As advances in cryopreservation make it more common, the impermanence of female fertility is best confronted at younger ages.
When Anne-Marie Slaughter -- Princeton professor, former Director of Policy Planning for the U.S. State Department, and mother of two -- spoke to a mostly female crowd this past Monday night in D.C., she had this advice to young women entering the workplace and worried about the inevitable entanglement of personal and professional life: "Freeze your eggs."
She brought up this idea in her article, "Why Women Still Can't Have it All," and it's not as out-there as it sounds. While society is no closer to making it possible for women to delay their careers, the technology that enable us to put off having kids has already arrived. This October, the American Society for Reproductive Medicine transitioned egg freezing, or "oocyte cryopreservation," away from the classification of "experimental."
Freezing our eggs is rapidly going to become commonplace. It's going to change the time frame of our "child-bearing years." At the moment, it's still prohibitively expensive. But as it evolves, it's an option women can and should begin to take seriously.
A significant advancement called vitrification -- that allows eggs to be stored safely, where before their high water content made them extremely fragile -- and the some 1,200 live births so far achieved through the procedure, have convinced the reigning experts to endorse the "TV-dinner version" of reproduction as a viable treatment for infertility. But it works only if we have foresight. If a woman who are having trouble conceiving want to have their own biological children, they need to have already frozen their eggs, and the earlier, the better.
The problem is, infertility is not on the minds of most girls in the early stages of independent adulthood. In my world, women my age only talk, think, and worry about not getting pregnant. Tellingly, I suppose, few of us choose to free ourselves from the clutches of our ovaries through sterilization. Our ideal outcome is to prevent ourselves from having kids now, but still be able to when we decide we're ready.
But even though almost everyone I know has had a pregnancy scare, or at least convinced herself, in a moment of hysteria, that a delayed period meant the worst had happened, we also can't help but notice that getting pregnant might not be all that easy to do. Forget "accidents"; couples have to actively try to reproduce for an entire year before they're officially considered infertile. And we all know older women who have tried -- and for many, failed -- to get pregnant through assisted reproductive technologies.
The longer we wait, the less likely we are to be able to have children. The data, when looked at from the perspective of being in my twenties but still far from ready to be a parent, can be pretty damn terrifying:
By the time I'm ready to include kids in my definition of "having it all," it could be too late.
I don't think it's that silly to be in one's twenties and worrying about fertility. The conversation, I'm told, occurs with more frequency among women in their mid thirties, whose remaining childbearing years are fewer. But just as fertility declines with age, so too does the quality of one's eggs. In our twenties, our fertility is at its peak -- eggs we freeze now would be more likely to thaw and become babies than eggs we freeze later. Dr. Nicole Noyes of the NYU Fertility Center puts our "prime," egg-quality-wise, between the ages of 16 to 28. If possible, she writes, this is the ideal time to start putting our future family plans on ice.
I asked Dr. Fady Sharara of the Virginia Center for Reproductive Medicine if there was a big difference in egg quality between our twenties -- when we're not thinking about this, and our thirties -- when we conceivably might be. "Absolutely," he said, although he was emphatically against the idea of asking young women to come up with $8,000 to $20,000 for a safety net they might not even end up needing. However, he also referred repeatedly to women in their forties who he's had to turn away -- hordes of women, by the sounds of it, desperate for one last shot at having children but whose eggs have already gone bad. We should at the very least start thinking about this sooner.
The eggs we have now are the ones we're stuck with -- our bodies aren't going to make any new ones, and as we approach the end of our fertile years, our ovaries are less like to produce mature, viable eggs. As our eggs near their expiration date, the risk of genetic problems and miscarriage rises. A large study in the New England Journal of Medicine found that live birth rates from assisted reproductive technologies reliably decline with mother's age, with optimal estimates declining from 74.6 percent for women under 31, to 27.8 percent for women aged 41 to 42, and down to 1.3 percent for those over 43. But when older women used eggs from donors in their twenties, they were able to restore their chances of getting pregnant to those of a woman in her twenties or thirties. If, down the line, our delayed childbearing means we need help conceiving, we'll have a much easier go of it if we had the foresight to freeze our eggs when they were at their youngest and freshest.
Sarah Elizabeth Richards, who's working on a book about the topic, wrote recently in the New York Times that OB-GYNs should at the very least least be broaching this topic with their patients regularly. But she concludes with the possibility that "after being asked about their plans from their very first visit, more will decide to start families when their eggs are at their prime, and won't even need to freeze."
It's true that although more women are delaying childbirth, the trend isn't increasing at the rate it once was. Advancing maternal age was a more pronounced phenomenon in the 1970s and 1980s. But as Slaughter would argue, career-oriented women have very few incentives to start families at prime biological time. Can technology jump-start this trend by making it easier for us to wait longer? Do we even want it to? Why do we even need to have children at all?
It would certainly be easier to focus solely on the other, multifaceted ways of making life worth living, and to let whatever happens, happen. "The idea [of wanting to freeze your eggs] is actually perfectly sensible," Dr. Sharara reassured me. "But it's unlike guys going in to do a sperm freeze, which is very, very simple and doesn't involve anything." They can even do it from home.
For women, cyropreservation is not a process that can be undertaken lightly. NYU's fertility center has a 61-page Powerpoint that guides its patients through the ordeal. There are consultations, tests, drugs delivered via hypodermic needles (including one extra-big one the night before the extraction). There's a need for advance planning and for dropping everything when your cycle indicates it's go time. The procedure itself doesn't seem too bad; it only takes about 15 minutes, and you're mildly sedated throughout. But the litany of medications you need to take in the weeks leading up to the big event come with potential side effects.
Insurance companies have yet to catch up with the insecurities of presently-fertile youth, although they could get there if egg freezing becomes heavily endorsed by infertility doctors. Down the line, should those eggs become necessary, their superior quality can end up making the in-vitro process a lot less expensive. But someone's going to have to foot the bill up front. "Unless your parents are willing to give you the money to do this, it's basically out of the question," he said. I suppose it all depends on how heavily your parents' definition of having it all includes grandchildren.
Go through all that, and egg freezing, as it now stands, is still in no way a fail-safe means of reproductive insurance. Even though it's no longer experimental, there are plenty of kinks that remain to be worked out. Typically, doctors will extract about 14 eggs in an attempt to maximize their chances of success. With the low rates of achieving pregnancy at an advanced age even with IVF, Dr. Sharara puts each individual egg's odds of eventually becoming a child at less than 5 percent.
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This all can certainly be worth it for young women like The New York Times' Suleika Jaouad. She did it, and she's only 24. But that was because she was facing near-certain infertility from chemotherapy. Her bid for her future was both more practical and more poignant. She was also able to land a scholarship.
If all goes well, and the eggs are successfully extracted, the embryologists take over. They examine the eggs and save the ones that look usable. There isn't much data, yet, on the consequences of having been frozen for the babies that made it through their years in storage. Thus far, eggs frozen with vitrification have a 90 percent survival rate, but no one knows how they'll look 20 years down the road. And just how long could one conceivably put off having kids? The oldest person to give birth through an egg donor was 72, and the process nearly killed her. "Theoretically, a uterus could be coaxed back into life way beyond menopause," said Dr. Sharara, whose talent for putting these things delicately cannot be overstated. "But this is not, obviously, what we're implying."
There is a litany of dangers, for both mother and child, associated with pregnancy over the age of 50. And then there's the risk of multiples: Per NYU's data, 44 percent of their in vitro patients who used fresh eggs retrieved from women under the age of 25 ended up with twins. Out of their 28 births from frozen eggs, 6 were twins as well.
All else aside, perhaps that's the biggest dissuading factor. If I end up putting off motherhood until I'm well into my forties, I know I'm not going to be able to handle more than one at a time.