When it came to going out, Ben and I had always been pretty far apart on the spectrum, but lately the divide had been causing problems. He almost always preferred staying out late and partied harder than I did. When I visited him in Houston, I’d often opt to stay in or leave the bar early, taking an Uber back to the apartment alone. This became a pattern, and it bothered me. There were times we simply did not enjoy doing things together the way we used to, as if the bitterness that built up after several small fights dulled the easy joy we were used to sharing. At our best, we fell naturally into what it is to be here now with a person you love. Once, burrowed in sleeping bags at the bottom of the Grand Canyon, he thanked me for being in the moment with him, living in the present as opposed to the future, where my thoughts often dwelled. Murmuring something in reply, I leaned up to kiss him and a bug with long legs bit me. I yelped, he promptly ushered the bug out of the tent, and we fell asleep spooning under the stars.

Lately, though, that levity and natural ease felt light-years away. The next night in New York, we lay in bed, tension between us. We’d been talking about moving in together for several weeks. “I’ve been having some doubts,” I said quietly into the dark. I asked him if he was sure he wanted me to move to Houston. “Ninety-five, ninety-eight percent sure, yeah,” he said, his voice low. A moment later: “Are you hesitant?”

“Yes,” I whispered. His arms were wrapped around me, but I felt far away.

Skip Notes

*1 EggBanxx, which was an arm of FertilityAuthority, was absorbed into Progyny when FertilityAuthority was acquired and became Progyny. Bartasi is no longer involved with Progyny.

*2 The company now thaws eggs as well as freezes them; it’s expanded to offer IVF and other standard fertility treatment services.

*3 The amount of medications an egg freezer needs varies depending on how aggressively her ovaries are stimulated—that is, the protocol determined by her doctor. So, the total amount spent on fertility drugs rises fast if a patient requires additional meds. Many egg freezers feel that the high and separate cost of the fertility medications is not explained well by clinics.

*4 And they’re going up; prices for egg, embryo, and sperm storage have risen sharply since 2019, largely due to inflation and supply chain pressures.

*5 In a preliminary national report from 2022, SART found that 43.1 percent of women under thirty-five had a live birth after a cycle of egg retrieval. The number was 3.2 percent for women over forty-two.

*6 For a few comprehensive resources pertaining to fertility insurance coverage laws, fertility treatment grants and financing programs, and getting fertility insurance coverage at work, see the top of chapter 9 in the Notes section at the back of this book.

*7 Infertility, a disease of the male or female reproductive system, affects roughly one in six adults worldwide and is defined by physicians as the inability to conceive despite having regular, unprotected sex for twelve months or more if you’re under thirty-five years old or for six months or more if you’re thirty-five or older.

*8 I spoke to a few women who, to get around this rule, were given an infertility diagnosis by the doctor they saw at the fertility clinic—even though they were not at the time actively trying to get pregnant—so that they could have egg freezing covered by their insurance.

*9 For a good resource on family-building coverage offered by employers, check out FertilityIQ’s Workplace Index. The report, which FertilityIQ publishes every year, analyzes industry trends and provides up-to-date employer fertility benefit information.

*10 I’d enrolled in an NYU-sponsored health insurance plan when I began graduate school, and when I called and asked them if and how I might have any kind of egg freezing coverage, I was told that without an infertility diagnosis I was out of luck.

*11 As I published more egg freezing pieces, I did receive offers of this nature from a couple of clinics and doctors. While the offers were enticing, journalism ethics make it clear that accepting free or discounted goods or services in exchange for press—even if, in this case, a fertility clinic doesn’t explicitly ask for it—isn’t okay.

*12 A different Valerie from the fertility doctor Valerie I mentioned earlier.

*13 After the Supreme Court ruling came down, fertility patients across the country immediately began contacting their clinics to arrange to move their eggs or embryos out of red states to avoid possible legal complications.

*14 In some states, this is already happening. One of many egregious examples: In 2022, public universities in Idaho stopped providing not just abortion referrals but contraception referrals, too—even going so far as stipulating that condoms are to be distributed only to prevent STIs, not to prevent pregnancy, and warning faculty members that they could face felony charges if they refer students to abortion services or “promote” abortion.

*15 Black women also suffer from higher rates of uterine fibroids—non-cancerous tumors in the uterus that typically develop during a woman’s childbearing years—and obesity, two conditions that can negatively impact fertility.

*16 The lack of ethnic diversity among donors leaves many intended parents without adequate options for building families that reflect their backgrounds.

*17 Meanwhile, in China, egg freezing and IVF are largely available only to married women (even though the country’s population has fallen for the first time in decades). On the other side of the spectrum, Japan and South Korea now provide subsidies for healthy women wishing to freeze their eggs for future pregnancies.

*18 RESOLVE has compiled a helpful list of resources specific to family building for LGBTQ+ people: resolve.org/​learn/​what-are-my-options/​lgbtq-family-building-options/.

10 Ovaries in Overdrive

Lauren: A Bad Bout of Lupron

I never, ever thought I would live in Texas. I also never thought I would move somewhere for a boyfriend, but, well, the heart wants what it wants, which is how I came to be barreling south on Route 287 in early March, making the trek to Houston in my red Volkswagen. Moving meant trading in a long-distance relationship for the start of a shared life in an awkwardly shaped apartment in Montrose. It was a few blocks from the bayou. We had dubbed it The Bungalow.

Houston. The country’s fourth-largest city; the most ethnically diverse place in America, according to an article I read in the Los Angeles Times a few weeks before I moved. I took it as a promising sign. I wasn’t moving to Texas; I was moving to dynamic, colorful Houston. A port; a metropolis; a million different stories. A city known for its intersections: on roads, within communities, through politics. A city still trying to find itself, and yet, in many ways, so comfortable in its own skin.

My honeymoon with Houston lasted all of six weeks. There were cold beers at neighborhood watering holes and cocktails at bars with names like Little Dipper and El Big Bad. There were crawfish boils, food-truck tacos, and more barbecue than I’d ever had in my life. We took salsa lessons and biked along the bayou. We toured NASA and watched aggressive roller derby games at a local rink. We joined a CrossFit gym around the corner from the apartment and suffered through workouts together in the early evening heat. The city was funky and fun, and Ben was an eager guide, taking me to places he knew I would enjoy: Rothko Chapel, the rodeo, slam poetry open mic nights. I wrote in the early morning light while Ben slept. He’d turned a corner of the kitchen into a tiny office for me and gone out of his way to make space for my (many) belongings. When the afternoons turned muggy, I would itch for the workday to be over and was glad to close my laptop when Ben arrived home from his sales job. We’d cook simple dinners, take walks in the cool night air, or sometimes meet up with friends, almost all of whom were Ben’s from before I moved in. I liked his friends but didn’t have much in common with most of them except for our mutual fondness for Ben. When feelings of unease crept up about having uprooted myself to live with him, I channeled my anxious energy into work and down-the-road plans. Thinking about the future was easier than worrying about the present.

—

During one of my visits months earlier, Ben had surprised me with an all-day culinary tour, and we’d stayed in touch with a few of the people we met that day. That’s how I came to know Lauren. We connected a few stops into the food tour, at an open-air market in a pocket of Houston I’d not been to before. I was wandering around the narrow rows of stalls and noticed one boasting an array of colorful spices and homeopathic powders. Curious, I stopped, then noticed Lauren, and we got to talking. She asked what sorts of things I wrote about as a journalist, and when I told her, her eyes widened.

“Do I have a story for you,” she said, putting her hand on my arm in a you’re-not-going-to-believe-this sort of way. She began to tell me about her experience freezing her eggs two days before her thirty-ninth birthday. As she talked, I looked more closely at the small, brightly colored signs sticking out of the dozens of bags of herbs arranged behind glass in front of us. They were not, in fact, food spices, but herbs for various illnesses and ailments, with handwritten labels in both English and Spanish, several misspelled: prostate and kednys, asthma and anemia, detox and relax/nervious, cancer and circulations. “I want to know more about these ones,” said Lauren, laughing as she pointed to three bags of herbs, each $40 per pound, labeled ovaries/cramps, hormones, and fertilily. As we walked back to the bus, I asked Lauren if I could interview her in more depth about what she’d told me as we stood at the market stall. She readily agreed. We would end up talking and texting frequently over the next few years, but at the time, I simply appreciated the coincidence of meeting someone who’d frozen her eggs in a place where I wasn’t researching or reporting about it.

Many of her friends had children or were trying to get pregnant, but Lauren, who was single, wasn’t sure how she would get to motherhood. Still, since turning thirty-five, she’d found her thoughts preoccupied by her biological clock in a way she’d never experienced before. When she turned thirty-eight, she decided to have a chat with her gynecologist about egg freezing at her annual exam. Conversations with friends and family members helped her decide that she did, in fact, want kids someday. Not now, but when she wasn’t too old, either. Her gynecologist recommended a fertility clinic in town, and after briefly perusing their website, Lauren made an appointment.

As far as egg freezing stories go, the impetus behind Lauren’s pursuit of the procedure was in line with much of what I’d heard from other women—but the similarities stopped there. What she remembers most about her first appointment at Houston IVF[*1] was that the clinic had an excellent sales pitch. “They were really pushy, which made it hard to say no,” Lauren told me. She did the usual blood work, and when the results came back, her doctor said, “Your body really wants to be pregnant.” When Lauren heard that, it felt like being told she was validated as a woman. “If the doctor had told me on day one, ‘You can’t have kids,’ I would’ve said, ‘Fine.’ I would’ve moved on. But the minute she said, ‘You have really strong, viable eggs,’ I was immediately married to it. I was going to have biological children at that point.”

Then everything started happening very fast. Lauren hadn’t made time to research egg freezing before her appointment but now wishes she had. She doesn’t remember having hesitations or concerns about the procedure at the time but thinks she would have if she had known what questions to ask. A few months after that first appointment, Lauren began the hormone regimen. She had sold stock to pay a pharmacy nearly $5,000 for the medications. Her experience at the bustling, urban fertility center was, in a word, terrible. “It felt like a sweatshop,” she said, reflecting on what it was like to go in several mornings for blood work and monitoring. “They lined us up like cattle.” At one of her appointments, she remembers a nurse used a pin cushion to demonstrate how to self-administer the shots, which Lauren did not find helpful. For the first few days, not knowing to change injection sites, Lauren injected the shot in the same spot; it started to bruise and hurt. She turned to YouTube for clearer instructions. Then, a few days after starting the medications, she began feeling strange—and not in the way she’d read was normal when starting fertility drugs. Her most immediate symptom was painful cystic acne, breaking out on her face and back. She also struggled with insomnia. At her next monitoring appointment, the nurse told her something wasn’t adding up and sent her home, saying they’d be in touch. Lauren had difficulty getting direct answers from the clinic but was eventually told that she had been taking the wrong form of leuprolide, commonly known as Lupron. Lauren was instructed to stop taking all of the medications, effectively ending her egg freezing cycle.

It’s not clear who was to blame for the issue with the Lupron that Lauren took. She went back and forth with the fertility clinic and pharmacy for weeks, trying to figure it all out. At this point she’d already paid more than $10,000—for nothing. Despite the distress from the first botched attempt, Lauren decided to try again. The pharmacy and the clinic continued to claim no responsibility for the mistake. “I told them, ‘Y’all can fight about this as long as you want. But I’m still thirty-eight and I would like to get my eggs out—if I still have any.’ ” Her resolve had hardened—“I’m a really competitive person and was hell-bent on having thirty-eight-year-old eggs frozen,” she told me—but she remained highly skeptical. On a sweltering day three months after her first failed attempt, Lauren went in for the egg retrieval. This second cycle was successful, yielding fourteen viable eggs. When she got the news, she sobbed with relief.

Two days later, Lauren turned thirty-nine. She celebrated with a birthday brunch at an upscale restaurant in downtown Houston with her mother, sister, and friends. She had felt bloated since early that morning, and when she arrived home from brunch, she felt much worse. She remembers weighing herself later that night and feeling shocked realizing she’d gained several pounds; her stomach had gone from being a bit puffy to looking nine months pregnant. She was so bloated she couldn’t put on her elastic-waist pajamas. Frantic, she asked her mother and sister to drive her to the hospital. After waiting for hours in the crowded emergency room, she was taken back to an exam room and told that her ovaries were so big that they were touching each other, swollen to the size of oranges. The physician told Lauren she needed to have fluid drained from her abdomen right away but that the ER physicians didn’t have the skill set to do the procedure. She left the hospital around 4 a.m. and later that morning returned to the fertility clinic to have the excess fluid drained from her belly.

What Lauren was experiencing was ovarian hyperstimulation syndrome (OHSS), the chief health risk that comes with egg freezing. I’ll go more into detail about this in a moment, but in short, OHSS is a response to excessive hormones. The painful condition happens when drugs used in fertility treatment cause the blood vessels surrounding the ovaries to swell and leak fluid into the body. Though her paperwork shows she signed off on the procedural risks of her egg retrieval, including OHSS, Lauren doesn’t remember hearing about the condition before she was diagnosed with it at the hospital or discussing it with her doctor. “The fertility clinic handed me a folder. The only thing they would walk me through was the money,” she told me. The procedure to remove the fluid worked, and within a few days, Lauren’s ovaries returned to their normal size, though it took another six months for her weight and body to return to normal. The cystic acne caused by the Lupron error left temporary dark scars on her face, chest, and back, which made her too self-conscious to take her shirt off at the pool that summer. She filed complaints with the Texas Medical Board and Texas Pharmacy Board and began preparing to pursue legal action against the clinic and the pharmacy.

Months after the whole ordeal, Lauren discussed the Lupron scare and OHSS nightmare with her OB/GYN. “I don’t think these errors will do permanent damage, but there’s really no way to be sure,” her doctor said. Lauren, only half-joking, replied: “Can I have my eggs back? And I want a cookie.” Lauren’s dry humor is one of her defining traits, and she makes jokes about nearly everything—usually in a deadpan, I’m-friendly-but-don’t-mess-with-me tone. Her first egg freezing attempt was a failure and her second landed her in the emergency room, and while she was able to freeze more than a dozen eggs, so much had gone wrong. Finding ways to laugh about the ordeal helped her feel less broken—which, to this day, is the first word that comes to mind when she’s describing her egg freezing experience and how it made her feel. Broken.

Fertility Drugs: The Nitty-Gritty

Lauren’s experience was among the most disturbing I had heard in all the time I’d spent reporting on and researching egg freezing. We mostly hear egg freezing success stories; it’s rare to hear about egg freezing gone horribly wrong. I wondered how many other women out there had experiences similar to Lauren’s. And I couldn’t stop thinking about the shots and drugs. One afternoon not long after moving to Houston, I pulled out the file that I’d been keeping on the procedure’s risks, which eventually led me to dive into the nitty-gritty science—and bits of quirky history—behind the hormones and medications used in fertility treatments.

As I read deeply into the history of infertility research, I noticed a repeating pattern: A person or people (white men, mostly) discover a previously unknown fact about the menstrual cycle or ovulation, and then someone develops a drug or medication that remedies in a woman what her reproductive system does not or cannot do on its own. One example is clomiphene, marketed as Clomid. First came the discovery that regular menstrual cycles were a good marker of ovulation in women. It was a major breakthrough for researchers focused on infertility as a medical issue and paved the way for what came next: In the 1950s, an organic chemist, Frank Palopoli, and his team of researchers began developing Clomid, which became one of the world’s most widely prescribed fertility drugs. For women who don’t develop and release eggs on their own, Clomid helps them to ovulate and then go on to conceive naturally or through intrauterine insemination (IUI) or IVF. It’s particularly effective for women with PCOS. The drug works by blocking estrogen production, which tricks the brain—ah, that familiar story of synthetic hormones deceiving our brains—into compensating by producing more FSH and LH, the hormones that stimulate ovulation. The drug addresses an essential first step that many women struggling to get pregnant have: getting eggs into the fallopian tube. For more than fifty years, clomiphene—on the World Health Organization’s list of essential medicines—has helped millions of women become pregnant.

Another example is Gonal-f, a fertility medication with a strange tale “involving the Pope’s blessing and gallons of nun urine” (part of the title of the Quartz article where I first encountered this story). Piero Donini, a scientist working in the late 1940s for the Italian pharmaceutical company that would later be known as Serono, was the first to extract and purify FSH and LH, which can be found in women’s urine. After experimenting with urine from pregnant women, Donini discovered the highest levels of the hormone actually were in postmenopausal women, who produce massive amounts of FSH and LH in a futile attempt to revive the ovaries, which stop developing eggs after menopause. “Donini called his new substance Pergonal, after the Italian ‘per gonadi,’ or ‘from the gonads,’ and speculated that it could be used to treat infertility,” the article said. A decade later, scientists researching the use of human hormones to stimulate pregnancy learned of Donini’s work.

Long story short: Ultimately, a man named Giulio Pacelli, an Italian aristocrat and nephew of Pope Pius XII, convinced Serono’s board of directors to make enough Pergonal to run a clinical trial. Doing so would require obtaining thousands of gallons of urine from menopausal women, which, in a speech to the board, Prince Pacelli assured wouldn’t be a problem, explaining that his uncle, Pope Pius, was prepared to ask nuns living in convents to collect urine daily for a sacred cause. The board hurried to commit money and resources. (As it happened, the Vatican owned 25 percent of Serono.) Tanker trucks began hauling the urine of hundreds of nuns from nearby retirement homes to Serono’s headquarters in Rome.[*2] Then, in 1962, a woman treated with Pergonal in Tel Aviv gave birth to a baby girl, the first child born from the treatment. “Within two years, another twenty pregnancies had been achieved with Pergonal,” the Quartz piece explains, “and by the mid-1980s, demand had grown so much that Serono needed 30,000 liters of urine a day to produce sufficient quantities of the drug.”

The company began to synthesize the hormones in labs, and the resulting treatment, Gonal-f, was first approved in 1995. The active ingredient in Pergonal equivalents used as fertility medications today, such as Menopur, is still obtained from the urine of postmenopausal women. Also, the modern method of producing FSH for fertility treatment comes from—equally bizarre, perhaps—cells derived from Chinese hamsters, whose ovaries are injected with the DNA for FSH, which tricks them into producing human FSH.[*3] Millions of cells are cultured in huge vats, enabling more FSH to be produced than can practically be derived from urine.

So, one of the most important advancements in infertility treatment was the ability to put the ovaries into overdrive. That’s not a technical term, of course, but it’s an easy way to conceptualize the act of stimulating a woman’s ovaries to produce a bounty of eggs by way of medications she takes, which are made in labs and/or through genetic recombination. Brief recap: During egg freezing, a woman’s ovaries are artificially prodded with hormone medications to prepare her body for treatment and to increase the probability that a plethora of viable eggs will be extracted from her ovaries. The cocktail of medicines involves drugs to stimulate the ovaries, drugs to prevent premature ovulation, and finally the trigger shot—usually hCG, the pregnancy hormone we discussed earlier—which causes the follicles to rupture, allowing the doctor to collect the eggs during the retrieval.[*4]

It’s remarkable, really, how scientists discovered and how doctors use synthetic hormones to manipulate the reproductive system. Ovaries in overdrive can yield an arguably invaluable return—a baby—but the powerful rewards go hand in hand with alarming risks, which aren’t talked about nearly as much as they ought to be. Lauren’s story made that clear, and her saga took me down an unsettling new side road of research.

—

Much of the concern around egg freezing stems from these self-injected hormones. The medical risks associated with egg freezing fall into two categories: short-term knowns and longer-term unknowns. Hyperstimulation is the common short-term risk most egg freezers are warned about. Other short-term knowns include pelvic infection and bladder and bowel damage. Less serious but still unpleasant side effects of the hormonal fluctuations caused by fertility drugs are similar to PMS symptoms and include headaches, insomnia, mood swings, breast tenderness, and bloating. Some women have a pretty awful time during the several days of hormone shots—their abdomens feel like bricks; the emotional volatility is overwhelming—while others experience mild discomfort. It’s uncommon to experience issues during the egg retrieval itself; the chances of pelvic infection, significant bleeding, or serious anesthesia complications are quite low.

OHSS, one of the most common and potentially most severe complications, occurs when a woman’s ovaries receive more stimulation than her body can handle, and then the final trigger shot acts like a flame igniting a kerosene-soaked woodpile. OHSS typically hits within a week of the patient taking the trigger shot and undergoing the egg retrieval, as it did with Lauren. The condition is diagnosed by a physical exam, an ultrasound, and/or a blood test measuring hormone levels. OHSS symptoms can be anywhere from mild or moderate (nausea, bloating, diarrhea) to severe (extreme abdominal pain, persistent vomiting, blood clots, shortness of breath, and rapid weight gain of more than ten pounds in a few days), with acute cases of OHSS causing abnormal enlargement of the ovaries and sometimes ovarian cysts and torsion. As many as one in three women experience mild OHSS during IVF or egg freezing; fewer than 2 percent will develop a severe case. Women who freeze their eggs in their twenties or early thirties are at more risk for OHSS because larger egg supplies can cause hyperstimulation; the more eggs a woman has, the higher the chance that the medication she takes before her egg retrieval will stimulate a higher-than-desired number of ovarian follicles. For the same reason, women with PCOS are also more at risk for developing OHSS.

Determining how much medication an egg freezing patient needs to safely stimulate her ovaries isn’t an exact science. Monitoring the patient’s hormone levels throughout the days of self-injected shots allows the doctor to make necessary dose adjustments. The initial assessments and blood work help the doctor ascertain a baseline level of hormones and determine a treatment regime, as well as assess for any risk of OHSS at the outset while considering existing risk factors.[*5] Individualizing treatment regimens is typically the best way to prevent OHSS. If a doctor does this properly, severe OHSS shouldn’t develop. But if a doctor prescribes an overly aggressive medication protocol or insists on pressing forward with stimulation in the face of mild to moderate OHSS, that’s when things can get dangerous.[*6]