The issue was not merely what we weren’t taught or told but what came to exist in the vacuum. The implications of all this not knowing extended to an entire new chapter of obliviousness or misguidance when women reached their thirties. Sex ed was long gone, dusty and mostly unhelpful as it faded in the rearview mirror. Now the vast bubble of ignorance and silence centered around fertility—around two troubling facts in particular. One, too many women have unrealistic expectations about how long their bodies can biologically bear children. And two, too many women don’t understand fertility until they learn they no longer have it.

—

Like Will before he met Kati, I didn’t learn about fertile windows until well into adulthood. A woman can only get pregnant on the day she ovulates: false. A woman can get pregnant all the time: also false. The more I learned about ovulation and hormones, the more I realized that my newly gained knowledge about a woman’s ability to get pregnant meant untangling myths and misconceptions I’d long believed to be true.

Also like Will, I woke up to how little I knew when I first thumbed through Taking Charge of Your Fertility. The book is clear and comprehensive, but also warm and approachable. I’ve dog-eared the pages and scribbled question marks and exclamation points in the margins. There are pictures and helpful diagrams and straightforward, easy-to-understand explanations for incredibly complex things. My copy was a gift from my mother after I began writing this book, many years after the American Girl book. She inscribed this one, too. Dear Natalie, her familiar, comforting cursive reads. I’ve had this book a few days now, and yesterday, I set it out to write a note before giving it to you. Last night I dreamed I was breastfeeding my baby girl! I certainly must have “fertility” on my mind. Use this book to enhance your knowledge. Use the knowledge you gain to be a better informed, and more relaxed, mother-to-be. I have not a doubt in the world that you will be a mother…and a great mother. I’m so happy to be your mother.

It was becoming clearer to me now that my relationship to my body was not separate from my decision about egg freezing. The broader truth was this: How women learn or do not learn about the basics informs if and when they learn about fertility and circumstances impacting their reproductive futures. One of the common frustrations voiced by women over the years, doctors told me, is that they wish they had known how much egg quantity and egg quality matter—and they wish they’d learned this earlier, before they found themselves seeking fertility treatment in their late thirties and early forties. Doctors I spoke with also confirmed what I had heard anecdotally to be true: that many women undergoing egg freezing wish they’d realized earlier how big a role age plays in the ability to conceive, instead of looking to celebrities having babies in their mid- to late forties—often through donor eggs, surrogates, or gestational carriers, though their ART interventions usually go unmentioned—to guide their sense of what’s possible.

It’s not just younger women who are in the dark. It’s common for women in their forties to blithely assume they can get pregnant, merely because they feel young and healthy. It’s an easy trap to fall into. Women think that because we are looking younger and living longer, the expiration of our eggs should be extended, too. But as I discussed in chapter 3, the realities of a woman’s fertility have mostly remained unchanged; in this area of life, thirty is definitely not the new twenty.

Okay, so by this point I’d come to terms with the social and personal reasons women are procreating later in life. I’d learned about the sex ed we never got and begun to grapple with the long-term implications of Not Knowing. But what to do about the pesky problem of biology? Try as we might to ignore or discount it, this biological truth is not easily swept under the rug. ASRM’s Ethics Committee reminds us: “Older female age increases the risk of inability to conceive due to reduced oocyte quantity and quality, with increased chromosomal abnormalities leading to more fetal abnormalities and pregnancy losses.” Translated: As the years accrue, fertility diminishes. Healthy eggs are hard to come by. Miscarriages and babies born with developmental issues become more common.

“Fertility meant nothing to us in our twenties; it was something to be secured in the dungeon and left there to molder,” writes Ariel Levy in The Rules Do Not Apply, her memoir about the loss of her pregnancy, partner, and home. “In our early thirties, we remembered it existed and wondered if we should check on it, and then—abruptly, horrifyingly—it became urgent: Somebody find that dragon! It was time to rouse it, get it ready for action. But the beast had not grown stronger during the decades of hibernation. By the time we tried to wake it, the dragon was weakened, wizened. Old.”

Her words were a warning. Coupled with the words of NYU bioethicist Arthur Caplan that I quoted before—there is this notion that you can get pregnant whenever you want, the technology is here, we’ve got the answers, it’s in your control—they haunted me. For educated, middle-class women, the list of things in life we can control and succeed at is long and growing. We live in an aspirational age; very little today ever slows down or de-escalates. It should come as no surprise that the message as we get older is that fertility is something we ought to be controlling—preserving, protecting, investing in. And infertility, then, is in many ways the ultimate loss of control.

“We lived in a world where we had control of so much,” Levy continues. “Anything seemed possible if you had ingenuity, money, and tenacity. But the body doesn’t play by those rules.” And so we intervene before our bodies can betray us. Deploy technology to not only command but enhance our reproductive systems, what and when they will produce. Capitalize on the scientific advancements that have made it possible to exponentially expand our ovaries’ capacity to generate eggs, thereby improving our chances of having a biological baby only when we are ready, completely or at least mostly on our own terms. Take action now to mitigate against loss of control down the road. These are the solutions women are encouraged to embrace. The nature of the game has changed, and the savvy among us will realize we no longer have to shrug and accept our bodies skirting the rules.

At least that’s what our can-do society is promising us.

Egg Freezing Up Close

I had gotten some clarity on the basics, and why I hadn’t known what I didn’t know until now. The next step, it seemed to me, was to learn more about the mysterious technology that my fertility doctor and the physicians at the EggBanxx event all spoke of as being the solution to the hard-to-get-around biology problem. And to better understand the whole process, I needed to see egg freezing in action.

I paid a visit to a lab belonging to Extend Fertility, a boutique egg freezing clinic in midtown Manhattan. On a snowy winter day, I hurried along West 57th Street to watch an embryologist demonstrate the actual technique of freezing a woman’s eggs. It was my first time visiting a fertility clinic as a reporter rather than a patient, but the potential egg freezing customer in me took note of Extend Fertility’s warm and inviting vibe, the orchids at the reception counter, the sunny, window-filled consultation rooms. Privacy rules prevented me from watching a patient have her eggs retrieved, but Leslie Ramirez, an embryologist and the company’s assistant director of its embryology laboratory at that time, offered to walk me through a sped-up demonstration of the process.

Most of the conversation around egg freezing centers around the several days of hormone injections and the day of the egg retrieval. But while the day a woman’s eggs are retrieved is in many ways the end of her experience, the journey for her eggs is just beginning. The actual “egg freezing” part of egg freezing begins immediately after a woman’s eggs are no longer inside her body. Amid the hype surrounding the whole procedure, the all-important step of vitrification—the ultra-rapid cooling technique that significantly improves egg survival and pregnancy rates—tends to be overlooked.

A crucial component of egg freezing, the delicate process of vitrification occurs shortly after the retrieval. While the woman is waking up from anesthesia, her eggs are hand-delivered to the lab and placed in an incubator for a couple of hours. Then, an embryologist inspects the eggs under a microscope to determine which ones are mature before exposing the mature eggs to cryoprotectants, the chemicals that shield the eggs from the stresses of freezing and thawing. Next, the embryologist attaches a few eggs at a time to labeled plastic strips (each about the diameter of a piece of spaghetti), called straws, and dips them in liquid nitrogen, where they freeze almost instantly; all biological activity in the eggs, including aging, stops. Once the eggs are flash-frozen, the straws are attached to a longer piece of plastic, called a cane, and placed in a sealed tank that looks like a propane canister used for a barbecue grill. The storage tank, which has been filled with liquid nitrogen and maintains a temperature of –196 degrees Celsius (–320 degrees Fahrenheit), keeps the submerged eggs cold—and preserved indefinitely.

Decorative snowflakes on the embryology lab’s door matched the cobalt blue scrubs I had been instructed to change into. Ramirez gestured for me to come in. I pressed “record” on my phone and shoved it inside my waistband, hoping it wouldn’t slide down my pants leg and clank onto the white-tiled floor, then stepped inside, pulling the heavy metal door closed behind me. The brightly lit lab had the faintly metallic smell of hospital-grade disinfectant. High-powered microscopes sat beside micromanipulators that resembled videogame consoles and white machines with pink or blue labels that said things like TransferMan 4m and incubator c16. There were also custom air filters, designed specifically for an embryology lab like this one. Because eggs and embryos are exposed to open air when being transferred in and out of petri dishes, keeping the air as sterile and contaminant-free as possible is important; even a lab worker’s perfume can impact the quality and development of an embryo.

Ramirez, a thirtyish, petite, Mexican-born Harvard-trained scientist with a PhD in biotechnology, was looking down at a petri dish that sat on the counter. Inside the pool of clear liquid, she told me, lay two human eggs. I moved closer to get a better look, careful not to bump against any of the expensive-looking equipment. Most cells are too small to be seen without a microscope, but a human egg—0.1 millimeters in diameter, about as wide as a strand of hair and right at the level of visibility—can be seen with the naked eye, though it’s a lot easier to see a group of eggs than just one. I could just barely make out the minuscule eggs in the petri dish, each about the size of the period at the end of this sentence. “Ooh,” I exclaimed softly, looking up at Ramirez. She smiled back at me, then briskly returned to explaining. The liquid solution, or culture media, mimics the nutrient-rich environment the egg has in the female body while the embryologist inspects them to determine maturity. Usually, only mature, viable eggs—typically 75 percent of retrieved eggs—are frozen because they’re the ones that can be fertilized, hopefully, later on.[*6] The petri dish in front of me, labeled Discard in handwritten black capitals, held oocytes that had been extracted from a woman whose retrieval had yielded several mature eggs that had been successfully frozen. The patient had given permission for her leftover, unviable eggs to be used for training purposes.

Ramirez placed the dish on the stage of a microscope and, using a pipette, moved the eggs from their nutrient-rich bath into a different petri dish. The liquid solution in this dish is where the vitrification magic happens: In a series of chemical processes, the cryoprotectants in the solution draw out water from the eggs. On the monitor attached to the microscope—the image of one of the eggs blown up, making the action look more dramatic—I could see how it immediately shrank. In its dehydrated state, the egg, projected on the screen, resembled a small, shriveled pea. Then, the egg expanded again, as the cryoprotectant filled the cell. Almost instantly, the egg regained its normal, perfectly round shape. Ramirez stepped aside and motioned for me to look through the microscope’s eyepiece myself. A tank of liquid nitrogen hissed; a machine whirred and beeped. I squinted my eyes and peered into the petri dish at the tiny scraps of life it contained.

I once heard it explained that preserving eggs is akin to preserving the crystals of a snowflake—except the eggs are far more delicate and even more vulnerable. In the laboratory environment, as they are transferred from a woman’s ovaries to a plastic straw to inside a tank of liquid nitrogen, these smaller-than-small cells are incredibly sensitive to any variation in temperature. Fluctuations of a few degrees can destroy them. As I watched Ramirez demonstrate transporting and submerging eggs in their liquid nitrogen bath, the decorative snowflakes on the lab’s door caught my eye and I found myself smiling. A coincidence, a small irony, maybe, or both. I wasn’t sure I was firmly grasping what I was seeing—literally, a woman’s fertility put on ice—and what it meant. My last biology class was in eleventh grade, which was also the last time I fumbled around with a microscope. Back then, more or less pretending I knew what I was looking at and why it mattered amounted to a teenage shrug and an A-minus. But standing in the lab that day, wearing borrowed scrubs and scribbling unfamiliar words into my notebook, I couldn’t even pretend I possessed the robust scientific background required to understand the most intricate parts of egg freezing.

But I hadn’t come this far to stop asking questions. I reminded myself that I’d already begun to go beyond the technology’s surface-level explanations. And so, burgeoning science journalist that I apparently now was, I would keep going, keep delving deeper to confront egg freezing’s implications beyond its sheen of complex science and oh-so-shiny promises.

Seesawing and Second Thoughts

Early spring. The end of a long day, back-to-back classes, and hours writing at the NYU library. Ben and I met friends for dinner on the Lower East Side. On the drive home, I rolled down the passenger-seat window in Ben’s rattly Civic and watched the twinkling Manhattan skyline recede in the side mirror. Cars bound for Brooklyn were backed up, their headlights piercing and brilliant. It was a velvety mid-March evening and the air had a pulse to it: the promise of seesawing seasons, of bloom. We climbed the five flights of stairs to my apartment and fell into bed, exhausted. Ben was, predictably, sound asleep within minutes. I lay awake, my mind racing, for no particular reason, just a lot of reasons. I felt completely overwhelmed by all I was juggling: my thesis and graduate school work, my fascinating internship at a magazine, my new relationship with Ben. And on top of my overcommitted day-to-day was this business of trying to figure out my fertility and make a decision about egg freezing, all of which was proving to be more complicated than I had bargained for.

Outside, bodega doors banged shut and an occasional siren wailed. My head rested on Ben’s bare chest, his arm wrapped around me and his hand cupping my breast. I blinked at the darkness. I wanted to be comforted by our tangle, our intertwined parts that at times fit perfectly, but his arm became heavier, our skin sweatier, the street noise louder, until all I could hear and feel was my galloping heart.

Something had shifted in how I’d come to think about egg freezing—and my fertility in general—since meeting Ben. While I know I can be a parent on my own, having children has, for me, always been tied to the idea of a committed relationship. I have always imagined having kids with all the basics in place: a fulfilling career, a savings account, health insurance. And a partner.

I broached the subject of kids with Ben sometime after our first weekend away together and before he met my parents. He told me he had no doubts that he would make a great father someday.

“Oh, yeah?” I chuckled. “And how do you know?” I tried to keep my tone casual—could I have asked for a better reply?—but I could feel my dimples giving me away.

“I’ll just do everything my dad did, because he was the best dad ever,” Ben answered.

My heart fluttered. He had said it so simply, so sincerely that I immediately trusted the pure place it came from. I murmured something in response, then sat back to savor the moment. I took a long look at Ben. He was nursing his beer, his tan, floppy loafers hanging off the barstool’s bottom rung. I had come to recognize the affable smile he wore, confident and a little coy. I imagined him approaching fatherhood with this same self-assuredness. I could easily picture him as a dad, running around a grassy backyard with a toddler on his shoulders and another at his feet. But imagining him accompanying me to egg freezing appointments and plunging hormone injections into my butt cheek? Couldn’t see it. And not just because Ben had a paralyzing fear of needles. I couldn’t imagine it because the scene did not fit in the nice narrative that had formed in my head about the story of my life.

I initially saw egg freezing as an independent, solo thing, a way for me to claim ownership of something that had never felt as if it was in my control. Now that I was in a relationship—getting serious quickly, in a good way—why did it make sense for me to freeze my eggs? I didn’t know how or whether Ben fit into my egg freezing decision. He’d been supportive since day one and showed genuine curiosity about all I’d been learning. I wondered if he had an opinion about if and when I might do it, although I wasn’t sure I wanted to hear it. Maybe, I thought, I should forgo freezing and start trying to get pregnant earlier than I had planned.

But still, lying in bed most nights with Ben’s arm wrapped around me, I’d find myself seized with anxiety about the possibility I might never be pregnant with my own eggs. That perhaps my missing parts wouldn’t amount to anything. Thoughts swirling, I would remember similar disquieting nights, like the ones in Sri Lanka years ago when I’d jerk awake, gripping my right side, in some kind of phantom pain summoned by memories of my long-ago surgeries.

Middle-of-the-night thoughts and nagging worries that come and go over years, as these do for me, tend to have connective tissue that is as strong as it is stubborn. When would the thought of accidentally becoming pregnant stop seeming like such a catastrophe? When would the possibility of never being pregnant stop haunting me? How much information and empowerment would it take to banish this angst from my—from every woman’s—head?

It had been several months since my last appointment with Dr. Noyes. She had sold me on the powerful potential of egg freezing; her ringing endorsement lingered in my mind. I had been surprised and pleased by the strength I heard in my voice when I told her I was going to freeze my eggs. But since that feet-in-stirrups declaration, I felt less sure. When I asked for help understanding the basic mechanics of egg freezing, I had secretly hoped that if I could understand at least at a rudimentary level how the process worked, I would have an aha moment that would make it easier for me to feel good about the decision I’d made. Because I had made a decision, lying there in my floppy gown, a goofy grin on my face because my ovary was doing great. You know too much, Dr. Noyes had said to me at my second appointment. That’s the problem. She’d said it facetiously, but I was beginning to think she was right. Observing egg freezing in action had helped demystify the science some, but it had left me with more questions, not fewer. It was almost as if, the more time I spent piecing together what I was learning about egg freezing, trying to get it all straight, the more of a Pandora’s box it all seemed to be.

I slipped out of bed and walked to the kitchen in my underwear, the wood floor cool beneath my bare feet. My phone screen read 1:11 a.m. I filled a glass with water and untwisted a half-empty bag of candy. In the living room, I curled up in my favorite wicker chair, which I’d had since college. Round and deep, a worn-in nest. The velvety air and laughing with friends that had punctuated the evening earlier felt so distant now. I closed my eyes and dozed fitfully, waking with candy stains on my fingers. It was still dark out. I opened my copy of Taking Charge of Your Fertility and, with a pink headlamp strapped to my forehead, read about cervical mucus and G-spots until it began to grow light.

Skip Notes

*1 Later, I learned that about one in ten women uses two methods of contraception, such as condoms and the Pill, simultaneously. So maybe also using condoms with my boyfriend was overkill, but the doctor really could’ve reacted better.

*2 Dr. Lubna Pal, a professor of obstetrics and gynecology at Yale School of Medicine who co-authored the study, noted: “We found that 40 percent of women in the survey believed that their ovaries continue to produce new eggs during reproductive years. This misperception is of particular concern, especially so in a society where women are increasingly delaying pregnancy.”

*3 The lack of communication is, in part, because health insurance doesn’t reimburse doctors for spending more time talking to their patients. Also, some OB/GYNs don’t discuss fertility with younger patients because they don’t want to unintentionally add to the pressure to have children that many young women already face.

*4 Names have been changed to protect their privacy.

*5 Having an abortion very rarely affects a person’s fertility or ability to become pregnant in the future. But many women have been socialized to think that it does.

*6 Only mature eggs can be fertilized. But some clinics freeze immature eggs as well, because there’s a small chance some might mature after the thawing process. Also, since egg freezing is intended for the long term, there’s the hope that new technology or techniques will be developed in the future that would make it possible to use these oocytes.

8 Ready, Set, Trigger Shot

Remy: Bring On the Eggs

By the end of the several days of hormone injections, Remy felt like she was about to pop. Legitimately feel like I am a goose waddling around with a gut full of (very expensive, like 14-karat) eggs, she texted me on the last day of her shots. We’d kept in touch since she’d started the egg freezing medications. She felt more or less okay, save for the intense bloating that was unlike anything she had ever experienced before. As her egg retrieval day neared, anxiety began to creep in, laced with humor in her texts: I’m so scared of something happening to them hahaa I’m hyper-conscious of my every move. MUST PROTECT THE EGGS AT ALL COSTS.

I flew to Nashville for Remy’s trigger shot and egg retrieval. This would be the first time I saw these parts of the egg freezing process up close. The night of that crucial last injection, I drove from my hotel to an apartment on the other side of town. Remy’s good friend Leah,[*1] also an anesthesia resident, lived there. When I arrived, Remy and Leah were draped on an overstuffed couch, watching Crazy Rich Asians on Netflix. A typical millennial Saturday night, save for the various vials of drugs and needles scattered on the kitchen counter. The two women howled at the movie, heads thrown back in laughter. Remy had been up for twenty-two hours by this point, having come off one of her long hospital shifts. She was wearing black leggings and a roomy gray sweatshirt, her hair in a high ponytail. Her feet were bare—pink toenails, from a recent pedicure—and her face fresh, makeup-free. She looked twenty-three, not thirty-three.

Outside, the skyline was gray and darkening. Leah turned off the TV. After ten days of injecting the hormone shots herself, Remy had decided to ask Leah to do this final one. This shot would go just above Remy’s right butt cheek. Remy’s biggest takeaway from the injection demonstration appointment at the fertility clinic had been learning what not to stress about throughout the egg freezing process and what to definitely stress about. In reassuring words, the nurse had told Remy not to worry too much about always injecting the shots at the exact same time each night. But Dr. Lewis, Remy remembered, had been explicit about the timing of the trigger shot. “If you take it too early,” she’d warned, “you’ll ovulate too soon and release all your eggs and I’ll have nothing. If you inject it too late, the eggs will be immature and I’ll have nothing.” At the time, Remy had half-groaned, already worried that she’d make a mistake and mess up the timing. The clinic had provided Remy with a video tutorial to review before taking the trigger shot, which she watched, but she still felt somewhat confused and nervous because it had different directions than the other meds she’d been injecting.

When it was nearly time, Remy and Leah stood at the kitchen counter and took stock of the vials and syringes spread out in front of them. Remy got to work reconstituting. The trigger shot is a powder that needs to be dissolved in saline. Mixed, but not shaken.

“Does that look ready?” Remy asked Leah.