I’m 34, single, and more focused on my next career move than on getting pregnant. Do I need to freeze my eggs?
It’s a question a lot of women my age are pondering, including Dr. Ashley Eskew, MD, MSCI, FACOG, a fertility physician and OBGYN with OvulifeMD (and a friend of mine from college).
Dr. Eskew and her husband are newly reunited in the same place after five years long distance and aren’t ready to expand their family. “We’ve definitely talked about kids but aren’t quite there yet,” she says. “I am 33 years old and I know there’s a lot more that I want to accomplish both professionally and personally before we actually try to have children honestly.”
So they’re weighing the same fertility preservation options and risks that Dr. Eskew helps her patients navigate.
Dr. Ashley Eskew (photo by Bazemore Studios)
Like me.
If I got pregnant today (*winks at absolutely no one*), I’d be turning 35 in my third trimester which would land me in “geriatric pregnancy” territory, a term I’m convinced doctors made up just to punish women. To the best of my knowledge, I won’t be getting pregnant today, or any time soon, so I’m exploring my egg-freezing options and sharing all the knowledge with you.
Here’s a breakdown of the million questions I fired at Dr. Eskew.
Disclaimer: This is not intended as direct medical advice in any way and is for informational purposes only. Please consult your physician for any medical questions.
The Process: How egg freezing works
Biologically, what happens to our eggs as we age?
Women are born with all the eggs they’ll ever have and that supply decreases over time. On average, women start with about 2 million eggs at birth. By the first menstrual cycle, or menarche, that total drops to about 400,000, and at age 40 most women have about 25,000 eggs left.
But total number of eggs isn’t the only factor that contributes to fertility as women age.
“It’s important to understand the concept of both egg quantity and egg quality,” Dr. Eskew says. “With advanced maternal age, the risk of aneuploidy, or having a chromosomally abnormal egg, increases, and also eggs become more fragile as women age.”
Optimal overall fertility lasts until about age 35, at which point conditions start to decline and risks increase. Pregnancy after age 35 has historically been referred to in the medical world as “geriatric pregnancy” but the archaic term is increasingly being replaced with the less sensational phrase “advanced maternal age.”
Why do women freeze their eggs?
Both married and single women freeze their eggs for a number of different reasons — to allow time to focus on career, to find the right partner, to finish school, or to steady their financial situation.
For some, egg freezing is prompted by medical conditions that affect fertility, such as systemic autoimmune diseases or cancer diagnoses.
For most, Dr. Eskew says, egg freezing is an unexpected twist in their life plan. “Most of the women who come into my office to discuss this will often say they never really thought they’d see themselves in this place,” she says.
But delaying pregnancy isn’t uncommon. The average age for first-time moms in the United States has been on the rise for decades. According to data from the Centers for Disease Control and Prevention, birth rates in the U.S. were at a record low in 2018, declining for nearly all age groups under 35 but rising for women in their late 30s and early 40s.
As that societal shift continues, more women are expected to freeze their eggs. According to data from the Society for Assisted Reproductive Technology (SART), there were nearly 11,000 cycles of oocyte banking for fertility preservation in 2017, up from about 8,700 cycles in 2016. That number is expected to increase by 25 percent annually over the next two years.
via @ashleyeskewmd
How exactly does the process of egg freezing work?
Oocyte preservation, or egg freezing, is the process of retrieving, freezing, and storing a woman’s eggs for future fertilization. The end to end process takes about two weeks.
Your doctor will start by discussing your reproductive goals and medical history as well as gathering baseline measurements of ovarian reserve.
From there, you’ll embark on 10 to 14 days of self administered injections of ovarian stimulating hormones, during which you may experience symptoms similar to PMS, including bloating (sometimes so severe you actually look pregnant) and a feeling of fullness.
Yes, you have to give yourself shots in the stomach. Dr. Eskew says it’s a very small needle.
“You can think of it like we’re basically giving you back the hormones that your body naturally produces in a menstrual cycle in a subcutaneous injection format at much higher doses than you would endogenously produce yourself,” she says.
The goal is to recruit multiple follicles to release eggs for retrieval as opposed to typically just one that’s normally released during a menstrual cycle.
Your doctor will monitor your response to the medications with a combination of transvaginal ultrasounds and a blood estradiol test to see how many follicles are growing and at which point they’ve matured.
When the follicles are ready, on average after 10 to 14 days of injections, you’ll receive a trigger shot of Lupron or Ovidrel that causes the eggs to mature. Your egg retrieval is then scheduled 36 hours after that injection.
How does egg retrieval work?
Egg retrieval is a minimally invasive outpatient procedure with no incisions required. It’s conducted transvaginally with a small needle that’s used to puncture and aspirate all visible follicles.
Dr. Eskew says different clinics have different procedures but that most will use propofol so that you’re sedated but breathing on your own without intubation. Some cramping may occur afterward, and she says most women take only the day of the procedure off work.
If you do high-intensity exercise, she recommends waiting 10 to 14 days to allow your ovaries to shrink back down to reduce the risk of them flipping, called ovarian torsion.
How are the eggs frozen? How do I know they’ll even survive the freeze?
Eggs are frozen with a process called vitrification, which Dr. Eskew describes as “flash freezing in liquid Nitrogen,” and then stored at minus-196 degrees Celsius.
Vitrification is an upgrade from older slow freeze methods because it reduces the risk of ice crystal formation which can damage the egg and threaten its survival of the thaw. The survival rate of eggs after vitrification is 90-97 percent, according to SART.
If you have a partner and plan to freeze fertilized eggs, or embryos, Dr. Eskew says the survival rate is higher at about 99 percent due to the lower water content of the embryo.
How many eggs will be retrieved? Is there an ideal number?
“The likelihood a woman’s frozen eggs will result in a live birth is a function her age when she froze them and the total number of high-quality mature eggs she froze,” says Dr. Eskew.
You can examine the percent likelihood that a patient will have at least one live birth using the probability chart here (Fig. 1).
For a woman age 35 or younger with 20 mature eggs, this model predicts a 90 percent chance of one live birth. For a 40-year-old woman with 20 mature eggs, the model predicts a 50 percent chance of one live birth.
About 10 to 15 eggs are retrieved per cycle, so it may take more than one cycle to reach the desired end result.
Is there an expiration date on how long the eggs will last frozen?
There is no expiration date on frozen eggs, but the age at which you can plan to use them will eventually hit a cut off point.
From the American Society of Reproductive Medicine (ASRM): “In view of the limited data regarding maternal and fetal safety, as well as concerns related to longevity and the need for adequate psychosocial supports for raising a child to adulthood, providing donor oocytes or embryos to women over 55 years of age, even when they have no underlying medical problems, should be discouraged.”
The Thaw: Getting pregnant using frozen eggs
What happens when you’re ready to use the frozen eggs?
There are three steps when you’re ready to use your frozen eggs — thawing, fertilization, and implantation.
Dr. Eskew explains that about 90 percent of eggs will survive the thaw. Of those, about 75 percent will fertilize and about half of those will grow into a day-five embryo called a blastocyst, which will be used for implantation.
You’ll take a combination of oral medication and patches of estradiol for two to three weeks to prepare your uterine lining for implantation. Progesterone is added ahead of implantation to improve endometrial receptivity.
The procedure itself is quick and simple. “Generally, most women don’t even feel it happen,” says Dr. Eskew. “It’s probably even less crampy than a pap smear.”
A catheter is inserted through the cervix into the uterus where the blastocyst is injected. You’ll take a pregnancy test after 10 days to see if it was successful. If it was, you’ll continue your hormonal support medications — including intramuscular progesterone shots, estrogen pills, and patches — for 10 to 12 weeks into the pregnancy.
What options do you have in viable egg selection prior to implantation? Can you choose the sex and weed out abnormalities?
The egg alone won’t tell you anything, but a fertilized day-five embryo can be biopsied for genetic testing and aneuploidy screening. Pre-implantation genetic testing for aneuploidy screening, or PTTA, can tell you the chromosomal analysis as well as the sex of the embryo at a 94-96 percent accuracy rate.
In this scenario, you could choose the sex of your baby in advance or choose not to move forward with an embryo carrying a genetic defect like, for example, the BRCA gene associated with breast and ovarian cancer or the cystic fibrosis gene.
What happens to unused eggs? Can you donate them?
If you never use your eggs, either because you got pregnant naturally or because you simply chose not to proceed any further, you can donate them — but you have to make that decision at the start.
“You certainly could donate them if you had the pre-required testing upfront to become an eligible donor as deemed by the FDA,” says Dr. Eskew. “But we would just have to know that up front because you can’t retrospectively test for those things. So if that’s something you’re interested in doing, that’s good to talk to your provider about it initially.”
The Cost: What’s the price of fertility preservation?
How much does egg freezing cost?
You can expect to pay about $15,000 to $20,000 for one cycle. (Keep in mind you may be pursuing multiple cycles to increase your odds of a live birth based on your age and desired number of children.)
This breaks down as roughly:
- $3,000-$5,000 for hormone medications
- $400-$1,000 a year for storage
- $10,000 for clinic costs, doctors visits, procedure, and lab fees
When you’re ready to use your eggs it will cost you another $8,000 t0 $12,000 on average for thawing, insemination, embryo transfer, and potential freezing of excess embryos for future use.
All told, that’s anywhere from about $23,000 to $32,000 for one live birth.
Does insurance cover egg freezing?
Almost never. However, some companies have caught on to offering fertility preservation as a benefit. Companies like Bank of America, Facebook, Apple, Tesla, Pinterest, and Spotify offer IVF coverage to employees. Starbucks has even extended its fertility benefit to hourly employees.
Benefits are offered at a specified spending cap, number of cycles covered, or unlimited. You can explore fertility benefits in all sectors at FertilityIQ.
What about fertility treatment for people who can’t afford it, particularly people with infertility or cancer diagnoses?
Fertility preservation is expensive. A number of organizations provide financial assistance to in-need people struggling with infertility.
Additionally, cancer patients who haven’t started or are not yet finished having children may face the decision to freeze eggs or sperm to preserve fertility ahead of chemotherapy. Some groups exist specifically to lessen the financial blow for people facing these two big medical expenses at once.
Check out these resources for fertility financial assistance:
- The Kyle and Samantha Busch Bundle of Joy Fund (Charlotte-based)
- Livestrong Fertility Program
- Ferring Pharmaceuticals Heart Beat Program
- BabyQuest
- Alliance for Fertility Preservation
Considerations
Difficulty getting pregnant is extremely common for any couple.
“1 in 8 couples will actually struggle with infertility in their lifetime and 1 in 4 pregnancies end in miscarriage,” says Dr. Eskew. “Just because people aren’t talking about it — because of the associated shame and stigma or feeling of failure — doesn’t mean no one else understands. I always tell patients they are not alone in this.”
An infertility diagnosis carries some of the highest rates of anxiety and depression of any medical condition, comparable to that of a cancer diagnosis.
“Emotional support throughout this process is one of the most important pieces that is often overlooked,” says Dr. Eskew, “so I pretty routinely offer people a referral for counseling as well.”
Resolve, a site from The National Infertility Institute, offers resources for infertility support groups and an infertility help line.
Freezing your eggs will not guarantee you a live birth.
“While egg freezing does not guarantee success,” says Dr. Eskew, “it increases the possibilities of having a biological child in the future.”
A failed egg freezing cycle is a blow financially and emotionally. You should be prepared for all outcomes.
Home fertility tests aren’t a perfect science.
Tests vary company to company but, in general, are testing a few different hormone levels to determine how well you’ll respond to ovarian stimulation medications (those shots you would give yourself to get the egg freezing process going). They do not diagnose infertility or predict your ability to have a live birth now or in the future.
“I’m a fan of women being empowered to get the information they need to make educated decisions, but it’s the interpretation of that test and the context in which it’s used that I think is really important and to have a professional to be able to counsel you appropriately,” says Dr. Eskew, “because there’s lots of things that can impact those results.”
Being on any kind of hormonal contraceptive, for example, can alter home test results and “cause unnecessary panic.”
Men don’t face the same parenthood pressures with increasing age.
Unlike the firm 35 for women, there isn’t an agreed upon number for advanced paternal age, and it can range anywhere from 40 to 50 years old and above.
“The risks associated with advanced paternal age have some mixed data surrounding them, but are thought to be associated with slightly increased risk of some forms of cancer, chromosomal abnormalities and single-gene mutations,” says Dr. Eskew. “Unlike eggs in women, sperm development continues throughout a man’s lifetime.”
Not all clinics are the same.
When selecting a clinic, Dr. Eskew says a referral from a friend is often the most reliable lead. Beyond that, she recommends checking the Society for Assisted Reproductive Technologies (SART) to review success rates for individual clinics. You can see how many cycles they do a year, how many live births they had, whether the births were full term or pre-term, and lots of other helpful statistics.
The average cost of a domestic adoption in the U.S. is $40,000.
There are many roads to parenthood, and there are more than 100,000 foster children eligible for adoption now in the U.S.
Counterpoint: Challenging the “myth of the biological clock”
If all this fertility preservation talk has you stressing on how much time you have left, exhale and read Moira Weigel’s 2016 piece on “The foul reign of the biological clock.”
The dense long read unpacks the history of the term “biological clock” as a metaphor for female fertility, as coined by Richard Cohen in a 1978 piece for The Washington Post.
Cohen’s article, entitled “The Clock Is Ticking For the Career Woman,” was published in a decade that saw the feminist movement, the development of oral contraceptives and intrauterine devices, and the legalization of abortion — all societal shifts that challenged the traditional role of women.
“The story of the biological clock is a story about science and sexism,” Weigel argues. “It illustrates the ways that assumptions about gender can shape the priorities for scientific research, and scientific discoveries can be deployed to serve sexist ends.”
It’s worth a read. For a shorter take, Dr. Catherine Aponte summarized it in Psychology Today here with the conclusion that “The imperfect data suggests two things: fertility declines with age and most women in their late 30’s will be able to get pregnant on their own.”
You can follow Dr. Eskew on Instagram at @ashleyeskewmd for more on egg freezing and fertility.
