I’m so excited to share the second installment of the Wine & Gyn series that covers women’s health, fertility, egg freezing, and more. This post covers questions on egg-freezing that were answered by Dr. Mary Rosser, Dr. Zev Williams, Dr. Brianna Ruddick, and Dr. Paula Brady from Sloane Hospital for Women at New York Presbyterian. Dr. Rosser’s specialty is Obstetrics and Gynecology and Dr. Williams specializes in Fertility, specifically recurrent loss. Dr. Ruddick is a Reproductive Endocrinologist within the area of third party reproduction and same-sex couples, and Dr. Brady specializes in egg-freezing. We were very lucky to have all four specialists in attendance to answer any and all of our questions to gain some clarity on sometimes confusing subject matter. To avoid a 30-page transcript of the conversation from the event, I divided the questions into three categories, like I did for the first installment of Wine & Gyn. Egg-freezing is becoming increasingly common for women in their 20s and 30s to be thinking about these days. This is a follow up to this post from a few months back with more questions and answers about the process. If you’re thinking about freezing your eggs, I hope this brings you clarity on the subject!
Dr. Brady: This is a question that comes up in most of our consults for egg-freezing. For a long time, we thought that freezing embryos was better because of the way that we froze eggs and embryos. Eggs are the largest cell in the body, about the same diameter of a human hair which is actually huge in terms of cells. We used to freeze them very slowly which meant they were prone to form ice crystals and then not survive the thawing process. We thought freezing embryos was better because they survived the freezing and thaw process better. Now, technology has advanced so much that eggs are much more able to survive the freeze and thaw process. We no longer, in our National Body the American Society of Reproductive Medicine, say that gametes (eggs) are better frozen as embryos. It’s very reasonable and accepted to freeze them as eggs. They survive the thaw at a very high percentage. The vast majority of frozen eggs will survive and then have the reproductive potential that they would of had as fresh eggs. You're sort of freezing eggs in time at the age you were when there were frozen, so they sort of have the reproductive potential of a younger woman.
Dr. Williams: What I would point out to you though is that Dr. Brady is talking about the success which is based on the places you choose to have your eggs frozen and them having a lot of experience doing that. One of the more worrisome concerns is that these places, like pop-ups, helping you freeze your eggs but you want to make sure that place has actually had successfully frozen eggs that have resulted in a future live birth. You don't want to be in a situation where eggs are frozen and you find out ten years later that the place didn't do it right. So, Dr. Brady is absolutely right, the success has gotten much, much better but that's due in large part through experience, practice, and skill that comes with it.
Dr. Brady: You definitely want ask the center that you go to for egg freezing what their experience is with thaw, fertilization, and embryos. A lot of centers are only doing the egg retrieval part and can’t tell you a lot about the thaw, which is a crucial part.
Dr. Rosser: I agree with Dr. Williams that you really do want to choose a medical center that does this all the time. The more people do, the better they are at it because it's their niche.
Dr. Williams: That's true. It's a little bit different when it comes to the fertility side of things compared to most other areas of medicine because the emotional toll that it takes on an individual or couple shouldn't be ignored. It actually does have an impact on success and that's why one of the things that we work very, very hard on is to try and create that comforting safe space where the patient feels not like a number, but really has a whole team around her. In creating a space that helps put people at ease and helps them relax, you're actually helping their chances of success go up.
Dr. Williams: That's actually something that is a great result of how the population is generally becoming much more educated and being much more proactive. It's no longer the situation as often, where you are following the standard guidelines. Those guidelines are if you are under the age of 35 and don’t have success conceiving after one year, then you seek medical attention and if you are over 35, limit that to six months unless you have menstrual irregularities or some other reason to think there's a problem. Now, as people become more and more educated they don’t want to wait until they've been trying for year to see if there might be an issue, so there are more people coming and wanting to see where things stand now. The thing that’s so important about fertility though is it's not a single blood test or a single diagnostic test that gives an answer. It's a much more comprehensive picture. So even when you have a couple who have been trying unsuccessfully to conceive, it's not the case that IVF is the answer. What's necessary is to look at where the roadblock is, where is this challenge for them, and in some cases there is a very simple medication or lifestyle change that is all that's required. In other cases, it is something like IVF, but with a lot of these things there's a little more nuance and complexity to it and trying to sort of simplify it can be misleading because you can get falsely reassured or falsely alarmed from it.
Dr. Ruddick: This was one of our maintenance of certification articles this year. It actually did not show an increase in time to pregnancy, but there is definitely a lot more research that has to happen before we can come up with any definitive conclusions and it is obviously challenging to get that research done.
Dr. Brady: It's definitely not recommended liking pregnancy and breastfeeding just because there's no research that and it definitely does affect those sperm parameters. Sperm turns over every three months so it’s a little more of a forgiving system than ours, but we don't we don't really know.
Dr. Ruddick: In studies, there were a lot of compounding variables, so people who smoked would also drink a lot. It’s a tough variable to tease out.
Dr. Williams: With the cigarette smoking, the part about the production is true, it is a three month turnover, but the damage of cigarette smoking on sperm production can be irreversible.
Dr. Brady: The process of egg freezing takes about two weeks, like the actual process of stimulating and retrieving the eggs. There's time for menstrual cycle so there's often some lag time of waiting for that to happen. It's essentially a process of using medications which are injectable, which sounds much scarier than it is I promise, injectable medications for about 10 to 14 days and frequent visits to see us early in the mornings so your in and out and off to work. You get blood work done, an ultrasound to see how the eggs are growing, by ultrasound they look like dark areas sort of like cysts but they're small enough that they should each contain eggs. We're sort of counting and measuring them each day. Watching your estrogen levels rise in your blood. When the follicles get to a certain size, about two centimeters, we give a final medication to prepare them for retrieval. That is an ambulatory surgical procedure. So your asleep but breathing on your own. We retrieve the eggs from the ovaries trans-vaginally, the procedure takes about 20 minutes, and folks are up on their feet and out of our clinic an hour after the procedure. We'll know how many eggs we retrieved on the day of your procedure before you leave. We retrieve as many eggs as we can safely and that varies very much by age and ovarian reserve but we get as many as we can. There really is no average. We can sort of estimate going into the process but it's variable from person to person.
Afterwards, there are no more hormones, you get a period a week or two later, and then you're pretty much back to normal. Someone had asked and I don't think I answered, what effect does egg-freezing have on fertility. We really don't have any evidence that it affects overall fertility and there's no increased risk of breast or ovarian cancer associated with doing this. Every month whether you're on birth control pills or just living your life, the body goes through hundreds of eggs. The idea of egg freezing is that instead of your body just ovulating the one each month, the goal is to try to save more of them from that retrieval process and to freeze them. So we're not affecting the overall number of eggs in the ovaries or anything like that.
The whole process takes about two weeks. It's an intense two weeks but folks are going to work and they feel pretty good. They miss the one day of work for the procedure and then they're back to their normal lives.
The cost varies by center. There are the costs for monitoring you leading up to the procedure, the procedure, and the medications. It's very hard to give an estimate because the medications are very expensive and the more you need, the cost goes up. It certainly is an investment and one to take seriously and kind of like Dr. Williams was saying, definitely go to an experienced center where you can feel some reassurance that you know what you've frozen actually will have success in the future.
Dr. Brady: It actually varies. A lot of companies are covering freezing. Sometimes insurance does cover it, a lot of times it does not. If it's being done for medical reasons, so in the face of a cancer diagnosis, then it often is.
Dr. Brady: To a very limited extent. The age of the uterus really doesn't affect the outcome to an appreciable extent other than to say that overall risk of pregnancy complications like high blood pressure and diabetes, for example. Complications in pregnancy are more common as women get older, particularly over age 40. The likelihood of pregnancy to implant is not so dependent on a woman's age, but the consequences that could happen downstream could be because of age.
Dr. Brady: Your question is kind of addressing this question of a biological clock that we hear a lot about, but don't really know what that means exactly. There are two things that go into thinking about eggs for women. One is count, so quantity to see how many eggs there are. Second is quality, so the likelihood that any one egg can go on to make a healthy baby. The testing we have only reflects quantity. The question of quality is very tied to a woman’s age because we're born with all the eggs we will ever have. Over time they start to accumulate small changes making them less able to go on to make a baby. Those changes accelerate after age 35-36 and very much so after age 40. When you're thinking about freezing eggs, earlier is better. Studies have tried to recommend the optimal age to freeze eggs. They've come up with numbers between 34 and 37 based on balancing this quantity and quality question. There is no magic number. It's really about your life and what makes you feel comfortable in having a sort of insurance policy in freezing eggs. The rule of thumb is the earlier the better just based on this quality question, but you know it's a definitely a personal decision.
Dr. Ruddick: To speak to your questions earlier about our lifestyle changes and when we think about the biological clock and the concept of quality and quantity, the one lifestyle change that’s crucial is cigarette smoking. It really affects both of those parameters in a major, major way that a lot of women are not aware of and it is cumulative. That probably would be the single most important lifestyle factor. If you're thinking about freezing or if you think that's an option for you, quitting smoking should be right up there as a priority.
Dr. Williams: It is one of the few things that has so many health effects and we don't often think about the effect on fertility, which is dramatic. It's also true in the male. The little blood vessels that feed the testes where the sperm are developing are very sensitive to what's in cigarette smoke.