Not everyone needs egg freezing

Posted on Feb 26, 2019

How do you know you need egg freezing? Hint: Not by going to egg freezing parties!

It started with egg freezing parties in private homes or private back rooms of restaurants and bars and now it has reached the streets of major metropolitan areas, where food truck-like contraptions on wheels, usually painted in bright and “happy” colors and fancily furnished “cocktail lounges” tempt perfectly healthy young women to commit to freezing their eggs (yes, alcoholic beverages are, indeed, offered at times).

What is happening in the egg freezing arena is truly remarkable and, in many ways, unprecedented: In less than a decade of increasingly sophisticated marketing efforts, egg freezing has gone from being a complex medical procedure to the “in-thing to do,” on the whim of a moment. If you are a single female between ages 21 and 40 years, you are considered a candidate. If you are outside of this already wide age range, that, often, does not matter, either.

The subject is now widely discussed on college campuses, where “sales people” are at times allowed to pitch the procedure to 18- to 22-year-olds. Marketing materials are inundating women of all ages in magazines, on the Internet and even at private parties. Cleverly presented as yet another tool of female self-empowerment in the #metoo era, marketing agencies, at times with help of celebrities, have succeeded remarkably well in turning a serious medical procedure into a fashionable fad, like a piece of designer clothing, a pair of high heels or a fashionable handbag going through its 10 minutes of transient fame.

Should every young woman freeze her eggs?

lidya nada 638316 unsplash 724x1024 Not every woman needs egg freezing

The widely propagated idea is, indeed, that every young woman should, as an “insurance policy,” freeze her eggs. One company leader in this rapidly growing industry went even further when he devised a concept that works something like this:

  1. Every young woman and every young man in their early 20s, at peak fertility, should freeze their respective gametes (eggs and sperm). It “insures” against later mishaps, if one no longer can produce gametes.
  2. But, since younger gametes are always “better” gametes, women and men should later in life always use only their younger gametes, even if they still have perfectly functioning (older) gametes in ovaries and testes, respectively. When ready to have children, simply thaw out some of your frozen younger gametes and have your IVF center make embryos.
  3. By using younger frozen gametes, they should have superior pregnancy chances. Under this marketing proposal, men and women would, therefore, remain “clients” of this company for at least all of their reproductive life and, maybe, even beyond that because gametes can also be turned into stem cells.

As bizarre and dystopian as this concept on first impression may sound, it has received hundreds of millions of dollars in funding and is currently already being realized here in the U.S. as the company purchases IVF centers and frozen egg and sperm banks. Even the best -sounding hypotheses, proposed by some of the smartest people, however, often fail in clinical practice. Here, we will discuss why in CHR’s opinion the current business-driven frenzy surrounding egg freezing, ultimately, will give way to a more rational, clinically-driven approach.

Why egg freezing is anything but an “insurance policy”

If one buys an insurance policy, one knows what can be expected in benefits, once the insurance comes due. Here, such assurances are not given; indeed, _cannot _be given since egg freezing, for one simple reason alone, is still an experimental procedure: Outcomes from egg freezing still cannot be reliably predicted.

Hardly a week passes at CHR, in which we do not see at least one woman with the same heart-breaking story that a number of years ago she cryopreserved X number of eggs. Now years later, and in her mid-40s, she decided to thaw those eggs and make embryos with the help of donor semen. Unfortunately, none of the eggs survived thawing or was successfully fertilized. Counting on her frozen eggs, she is now 45 years old, with, likely, too old eggs to still allow her to conceive with use of her own, and everyone advises her to pursue egg donation.

Faithfully believing the marketing propaganda of “buying insurance by freezing eggs,” so-affected women in reality never did really buy insurance. They were misled! As of today, nobody can accurately predict how many frozen eggs will survive thawing and make good embryos when, sometime in the future, fertilized with sperm. Based on female age, ovarian reserve and other medical factors, variabilities in outcomes are simply too wide, even if laboratory expertise in egg freezing has greatly improved and in some laboratories is really excellent.

How does one then counsel women as to how many eggs to freeze? The answer is that all such counseling is still mostly just an educated guess and far from being an evidence-based recommendation. Who advises the patient is, therefore, of crucial importance, not only because of varying knowledge bases but also because of different incentives. For example, a counselor who is financially rewarded based on how many women he/she places into egg freezing cycles will, likely, offer different information than a physician who has no such incentives. Everybody who counsels young healthy women on undergoing an elective invasive medical procedure at significant costs and some physical risk must have the knowledge and integrity to provide information that aligns expectations and realities. Unfortunately, that is not what often happens in egg freezing parties and other inappropriate frameworks, where young women are supposedly “educated” about egg freezing.

Whenever, as in this case, outcomes of a medical intervention cannot reasonably be defined in advance, a procedure must be considered “experimental.” The only exception is, if even potentially greater harm
will come from failure to perform the procedure. This is exactly why the American Society for Reproductive Medicine (ASRM) declared egg freezing no longer experimental in women with impending loss of all ovarian function (from surgery, chemotherapy or radiation), but did not declare “voluntary” (also called “social” or “non-medical”) egg freezing no longer experimental.

The egg freezing this article addresses, therefore, must still be considered an experimental procedure and, under basic medical ethical guidelines, must be explained to patients as such.

This is not what, unfortunately, has been happening in the increasingly “free-for-all” commercial world of egg freezing: As recently discussed in the VOICE, with rapidly increasing entry of non-medical financial sponsors into the clinical practice of in vitro fertilization (IVF), “voluntary” egg freezing was quickly identified as a potentially highly lucrative new product line of much larger potential market size than the relatively small traditional infertility market. In the rush to conquer this new market, the still experimental nature of “voluntary” egg freezing was not only overlooked but on purpose misrepresented when marketing efforts widely claimed that “egg freezing was no longer considered an experimental procedure by the ASRM."

dakota corbin 243775 unsplash 1024x683 Determining how many eggs to freeze to ensure a good chance of having one baby later is as much an art as it is science

This highly coveted new market for services unleashed aggressive competition between traditional IVF centers and a brand-new format of IVF centers created with financial investments from non-physician sources, which almost exclusively concentrate on performing egg freezing cycles.

The new kind of IVF centers, exclusively offering egg freezing

As a business model, what is better than a previously unexplored market of healthy young women, larger than the traditional infertility market for IVF, where, in addition, treatment outcomes do not matter because they would not be known for years to come, if ever?

For the public, it is important to understand how different these new IVF centers are in comparison to traditional IVF providers. It all starts with the concept of egg freezing under the still unproven hypothesis that freezing one’s eggs really improves pregnancy chances later in life. Though the concept sounds logical and rational, many great-sounding concepts have in clinical practice proven to be false.

For example, what if the false security of having frozen eggs stored away makes women delay childbearing even more than is already in practice? It is entirely possible that the negative effects of such a development far outweigh the potentially positive effects on population growth of freezing eggs. One, therefore, cannot automatically assume that just because interested commercial parties claim that freezing eggs at young ages makes sense and, indeed as claimed, potentially extends a woman’s reproductive life span. And such a decision cannot be made based on “beliefs” or what on first impulse appears logical; it must be seriously studied!

To advocate that young healthy women electively and routinely freeze their eggs at considerable expense and some bodily risks before such studies have established long-term benefits from such an approach, appears to CHR as unethical, illogical and exactly the opposite of self-empowerment of women; it represents abuse of women!

The public, therefore, must understand that so-called IVF centers and other commercial enterprises, established to almost exclusively offer egg freezing, are economically also almost exclusively motivated to perform as many egg freezing cycles as possible. They, indeed, frequently do not have the expertise to perform other services and do not even maintain comprehensive embryology laboratories with all-encompassing cryopreservation services. Most of these egg freezing clinics, indeed, do not even maintain their frozen eggs on premises but sub-contract long-term storage of cryopreserved oocytes to outside resources.

Do you know where your frozen eggs will be, and who is taking care of them when you will need them?

Egg freezing clinics are frequently staffed by young physicians straight out of fellowship programs, perceived to share a common language with the targeted young population of women in egg freezing campaigns. More established and experienced physicians in the field also, often, do not want to be restricted in practice and are usually not recruitable into these ventures.

But here is the central problem with these centers: They are often unable to verify the quality of their medical services because how would they know how well (or poorly) they cryopreserve eggs? Most women who cryopreserve eggs at younger ages never return to use them. Those who do, usually thaw their eggs years later. This is very different from the constantly ongoing scrutiny IVF laboratories in full-service IVF centers are undergoing, where eggs and embryos are cryopreserved and thawed on an almost daily basis. In such a framework, any lab problem is immediately recognized. In egg freezing clinics, where egg freezing is often for years a straight one-way street, there is, simply, no reliable way to know how well or poorly a laboratory is doing in freezing and thawing and, ultimately in establishing pregnancies from previously cryopreserved oocytes.

That at least some of these labs are not doing that well is becoming increasingly obvious, as CHR sees more and more women who report that none, or only very few, of their cryopreserved oocytes survived thawing. The public, therefore, must recognize that in their egg freezing parties and colorful transformed food trucks, commercial interests peddle on the streets of NYC (and probably also elsewhere) to young people an experimental procedure with undefined outcome criteria.

Most young women, fortunately, will never need their frozen eggs

Data demonstrate that most young women who freeze their eggs never end up using those frozen eggs because, as one would expect, they are healthy and 90% of all women never develop premature ovarian aging (POA), also called occult primary ovarian insufficiency (oPOI). These women, therefore, can expect to be able to spontaneously, or with some medical help, conceive up into their early 40s. The optimistic interpretation of this observation is that most women, after all, do meet their dream partners before they become dependent on frozen eggs. A more pessimistic view point suggests that, even if they have cryopreserved oocytes, many single women still avoid pregnancy.

Whatever the real reason, these statistical data raise concern about the cost effectiveness of freezing eggs. If one ends up freezing many times the demand downstream, egg freezing at the current time does not seem to represent a very cost-effective treatment.

Many women are inadequately advised how many eggs to cryopreserve

Another disappointing observation CHR has made in the national egg freezing scene is that many women end up freezing inadequate numbers of eggs. As already noted, the determination of how many eggs a woman should cryopreserve is more art than science. The older the woman and the lower her ovarian reserve, the more eggs must be cryopreserved. In other words, a 35-year-old must cryopreserve more eggs than a 25-year-old, and a 25-year-old with excellent ovarian reserve does not need as many eggs as a 25-year-old with diminished ovarian reserve for age. These associations are important because age and ovarian reserve are both inversely correlated to egg quality. And as egg quality declines, pregnancy chances decline in parallel, establishing need for more cryopreserved eggs.

It is quite astonishing how many women CHR sees who underwent a single egg freezing cycle. With very few exceptions, this should never happen, because if a woman already spends time, effort and considerable treasure on egg freezing, she, at least, should know that she has enough oocytes cryopreserved for likelihood of at least one successful birth. In practical terms, this means freezing on average 20 eggs in women under 30, 25 eggs between 30 and 35 and around 30 oocytes for women between 35 and 38 years. Over age 38, we no longer recommend egg freezing but immediate pregnancy attempts. If for social or other reasons that is not possible, we recommend cryopreservation of even over 30 eggs per desired child.

How to assess ovarian reserve?

In parallel to the rapid growth of the egg freezing industry, the IVF field has over the last decade also witnessed the possibly even more explosive growth of a diagnostics industry surrounding fertility that really added mostly very little value but substantial additional cost to IVF. From sperm fragmentation to expanded recessive mutation testing, over embryo testing for alleged chromosomal abnormalities by PGS/PGT-A and endometrial receptivity testing, it is impossible to state that any of these tests has improved IVF outcomes or in any other way contributed.

The latest offering has been direct-to-consumer ovarian reserve testing in young women, often intertwined with recommendations to freeze eggs if ovarian reserve is found to be diminished.

CONFLICT STATEMENT: We have to interrupt here for a moment because in reference to this subject, CHR must disclose a potential conflict of interest: CHR is the owner of another professional corporation (“What’s My Fertility?”), which applies a diagnostic algorithm, patented by CHR, in diagnosing POA/oPOI at young ages. Testing FSH and AMH levels is part of the algorithm, but the prediction model goes far beyond just an AMH or FSH test. Since AMH is the principal test applied by some of these direct-to-consumer diagnostic marketing companies, and is also part of CHR’s patented algorithm, CHR feels that this must be disclosed as a potential conflict.

In contrast to What’s My Fertility?, a number of new start-ups are claiming in young women to be able to offer an accurate fertility assessment based on AMH only. And that is, of course, again an incorrect suggestion, with potential for abuse. The abuse can also lead to premature recommendations to freeze eggs for all the wrong reasons. However, the process smartly unifies the economic interests of diagnostics and egg freezing industries, and such collaboration virtually guarantees success, as we witnessed when IVF centers and genetic labs united in promoting PGS/PGT-A. Of course, not surprisingly, we believe that CHR’s What’s My Fertility? algorithm for predicting POA/oPOI is far superior.

Moreover, in contrast to the current mindset of testing everybody and freezing eggs for everybody, What’s My Fertility? is an attempt at early diagnosis of that 10% of the female population who, indeed, will develop POA/oPOI and, therefore, would greatly benefit from early diagnosis and possible egg freezing. For further information we invite our readers to visit the above noted website to familiarize themselves with this new concept, which CHR is in the process of commercializing.

How egg freezing should be presented to the public

Egg freezing is a serious medical procedure that requires specialized knowledge in accurately assessing women’s ovarian reserves and other relevant medical factors in any counseling. It then requires detailed knowledge in how to correctly counsel patients what egg freezing can and cannot do in potentially helping them preserve fertility potential. Egg freezing, however, also requires knowledge on how to maximize performance of ovaries in producing egg in largest possible safe numbers and in best possible quality and that, in turn, especially in women who do not have normally functioning ovaries, requires knowledge on how to prepare ovaries properly for an egg retrieval cycle.

And then comes the ovarian stimulation in the IVF cycle itself. There are many ways to medically stimulate ovaries to produce eggs, and every stimulation protocol has advantages and disadvantages. The secret of a well-stimulated cycle lies in selecting exactly the right stimulation protocol for each patient. Unfortunately, many egg freezing mills utilize only one protocol for everybody and such an approach, of course, does not result in best possible outcomes.

Achieving the best possible outcomes means obtaining the largest possible number of good-quality, mature eggs that can be safely obtained in any given cycle. Protecting the safety of the patient (yes, a young woman going through an egg freezing cycle is, indeed, a “patient”), of course, must be the primary concern in every egg freezing cycle. And, though IVF cycles in general are very safe, ovarian stimulations and subsequent egg retrievals carry risks. Complications, fortunately, only rarely occur, and careful prospective management will further minimize such risks. Nothing, however, demonstrates better the fact that egg freezing is a serious medical procedure than the fact that it can lead to serious complications.

Women enquiring about egg-freeing must be advised of this fact; otherwise, they did not receive appropriate informed consent. The two most dangerous potential complications associated with egg freezing cycles are the same as in routine IVF cycles: The so-called ovarian hyperstimulation syndrome (OHSS), though nowadays a very rare complication, in its most serious form, can even be life-threatening and usually requires hospitalization. Since egg retrieval involves insertion of a needle into the peritoneal cavity and the ovaries, bleeding can also be a potentially dangerous complications if, by mistake, a vessel is damaged by the needle. And then there are even rarer complications possible, like allergic reactions to medications or anesthesia medications during egg retrieval.

In short, like practically all medical intervention, egg freezing is safe, but complications occur. They will occur less frequently in experienced hands and, if they do occur, experienced physicians will, of course, be better prepared in handling them than less experienced physicians.

Quality of medical management and potential complications are not only restricted to the clinical care of the woman. After all, the ultimate purpose of every egg freezing cycle is to end up with a good number of good-quality eggs. This means that how eggs are “managed” after retrieval is also of crucial importance. There are still substantial differences in the quality of embryology laboratories between IVF centers, and there can be no doubt that there are labs that freeze eggs better than others. We noted above that laboratories that function almost exclusively as one-way facilities, only freezing but almost never thawing, fertilizing and transferring embryos, have really no practical ways of testing their laboratories’ performance. Our strong recommendation, therefore, is to stay away from such facilities and to entrust your frozen eggs to full-service IVF laboratories.

Which brings us to our final recommendation regarding long-term storage. Even many traditional IVF centers no longer maintain their own long-term storage, and transfer all of their frozen gametes and embryos out to third-party cryopreservation companies. There are a number of reasons why this is increasingly happening, the most important ones, not surprisingly, being cost-effectiveness and risk of legal exposure. For many IVF centers, long-term storage is financially not a profitable business proposition, as storage requires considerable space and very close surveillance. Two recent accidents in storage facilities of prominent IVF centers on East and West coasts on the same day reemphasized the risk aspect, since both are now subject to large numbers of lawsuits over lost embryos and gametes because of accidental thaws due to equipment malfunction.

CHR, nevertheless, prefers to maintain its own long-term storage because, like in many other situations, we prefer to control our own destiny. We, simply, trust ourselves more than third parties. This is why CHR has not, and will not, follow outsourcing trends in long-term cryo storage, egg donor selection, etc. We strongly feel in this instance that women who freeze their eggs for potential use many years down the road, should not have to start searching where their eggs are at that moment. Moreover, though transportation of frozen gametes and embryos is generally very safe, accidents can happen. Then why take an unnecessary chance?

Our advice to those who want to freeze their eggs, therefore, is, make certain you will know where your eggs will be 5-10 years down the road, when you may want to use them!

The cost of egg freezing

We noted earlier that hardly any woman will obtain enough eggs for satisfactory egg freezing from one retrieval cycle. It, therefore, is crucial to offer patients honest and as accurate predictions as possible about how many retrieval cycles they will have to undergo to meet minimum numbers of cryopreserved eggs for their desired number of future children.

In practical terms, this means for an overwhelming majority of women multiple cycles, with required cycle numbers increasing with female age and declining ovarian reserve. A good number of centers offering egg freezing cycles, CHR included, therefore, developed multiple egg freezing cycle packages to offset potentially high egg freezing costs.

To the best of our knowledge, no other center has taken pricing these packages, however, as seriously as CHR. In recognition of the fact that women who need more eggs, unfortunately, usually produce only the smallest egg yields, CHR, therefore, developed a uniquely progressive pricing structure for multiple cycle packages, which we believe is the least costly offer in NYC and, likely, nationwide.

We invite you to call our center at 212-994-4400 and inquire about the cost structure for our progressive multiple egg freezing cycle packages with declining per-cycle costs with increasing cycle package sizes. Please also note that after oocytes are frozen, monthly storage costs become due. Here, too, CHR’s cost structure is progressive and highly competitive.

This is a part of the February 2019 CHR VOICE.

Norbert Gleicher, MD, FACOG, FACS

Norbert Gleicher, MD, FACOG, FACS

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.

We have helped women bring over 17,800 babies into the world.

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