A thorough exploration of egg freezing, adapted from “What’s a Young Woman to Do?: Update on Non-medical Fertility Preservation,” submitted to the Choice Mom community by long-time supporter Joann Paley Galst, Ph.D.
A politically correct term for social or non-medical fertility preservation — AGE-banking (anticipated game exhaustion; Stoop et al., 2014) — has entered the mainstream. Facebook, Apple, and other U.S. companies have offered to cover the cost of an egg-freezing cycle for female employees.
Age of first pregnancy has continued to rise for women. Many wait too long to consider egg freezing because they:
- believe they have plenty of time,
- underestimate their naturally fertility decline after age 35,
- inaccurately assume IVF can overcome the effects of aging.
The Process of Egg Freezing
Egg freezing has been heralded as a boon to women’s reproductive autonomy, akin to the birth control pill in the 1960s. But success rates differ greatly — the birth control pill offers close to 100% protection against pregnancy if used reliably, while egg freezing offers much lower chances of a take-home baby.
And, unlike taking a daily pill, freezing one’s eggs is not a quick and easy procedure. It involves: 1) two weeks of self-injections, 2) the removal of eggs from the ovaries with the woman under sedation, 3) quickly freezing the eggs in liquid nitrogen, and 4) placing them in storage until the time when she chooses to use them.
If she does return for her eggs, she prepares for a transfer cycle, often with medications. Some eggs are thawed and fertilized using the process of sperm injection (ICSI), as the shell of the eggs hardens due to the freezing process. She goes through a transfer, and begins injecting another medication to support the pregnancy.
What do we know about AGE-banking?
Methodology: The methodology keeps improving. Vitrification offers a fast freeze with extreme cooling rates, avoiding the formation of ice crystals that caused cellular damage to the eggs in the past. Clinical pregnancy rates have been reported at almost four times higher in eggs frozen by vitrification, compared to the older method of slow freezing (Glujovski et al., 2014). There are no significant differences reported in live birth rates between fresh or frozen eggs (Kushnir et al., 2015).
Success Rates: The “take home baby” statistic is of greatest interest to women. The age at which a woman freezes her eggs remains an important predictor of success (Rienzi et al., 2012; Ubaldi et al., 2010). Clear and concise information is difficult to abstract from available literature as there is quite a range reported:
- take home baby rates ranging from ~61-77% for women aged 30-35;
- a far greater range for women over 35 years of age at freezing, i.e., ~18-62% (Bianchi et al., 2012; Cil et al., 2013 [with infertile women]; Devine et al., 2015; Mesen et al., 2015).
- The likelihood of each frozen egg resulting in a live birth has also been reported to vary, from ~4-14% (Chang et al., 2013; Goldman et al., 2013).
- The experience and expertise of the IVF center is also likely to make a difference. However, it may be difficult to obtain useful information from IVF clinic websites (Avraham et al., 2014). An online egg-freezing success (live birth) probability estimator may assist women considering egg freezing.
When is the best time for a woman to freeze her eggs?
That depends on what is most important to a woman. Devine et al. (2015) created a mathematical model based on the records of 900 women.
Mesen et al. (2015) found that egg freezing provided the greatest improvement in the probability of a live birth compared to no action, when performed at 37 years of age (51.6% vs. 21.9%).
The highest probability of a live birth occurred when egg freezing was performed at under 34 years of age (>74%), but was most cost effective at age 37, at $28,759 per each additional live birth in the oocyte cryopreservation group.
Health and Safety
There are some risks, though infrequent, of undergoing oocyte cryopreservation (e.g., pelvic and abdominal pain; injury to the bladder, bowels, or blood vessels; pelvic infection; damage to the ovaries; and ovarian hyper-stimulation syndrome).
Discovering later that none of her frozen eggs produced a baby when she returned to use them may mean that she missed her reproductive window of opportunity to become pregnant with her own eggs.
No differences have been found between the use of vitrified or fresh eggs in the rates of obstetrical problems (including gestational diabetes, preterm births, gestational age at birth, APGAR scores, natal anomalies, birth defects, admission to a neonatal ICU, or perinatal mortality) (Cobo et al, 2014; Noyes et al., 2009).
The limited data available suggests no increased risk of chromosomal anomalies or significant physical or developmental deficits in the babies created (Chian et al., 2008; Cobo et al., 2014; Setti et al., 2013), although Setti et al (2013) did find higher miscarriage rates in pregnancies with frozen thawed eggs in infertile patients.
Nevertheless, long-term studies on safety for children born from this process are not yet available, there being only approximately 2,000 babies born worldwide from cryopreserved eggs.
And, regardless of the age when eggs were frozen, health concerns do remain for women becoming pregnant later in life (higher risk of high blood pressure, gestational diabetes, placenta previa, miscarriage, and early delivery because of preeclampsia) than for younger pregnant women.
ICSI is also related to an increased chance of passing on genetic problems because of embryologist-selection for insertion, rather than allowing a natural selection process in fertilizing an egg.
As many women on the Choice Mom path know, it can be a lonely and disquieting place to realize that you have no partner and, perhaps, life is not going exactly as expected. Information about limited ovarian reserve might be very disappointing news. It can be an emotional tailspin for many women, who wonder what this information means to her. Soul searching questions can include:
- Did she put too little emphasis on establishing a relationship?
- Does she want to be a single mother?
- At what age might it become unfair to a child to have an older single parent?
- Will this preclude her ever finding a partner?
Egg cryopreservation doesn’t offer guarantees. It is more accurate to consider it a gamble or wager. Maybe you’ll win, and maybe you’ll lose.
For truly informed consent to freeze her eggs, a woman needs:
- transparency regarding what the process entails (physical, emotional, risks to self and baby, cost, conditions for storage);
- age- and clinic-specific information about success, with success rate specifically defined (usually women are most interested in the take-home healthy baby rate, less so in the thawing, fertilization, implantation, or pregnancy rates, as pregnancies may be miscarried);
- to be informed that egg freezing is still a relatively new technology, the number of children born from this technology is still limited, and the long-term safety of this technology for children has yet to be determined;
- information about disposition options for her leftover oocytes;
- information about alternatives to egg freezing to preserve her fertility and to create a family.
If payment for egg freezing is offered by her employer, she needs to know:
- is she expected to wait to get pregnant?
- is she expected to make a commitment to work for this employer for a specific period of time?
- if she changes her job or is laid off, who will pay for storage?
- enhanced reproductive freedom and reduced time pressure;
- possibility to have genetically-related child when no partner available;
- reduced need for oocyte donors;
- reduced number of inefficient infertility treatments being performed today at advanced maternal ages;
- reduction of future regrets and self-blame for not taking advantage of current technology (Daniluk, 2001; Tumstra, 2007);
- promotes gender equality in employment and educational endeavors, i.e., Reproductive Affirmative Action (Goold & Savalescu, 2009);
- an advantage for those rejecting embryo cryopreservation for moral reasons.
- medical risks, with increased medicalization of women’s bodies;
- cost, and commercial exploitation, preying on women’s anxieties;
- pressure on women to freeze eggs and delay procreation, while creating false hopes and a false sense of security, and not offering a foolproof way to optimize career success and family planning;
- reduced focus on necessary societal changes (e.g., flexible work environments, better leave policies) so women can have children in their peak fertile years;
- perpetuates an injustice by exacerbating a class divide between women who can afford to freeze eggs and pursue careers while encouraging other young financially pressured women to sell their eggs;
- overemphasis on need for a genetic connection between parent and child, possibly stigmatizing other ways of pursuing parenthood (Cattapan et al., 2014).
What can be done to preserve fertility?
- Educate yourself.
- Be aware of your menstrual cycle, as ovulatory problems contribute to infertility.
- Set up a counseling appointment with your gynecologist. Your doctor can share with you the reality of declining fertility and how to keep yourself healthy. You may also wish to have your ovarian reserve tested.
- Know your intergenerational history. Ask your mom the age at which she entered menopause, as this can be associated with the age at which your own fertility will decline (Bentzen et al, 2013).
- Stay healthy.
- Maintain a healthy weight, ideally between a BMI of 19-25. Higher or lower weights are associated with miscarriage, subfertility, and poor IVF outcomes (The Practice Committee of the American Society for Reproductive Technology, 2015).
- Don’t smoke. Smoking can also reduce fertility (The Practice Committee of the American Society for Reproductive Medicine, 2012).
- Protect yourself from STDs. They can cause pelvic damage resulting in infertility.
- Reduce your exposure to environmental toxins. Bisphenols (BPAs), often found in soft plastics and food packages, are known endocrine disruptors that can reduce sperm quality and sexual function, and, potentially, egg quality.
Both women and men need to be aware of the impact of age on fertility. Egg freezing does not offer insurance of a take-home baby.
One reproductive endocrinologist has been quoted as telling his patients to freeze their eggs, but pretend they didn’t, thereby hoping they won’t delay starting their family on account of frozen eggs (K. Oktay in Rabinowitz, online).
Other researchers recommended that a woman not consider cryopreserved eggs as an alternative to conventional reproduction, but rather as a backup if all else fails and her biological time runs out (Cobo et al., 2014).
Success rates need to be more transparent:
- clearly defined in terms of take-home baby rate,
- stratified by age group, ovarian reserve test results, and technique of cryopreservation used,
- with the experience and expertise of each IVF center offering oocyte cryopreservation also being reported.
A national registry to collect data on outcomes would help in accomplishing this goal.
Even with transparency, egg freezing opens up ethical questions:
- Does egg freezing promote or undermine sexual equality?
- Are we responding to a fear or creating one?
- Does it enhance human health and well-being, or encourage a harmful bio essentialism requiring a genetic connection between parents and children?
- Should there be an age limit for using one’s stored egg reserve?
Although there can be some advantages to older motherhood (e.g., fewer financial worries, less concern about pursuing personal or career goals, greater engagement in parenting), there are also disadvantages (less energy, more likely to have health issues when the child is still a young adult, children could be deprived of social contact with grandparents). Children can be harmed if they do not have at least one parent to guide them into adulthood.
Women’s reproductive choices may not be voluntary — being shaped by our current social structures which shape and confine women’s reproductive options. Until this changes, men and women may continue to find their lives unfolding in ways that result in delayed parenthood.
The egg freezing decision requires a complex individual calculus that takes into consideration your age, likelihood of success, future intentions to start a family, finances, and both the potential for physical and psychological risks of undergoing the procedure.
It must not be oversold, as it is not a guarantee and women should not overlook other variables that impact their health and fertility. The impact of egg freezing on women’s reproductive autonomy, the family, and the workplace remains to be seen.
However, knowledge, not fear, will result in the best choice of when and why to have children.
Joann Paley Galst, Ph.D. is Co-director of Support Services and Chair of the Mental Health Advisory Council of the Path2Parenthood, formerly the American Fertility Association. She is a psychologist in New York City specializing in reproductive health issues including infertility, pregnancy loss, and pregnancy termination after the diagnosis of a fetal anomaly, and is a past chair of the Mental Health Professional Group of the American Society for Reproductive Medicine. She has written extensively in the fertility field, is a co-author with Judith Horowitz, Ph.D. and Nanette Elster J.D., of “Ethical Dilemmas in Fertility Counseling,” and co-edited, “Prenatal and Preimplantation Diagnosis: The Burden of Choice,” with Marion Verp, M.D.
She can be reached at 212-759-2783 or firstname.lastname@example.org
Joann Paley Galst is a long-time supporter of Choice Mom resources. Find more from her here:
- Podcast on egg freezing and the emotions of waiting too long
- Postpartum depression
- Fear of miscarriage
- Being tired of the fertility rollercoaster
- Asking the right questions of sperm banks
Other related resources
- Egg freezing: when is it a good idea?
- Concerns about egg freezing
- Podcast: Rachel Lehmann-Haupt’s egg-freezing story
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