To freeze or not to freeze–why is that the question?

There are no “ifs, ands, or buts” about it–the cultural mindset around having kids is changing. A decade ago, women were having kids in their twenties. Not so much now. Why the shift? A 2016 study by the Fertility Centers of Illinois, interviewing over 1,200 women, revealed three major drivers: 1. Desire for financial stability (82%) 2. Having more life experiences and being more emotionally stable (80%) 3. Focus on career (63%).

While becoming a mother is less of an expectation now than ever before, two-thirds of millennial women still have the desire to become mothers—and the biological realities of fertility timelines haven’t changed. However we slice it, fertility declines with age. All of this helps explain why more and more women are asking a big question–“should I freeze my eggs?”

Egg freezing is a remarkable procedure. It’s been deemed the “pause button” for fertility decline and it seems like something out of a science fiction novel–wait really?! You can seriously collect and freeze my eggs for later? This procedure could increase the odds of a successful pregnancy down the road but it also has risks (and it can be very expensive). So how do we wrap our minds around all of the buzz? We arm ourselves with science and then map out questions for our doctors–and we do it together.

What happens when you freeze your eggs?

Every fertility clinic is different but here’s a quick snapshot of how the egg freezing process works:

Consultation: You find a fertility clinic (there are about 464 in the U.S.) and go in for an initial consult to talk through your medical history.

Testing: You have your fertility hormone levels tested to assess the quantity of your eggs, ovulation, and check for any red flags. The clinic also does a transvaginal ultrasound–an ultrasound inside your vagina–to count your follicles. This checks for any issues that would inhibit a healthy cycle (like cysts or problems with the uterine lining) and helps determine the right “stimulation” medications. There is also some required infectious disease screening.  

Hormone treatments and checkups: Once you’ve completed testing, your doctor will likely wait for your period to start hormone medication. Then, you typically begin hormone shots (yup, you give them to yourself!) for 8-11 days that grow all of the follicles currently in your ovaries (instead of just the one that would normally grow and release one egg). You visit the clinic every 1-3 days to check your blood levels and monitor the growth of your follicles with more ultrasounds. Your doctor will dial hormone dosages up or down accordingly.  

Extraction and cryopreservation (say that 5 times fast): About 2 weeks later, the eggs in the stimulated follicles will be extracted while you’re under anesthesia. Your clinic freezes and stores them.

After the procedure: Recovery time is different for everyone and can depend on number of eggs retrieved and age. If fewer follicles are stimulated, recovery time may be quicker. If more follicles are stimulated, recovery may take more time. Either way, it’s common to gain 2-8 pounds of fluid weight and feel cramping and pressure 10-14 days after retrieval. Your doctor may suggest that you avoid physical activity until your body has healed. Many women get a period in two weeks and return to normal cycles.

Then what?: If and when you decide to use your eggs, here’s what happens (in an eggshell): Your eggs will be thawed, tested, fertilized (sperm will be injected into the egg), and implanted into your uterus through the same process as IVF. More on the ins and outs of implantation later.

Got all that? Ok, now for a more in-depth look at what’s going on in your body when you freeze your eggs.

To collect eggs, you need more eggs

When you ovulate naturally, your ovaries usually release one egg around day 14 of your menstrual cycle (of course, the exact timing of ovulation depends on the length of your cycle—not everyone has a 28-day cycle). In order to freeze your eggs, your doctor needs to plan out exactly when you’ll ovulate and induce your ovaries to develop multiple eggs at once.

That’s where the fertility injections come in. Typically, you’ll go through roughly 2 weeks of daily (usually self-administered) hormone injections and you’ll go to your clinic every 1-3 days to monitor hormone levels and follicle growth. Every treatment protocol is different. The amount of fertility medication administered will depend on the number of follicles you have and your health history. Some clinics adjust protocols for cancer risk in the family. If you have specific health concerns or know of risks, be sure to ask your doctor how she plans to adjust your protocol.

The first set of shots are stimulation medications that help your ovaries grow a greater number of follicles. Then, around day 5, you’ll begin antagonist shots that prevent you from ovulating–it’s kind of like filling up a basket of apples and then reinforcing it so the apples don’t tumble out.

ASK YOUR DOCTOR:

  • Walk me through exact timing of the whole treatment. How many appointments will I need total?
  • What time does your clinic open and close for my monitoring appointments and for my bloodwork and transvaginal ultrasound?  
  • How do your protocols change based on health history and risk profiles?
  • Based on my hormone testing and general health, what fertility medication will I be prescribed? What will the routine of self administering shots look like? 

Go time

When your doctor is satisfied with the size of the follicles, the thickness of the uterine lining, and your estrogen levels, you’ll get your “trigger shot” comprised of one of three medications, Urinary-derived hCG (hCGu), Recombinant hCG (hCGr), or an agonist such as Lupron–which some doctors choose to use for women at risk of OHSS (more on this later). The trigger shot basically accelerates the maturation of your eggs.

36 hours after you receive your trigger shot (which is when your eggs have reached optimum “maturity”) your doctor will bring you in for the final extraction of the eggs. You’ll be sedated and your doctor will place an ultrasound-guided needle into each of your follicles to suck out the egg inside. Kind of like the world’s tiniest vacuum. 

ASK YOUR DOCTOR:

  • What trigger shot will you recommend for me?
  • How many retrievals have you done?
  • How many live births have resulted from those retrievals?

Freeze, baby, freeze

This part is pretty cool. Your eggs will then likely be frozen using a process called egg vitrification. The name aptly means “a glass-like state” and it’s different from early methods of “slow freezing” because it uses high levels of an antifreeze called cryoprotectant that protect the egg from damaging ice crystals. How long does this all take? Most clinics quote an average of 2-3 weeks for a cycle, from when you begin hormone injections to when your eggs are extracted (not including the time it takes to  wait for your period as we mentioned). So from start to finish–one cycle of egg freezing can take 2-3 months.

ASK YOUR DOCTOR:

  • What is the specific method you use for freezing eggs?
  • How long have you been using this method?

So how many eggs do you need?

While there’s no set number of eggs that you should freeze, doctors may suggest anywhere from 15 to 40 depending on your age. A 2016 study in Fertility and Sterility recommended that women under 38 cryopreserve 15–20 oocytes (eggs) “giving them a roughly 70%–80% chance of at least one live birth” and women 38-40 cryopreserve 25–30 oocytes “giving them a roughly 65%–75% chance of at least one live birth.”

Keep in mind that collecting this amount of eggs may take more than one retrieval cycle–it’s not necessarily “one and done.” At the same time, not having the “recommended” number of eggs doesn’t necessarily mean a woman won’t be successful in getting pregnant. After all, it takes one healthy egg. However you slice it, egg freezing is not a guarantee or an insurance policy–but it can increase the probability of pregnancy.

Doyle, Joseph O., et al. "Successful elective and medically indicated oocyte vitrification and warming for autologous in vitro fertilization, with predicted birth probabilities for fertility preservation according to number of cryopreserved oocytes and age at retrieval." Fertility and sterility (2016)

ASK YOUR DOCTOR:

  • Based on my profile, how many eggs do you expect to collect?
  • How many eggs total would you recommend collecting for someone like me?
  • What are the costs of each cycle?  
  • Can you tell me a bit about success of patients who had a similar profile?

Let’s talk risks

The American Society for Reproductive Medicine removed the “experimental” classification from the egg freezing procedure in 2012. It’s still unregulated and, with that, comes the potential for risk. While there are certainly both benefits and risks involved in freezing your eggs, your edge is your information.

Success rates: Despite the increasing popularity of egg freezing, it can be tough to measure exact success rates. After all, a woman needs to freeze her eggs then decide to use them–and this can take time.

A study published in the Journal of Law and the Biosciences in 2014 stated that “the larger and more experienced [egg freezing] programs will have success rates comparable to the use of fresh or frozen embryos, 30-50% per frozen-thawed egg.”  That has improved in the last three years. A 2017 study showed that the transfer of frozen eggs was equitable to the transfer of fresh eggs finding, “no difference” between the “cancellation, implantation, pregnancy, miscarriage, or live birth rates” between fresh and cryopreserved eggs. Make sure to ask any clinic you’re considering about the number of eggs that have been thawed, inseminated, and implanted. They should be able to provide you with success rates. Yes to information!

ASK YOUR DOCTOR:

  • How many egg retrievals have you done in your career?
  • How many implantations have you done?
  • How many live births have come from the implantation of those frozen eggs
  • Can you share your clinic’s overall success rates?

Tip: Check out the CDC’s egg freezing success rates here. They’re from 2014 so things have definitely changed but this is still a good way to get your context. 

Ovarian Hyperstimulation Syndrome: Ovarian Hyperstimulation Syndrome (OHSS), is an issue that some women run into with fertility treatments. Mild forms of OHSS are common. Having too much hormone medication in your system can cause your ovaries to become inflamed and painful.

This can cause symptoms similar to a severe menstrual cycle including nausea, cramping, and bloating. In more serious cases, it can cause shortness of breath and fluid buildup in your lungs, abdomen, uterus, and even be life threatening. A 2014 study showed that the stimulation required to extract over 15 eggs can lead to higher risks of OHSS. Your doctor will use blood tests and transvaginal ultrasounds to mitigate this risk. It’s a good idea to ask yours how she has handled this in the past.

ASK YOUR DOCTOR:

  • Given my health profile, how do you plan to mitigate OHSS?
  • How have you handled cases of OHSS in the past? How many have you seen?
  • Do you have reason to believe I am more or less prone to OHSS?

Genetic abnormalities: Freezing your eggs doesn’t pose any specific genetic risks. In fact, if you do decide to use your frozen eggs, you’ll have the option to do genetic testing after they are thawed and fertilized. This genetic testing can help a doctor determine which embryos to implant in your uterus. It is pricey, though. We’ll explain just how pricey below.

Implantation: There’s also the possibility that your once-frozen, now fertilized egg may not properly implant into your uterus. This can happen if the uterine lining is too thin, ovulation occurs too early, or if there is excess fluid in the uterus. This can also happen if an embryo is deemed abnormal by the body.  Keep in mind, though, that all eggs–whether fresh or frozen–can have difficulty implanting.

ASK YOUR DOCTOR:

  • If I were to come back and fertilize my eggs, what types of genetic testing do you offer? What is the cost?
  • Have patients who have come back to use their frozen eggs had difficulty with implantation? What do you do to mitigate this?

Okay, so what does it cost?

In the United States, the average cost to freeze your eggs is $16,000 — including $11,000 for the clinic and $5,000 for the medication — but can range anywhere from free with insurance to $18,000 depending on where you live. It’s important to note that this cost estimate does not include elective preimplantation genetic screening on fertilized embryos (which can cost $3000-5000), the yearly fee for frozen egg storage, or egg thawing and IVF once you’re ready to use your frozen eggs. Since costs (and what’s included in a package) can vary between clinics, it’s something you’ll want to discuss upfront if you decide to get a consultation.

As you think about costs, make sure to think about the whole process. You may need to do  more than one round of egg retrieval or implantation when you’re ready to use your eggs.

While some companies, the first being Facebook and Apple, have included egg freezing as part of their employee health plans, it’s not yet the norm. Most insurance companies don’t cover fertility treatments like egg freezing or IVF (15 states have mandated infertility insurance–but there is no federal coverage). However, things are shifting. Companies like Progyny and Carrot are bringing coverage to employers–and we’re hopeful that more women will have coverage in the future!

ASK YOUR DOCTOR:

  • Can you give me an itemized breakdown of the clinical costs per cycle as well as the medication and storage costs?
  • Can you help me understand how much/if my insurance covers my treatment?
  • Can you help me understand the other costs I can expect, like egg storage?

Fertility first, freezing later (maybe)

Making the decision to freeze your eggs is a big step but it doesn’t have to be the first one. There is a lot you can do to learn about and monitor fertility before you’re ready for kids. You can check in on key fertility hormones and track them over time and use your levels to have conversations with your doctor. Many women choose to freeze their eggs and feel completely empowered by it.  With information in hand, you and your doctor can dig in and make decisions that make you feel awesome about your family planning down the road.

When it comes down to it, egg freezing is your choice. Dr. Imogen Goold says it all in her paper, Trust Women to Choose. “Women who are presented with full, accurate information are not only fundamentally capable of but also entitled to make their own choices about their bodies. To do otherwise and so effectively fail to trust them to make their own decisions about the reproductive risks they run leads us down a paternalistic path we would do better to avoid.”

All we have to say to that: Amen.




References:

Afton + Carly

We're the co-founders of Modern Fertility–working on making fertility information more accessible for women everywhere–and we're so glad you're here.

Fertility Unfiltered