Fertility Extension at CHR through Egg Freezing
Honestly and economically revolutionizing egg freezing
Some general background
Egg freezing is quickly gaining popularity. A brand-new “industry” has, indeed, evolved around the concept of egg freezing, often driven by corporate interests rather than medical concerns. “Egg freezing parties” peddle egg freezing as a “product” rather than a valuable preventive medical service, as egg freezing was conceived initially. We, therefore, want to start with a word of caution: Where you freeze your eggs matters!
Freezing eggs is like buying insurance: One hopes never to have to use it, but should something happen, we want to be certain that the insurance company will fulfill its obligations. In other words, once one decides to freeze eggs, it matters how eggs are frozen, who does the freezing, which methods of freezing are employed and, most importantly, of course, how good the eggs are a few years later, should they be needed. How well they thaw out, is then the principal question! To maintain the insurance analogy, nobody wants to be surprised to find out that none or only very few eggs survived thawing.
Even if parents often help out their daughters financially, because egg freezing primarily serves younger single women, many just starting their professional careers, it must be cost-effective and honest in presentation. Watching the increasing commercialization of the procedure and often grossly misleading information young women are exposed to, CHR, after lengthy considerations and considerable planning, decided to intervene with, likely, the most progressive, honest and cost-effective program of egg freezing ever conceived.
Steady readers of the VOICE know that getting on the commercial bandwagons was never CHR’s way of doing things. CHR’s patients have greatly benefited from this approach for over three decades. Yes, we have been offering egg freezing to a good number of women over the years; and, yes, those few who have returned with requests to thaw some of their frozen eggs usually experienced good thaw rates and pregnancy outcomes; however, in contrast to many other fertility centers, egg freezing at CHR represented a much smaller percentage of overall IVF cycles, and to a disproportionate degree concentrated on cancer patients. One reason for CHR’s conservative attitude toward egg freezing was that, like the American Society for Reproductive Medicine (ASRM), CHR still considers egg freezing (except in cases of cancer) an experimental procedure, and advises patients accordingly. The reason is simple: accurate outcome data either are lacking or are inadequate, and that makes a procedure automatically “experimental.”
Most centers don’t see it that way and, certainly, do not communicate it this way to their patients. In some IVF centers, egg freezing cycles have, indeed, become the “main” business; unbelievably, in others, it is the “only” business. Yes, some centers no longer even pretend being IVF centers and, rather proudly, differentiate themselves from full-service fertility centers by “doing nothing but egg freezing cycles.” They produce and freeze eggs, and then mostly transfer those eggs to cryobanks for long-term storage. Whatever happens, often years later, is then no longer their concern. No follow-up and, therefore, no quality control required and, since no embryo transfer occurs, these cycles also do not have to be reported to the Centers for Disease Control and Prevention (CDC), as IVF cycles have to.
With “industrialization” of egg freezing quickly progressing, unpleasant surprises for patients have increased in parallel. Especially over the last year, CHR physicians with increasing frequency heard from patients that, upon thawing of their eggs, they were devastated to find out that none, or only very few, had survived the thawing process.
Of course, there are many potential reasons for poor thawing rates, from poor egg quality in the first place, poor cryopreservation techniques, poor maintenance of frozen eggs and poor thawing techniques. Ultimately, causes are often difficult to determine; they, however, also do not really matter much because what makes these experiences so devastating is that expectations were not met. Almost uniformly, either incomplete or often incorrect informed consent discussions prior to egg freezing cycles are the primary reason for these disappointments.
In comparison to embryo freezing, egg freezing is still much more unpredictable, and this is exactly why egg freezing is still widely considered an experimental procedure. This is not always properly communicated to women seeking information on egg freezing. ASRM only declared egg freezing in young cancer patients an “established procedure,” while many IVF centers erroneously consider all egg freezing no longer experimental. Cost-benefit ratios in healthy young women and cancer patients, however, differ markedly, and must be accurately communicated to avoid disappointments at thawing of cryopreserved eggs.
Increasing exposure of young healthy women to what CHR has come to consider often incorrect marketing efforts by the evolving egg freezing industry, convinced CHR to reevaluate its so far rather passive position on the subject. After careful considerations, a decision was reached to more substantially engage in this arena. As of January 1, 2018, CHR, therefore, will offer a greatly expanded egg freezing program. Like in other areas of fertility practice, it will be second to none in quality of care, honesty and cost effectiveness.
How a woman’s ovaries are stimulated for egg retrieval is essential in determining ultimate egg quality; how an embryology laboratory (note that there are no “egg-laboratories”) cryopreserves eggs, is the single most important aspect of how well those eggs will thaw later. Differences between comprehensive IVF center like CHR and egg freezing centers are, therefore, important to understand. While IVF centers under federal law must be aware of their outcomes and report them to the CDC, egg freezing centers have no such obligation. Their commercial structure, indeed, basically makes follow ups for quality control purposes almost impossible.
Who needs egg freezing?
Though these statements will not appear on many egg freezing websites, not every young woman needs egg freezing; not everybody needs egg freezing at same ages; and not everybody needs egg freezing with the same urgency! One reason is that not all women age their ovaries in the same way and on the same time table. Independent of race and ethnic background, approximately 10% of women, indeed, age their ovaries prematurely (a condition called premature ovarian aging, POA), which means they at any given age have fewer eggs left in their ovaries than the other 90%.
If at all possible, women with POA, therefore, must freeze eggs at younger ages than women with normally aging ovaries. Egg freezing in a 26-year-old with POA may, therefore, be much more urgent than in a 33-year-old with normal ovarian reserve (OR).
This example emphasizes the importance of diagnosing POA as early in life as possible. Already a few years ago, investigators from CHR were awarded a U.S. patent for an algorithm to screen young women for the risk of developing POA. The program is called “What’s My Fertility,” and can be accessed at www.whatsmyfertility.com or at CHR.
Though 10% of the female population is affected, POA represents only a relative small minority of all women. In fertility centers, these women represent, however, a much larger block of patients than 10%. The principal reason is that POA develops silently and mostly unsuspected. The diagnosis becomes apparent only much later in life, when women try to conceive and fail.
Any first assessment of young women at CHR, therefore, includes an assessment of risk to develop POA. If a young woman is identified to be "at risk," this does not necessarily mean she will develop POA. It, however, does mean that she must be followed closely to detect earliest signs of POA. Should that happen, she, as of that point, will still produce excellent egg numbers (i.e., will still have excellent OR). Egg freezing will, therefore, still be very successful. Women who are diagnosed many years later, will, however, already have lost much of their OR. Egg freezing then will yield a much smaller number of eggs and usually also poorer egg quality. Women who are unequivocally diagnosed with POA in this screening process should immediately undergo egg freezing, though they may require prior medical preps of their ovaries over approximately two months to achieve best cycle outcomes in terms of egg numbers and egg quality.
The younger a woman is when she freezes her eggs, the better will her eggs freeze and thaw. Should she later in life need them, the younger they were when frozen, the better the pregnancy chances will be with their use. Most experts recommend against egg freezing after age 36-38, and freezing eggs in the 20s is clearly superior to freezing them in the 30s. Like in many other clinical situations, CHR advises but does not make decisions for our patients. After age 38, our advice usually is to attempt pregnancy right away rather than freeze eggs. We, however, do understand that social circumstances at times do not permit first choices. Rightly, the patient should, therefore, always be the ultimate arbiter.
How many eggs should be frozen?
The honest answer is that nobody knows for sure how many eggs a young woman should freeze to preserve her fertility. There are many reasons for this honest answer:
This number, of course, depends on the age of the woman when she freezes her eggs: the older she is the more eggs will be required to achieve pregnancy, because the quality of each egg, i.e., its future pregnancy potential, is lower.
Secondly, however, the answer also depends on the OR of the patient. Even if young, a woman with very low OR will need more eggs frozen than a woman with normal OR because low OR is not only associated with smaller egg yields but also with poorer egg quality.
Thirdly, because egg numbers decline with advancing age and with declining OR, under both of these circumstances women will, therefore, need more egg freezing cycles. Older women and younger women with low OR, thus, face a double whammy: When they need more good eggs/embryos, they produce fewer and fewer and, therefore, will need more and more ovarian stimulation cycles. After age 38, egg freezing, therefore, is no longer considered economical.
It is also important to understand that only very few eggs lead to pregnancy. Not every egg retrieved is a good quality egg of just the right maturity to be frozen. Not every frozen egg survives thawing. Not every egg that survives thawing gets fertilized by sperm, and not every so fertilized egg becomes a good enough embryo to be transferred into the uterus. Not every embryo transferred into the uterus implants, and not every embryo that implants becomes a normal pregnancy leading to a normal delivery. In other words, there is considerable loss in human reproduction and this is the main reason why it takes so many eggs to make a baby.
Table 1 offers recommended estimates for number of eggs that should be frozen at different ages for one desired child. For two desired children those numbers should be doubled, for three tripled, etc. The table also presents estimates for how many ovarian stimulation cycles it, likely, will take at various ages to reach this minimum egg number per child.
Revolutionizing cost considerations
Just as CHR in 2016 revolutionized the cost structure for using donor eggs, the center now radically revolutionized the cost structure for egg freezing. Table 1 above laid out what we consider the minimum egg numbers women of different ages have to freeze to end up with high likelihood of at least one successful pregnancy and delivery. The table then also demonstrates what we believe the number of ovarian stimulation cycles and egg retrievals is that it will take to reach that required egg number at different ages.
As also noted in the table, these are estimates based on women with normal OR, and they can, of course, vary upwards and downwards. Moreover, women with low OR will produce fewer eggs per cycle; how much fewer will depend on severity of their low OR. We, therefore, strongly recommend that, before reaching final conclusions based on this table, a reproductive endocrinologist with experience in egg freezing be consulted.
Table 1 demonstrates that with advancing age the number of, likely, required ovarian stimulation cycles significantly increases for one live birth. We, therefore, accordingly offer egg freezing options with highly competitive package pricing for single cycles over 2-cycles up to a 6-cycle package. Couples desirous of more than one child, of course, must consider the appropriate multiples. Table 2 below, to the best of our knowledge, describes the currently most rational and most cost-effective package costs for egg freezing offered in New York City and, maybe, in the country. Most importantly, however, this program is not offered by a fly-by-night outfit but by one of the most recognized IVF centers in the world.
*Each plan, except for Plan A, offers a maximal number of ovarian stimulation cycles/egg retrievals and a minimum number of eggs frozen, whichever is reached first. **The following is included in package cost: All ovarian cycle monitoring, follicular ultrasounds, hormone monitoring, egg retrievals and egg cryopreservation (vitrification). Not included are: Initial ($350) and subsequent physician consultation ($250), anesthesia services during retrieval ($350), medication costs (dependent on patients’ OR). Quarterly storage fees for each frozen egg batch is $250.
Alternatives to egg freezing
To understand egg freezing as anything but a prophylactic medical treatment minimizes the complexities involved. Every medical treatment, however, has alternatives, and egg freezing is no exception. We noted before that not everybody needs egg freezing. Like with any medical procedures, cost-benefit and risk-benefit considerations must support performance of the procedure. Before making any final decisions, a consultation with a reproductive endocrinologist with special expertise in this subject is, therefore, strongly recommended.
Not relying on egg freezing is one alternative and can assume various forms: The simplest is doing nothing, which may be entirely appropriate in a young woman in her mid-20s with normal age-appropriate OR. Another frequently chosen alternative is the decision to have children at earlier ages. Because women used to have children at much younger ages, 30-40 years ago the condition of POA was almost unknown. Even if demonstrating low OR at younger ages, most women can and will, still, conceive without major problems. Once they fall below a certain age-threshold (which varies between patients), however, pregnancy no longer occurs spontaneously, and patients require costly fertility treatments.
One also should not forget that, in contrast to egg freezing, embryo freezing has been an “established” procedure for decades. Especially for married couples or other stable relationships, embryo freezing may, therefore, be a more predictive and advisable method of fertility preservation. Should there be further questions on the subject, we welcome inquiries.
This is a part of the December 2017 VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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