: J. 5. Gilbertson, J. 6. Woelinga, H. 1 'lt:n
Do
7. 8. 9.
B~'rkl~;~·
11.
12. 13.
1
2: 106, 1903.
A. M. A. 55: 568, 1910. H.: Brit. M. ]. 1: 378, 1917. D.: Nederl. T. Geneesk. 102:
Summary
Various series of cases of full-term delivery in women of age 50 have been reviewed and a number of apparently authentic cases reported. The rarity of this event in the records of a number of large lying-in hospitals, both here and abroad, is noted. The significant number of such cases appearing in the records of vital statistics seems somewhat to contradict this experience which may be partially or wholly explained by faulty recollection by the mother of her age. The author acknowledges his debt to Miss Ruth Tyler and her staff at the Welch Medical Library; The National Library of Medicine in Bethesda; The Library of the Medical and
Chirurgica! Faculty of Maryland. Miss Tyler and her staff made a search of the medical literature as far back as 1860. Without their efforts, this section of our study would not have been possible.
t
,
•
14. 15. 16.
n~o
Bonney, v., and McLeod, D.: The Abnormal in Obstetrics, Baltimore, 1938, Wm. Wood, p. 10. Editorial: Lancet 2: 171, 1905. Greenhill, J. P.: Obstetrics, ed. 12, Phila•n.rl"t. vv. D. o:>aunuers vompany. ae1pnm, 1:1ov, Koren, Z., Zuckerman, H., and Brzezinski, A.: Obst. & Gynec. 21: 165, 1963. Bickers, W.: Personal communication from the American University Hospital, Beirut, Lebanon, 1962. Wyier, J.: Schweiz. med. Wchnschr. 87: 23, 698, 1957. Woman delivered of a child when above 80 ,
10.
c.:. .
J.
Gaz. d. gym!c., Paris 6: 241,
"':.l.r
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,.,
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Obst. & Gynec.
facts and tell the patient frankly that the chance of conception after the age of 50 is negligible and decreases to an indefinite and unknown vanishing point. Since, however, a small number of women will bear children after 50, it may contribute to their peace of mind if contraception is continued for possibly a year after menstruation has ceased.
REFERENCES
1. Taylor, R. A.: Daniel's Texas M. J. 5: 259, 1890.
J.
17. 18. 19.
..-.
20. 21. 22. 23.
years of age: Philosophy, History, and Memorials of the Royal Academy of Science, Paris ABR. 1699-1720, London, 1742, p. 329. Valentin, M.: Compt. rend. Soc. gynec. 27: 55, 1957. Kennedy, W. J.: Edinburgh M. J. 27: 1085, 1882. Eastman, N. J., and Hellman, L. M.: Williams' Obstetrics, ed. 12, New York, 1961, .c\ppleton-Century-Crofts, Inc., p. 223. Stanton, E. F.: AM. J. 0BST. & GYNEC. 71: 270, 1956. Calk, Guy L., and Cofer, 0. S.: South. M. J. 52: 1078, 1959. Youssef. A. F.: Personal communication from Cairo, Egypt, 1961. Engineer, A. D.: Personal communication from K. G. Medical College, Lucknow, India, 1962. Chun, D.: Personal communication from Queen Mary Hospital, Hong Kong, 1961. Sarma, V.: Personal communication from Madras, India, 1961. Strassmann, von P.: Die Haufigkeit der
Volume 90 Number 5
Geburten. In von Winckel, F.: Handbuch der Geburtshiilfe, Wiesbaden, 1903, vol. I, chap. 1, pp. 96-101. 24. Grove, R. D.: Personal communication, 1962. 25. Taylor, A. S.: Medical Jurisprudence, fourth American from the fifth and improved London edition, Philadelphia, 1856, Blanchard & Lea, p. 493.
Discussion DR. M. EnwARD DAvrs, Chicago, Illinois. In most mammals, ovarian life expectancy and general life expectancy coincide. Zoologists do not dispute this, but they point out that the aged female mammal stops breeding because of physical deterioration. The human female has been singled out in our evolutionary process so that her reproductive period is limited to an average of 30 or 35 of her early years, and it is over in her middle forties even though her average length of life has increased greatly. In 1959, the life expectancy of females at birth in the United States was 6.3 years higher than comparable figures for males. Sharman1 studied multiple endometrial biopsies in women aged over 45 years to determine when gonadal function ceases. His findings demonstrated that there was no evidence of ovulation after the age of 52, although several women aged 50 to 52 did provide such evidence. There appears to be a high incidence of anovular menstruation, increasing with age, in women over 40. There are marked differences in the biologic function of the human male and female gonads. The functional life of the ovaries is probably predestined and under genetic control. There is a tendency for the daughter to follow the menstrual pattern of her mother. However, racial, physical, and social factors are all implicated in determining the life of the ovaries. The exhaustive study presented by Dr. Wharton emphasizes once again that it is extremely rare for a woman in the early fifties to give birth to a baby. The outstanding feature of the mammalian ovary is the continuous depletion of the number of oocytes, only slightly and temporarily checked by the intervention of pregnancy. Block2 has estimated that the number of oocytes in the human gonads falls from 484,000 at ages 6 to 9 years to 155,000 at 18 to 24 years and to
Pregnancy in women past fifty
677
26. Taylor, A. S.: Medical Jurisprudence, fifth American edition, Philadelphia, 1961, Blanchard & Lea, p. 512. 27. Leach, W. B.: Harvard Law Rev., vol. 51, 1938. 4504 Roland Avenue Baltimore, Maryland 21210
8,300 at 40 to 44 years. It is of interest that marked differences in the rate of atresia of oocytes between species and even between different strains of the same species, e.g., mice, and thus in their reproductive potential have been demonstrated. 3 • 4 When all oocytes have degenerated or disappeared, and in some species before that stage, reproductive life comes to an end. This is not necessarily accompanied by the cessation of the ovary's hormonal activities. 5 Too little is known about the process of atresia, and it is unlikely that it can be retarded. More information is necessary about the effects of the depleted supply of oocytes on fertility and the length of reproductive life. Modern research in this area may be most rewarding. The functional life of the gonads in the male may continue throughout the life of an individual. He may produce spermatozoa capable of fertilization throughout life. However, as in other mammals, the aging process may interfere with his ability to fertilize the female. That fatherhood can be achieved very late in life is beyond question. It is these differences in the biologic function of the male and female gonads that have led to much confusion in our thinking. There have been some suggestions in the recent literature that our ability to suppress ovulation in our increasing tempo to meet the population explosion may retard the exhaustion of woman's greatest asset, her ova, and that these may be saved for later years. Alas, here too I must disappoint you. The administration of steroids to suppress ovulation does not interfere with the normal development of primary follicles and their subsequent atresia with the continuous depletion of oocytes. Dr. Wharton has reaffirmed the results of our studies, 6 those of Newall and Rock,7 and many others that parturition in a normal woman over 52 years of age has not been proved. It is my hope that this presentation will stimulate more
678
Wharton
accurate vital statistics and help bring our laws in tune with our scientific knowledge and modern thinking. It is indeed unlikely that our courts will be asked to protect the rights of another Sarah who begat Isaac at the age of 90. REFERENCES
1. Sharman, A.: The ovary, vol. I, 1962, ed. Sir Solly Zuckerman. 2. Block, E.: Acta anat. 14: 108, 1962. 3. Fekete, E.: Anat. Rec. ii7: 93, 1953. 4. Jones, E. C.: The aging ovary, Thesis, University of Birmingham, 1957. 5. Zuckerman, S.: Proc. Fifth International Conference on Planned Parenthood, Tokyo, 1955, pp. 197-200. 6. Davis, M. E .. and Seski, A.: Surg. Gynec. & Obst. 87: 1+5, 1948. 7. "Jewell, J. W., and Rock, J.: AM. J. 0BST. & GYNEC. 63: 875, 1952.
DR. R.
DouGLAS, New York, New York. Dr. Wharton has posed the question frequently asked by menopausal women, when may they n·as•· to employ contraceptive measures. In answrring this question he has carried out an exhausti\·e survey of the literature, hospital n•cnrcls, vital statistics, and court decisions. His conclusions are valid and most conservative. He has. in fan, sustained the old dictum, at least as far as the upper age limit is concerned, that "pregnancy is always possible between the ages of ti through 60." Dr. \Vharton has answered the question concerning tlw possibility of pregnancy in women ovcr tlw a,2,c of .50 and the chances appear extremely remote. He has indicated the probability that some instances of pregnancy over the age of 50 are not recorded in the literature. He has nor, however, answered the question concerning the possibility of pregnancy in slightly younger women. This scl'ms justifiable because the biological age of women does vary from chronological age and in some respect consideration of only \\omen 50 years of age or older appears quite arbitrary. The question of pregnancy may be equally as important or more so to the woman agt'd +7 or 49 years. .\ccnrdingly, I have reviewed some of our data in the I\ ew York Lying-In Hospital. Among 114,970 womPn who were delivered in the New York Lying-In Hospital from Sept. 1, 1932, through Dec. 31, 1963, the oldest age was 48 and only 2 were this old, one in 1935 and one in 1955. The proportion of total mothers of ages 44 and over per 10,000 total deliveries is shown in Table I. GoRDON
Am.
I\ ovember I. 1964 J. Ob;t. & Gynec.
As a part of the likelihood of becoming pregnant, results of the inclusion of mothers who had abortions or were delivered of nonviable or very immature infants arc shown in Table II for
Table I. Deliveries by age of mother 44 years and over at New York Lying-In Hospital (1932-1963)
Age
No.
+1-
139 90 37
45 46 47 4R
Total
Total deliveries (rate per 10,000)
12.1 7.8
3.2
9
0.8
2
0.2
277
H and over
24.1
-·-·-·--·-····-
Table II. Pregnancies by age of mother 4+ years and over at New York Lying-In Hospital ( 1932-1963) I
Total p~egnancies
1
No.
10,000)
44 45
206 125
16.3
46 47
+B
*Decidual
0.7 O.:l 0.2 0.2
4 2 2*
44 and over n~action
9.9 4.9 1.9
63 24 9
49 50 53
Total
(rate per
Age
~
435
:34.4
no ,·il!i.
Table III. Live births by age of mother* I
United States 1960 Live births
44
45
13.2
47 48
6.9 3.0 1.3 0.5
50 and
0.3
46 49
over
Total
0.2
25.3
New York I Lying-In 1953-1960 Live births 1
15.5
6.3
2.9 0.9 0.3
25.9
I I
New York Lying-In 1932-1963 Total deliveries
12.1 7.8 3.2 0.8
0.2
24.1
*Rates per 10.000 total live births and total dl'liwric,.
Volume 90 Nurnhcr 5
Pregnancy
NEW YORK LYING-IN HOSPITAL,
1932~
1963
201
...... -.& PREGNANCIES (TOTAL :126,343) ._.... DELIVERIES (TOTAL :114 ,lHO
i
•••\ .
5-
~. ··:.::--. . . . . . . . .....
AGE
oI
I 44
I 45
~
46
47
.. 48
·---:+-----•-----A 49
50
women past fifty
679
deliveries and for the more recent sample 25.9 per 10,000 live births. Of a total of 34,788 live born viable (500 and more grams birth weight) infants in the years 1953 through 1960 inclusive at the T'Je\V York Lying=In, mothers of 90 'Ncre 44 years of age or over, 54 aged 44, 22 aged 45, 10 aged 46, 3 aged 47, and one aged 48. While this is a relatively small number to compare with the 10,790 aged 44 and over in the United States, there is striking similarity in the proportion in specific ages. For example, the proportion at age 46 is 3.0 per 10,000 for the United States and 2.9 at the Lying-In Hospital, for age 4 7, 1.3, and 0.9, respectively. The precipitous drop from ages 44 to 4 7 is apparent. In recent years the published yearly Summary of Vital Statistics of The City of ::-\ew York has contained as the highest age category of mother, 40 years and over. Through personal communication with Dr. Erhardt, Director, Bureau of Records and Statistics, New York City Department of Health, live births and fetal deaths were obtained for the years 1940 through 1955 for thost' mothers in the 50 years and over age category. In this period there were 2,352,022 live births, of which 31 were recorded to mothPrs of age 50 and over, or 1.3 per 100,1100 total live births. In the same period among 225,400 fetal deaths (of all periods of gestation) +7 or 20.9 per 100,000 total fetal deaths rPported occurred in mothers 50 years of age or over. Combining live births and fetal deaths tht•re wrre 78 to mothers of 50 years of age <~nd over or 3 per 100,000 pregnancies reported. In this 16 year period ( 1940 through 1955) the yearly average of prPgnant patients in the fifties was +.9 ( 78 di\'ided by 16). The ~wrage yearly femalt-
RATE PER 10,000 TOTAL PREGNANCIES AND PER 10,000 TOTAL DELIVERIES
J_·\\ 00-~
1n
OVER 50
Fig. 1. Proportion of total pregnancies and total delinries among mothers of each age group from
44 and over.
the total of 126,343 pregnancies (deliveries plus abortions). Among 11,373 abortions and previable deliveries, 7 occurred in mothers at age 48, 4 at age 49, 2 at age 50, 2 at age 53. Fig. 1 shows graphically the marked falling off in each successively older year of age of deliveries and j)fPgnancies. The proportion of total mothers that each age from H on comprises has been computed for the United States for the year 1960 and compared in Table III with deliveries at these age' in The New York Hospital for 1932-1963, and also compared with a sample of more recent yrars of lin~ births in our institution, namely 19.51 through 1960. In 1960 in the United States live births to mothers of these ages were 25.3 for every 10,000 live births, and in the Lying-In for the total period EJ32 through 1963, 24.1 for every 10,000
NEW YORK LYING-IN PREGNANCIES IN MOTHERS AGE
44 8
HOSPITAL OVER
1932-1963 PREGNANCIES IN MOTHERS EXCLUSIVE AGE 44 & OVER
,--------------,
:
3.9°/o
ADBOAN 17
ONATAL
l
:
I PERINATAL
~DEATHS
ATHStll
6.4%
2.5°/oJ
: TOTAL
LOSS
186
42.8 °/0
28
TOTAL LOSS
14,444
11.5%
I
ABORTIONS 158 36,4 °/o
~-----------------' TOTAL PREGNANCIES 435
Fig. 2.
TOTAL PREGNANCIES 125,908
680 Wharton
Am.
November 1, 1964 J. Obst. & Gynec.
population in ages 50 to 59 in New York City in this period was 468,7 41, so that 1.0 pregnancy per 100,000 was the average expected in a given year. If it can be assumed that all these preg·
women age 45 to 49 appears to be very remote and the data from our institution, New York City, New York State, and the National Office of Vital Statistics appear to agree quite well.
nancies occurred in the early fifties, the average yearly female population for ages 50 to 54 was 261,361 giving an expected average in a given year of 1.9 pregnancies per 100,000 in this age
It could be argued of course that a large per . .
group, and none in the later fifties. In the age group 45 to 49 the chances of becoming pregnant are considerably greater, judging from New York City Statistics. In the 13 year period 1941-1953 for which number of pregnancies in women of age 45 to 49 is available to me for both live births and fetal deaths, the average yearly number of pregnancies re· ported was 202, and the average yearly number of females in the 45 to 49 age group was 289,015, so that in a given year 69.9 per 100,000 women in this age category was the approximate number expected to have a pregnancy terminate in either a live biith Oi fetal death. In New York State, out of a total of approximately 360,000 births in 1960, 282 (0.1 per cent) were under the age of 15 and 364 (OJ per cent) were in the age group 45 to 49. These data indicate the extreme infrequency of pregnancy in both the higher and lower reproductive years. I have no data to indicate whether this situation is caused by a precipitous decrease in fertility or by choice of the individuals concerned. Dr. Wharton has referred only to the outcome of pregnancies in women over 50, when the baby was apparently healthy, at least from the physical point of view. I have been interested in the high incidence of pregnancy wastage in our more elderly patients. Of the 435 pregnancies in mothers age 44 and over in our institution from 1932 through 1963, 186 (42.8 per cent) resulted in loss through abortion, stillborn, or neonatal death. Approximately 126,000 pregnancies were seP-n during this period. In those women younger than age 44, 14,444 or (11.5 per cent) were lost. Accordingly the total loss is almost 4 times greater in women age 44 to 49 as compared to all other ages (Fig. 2). There were 28 perinatal deaths in the older group which is ( 10.1 per cent) compared to 2.8 per cent for the rest of the clinic. The incidence of abortion in this group age 44 to 49 was 36.4 per cent. At age 44 pregnancy wastage was 38.3 per cent, at age 46, 49.2 per cent, at age 4 7, 66.7 per cent, at age 48, 77.8 per cent, and over this age 100 per cent. The possibility of pregnancy, then, in those
centage of these women were employing some method of conception control. In general, it has been our policy to suggest the discontinuance of pregnancy control measures in menopausal won1en following 6 n1onths of an1enorrhea. In addition to the extreme rarity of pregnancy and the high incidence of reproductive failure more precise knowledge concerning anomalies and mental development of infants born of mothers over the age of 45 is certainly a vital part of the problem of pregnancy in our more senior reproductive citizens. DR. NrcHOLSON J. EASTMAN, New York, New York. I have long been interested in this subject and look at it in this way: How old can a man live? Who is the oldest man of whom you have ever heaid? You probably have heard of a man 110 years old. Could a man live to be 125?
That is impossible, you may say, but if you look at the records you will find that certain men are said to have lived 125 years. Can he live to be 135? There are a few such cases reported, authentic or otherwise. There are 3 billion people in the world and apparently once in many, many millions, through circumstances we do not know much about, one individual does live to an extremely advanced age. Now, can a woman have a baby when she is 52, 54, 56 years old? You may say that is not possible, but there appear to be a few authentic cases where this has occurred. Every year there are some 80 million babies born in the world. In 10 or 15 years there may be 1 billion babies born. Through circumstances we do not know much about, it appears to happen that one woman in many million does have a baby at the age of 54 or 55. This is the basis for the attitude of the law in these cases. The law wants to know absolutely: Can a woman of 54 have a baby? If you say no, you have to be able to prove that no woman has ever had a baby at that age, for these extreme cases, if they can be documented, are interpreted by the law to mean that a woman can have a baby at very advanced ages. This is a most interesting problem, and Dr. Wharton is to be congratulated on the time and intelligent thought he has given it. DR. WHARTON (Closing). With regard to Dr. Douglas's remarks about complications that occur to women who have babies late in life, I can
Volume 90 Number 5
state that some hydatid moles have been re· ported in women past the age of 50. There is often a problem in diagnosing pregnancy and its complications in a woman over 50 who has stopped menstruation. The history is at times suggestive, but the diagnosis of pregnancy or its complications, like hydatid mole, is difficult unless the patient has passed hydatid vesicles in her bleeding. You do not expect pregnancy and you do not look for it. The possibility of pregnancy late in life is usually entirely overlooked, and the diagnosis in these cases has usually been carcinoma of the endometrium or some endometrial disorder. There were many things in connection with these elderly women that I could not bring out because of time limitation. They are all usually multiparas, and the highest number of babies born to one of these women was 21. There is often a space of 10 to 12 years since the last pregnancy. Some of the old histories are fantastic, so
Pregnancy in women past flfty
681
fantastic that one hesitates to include them. For example, there is the woman who knew the date of her birth because she was born the year Wellington defeated Napoleon in 1815. She married a British soldier, who died; she married again and had in all 10 children. This woman had twins at the age of 50 and was delivered by her old family physician. Then she stopped menstruation for one year, and then menstruated normally for another year. ~~fter that, for 11 years she had amenorrhea. Then she began to feel poorly and called on various doctors who could not make out anything. Finally she called on her old family physician who told her that she was going to have a baby, and he delivered her of a healthy child when she was 63. That case is reported in the literature and her doctor went to much trouble to check her age. There are many stories like that in the older literature and some of them must be true. In spite of that, we have not included them but have relied upon more recent data.
I N D A r L y gynecologic practice, one of the questions most frequently asked by the menopausal woman is when she can stop using contraceptive measures. In medical jurisprudence, the courts are interested in the same problem for a different purpose. Wondering women have raised the question since the time of Abraham and Sarah, several thousand years ago and in the intervening centuries, very little has been added to our ability to answer the question. Recently, more profitable avenues of investigation have been opened and more information has been and will continue to be obtained. On the basis of the present study, however, it may be said that it is impossible to fix a definite upper limit to human fertility and that dogmatic assertions in the literature probably would not have been made if present information had been available. In studying this problem, four different sources of information have been used. 1. The medical literature from 1860 to thP nrPsent time and some contemnorarv sources. 2. Hospital statistics of obstetrical and gynecological departments in this country and also the Near and Far East. 3. Vital statistics published in this and other countries. ~
.
-
.1.
4. Court decisions m Great Britain and the United States. Women who have had normal, living babies after 50 according to the literature and contemporary sources
The staff of the Welch Library made a thorough search of the medical literature back to 1860, obtaining copies of almost every relevant article. There proved to be infrequent articles on this subject and very few authentic cases, especially before 1900. Certain records of the past 10 to 15 years, obtained by personal investigation, are much more illuminating and, possibly, more accurate than those of the preceding years. Table I gives the essential data on 26 apparently authentic cases of women who had normal living babies after the age of 50 years. These 26 cases have been collected from various sources. The first 6 were single case reports which appeared in the medical literature years ago. The modern student 'vi!! probably be more impressed \vith the reports of more contemporary physicians, which were the source of the last 7 cases in the list. In contrast with the first 6, not one of these later authors published his case as an individual report. Some, such as Berkley, Bonney, and McLeod 7 and Greenhill" mentioned them rather casuaiiy in their textbooks. Others reported their cases in collections from various sources and published in articles such as those by the editors of Lancet. 8 Koren, Zuckerman, and Brzezinski1" discovered their 5 cases in a study of
'
From the Department of Obstetrics and Gynecology, Johns Hopkins Hospital. Presented at the Eighty-seventh Annual Meeting of the American Gynecological Society, Hot Springs, Virginia,
May 25-27, 1964.
672
Pregnancy in women past fifty
Volume 90 Number 5
pregnancy in women over 40 in Jerusalem. Bickers' 11 case was described to the author in a personal letter from Beirut. The cases of Wykr 1 ~ and Wharton are unique in that they were derived from the first efforts to analyze general vital statistics on this point. These 2 cases will be discussed later in the section on vi tal statistics. It is perhaps noteworthy that between 1860 and 1900 only 2 apparently authentic cases are recorded in the literature, whereas since then 24 cases have been described by sources that seem unimpeachable. Also, as we have noted, not one of these 24 recent cases was reported individually in the literature. One may doubt whether the paucity of individual reports is a fair index of the actual incidence of the condition. In assembling these cases, the author encountered numerous others some of which were probably authentic but which for various reasons were not included in the present review. Among these are some interesting, almost fantastic, obstetrical experiences. Certain of the cases, as that presented to the Royal Academy of Sciences in London by a
673
bishop of the Church of England 13 had little or no medical confirmation. The bishop merely thought it worth reporting that one of his parishioners had a healthy baby when she was more than 80 years old. The Royal Academy accepted the statement and included his report in its proceedings. Other cases, such as those reported by Valentin 14 and Kennedy15 have long been quoted and have become almost classic. They are almost surely authentic, although in the last few years interest in them has been replaced by that of more recent material. Most of the women who had healthy children after age 50 were "grand multiparas," the highest number of those children being 11. There were only 2 primiparas in the collection and both were delivered without complications of healthy children. Hospital statistics
A review of the statistics of our large lying-in hospitals and obstetrical departments might suggest the conclusion that no woman past the age of 50 ever has a child, for, as Table II shows, not one of the reporting hos-
Table I. Apparently authentic cases of full-term healthy children born to women more than 50 years of age
Reference
Date
No. of cases
Mother's al(e
Father's age
Para
Taylorl Ha!P
1890 1903
54 51
64 24
Depasse3
1891
59
28
Buckle4
1910
63
7
Gilbertson 5 Woelingas
1917 1958
50 52
11
Berkley, Bonney, and McLeod7 Editorial, Lancets Greenhill9 Koren, Zuckerman, and BrzezinskilO
1938
2
1905 1960 1963
1
Bickersll Wyler 12 Author
1962 1957 1964
7
5
1 3 1
51 52 51 52 53 54 52 51 52
(2 cases) ( 1 case)
( 1 case) ( 1 case)
0
Years since last pregnancy (No.)
Comment
11
19 13 5
Five years postmenopausal Nine years since last menstrual period Amenorrhea of 11 years before pregnancy at 63 Last child, at 4 7, a Mongoloid idiot
674 Wharton
~ovember
1. l~J6.f
Am. J. Ob'>t. & Gyuec.
Table II. Incidence of viable births after 46 in relation to age (Stanton 17 ) Hospital Chicago Lying-In Hospital Johns Hopkins Hospital Boston Lying-In Hospital Jersey City Medical Center Lenox Hill Hospital ~ew York Lying-In Hospital New York City Statistics 1940-1950
Age
Total No. of cases 50:000 65.000
2
42,000
10 6
5o:ooo 27,273
65,880 1,427,106
25
48
49
50
2
50+
0 2
0
0
(J
()
1 1
0
()
()
0
4
3
0
()
5 5
1 2
0 1
u
0
(J
(I I)
25
-----------------------------------------------------------------------
pitals records such an event. In 1961, Eastman reported that in 65,000 full-term deliveries, not one mother was 50 years old. Some smaller hospitals have reported the same findings. In 1959, Calk and Cofer 18 of the Georgia Baptist Hospital in Atlanta, reported that 18,037 women were delivered of normal full-term children, the oldest mother was 48 years of age. The statistics of New York City, during the decade 1940 through 1950, as cited by Stanton, duplicate similar data obtained from every governmental unit that has been investigated by us. In practically every census, a certain number of women have reported that they had borne normal children after they were 50 years old. Stanton's comment was simply that New York City contained a great many unfortunate people of almost every nationality, displaced by war or persecution and completely separated from their families, who simply had no idea of their correct age. This comment might be applied to every large city. Reports from foreign hospitals
By personal correspondence, reports have been obtained from several hospitals in the Near and Far East. Among the obstetricians in charge of these departments were Dr. William Bickers 11 of the American Hospital in Beirut, Lebanon; Dr. Abdel Fattah Yousse£19 in Cairo, Egypt; Dr. A. D. Engineer 20 from the K. G. Medical College in Lucknow, India; Dr. Daphne Chun~ 1 from Queen Mary Hospital in Hong Kong; and Dr. Vishnu Sarma~~ in Madras, India. Not one of these obstetricians reported the delivery of a
healthy, full-term baby in a woman as old as 50 years. Dr. Bickers, however, reported that one of his colleagues had delivered a woman just preceding her fifty-second birthday of a healthy child. This woman already had 5 children, the last pregnancy having been 12 years previously. Vital statistics
In every nation or municipality that has been investigated the vital statistics allow somewhat different conclusions for in almost all census records a certain number of women have had normal babies when they were more than 50 years old. Nor is this a recent tendency, as is shown by the records of Germany as far back as 1861. In 1903, Strassmann 2 " published a study of the problem of Fertility in the German Empire on the basis of vital statistics from 1861 to 1894. In the city of Berlin, for example, in the year 1898, there were 50,510 live births. Among these, + women stated that they were 50 years of age or older, when they gave birth to healthy, living babies. Almost universally, these reports have been completely dismissed on the assumption that the women who made such reports were ignorant of their age. In 1957 Wyler"" decided to check the situation in Switzerland and, as has been indicated in Table I, found that in the years 1946 and 1947, there were 3 women who had healthy babies after they were 50 years old. Wyler corroborated these claims. Wyler also obtained the Vital Statistics from Scotland, which showed that in the years 1939 through 1946, seventeen women older than the age of 50 years reported that
Volume 90 :\umber:>
Pregnancy
they had given birth to healthy, living children. In the United States, the records have been about the same. The effort of a member of the staff of the National Vital Statistics Division, Dr. Grove, to find out more about the "vvomen v;ho report pregnancies after the age of 50 or 55 years alone will be
reported. Dr. Grove was skeptical about the accuracy of the ages of the older women, whose pregnancies were listed in Table III. He therefore ''queried" these mothers, in the group prior to 1943, with the result that many reduced their stated age and consequently dropped into the next lower age, i.e.~ the 50 to 54 group. ~~everthelcss, a certain number still insisted that they were 55 years old or more. Dr. Grove did not make a detailed analysis or publish a report on these remarkable cases, and apparently no other attempt has been made to study these women who insist that their ages were above 50 or 55 at the time of their delivery. The Commissioner of Health for Baltimore, Dr. Huntington Williams, and his entire staff were also found by the author to be cooperative and anxious to help. In the census for 10 years preceding 1961, they found that 2 women, residents of Baltimore, had reported that they had borne living babies after the age of fifty. One of these could not be traced, but the Health Department of Baltimore City soon found the second. She was, fortunately, an intelligent, educated person, a full-blooded Cherokee Indian, married to an employee of one of our large construction corporations. Her husband was 15 years her junior. This couple has lived in Baltimore 25 years. This woman has had 2 healthy full-term children, after her fiftieth year, both delivered at the North Charles General Hospital in Baltimore. The first, a healthy daughter, was born on April 5, 1957; the second in the mother's fifty-third year, a healthy, fuil-term son on April 30, 1959. The hospital records of both admissions are complete and well kept. It has not been possible to obtain a birth certificate of this mother, but her birth was recorded in the family Bible. The Baltimore City Health 24
1n
675
women past fifty
Table III. Live births to mothers 50 years and over (United States, 1937-1946)-1{Age of mother 50 to 54 Years Year
White
1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936
84 119 112 109 118 96 122 148
129 131 J(J:j
I
55 Years and older
iNonwhitel H'hite
47 ~2
22
++
51 40 54 51 46 50 59
52 48 41
+fi
jNonwhite
12
19
u
q
0 0
0
0
I)
()
I)
1
2
:l
1
---·--·-····-· *Personal communication frmn Dr. Robert D. Gro\·e, Acting Chief, National V.itai Statistics Division.
Department considered the evidence furnished by their long residence in Baltimore, and former hospitalization sufficient to establish the responsibility of this couple and the accuracy of the stated age. It is thus apparent that the vital statistics of a country or municipality contain valuable information, if one can only obtain the interest of the various health departments.
Medicolegal aspects The problem of the upper age limit of female fertility has been of legal concern for many years. In English courts, it has been important in suits concerning legitimacy, the inheritance of titles, and property. In American courts, the question has arisen chiefly in cases involving legitimacy, wills, and trusts. The decisions of both the English and American courts have been uniform, consistent, and clear. The opinion of the English courts of law was summarized many years ago by Taylor~:; in his textbook, Medical Jurisprudence, the first edition of which appeared in London in 1843. The fifth American edition of this standard text appeared in 1861, and contains a searching study of this question. Decisions of many courts arc cited, trials are quoted and medical records now inaccessible are presented. In conclusion, Taylor stated that the Eng-
~ovember
Wharton
676
Am.
lish courts have long maintained that "we cannot pretend to fix the age at which pregnancy ceases to be possible, and beyond which it cannot occur." The same opinion is repeated in subsequent editions of this book. The Common Law in the United States of America concurs with the English. This was summarized by Leach 26 in 1938 in the Harvard Law Review as follows: a woman "is conclusively presumed to be capable of having children until death." In discussing this, the American reviewer states that this presumption is "silly," on various grounds. Nevertheless, he concludes that "no court, English or American, has failed to follow the presumption." Conclusion
In conclusion, what answer can be given to women soon after menopause who want to knovv "vvhen they can discontinue contraceptive measures? It is impossible to fix definitely an upper limit since there have been too many authentic cases of women who have had healthy babies after the age of 50 or 55. In discussing this problem with women, the physician will be wise to present the
2. Hall, F.
J.
V.: Midland M.
3. DePasse, E.: 1891. 4. Buckle, L.: J. 5. Gilbertson, J. 6. Woelinga, H. 1 'lt:n
Do
7. 8. 9.
B~'rkl~;~·
11.
12. 13.
1
2: 106, 1903.
A. M. A. 55: 568, 1910. H.: Brit. M. ]. 1: 378, 1917. D.: Nederl. T. Geneesk. 102:
Summary
Various series of cases of full-term delivery in women of age 50 have been reviewed and a number of apparently authentic cases reported. The rarity of this event in the records of a number of large lying-in hospitals, both here and abroad, is noted. The significant number of such cases appearing in the records of vital statistics seems somewhat to contradict this experience which may be partially or wholly explained by faulty recollection by the mother of her age. The author acknowledges his debt to Miss Ruth Tyler and her staff at the Welch Medical Library; The National Library of Medicine in Bethesda; The Library of the Medical and
Chirurgica! Faculty of Maryland. Miss Tyler and her staff made a search of the medical literature as far back as 1860. Without their efforts, this section of our study would not have been possible.
t
,
•
14. 15. 16.
n~o
Bonney, v., and McLeod, D.: The Abnormal in Obstetrics, Baltimore, 1938, Wm. Wood, p. 10. Editorial: Lancet 2: 171, 1905. Greenhill, J. P.: Obstetrics, ed. 12, Phila•n.rl"t. vv. D. o:>aunuers vompany. ae1pnm, 1:1ov, Koren, Z., Zuckerman, H., and Brzezinski, A.: Obst. & Gynec. 21: 165, 1963. Bickers, W.: Personal communication from the American University Hospital, Beirut, Lebanon, 1962. Wyier, J.: Schweiz. med. Wchnschr. 87: 23, 698, 1957. Woman delivered of a child when above 80 ,
10.
c.:. .
J.
Gaz. d. gym!c., Paris 6: 241,
"':.l.r
-
,.,
_.1
1, 1964
Obst. & Gynec.
facts and tell the patient frankly that the chance of conception after the age of 50 is negligible and decreases to an indefinite and unknown vanishing point. Since, however, a small number of women will bear children after 50, it may contribute to their peace of mind if contraception is continued for possibly a year after menstruation has ceased.
REFERENCES
1. Taylor, R. A.: Daniel's Texas M. J. 5: 259, 1890.
J.
17. 18. 19.
..-.
20. 21. 22. 23.
years of age: Philosophy, History, and Memorials of the Royal Academy of Science, Paris ABR. 1699-1720, London, 1742, p. 329. Valentin, M.: Compt. rend. Soc. gynec. 27: 55, 1957. Kennedy, W. J.: Edinburgh M. J. 27: 1085, 1882. Eastman, N. J., and Hellman, L. M.: Williams' Obstetrics, ed. 12, New York, 1961, .c\ppleton-Century-Crofts, Inc., p. 223. Stanton, E. F.: AM. J. 0BST. & GYNEC. 71: 270, 1956. Calk, Guy L., and Cofer, 0. S.: South. M. J. 52: 1078, 1959. Youssef. A. F.: Personal communication from Cairo, Egypt, 1961. Engineer, A. D.: Personal communication from K. G. Medical College, Lucknow, India, 1962. Chun, D.: Personal communication from Queen Mary Hospital, Hong Kong, 1961. Sarma, V.: Personal communication from Madras, India, 1961. Strassmann, von P.: Die Haufigkeit der
Volume 90 Number 5
Geburten. In von Winckel, F.: Handbuch der Geburtshiilfe, Wiesbaden, 1903, vol. I, chap. 1, pp. 96-101. 24. Grove, R. D.: Personal communication, 1962. 25. Taylor, A. S.: Medical Jurisprudence, fourth American from the fifth and improved London edition, Philadelphia, 1856, Blanchard & Lea, p. 493.
Discussion DR. M. EnwARD DAvrs, Chicago, Illinois. In most mammals, ovarian life expectancy and general life expectancy coincide. Zoologists do not dispute this, but they point out that the aged female mammal stops breeding because of physical deterioration. The human female has been singled out in our evolutionary process so that her reproductive period is limited to an average of 30 or 35 of her early years, and it is over in her middle forties even though her average length of life has increased greatly. In 1959, the life expectancy of females at birth in the United States was 6.3 years higher than comparable figures for males. Sharman1 studied multiple endometrial biopsies in women aged over 45 years to determine when gonadal function ceases. His findings demonstrated that there was no evidence of ovulation after the age of 52, although several women aged 50 to 52 did provide such evidence. There appears to be a high incidence of anovular menstruation, increasing with age, in women over 40. There are marked differences in the biologic function of the human male and female gonads. The functional life of the ovaries is probably predestined and under genetic control. There is a tendency for the daughter to follow the menstrual pattern of her mother. However, racial, physical, and social factors are all implicated in determining the life of the ovaries. The exhaustive study presented by Dr. Wharton emphasizes once again that it is extremely rare for a woman in the early fifties to give birth to a baby. The outstanding feature of the mammalian ovary is the continuous depletion of the number of oocytes, only slightly and temporarily checked by the intervention of pregnancy. Block2 has estimated that the number of oocytes in the human gonads falls from 484,000 at ages 6 to 9 years to 155,000 at 18 to 24 years and to
Pregnancy in women past fifty
677
26. Taylor, A. S.: Medical Jurisprudence, fifth American edition, Philadelphia, 1961, Blanchard & Lea, p. 512. 27. Leach, W. B.: Harvard Law Rev., vol. 51, 1938. 4504 Roland Avenue Baltimore, Maryland 21210
8,300 at 40 to 44 years. It is of interest that marked differences in the rate of atresia of oocytes between species and even between different strains of the same species, e.g., mice, and thus in their reproductive potential have been demonstrated. 3 • 4 When all oocytes have degenerated or disappeared, and in some species before that stage, reproductive life comes to an end. This is not necessarily accompanied by the cessation of the ovary's hormonal activities. 5 Too little is known about the process of atresia, and it is unlikely that it can be retarded. More information is necessary about the effects of the depleted supply of oocytes on fertility and the length of reproductive life. Modern research in this area may be most rewarding. The functional life of the gonads in the male may continue throughout the life of an individual. He may produce spermatozoa capable of fertilization throughout life. However, as in other mammals, the aging process may interfere with his ability to fertilize the female. That fatherhood can be achieved very late in life is beyond question. It is these differences in the biologic function of the male and female gonads that have led to much confusion in our thinking. There have been some suggestions in the recent literature that our ability to suppress ovulation in our increasing tempo to meet the population explosion may retard the exhaustion of woman's greatest asset, her ova, and that these may be saved for later years. Alas, here too I must disappoint you. The administration of steroids to suppress ovulation does not interfere with the normal development of primary follicles and their subsequent atresia with the continuous depletion of oocytes. Dr. Wharton has reaffirmed the results of our studies, 6 those of Newall and Rock,7 and many others that parturition in a normal woman over 52 years of age has not been proved. It is my hope that this presentation will stimulate more
678
Wharton
accurate vital statistics and help bring our laws in tune with our scientific knowledge and modern thinking. It is indeed unlikely that our courts will be asked to protect the rights of another Sarah who begat Isaac at the age of 90. REFERENCES
1. Sharman, A.: The ovary, vol. I, 1962, ed. Sir Solly Zuckerman. 2. Block, E.: Acta anat. 14: 108, 1962. 3. Fekete, E.: Anat. Rec. ii7: 93, 1953. 4. Jones, E. C.: The aging ovary, Thesis, University of Birmingham, 1957. 5. Zuckerman, S.: Proc. Fifth International Conference on Planned Parenthood, Tokyo, 1955, pp. 197-200. 6. Davis, M. E .. and Seski, A.: Surg. Gynec. & Obst. 87: 1+5, 1948. 7. "Jewell, J. W., and Rock, J.: AM. J. 0BST. & GYNEC. 63: 875, 1952.
DR. R.
DouGLAS, New York, New York. Dr. Wharton has posed the question frequently asked by menopausal women, when may they n·as•· to employ contraceptive measures. In answrring this question he has carried out an exhausti\·e survey of the literature, hospital n•cnrcls, vital statistics, and court decisions. His conclusions are valid and most conservative. He has. in fan, sustained the old dictum, at least as far as the upper age limit is concerned, that "pregnancy is always possible between the ages of ti through 60." Dr. \Vharton has answered the question concerning tlw possibility of pregnancy in women ovcr tlw a,2,c of .50 and the chances appear extremely remote. He has indicated the probability that some instances of pregnancy over the age of 50 are not recorded in the literature. He has nor, however, answered the question concerning the possibility of pregnancy in slightly younger women. This scl'ms justifiable because the biological age of women does vary from chronological age and in some respect consideration of only \\omen 50 years of age or older appears quite arbitrary. The question of pregnancy may be equally as important or more so to the woman agt'd +7 or 49 years. .\ccnrdingly, I have reviewed some of our data in the I\ ew York Lying-In Hospital. Among 114,970 womPn who were delivered in the New York Lying-In Hospital from Sept. 1, 1932, through Dec. 31, 1963, the oldest age was 48 and only 2 were this old, one in 1935 and one in 1955. The proportion of total mothers of ages 44 and over per 10,000 total deliveries is shown in Table I. GoRDON
Am.
I\ ovember I. 1964 J. Ob;t. & Gynec.
As a part of the likelihood of becoming pregnant, results of the inclusion of mothers who had abortions or were delivered of nonviable or very immature infants arc shown in Table II for
Table I. Deliveries by age of mother 44 years and over at New York Lying-In Hospital (1932-1963)
Age
No.
+1-
139 90 37
45 46 47 4R
Total
Total deliveries (rate per 10,000)
12.1 7.8
3.2
9
0.8
2
0.2
277
H and over
24.1
-·-·-·--·-····-
Table II. Pregnancies by age of mother 4+ years and over at New York Lying-In Hospital ( 1932-1963) I
Total p~egnancies
1
No.
10,000)
44 45
206 125
16.3
46 47
+B
*Decidual
0.7 O.:l 0.2 0.2
4 2 2*
44 and over n~action
9.9 4.9 1.9
63 24 9
49 50 53
Total
(rate per
Age
~
435
:34.4
no ,·il!i.
Table III. Live births by age of mother* I
United States 1960 Live births
44
45
13.2
47 48
6.9 3.0 1.3 0.5
50 and
0.3
46 49
over
Total
0.2
25.3
New York I Lying-In 1953-1960 Live births 1
15.5
6.3
2.9 0.9 0.3
25.9
I I
New York Lying-In 1932-1963 Total deliveries
12.1 7.8 3.2 0.8
0.2
24.1
*Rates per 10.000 total live births and total dl'liwric,.
Volume 90 Nurnhcr 5
Pregnancy
NEW YORK LYING-IN HOSPITAL,
1932~
1963
201
...... -.& PREGNANCIES (TOTAL :126,343) ._.... DELIVERIES (TOTAL :114 ,lHO
i
•••\ .
5-
~. ··:.::--. . . . . . . . .....
AGE
oI
I 44
I 45
~
46
47
.. 48
·---:+-----•-----A 49
50
women past fifty
679
deliveries and for the more recent sample 25.9 per 10,000 live births. Of a total of 34,788 live born viable (500 and more grams birth weight) infants in the years 1953 through 1960 inclusive at the T'Je\V York Lying=In, mothers of 90 'Ncre 44 years of age or over, 54 aged 44, 22 aged 45, 10 aged 46, 3 aged 47, and one aged 48. While this is a relatively small number to compare with the 10,790 aged 44 and over in the United States, there is striking similarity in the proportion in specific ages. For example, the proportion at age 46 is 3.0 per 10,000 for the United States and 2.9 at the Lying-In Hospital, for age 4 7, 1.3, and 0.9, respectively. The precipitous drop from ages 44 to 4 7 is apparent. In recent years the published yearly Summary of Vital Statistics of The City of ::-\ew York has contained as the highest age category of mother, 40 years and over. Through personal communication with Dr. Erhardt, Director, Bureau of Records and Statistics, New York City Department of Health, live births and fetal deaths were obtained for the years 1940 through 1955 for thost' mothers in the 50 years and over age category. In this period there were 2,352,022 live births, of which 31 were recorded to mothPrs of age 50 and over, or 1.3 per 100,1100 total live births. In the same period among 225,400 fetal deaths (of all periods of gestation) +7 or 20.9 per 100,000 total fetal deaths rPported occurred in mothers 50 years of age or over. Combining live births and fetal deaths tht•re wrre 78 to mothers of 50 years of age <~nd over or 3 per 100,000 pregnancies reported. In this 16 year period ( 1940 through 1955) the yearly average of prPgnant patients in the fifties was +.9 ( 78 di\'ided by 16). The ~wrage yearly femalt-
RATE PER 10,000 TOTAL PREGNANCIES AND PER 10,000 TOTAL DELIVERIES
J_·\\ 00-~
1n
OVER 50
Fig. 1. Proportion of total pregnancies and total delinries among mothers of each age group from
44 and over.
the total of 126,343 pregnancies (deliveries plus abortions). Among 11,373 abortions and previable deliveries, 7 occurred in mothers at age 48, 4 at age 49, 2 at age 50, 2 at age 53. Fig. 1 shows graphically the marked falling off in each successively older year of age of deliveries and j)fPgnancies. The proportion of total mothers that each age from H on comprises has been computed for the United States for the year 1960 and compared in Table III with deliveries at these age' in The New York Hospital for 1932-1963, and also compared with a sample of more recent yrars of lin~ births in our institution, namely 19.51 through 1960. In 1960 in the United States live births to mothers of these ages were 25.3 for every 10,000 live births, and in the Lying-In for the total period EJ32 through 1963, 24.1 for every 10,000
NEW YORK LYING-IN PREGNANCIES IN MOTHERS AGE
44 8
HOSPITAL OVER
1932-1963 PREGNANCIES IN MOTHERS EXCLUSIVE AGE 44 & OVER
,--------------,
:
3.9°/o
ADBOAN 17
ONATAL
l
:
I PERINATAL
~DEATHS
ATHStll
6.4%
2.5°/oJ
: TOTAL
LOSS
186
42.8 °/0
28
TOTAL LOSS
14,444
11.5%
I
ABORTIONS 158 36,4 °/o
~-----------------' TOTAL PREGNANCIES 435
Fig. 2.
TOTAL PREGNANCIES 125,908
680 Wharton
Am.
November 1, 1964 J. Obst. & Gynec.
population in ages 50 to 59 in New York City in this period was 468,7 41, so that 1.0 pregnancy per 100,000 was the average expected in a given year. If it can be assumed that all these preg·
women age 45 to 49 appears to be very remote and the data from our institution, New York City, New York State, and the National Office of Vital Statistics appear to agree quite well.
nancies occurred in the early fifties, the average yearly female population for ages 50 to 54 was 261,361 giving an expected average in a given year of 1.9 pregnancies per 100,000 in this age
It could be argued of course that a large per . .
group, and none in the later fifties. In the age group 45 to 49 the chances of becoming pregnant are considerably greater, judging from New York City Statistics. In the 13 year period 1941-1953 for which number of pregnancies in women of age 45 to 49 is available to me for both live births and fetal deaths, the average yearly number of pregnancies re· ported was 202, and the average yearly number of females in the 45 to 49 age group was 289,015, so that in a given year 69.9 per 100,000 women in this age category was the approximate number expected to have a pregnancy terminate in either a live biith Oi fetal death. In New York State, out of a total of approximately 360,000 births in 1960, 282 (0.1 per cent) were under the age of 15 and 364 (OJ per cent) were in the age group 45 to 49. These data indicate the extreme infrequency of pregnancy in both the higher and lower reproductive years. I have no data to indicate whether this situation is caused by a precipitous decrease in fertility or by choice of the individuals concerned. Dr. Wharton has referred only to the outcome of pregnancies in women over 50, when the baby was apparently healthy, at least from the physical point of view. I have been interested in the high incidence of pregnancy wastage in our more elderly patients. Of the 435 pregnancies in mothers age 44 and over in our institution from 1932 through 1963, 186 (42.8 per cent) resulted in loss through abortion, stillborn, or neonatal death. Approximately 126,000 pregnancies were seP-n during this period. In those women younger than age 44, 14,444 or (11.5 per cent) were lost. Accordingly the total loss is almost 4 times greater in women age 44 to 49 as compared to all other ages (Fig. 2). There were 28 perinatal deaths in the older group which is ( 10.1 per cent) compared to 2.8 per cent for the rest of the clinic. The incidence of abortion in this group age 44 to 49 was 36.4 per cent. At age 44 pregnancy wastage was 38.3 per cent, at age 46, 49.2 per cent, at age 4 7, 66.7 per cent, at age 48, 77.8 per cent, and over this age 100 per cent. The possibility of pregnancy, then, in those
centage of these women were employing some method of conception control. In general, it has been our policy to suggest the discontinuance of pregnancy control measures in menopausal won1en following 6 n1onths of an1enorrhea. In addition to the extreme rarity of pregnancy and the high incidence of reproductive failure more precise knowledge concerning anomalies and mental development of infants born of mothers over the age of 45 is certainly a vital part of the problem of pregnancy in our more senior reproductive citizens. DR. NrcHOLSON J. EASTMAN, New York, New York. I have long been interested in this subject and look at it in this way: How old can a man live? Who is the oldest man of whom you have ever heaid? You probably have heard of a man 110 years old. Could a man live to be 125?
That is impossible, you may say, but if you look at the records you will find that certain men are said to have lived 125 years. Can he live to be 135? There are a few such cases reported, authentic or otherwise. There are 3 billion people in the world and apparently once in many, many millions, through circumstances we do not know much about, one individual does live to an extremely advanced age. Now, can a woman have a baby when she is 52, 54, 56 years old? You may say that is not possible, but there appear to be a few authentic cases where this has occurred. Every year there are some 80 million babies born in the world. In 10 or 15 years there may be 1 billion babies born. Through circumstances we do not know much about, it appears to happen that one woman in many million does have a baby at the age of 54 or 55. This is the basis for the attitude of the law in these cases. The law wants to know absolutely: Can a woman of 54 have a baby? If you say no, you have to be able to prove that no woman has ever had a baby at that age, for these extreme cases, if they can be documented, are interpreted by the law to mean that a woman can have a baby at very advanced ages. This is a most interesting problem, and Dr. Wharton is to be congratulated on the time and intelligent thought he has given it. DR. WHARTON (Closing). With regard to Dr. Douglas's remarks about complications that occur to women who have babies late in life, I can
Volume 90 Number 5
state that some hydatid moles have been re· ported in women past the age of 50. There is often a problem in diagnosing pregnancy and its complications in a woman over 50 who has stopped menstruation. The history is at times suggestive, but the diagnosis of pregnancy or its complications, like hydatid mole, is difficult unless the patient has passed hydatid vesicles in her bleeding. You do not expect pregnancy and you do not look for it. The possibility of pregnancy late in life is usually entirely overlooked, and the diagnosis in these cases has usually been carcinoma of the endometrium or some endometrial disorder. There were many things in connection with these elderly women that I could not bring out because of time limitation. They are all usually multiparas, and the highest number of babies born to one of these women was 21. There is often a space of 10 to 12 years since the last pregnancy. Some of the old histories are fantastic, so
Pregnancy in women past flfty
681
fantastic that one hesitates to include them. For example, there is the woman who knew the date of her birth because she was born the year Wellington defeated Napoleon in 1815. She married a British soldier, who died; she married again and had in all 10 children. This woman had twins at the age of 50 and was delivered by her old family physician. Then she stopped menstruation for one year, and then menstruated normally for another year. ~~fter that, for 11 years she had amenorrhea. Then she began to feel poorly and called on various doctors who could not make out anything. Finally she called on her old family physician who told her that she was going to have a baby, and he delivered her of a healthy child when she was 63. That case is reported in the literature and her doctor went to much trouble to check her age. There are many stories like that in the older literature and some of them must be true. In spite of that, we have not included them but have relied upon more recent data.