Fertility specialist Mark Trolice MD discusses the evolution of social egg freezing

In my 20 years of being an infertility specialist and my ten years as an infertility patient, I have learned the most devastating news a woman can hear, in no particular order, are: 1. you have or your partner has cancer; 2. your child has a fatal illness; 3. you have infertility and may never be able to be a mother. My world focuses on number three.

The field of reproductive medicine has evolved from physician owned practices to PE owned start-ups that hire physicians and are driven by revenue. Any variation on the theme of IVF has become the battle cry of biotech entrepreneurs. The result, IMHO, is exploitation of women. From encouraging IVF prematurely or requiring all embryos be genetically tested to selling the option of egg freezing, the new world order of RM has morphed into dangling the baby carrot at a premium, not just financial.

PR firms can be easily hired to successfully put this “new field of empowerment” onto the front page and spin the topic in an enticing manner. But true advocates focus on enlightening women with appropriate knowledge not preying on one of their three deepest fears.

Egg freezing costs approximately $10,000 including ovarian stimulating fertility medication. Fertility preservation options depend on many factors. The age of the patient will provide insight to her ovarian reserve. The patient’s relationship status may influence the choice of freezing eggs or embryos (if she has a partner). The entire cycle can be usually be performed within two weeks and the woman typically will only miss one day of work for the egg retrieval which occurs while she is under conscious sedation.

Success rates following egg freezing clearly depend on the woman’s ag

If she is between 30 and 34, her chance for a live birth with ten mature eggs frozen is approximately 60 per cent; if she is 38 to 40, her chance will drop to 35 per cent. These numbers are very important for women to realise. Egg freezing is not a guarantee for subsequent pregnancy. Once a woman pays for egg freezing, it is possible she may never conceive with those eggs or she conceives naturally and never uses the eggs. This is why an extensive consultation is vital prior to her decision. Physicians must provide realistic expectations to the woman and share their own laboratories success with egg freezing.

Some Background on Planned Oocyte Cryopreservation (POC)

In 2012, the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) announced OC would no longer be deemed experimental. The Canadian Fertility and Andrology Society recently described OC as ‘an option for women wishing to preserve their fertility in the face of anticipated decline’.

Later in 2014, companies like Apple and Facebook started offering up to $20,000 towards OC as part of their employee benefits to attract more female employees. Once OC became available for medical indications, its use for non-medical reasons was imminent.

Currently, OC uses the “fast-freeze” technique of vitrification with the subsequent warming process producing outcomes equivalent to the use of fresh oocytes and far superior to the older slow-freezing method of OC5. Vitrification results in highly successful frozen oocyte survival rates above 90 per cent, fertilisation rates of 75 to 90 per cent, pregnancy rates of 32 to 65 per cent per embryo transfer (ET), and live-birth rates of over 50 per cent. Due to the advances of vitrification, the number of oocytes required to achieve a pregnancy have dramatically declined: from nearly one hundred in 1999 to only 20 in 2013.

Using IVF outcomes, as in natural conceptions, the live birth delivery rate is inversely correlated, and the miscarriage rate is directly related to maternal age. Women may opt to undergo oocyte cryopreservation for medical reasons prior to exposure to gonadotoxic treatments for medical conditions or may pursue POC to circumvent age-related decline in ovarian reserve. Women are either postponing motherhood or failing to achieve it at all for a complex number of reasons that include educational and career aspirations, delayed marriage, lack of partner, more frequent marital and relationship breakdown, attitude towards material assets being just as fulfilling as parenthood and lack of affordability of a child in their 20s.

Most women who present for POC are single (75.6%), professionals with a high level of education (72.8%), who decided on POC when they were aged 37 to 40 years. This is the same age group of women who commonly present to IVF clinics to treat infertility problems.

Advantages of POC

The benefits of POC are illustrated by examining the variables of maternal age and lifestyle shifts. Maternal age has a significant impact on reproduction.  The risk of chromosomal abnormalities like Down Syndrome (DS) also increases in direct proportion to advancing maternal age. The incremental lifetime cost of raising a child with DS is up to $900,000.  Nevertheless, not all studies consider the mental, emotional and physical toll on parents faced with the option of terminating an aneuploid pregnancy.

Age at vitrification strongly impacts the outcomes of retrieved oocytes, pregnancy and live birth rates. There is a 6 per cent risk of permanent childlessness when women delay pregnancy attempts until age 30, a 14 per cent risk when those attempts begin at 35 and a 35 per cent risk when they begin at age 40.  POC offers a potential viable option to all the above problems through fertility preservation. By freezing their eggs at a young reproductive age, women can provide themselves the opportunity at a later age of improved monthly fecundity compared to natural pregnancy attempts.  A recent retrospective cohort study included 201 women who underwent POC showed 88 per cent of participants reported increased control over reproductive planning and 89 per cent affirmed they were happy they froze eggs, even if they never use them.

Beginning in their early 30s then accelerating in their late 30s and early 40s, ovarian aging places women at a biologic disadvantage for reproduction. Despite educational efforts toward reproductive awareness, many people overestimate the true extent of their procreative lifespan. Media coverage also influences public perception of female fertility by reporting on celebrities who achieve a later-aged motherhood due to a healthy lifestyle.

POC offers a plausible option to these prevalent social and biological problems. It seems incongruous to encourage a woman at age 42 to undergo IVF using autologous eggs with a resulting live-birth rate of 6.6 per cent per cycle, when the equivalent rate using her cryopreserved oocytes at age 30 would be below 40 per cent per embryo transfer. Further, survival rates, fertilization rates and implantation rates of cryopreserved oocytes are comparable with those of matched fresh oocytes. As a result, and to potentially stave this biologic inevitability, it is reasonable to increase the availability and affordability of POC.

Other points about egg freezing:

Ovarian stimulation with fertility medications will not make you lose your eggs faster. Every month hundreds of eggs get ready to ovulate, but only one does; the rest die off. So, fertility medications “push” the eggs that would have normally been reabsorbed in a woman’s body:

  1. There are no known long-term negative health effects definitively proven to be related to ovarian stimulation
  2. Ovarian stimulation with egg retrieval does not reduce a woman’s fertility.
  3. A woman’s chance for future pregnancy after egg freezing is based on how many mature eggs are obtained and her age at egg retrieval. So, the younger age and more eggs, the higher the chance for at least one baby.
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