“It had always been, like, ‘Oh, I have to go get my oil changed,’ ” Mandy told me when we first started talking. “ ‘Figure out my ovary situation’ was on my long-term to-do list.” But it was time to make a decision. “I’m hoping that if I ignore the problem long enough, it will just go away,” she said. I heard the tension in her voice, an inner conflict just beginning to bubble up. “But time is not on my side, especially with my medical history.”
A few months after her thirtieth birthday, she decided to freeze her eggs.
At Mandy’s initial consultation at Spring Fertility, the clinic she’d decided to go with, a doctor advised her to freeze embryos instead: combine Quincy’s sperm with her eggs and put the resulting healthy embryos on ice. So that’s what she’d do. Next, she attended a two-hour orientation at the clinic, where a nurse demonstrated to Mandy and several other women about to freeze eggs or embryos how to self-inject the drugs. There were boxes and vials of medications and various sizes of needles. Some meds needed refrigeration, others not. Some had to be taken at a certain time of day, others not. It was a lot of information and words Mandy had never heard before—too much for her to absorb. Later, at home, she turned to YouTube to get a grip on the process, watching hours of videos that explained, step by step, how to prepare and administer the shots. Fertility medications are usually injected either into the skin at the lower belly or upper thigh or into the muscle just above a butt cheek. Typically, ovaries are around one inch in diameter; during an egg freezing or IVF cycle, they increase to four to five inches, about the size of a clementine.[*2] Mandy dreaded the painful shots so much that she wasn’t able to do them herself; Quincy did them instead. The first injection hurt enough to make her cry, at which point she briefly considered abandoning the whole thing.[*3] Quincy learned to go as slowly as possible with the needle so the shots hurt less.
Before long the nightly injections began to feel like a kind of ritual, and Mandy was surprised by how easily she and Quincy had fallen into such an odd routine. Each night around nine o’clock, for ten days, Mandy changed into her pajamas while Quincy surreptitiously prepared the shot in the kitchen. In the living room, Mandy lay on the couch with their dog, an Italian Greyhound Chihuahua mix named Doe, sometimes turning on Netflix to distract herself. She always looked away while Quincy iced and cleaned the bit of belly fat he’d inject the medication into.
On a warm night in late June, when Mandy’s ovaries were lush with what she hoped were lots of mature eggs, Quincy injected the last injection—the trigger shot, a hormone called human chorionic gonadotropin, or hCG—just above Mandy’s left butt cheek. It was exactly eleven o’clock. The timing of the trigger shot is crucial, whether the woman is preserving her eggs for later (egg freezing) or fertilizing them with sperm to become pregnant now (IVF). The follicles holding the eggs have been developing steadily throughout the days of hormone injections. The trigger shot is the final kicker, stimulating the eggs’ final bit of maturation, and the carefully timed egg retrieval is thirty-six hours later.
The morning of her egg retrieval, Mandy dressed quickly and reread the procedure paperwork. In the kitchen, she glared at the coffeemaker, as she had most mornings since she’d begun the egg freezing process and had to forgo caffeine and exercise.[*4] Her phone lit up with a text message from her mother, part of it written in Chinese: Go celebrate with Quincy after it’s done, it read. Love you! I am with you, sweetie. Mandy let the words and heart emojis on the screen sink in. It had been a long several days of needles. The egg retrieval seemed like the easy part after all those shots, she thought. It was also the only part of this process completely out of her hands. She would be under sedation and had no control over how many or how few eggs her ovaries had produced. As she puttered around the kitchen, a wave of exhaustion came over her. She was ready for all that had led up to today—the blood work and all the tests, the worry about success rates and probabilities, the feelings of being tired and bloated and anxious—to be over. Tomorrow’s going to be a regular day, Mandy reminded herself, and for a moment she felt lighter. No more shots. No more stress. And all the coffee she wanted.
They piled into their reliable old Toyota Corolla, Quincy at the wheel. Mandy had gotten the car when she was in high school, a decade and a half earlier. She had driven it to take her SATs, to get married, and, now, to freeze her eggs. It was after rush hour and they had an hour to get into San Francisco to make her eleven o’clock appointment. Plenty of time.
“Wait, what’s going on?” said Mandy, leaning forward to better see out the windshield. Standstill traffic stretched along the San Francisco Bay Bridge—a massive traffic accident. She looked down at her phone. The maps app showed they were now due to arrive at the clinic half an hour late. She closed her eyes and tried to stay calm. No way was she going to miss her retrieval—a procedure for which she’d put several weeks of her life on hold—because of traffic.
Cars inched along. Quincy’s hands were tight on the steering wheel. It was, Mandy thought, the longest hour she’d ever experienced.
Finally, Spring Fertility came into view.
—
In addition to aiding with age-related fertility issues, ART helps people overcome infertility problems caused by medical conditions. Some women freeze eggs and/or undergo IVF because of factors associated with female infertility such as ovulatory disorders, fallopian tube blockages, structural problems with the uterus, and low egg count. Two common diagnoses that can affect fertility are polycystic ovary syndrome, or PCOS, and endometriosis. PCOS, a disorder caused by hormonal imbalances in which a woman’s ovaries develop many follicles but don’t actually release an egg, can prevent ovulation. It affects about 10 percent of women in the United States, although experts estimate that more than 50 percent of women with PCOS remain undiagnosed. And endometriosis, a painful inflammatory condition in which tissue similar to uterine lining grows outside the uterus—roughly one in ten women of reproductive age in the United States have it—often interferes with ovulation and can lead to scar tissue and ovarian cysts that can impair fertility. Women who suffer from either of these conditions are more likely to have trouble conceiving and, on average, take longer to become pregnant.
The most common medical condition typically aided by ART is medically induced infertility, which is when a person experiences fertility issues or becomes infertile due to a procedure to treat another problem—most often, chemotherapy or radiation for cancer. One of the thousands of women with cancer who froze her eggs is twenty-five-year-old Olivia, a freelance music teacher from North Carolina who worked part-time at Starbucks for the health insurance. On a chilly day in March, Olivia woke up and dressed carefully for the day—makeup, hair, a determined smile, and her favorite pink purse. She was headed out to get her recent biopsy results. If I’m about to get a cancer diagnosis, I refuse to look like crap when they tell me, she thought. She slipped on her lucky pink sneakers. Then she drove to her doctor’s office.
She was diagnosed with breast cancer later that day.
Olivia’s specific cancer treatment required medication that would put her in menopause for five to ten years. Her doctors urged her to freeze her eggs right away. “It was do or die,” Olivia told me. “We needed to get my ovaries turned off five days before I started chemo.” She ultimately couldn’t freeze her eggs but was able to freeze two embryos fertilized with her boyfriend’s sperm.
While Olivia’s case is a straightforward example of medical egg freezing—thousands of women like her urgently preserve eggs before undergoing fertility-compromising cancer treatments—Mandy’s situation, like mine, is less clear-cut. While our medical charts don’t constitute the same solid rationale to freeze eggs as Olivia’s does, we are both what doctors call “cyst-formers”—as in, prone to developing problematic cysts—which, in addition to our history of gynecological surgeries and lack of two healthy ovaries, means we are at higher risk of diminished fertility in the future.
—
In Spring Fertility’s waiting room—they’d arrived just in time—Mandy looked around at the familiar warm, calming hues. The mood lighting and modern decor gave off the vibe of a fancy spa but didn’t quite mask the typical sterile feel reminiscent of a doctor’s office. The place was a little over the top; I see what you’re doing, Mandy often thought while she sat and waited before her appointments. She took a deep breath, trying not to fidget. Next to her, Quincy—her mostly serious, reliably calm Quincy—was absorbed in a Garth Greenwell novel.
A nurse called her name and led her to a small room. Mandy changed into a pink surgical gown, medical bonnet, and oversized grippy socks. In the photo Quincy took just before the procedure, her thick-rimmed glasses are slightly crooked, her spill of shiny black hair partially covered by the pink cap. Her hand is raised in a wave; her smile, nervous. Quincy kissed her and promised to save her a cereal bar from the waiting room. It was her little tradition; Mandy took one every time she visited the clinic. She didn’t exactly enjoy the appointments, but at least she had the cereal bars to look forward to.
She sat alone in the procedure room, waiting. She felt anxious. Vulnerable. She couldn’t stop thinking about the limitations of her body, if pushing it to the extreme with medications and hormones had been the right thing to do. Egg freezing, Mandy decided, felt like something between giving birth and being in a science experiment. And even though it was finally Retrieval Day, she still felt conflicted about the whole process. She had invested so much time, money, and emotional energy in this process that was supposed to put her in control. But all she wanted now was for the worry to cease, for relief to settle in. Almost there, she thought. This will be over soon. From the procedure room, she could see the clinicians through a large glass window. Clipboards in hand, they peered through microscopes and handled lab equipment. Look at these men playing God, Mandy thought. A doctor saw her staring and waved. It reminded her of the movie Ex Machina: technology, money, the future. She waved back at the god.
When she opened her eyes, she was in the recovery room. A doctor and Quincy stood next to her. “It went really well!” the doctor exclaimed brightly. “You got plenty of eggs—we extracted twenty.” Mandy blinked, trying to clear the fog in her head. Twenty? A wave of relief washed over her. She knew that having partial ovaries meant it was unlikely she’d be able to freeze a lot of eggs; she had been careful to keep her expectations low. At one of her initial appointments, the doctor had told her that her ovaries were working very hard but her follicles weren’t developing as well as he’d hoped. We’re not where we want to be yet, he had said, choosing his words carefully, but I’m sure we’ll get there soon. At a later appointment, he’d counted only eleven follicles. Mandy had lain on the exam table trying to read his expression, as she did at every exam, but at that appointment the doctor was more direct: Not a great number, but we can work with it. So twenty eggs was good—great—news.
Half an hour later, Mandy and Quincy were ready to leave. A nurse handed them a small box of Godiva chocolates on their way out of the clinic. In the elevator, Quincy showed Mandy the inside of his coat pocket, stuffed with cereal bars.
Hope and Heartbreak: Why Most Women Freeze Their Eggs
Lots of people use ART for non-medical reasons as well. One’s ability to be a parent is not limited by genitals; egg freezing and IVF, in particular, have made pregnancy possible for women experiencing or facing age-related fertility decline, as well as scores of people in the LGBTQ+ community. This is an important subject, which I’ll discuss more in chapter 9. While the demographics are beginning to shift as more people from a variety of ethnicities and income levels pursue egg freezing, for the most part the majority of people who freeze their eggs are healthy, mostly young, cisgender women—and, more specifically, white middle- to upper-middle-class professionals. They tend to fall into one of two groups. The first group is made up of women in their twenties or early thirties; a growing number of egg freezers—roughly 35 percent now, compared to 25 percent in 2012—are women under the age of thirty-five. These women know they want to have children someday, perhaps within the next five years or so, but aren’t ready yet. For them, egg freezing is a proactive measure. The second group includes women in their mid- to late thirties or early forties who know their fertility window is closing and want to give themselves the best chance of pregnancy in the near future. Many hoped to be mothers by now. They want children but aren’t in a position to have them yet—usually because they aren’t in a relationship with someone who feels ready.
When I began looking into the research and data behind why healthy young women freeze eggs, I expected the main motivation to be fitting fertility around ambitions and careers. But I was surprised to learn that, contrary to popular belief, egg freezing is rarely undertaken for that reason. It’s actually because of what medical anthropologist and Yale University professor Marcia Inhorn calls “the mating gap”—a lack of eligible, educated, equal partners ready for marriage and parenthood. Inhorn, who embarked on a decade-long study to understand what drives healthy women to freeze their eggs, found that the majority—more than 80 percent—do so because they lack a partner. (While, obviously, one does not need a partner to have children, this cohort of women envisions rearing children with a partner.) Inhorn identified three main categories of those who froze their eggs: women freezing after a breakup or divorce, women still single despite years of dating, and women with partners who weren’t ready for children. The typical egg freezer is a highly educated professional woman in her thirties, well established in her career by the time she walks into a fertility clinic. What she doesn’t have is a suitable partner with whom to start a family. Freezing her eggs is “a reproductive backstop,” Inhorn writes in her book Motherhood on Ice, “a technological attempt to bridge the gap while waiting for the right partner.”
This was the case for thirty-six-year-old Valerie, who, until she froze her eggs, couldn’t look at romantic relationships objectively. Valerie, who lives in Atlanta, has undergone egg freezing cycles on four different occasions, in three different states.[*5] She’s carried hormone injections on planes and more than once has excused herself from a date to self-administer a shot in the restaurant bathroom. As it happens, Valerie is a fertility doctor. The first time she froze eggs, she was twenty-eight and in medical school. Armed with the knowledge that her mother went through early menopause, Valerie initially saw egg freezing as both a means of protecting against possible fertility issues in the future and a way to pursue a demanding career without sacrificing her vision of having three kids down the road.
A few cycles in, she began to also see egg freezing as a worthwhile way to hold on to her reproductive potential while she waited for true love with the right person to come along. When Valerie went for her last retrieval, she had an epiphany. For years, she’d struggled to see her romantic relationships for what they really were, sometimes staying with an unsatisfactory partner only for the sake of the theoretical children she knew she wanted someday. Putting eggs on ice changed all that for her. She credits her frozen eggs for saving her from a miserable marriage. She says of one recent partner, whom she was living with and planned to marry: “He was wonderful on paper, but ultimately he wasn’t the partner I needed for the rest of my life. And, honestly, knowing I had twenty-two eggs on ice helped me have the strength to end the relationship.” What Valerie’s attitude illustrates is that for many women freezing their eggs, the decision is as much about independence now as it is about family in the future. “I’m paying for peace of mind,” she told me. “To be able to make decisions not based on my biological clock—which I still hear screaming in my ear.”
So, egg freezing is often seen as a technology of hope for future romance. But research has shown it can also be described as what some call a technology of despair. Most women who freeze their eggs are hopeful, heartsick, or a mix of both. Inhorn’s work is based on the largest egg freezing ethnographic study to date. What she and her team of researchers learned was that for many women, relationship dissolution, as Inhorn refers to it—divorce, separation, a broken engagement—is one of the primary pathways to egg freezing. A woman pursuing egg freezing at the end of a failing relationship has left or been left by someone she has loved. She’s at a critical reproductive juncture, depending on her age, but even if she’s in her twenties, she’s old enough to internalize the breakup as an assault on her sense of self and her hopes for the future. She freezes her eggs in the midst of heartache, perhaps even a sense of hopelessness. “For women whose anticipated life course trajectories had been disrupted or broken, egg freezing provided them with a temporary biological reprieve, allowing women to heal their relationship wounds [and] recalibrate their sense of identity,” writes Inhorn in Motherhood on Ice. “Egg freezing also fueled some women’s visions for different futures, in which partnership no longer became an end goal.”
—
A few days after Remy’s injections appointment, she went for a long walk after work in her favorite park. She was still processing everything the doctor and nurses had gone over. Her egg freezing to-do list was growing longer. Submit pharmacy paperwork. Ask Sarah in San Diego for her extra hCG shot to save some cash. Apply for a new credit card to help pay for meds. She was all but certain she was going to break the “no caffeine for a month” rule—she simply could not wrap her head around that scenario—and figured if it was the one thing she did off protocol, it wouldn’t be the end of the world.
It was a brilliantly sunny day, a welcome reprieve from the recent dreary ones. As Remy walked and prepared to jog for a bit along her usual loop, she noticed women about her age, one after another, pushing babies in strollers. Normally, the sight of so many stay-at-home moms (she presumed; at least some probably were) would have given her pangs, a stinging reminder that she was single and nowhere close to having children of her own. But today it affirmed for her that her experience of having a baby would likely be quite different from theirs, and that was liberating. She felt run-down and ragged—sleep deprivation was a fact of life these days—but she also felt calm and in control. Yes, she was single, again. But she was taking advantage of the fact that that meant she could live a little selfishly. She had only herself to take care of, to consider; no one depended on her, except, in some ways, her patients. Life consisted of going to work and coming home. She might not have this kind of selfish period in life ever again. That had been on her mind ever since she made the decision to freeze her eggs; it was an optimal time to do it. She was totally on top of the fertility thing now. She was being proactive about motherhood. Her stroller-pushing days were hopefully not too far away, but if they were, that’d be okay.
Everything in medicine was constantly telling her she was late. Late, late, late. At least Remy was two years shy of that dreaded “advanced maternal age” classification. She knew more than she’d like to, maybe, about high-risk pregnancies and how common infertility diagnoses were.[*6] She was determined not to have a high-risk pregnancy and wanted to avoid, at all costs, the heartache that often came with undergoing fertility treatment at an older age. Remy was freezing her eggs to buy herself time to date, pursue relationships, and look for the husband she ultimately hoped to have. He was out there somewhere, putting in the time to develop himself and ready himself to be a committed partner. This was Remy’s way of doing that, too, controlling the unknown as best she could.
Remy loved lists. Even more, she loved checking off items on lists. Life’s big moments and decisions had neat square boxes next to them, and as Remy progressed through her twenties, she checked those things off her list. Go to medical school, get engaged, get married: check, check, check. But life wasn’t always sunshine and checked boxes, Remy learned. Going through a broken engagement with one man and then a divorce with a different man convinced her that choosing the right person—to share life with, start a family with—was one of the most important life decisions she’d make, if not the most important.
She began to jog at an easy pace, her thoughts swirling as they propelled her back to her last egg freezing appointment. She remembered when a woman who identified herself as the clinical business coordinator had poked her head in the door. “Finished reading through everything? There’s one form I have to notarize when you’re done.” Remy held up one of the forms from the pile in her lap. “This is more about, like, couples doing it—IVF, I mean. But I’m just freezing eggs. And the top of this page says it needs to be completed by a significant other.”
“Yeah, you still need to fill it out, though,” the woman said.
Remy read from the paper. “ ‘In the event of my separation or divorce’…‘transfer ownership to’…‘donate reproductive…’ ” She looked up. “Is that, like, in the event that I die?”
“Huh,” the woman said. “I don’t know that you would need to fill that out.” She left the room and returned a few moments later. “Dr. Lewis said to write, ‘Not applicable.’ ”
“Not applicable,” Remy repeated slowly.
“Just put ‘n/a,’ ” the woman said, as if that was that.
Remy ran hard, wanting to wear herself out. She could still feel the heaviness of that moment; it was sad to think about dying before using her eggs. Ultimately she had written her mother’s name on the form, later adding both her parents’ phone numbers, which felt a bit strange. Her mom, Remy knew, would have a strong opinion about where her eggs should go in the event of Remy’s death. But would anyone else? If signing the blizzard of forms and making rushed decisions about what would happen to her frozen eggs and who would care were supposed to make her, as an egg freezing patient, feel better, she didn’t.
