In darker moments, Mandy vacillated between wishing she would accidentally get pregnant and wishing she’d just discover she was infertile. She wanted to be free from worrying she was making the wrong decision—or would, or already had. An accidental pregnancy or infertility diagnosis would mean the decision had been made for her: She would accept the reality and that would be that. No more “figure out my fertility” as an item on her someday to-do list.

Finally, after all the visits to the clinic and the days of shots, it was time to harvest her eggs. Mandy’s egg retrieval resulted in twenty eggs extracted from her ovaries, which were then fertilized with Quincy’s sperm. They had successfully frozen eight embryos—which was a lot. The doctor told them that the chances of having one healthy child from their frozen embryos was extremely high.

Mandy accepted that being forced to consider her fertility at an early age meant always knowing that having biological children might not be possible for her. Most of her friends who knew they someday wanted children hadn’t given their fertility much thought. Mandy, at least, felt somewhat mentally prepared. The cyst her doctors had discovered that changed everything for her now felt like a blessing in disguise. Even so, despite having a medical reason for freezing, Mandy never really felt solid about her decision. Shouldn’t we just get pregnant now? a voice in her head kept murmuring. But she and Quincy hadn’t felt ready to be parents. It wasn’t until the day she got the final results that the voice quieted down.

With the experience behind her, Mandy focused her thoughts on what it had all led to: her and Quincy’s eight embryos on ice and the peace of mind that gave her. “It was really hard, and really expensive,” she tells her friends when they ask. “And it’s going to be more involved than you think. But I’m really glad I did it.” Going back to regular life felt strange at first. For a while, it had felt as if fertility was all Mandy thought about. Just freezing my eggs had unexpectedly turned into months of contemplating motherhood and starting a family with her partner. Unaccustomed to dwelling on the future, she used to cringe when the subject of having kids was brought up. All those years she spent actively protecting against pregnancy meant that almost by default she had put off all thoughts of possible parenthood. But all that shifted while she was going through the many steps of egg freezing. She began to imagine what it would be like to have a family, how many kids she and Quincy might have, what he’d be like as a dad. Getting pregnant had, for so long, been the worst thing that could happen. Egg freezing changed all that. Having frozen embryos made motherhood seem more manageable; now, she felt she had more of a choice of when it would happen.

And if it didn’t? She’d at least know she had done everything she could.

—

Our ovary sagas brushed up against each other in small but striking ways. It was almost as if where mine left off Mandy’s began, and where mine lulled hers returned. We both had had two surgeries for ovarian cysts eight years apart: mine at ages twelve and twenty, Mandy’s at twenty and twenty-eight. We both had fewer than the normal two healthy ovaries most women have, and before we met each other we’d never known someone with an ovary situation like ours. We both grew paranoid anytime we felt cramps or a sharp pain in our lower abdomens, thinking it was an ovary dangerously twisting on itself again.

I saw myself in Mandy’s experience: her fragile ovaries and history of painful operations, the confused guilt she felt about the cyst that threatened her fertility, the ache in her voice when she said, “I should have known better. How did I let this happen again?” I empathized with how, for so long, she’d had low expectations about her ovaries’ capabilities. Did they work? Would they one day help her conceive? She had harbored little hope over the years. Mandy was the sort of person who thought twice about a lot of things and often felt anxious about the future, quick to spiral into a thick fog of what if and what then. I understood this deeply. My doctors had painted a rosier picture for my one ovary, but no matter what any doctor ever said, I always wondered—and always knew the wondering would stop only if and when I became pregnant. For Mandy, freezing her eggs turned the wondering down to a low hum. I envied her that.

As we sat in the fading light of her kitchen, I realized I had been subconsciously hoping Mandy’s journey would inform my decision. This truth had been simmering inside me for a while, and in that moment it welled up like a confession: A part of me wanted to let Mandy and the other women I had spent hours talking with over the past many months make my egg freezing choice for me. I had done my homework, but they had done the actual thing itself. I had uncovered some answers—some illuminating, others inconvenient—but they had decided, they had experienced it, and what truths, what answers, are more powerful than that? I could make my egg freezing experience look like theirs, couldn’t I?

As I was getting ready to leave, Mandy repeated in almost an offhand way a comment one of her doctors had made at one of her early egg freezing appointments: “Ovaries are really resilient, you know.”

Heartbreak, Hormone Shots, and a Change of Plans

My last night in California, I holed up in the basement of a friend’s apartment in Oakland. My half-open suitcase sat wedged between two large racks of Burning Man garb. During the week’s meetings and interviews, I had compartmentalized my grief, cosplaying a put-together reporter instead of being a person with no idea how to start over.

My decision to freeze my eggs no longer felt sturdy. I wanted to Velcro myself to the facts. I was a reporter; facts were the bricks of gold paving the path to Knowing, to the Right Decision. I was nearing thirty and fresh out of a breakup. Egg freezing made more sense now than ever, at least on paper. But I still had questions about the fertility drugs and about the fact that I was a “cyst-former” with a history of my body overreacting to just natural hormones. The journalist in me had concluded that egg freezing was a striking, if presently overhyped, technology with powerful potential—but I wasn’t sure I could live with the risks. As for the woman in me: My research into freezing eggs versus embryos, plus my recent visit with Mandy and hearing about her frozen embryos, had me close to convinced that freezing embryos was smarter than freezing just eggs. But now Ben—and his sperm—were gone.

I lay back on the bed, feeling weary. I closed my eyes and pictured going through with it by myself, injecting drugs into my abdomen late at night until the skin came to resemble a dartboard. It was getting more and more difficult to imagine putting myself through the hormone shots unless a doctor told me I was infertile and couldn’t get pregnant without them. Harder to admit was that for now, at least, it was difficult to imagine going through any major life event without Ben.

As more time passed, I realized that I had been using my relationship with Ben to distract myself from actually making a choice. In both cases, to some degree, I’d been hedging, brushing aside many of the doubts and hard questions. I worried that I’d wanted things with Ben to work out so badly that I had lost the ability to tell if I was still happy. Now it sometimes seemed I’d begun looking at egg freezing with the same rose-colored glasses. As if the more I wanted it to be right for me, the less able I was to tell if it was a smart choice. But whether or not to freeze my eggs had been my decision to make before I met Ben, and it was mine to recommit to now that I was once again single. It was—still—just me and my ovary. That thought used to bring me comfort; now it made me feel profoundly alone.

I had wanted a straight line to what had felt like the right decision: to freeze my eggs. I wanted to be sold on egg freezing. I longed for the wave of relief I had been assured it would bring me if I went through with it. I’d already been counting on how sensible it was for me, the woman who’d always been certain about having biological children, the woman with one ovary who knew she wanted kids later but not now. Instead, on top of my achy heart, I was angry about how ending my relationship with Ben had thrown a wrench into my egg freezing plans. I worried Dr. Noyes had been right all along: The problem was that I knew too much. And that made it nearly impossible to stop vacillating, stop researching, stop chasing more data. Mostly I was afraid that I had no idea about anything anymore: where to live, how to write and do my job, how to move on.

“Freezing my eggs seemed like the best decision I could make with the information I had at the time,” writes Sarah Elizabeth Richards, who spent $50,000 on several rounds of egg freezing more than fifteen years ago, in her memoir Motherhood, Rescheduled. Money aside—I’d never spent so much on anything—her statement made complete sense to me. But, unable to distinguish what I knew, or couldn’t know, about the drugs’ risks and shaky success rates from how I felt, which was lost and heartbroken, I had arrived at a fraught in-between place with egg freezing: I was afraid to do it and afraid to not do it.

I didn’t know where to begin with confronting all this personal fear. I could, however, continue to channel my reporter energy in pursuit of more balanced answers and perspectives. Dr. Noyes was wrong, I decided: I didn’t know too much. Not yet, at least. To recommit to freezing my eggs, I concluded, I needed to reassure myself I could live with the risks attached to the hormone injections—risks to my ovary as well as to my long-term health. And I wanted to learn more about the powerful peace of mind that Mandy, and many other egg freezers I’d interviewed, had gushed about.

That night, I fell asleep with Mandy’s words echoing in my head: Ovaries are resilient.

Skip Notes

*1 These percentages can vary among labs, which is one reason why choosing a fertility clinic that has a reputable laboratory and well-trained embryology staff is important—really important. More on this in chapter 14.

*2 Frozen eggs and sperm, on the other hand, do not independently have the potential to initiate a pregnancy, which makes the choices surrounding the disposition of stored gametes less fraught. More on egg and embryo disposition decisions in chapter 14.

*3 A major benefit: By fertilizing half of my retrieved eggs and hopefully getting a few high-quality embryos, I’d have a sense of how good my remaining unfertilized eggs were likely to be.

*4 Icing the area before can make the shots more bearable; ice globe roller balls, the kind some people use to depuff their eye areas, work well.

12 Fertility-Industrial Complex

The Lovely Louise

It was just after eight on a Monday at the convention center in San Antonio, Texas, the site of the American Society of Reproductive Medicine’s annual meeting. Every year, the ASRM—the governing body that oversees most reproductive medicine and technology in the United States—holds a large conference for the industry’s doctors and researchers. I wanted to see the world of fertility technology in action and put faces to names of the physicians at the forefront. So I reached out to the ASRM press office and obtained a media pass for the four-day event. Then I packed a bag and flew to Texas.

I stood there in the convention center, marveling at how huge it was. Thousands of fertility experts attend ASRM each year, with nearly one-third of them coming from outside the United States. The large hall echoed with the click-clack of women’s heels and deep male voices. I shuffled around in a black dress and shoes that gave me blisters, getting the lay of the land before I made my way to one of the ballrooms for the conference’s opening plenary. It was going to be a long day, and I was glad; being back in Texas just a couple of months after leaving Houston and Ben was painful, a dull ache and sharp sting all at once. The buzz of the conference, I hoped, would take the edge off.

“It is every woman’s right to decide when, how, and with whom she wants to have a baby,” ASRM’s president at the time, Dr. Richard Paulson, said in the opening keynote address. He looked a lot like Tom Selleck. “This includes the ability to access not only family planning services, but also fertility promoting services.”

That evening, I attended a talk titled “Louise Brown: My Life as the World’s First Test Tube Baby.” Louise, I knew, was the poster child for IVF and assisted reproductive technology. She was conceived in a petri dish—not a test tube, although the “world’s first test-tube baby” moniker has stuck—and with her birth, the idea of making embryos outside of a woman’s body became a reality. Louise Joy Brown came screaming into the world at five pounds twelve ounces on July 25, 1978, at Oldham General Hospital in England. When I learned that this year marked the fortieth anniversary of IVF and that Louise, the world’s first IVF baby, would be speaking at ASRM’s annual conference, I reached out to inquire about interviewing Louise in Texas. Her team said yes.

As I sat in the audience that evening, a huge telephoto camera was making click click click noises over my left shoulder. Rows of doctors held up their cellphones to take photos of Louise, seated in a chair on the stage next to Dr. Paulson. She wore glasses with square, slim frames. Her gray-blond curls shone with texture under the harsh stage lights. “None of us would be here without the lovely Louise,” said Dr. Paulson. He beamed at her as they talked. The entire audience seemed to be beaming. I had read a lot about Louise and knew how significant her birth was within the field of reproductive medicine and beyond. Her birth had been an incredible breakthrough: Life could be created outside the body. But it wasn’t until that evening that I realized how much of a legend and a celebrity she was to fertility doctors across the globe.

In ART’s early days, embryos created through IVF were transferred to the uterus right away. This is how Louise, the first baby in the world made from fresh eggs, was born. Back then, IVF success rates were low; transferred embryos didn’t often successfully implant in the uterine wall. IVF was originally intended to help a specific demographic—young married women—who were struggling to conceive. Louise’s mother, Lesley Brown, had been unable to conceive naturally because of a blockage in her fallopian tubes. IVF had been designed to solve medical problems like hers.

Louise read to the audience from her memoir. Dozens of doctors lined up to take a selfie with her. I’d read that some say her birth was more monumental than a man landing on the moon. That struck me as a bit outlandish until I remembered that since Louise’s birth in 1978, millions of babies around the world have been born as a result of ART—children who otherwise would not exist. After Louise’s birth, it took doctors six more years to perfect the freezing and unfreezing technique. In 1984, the first baby from a frozen embryo was born, in Australia; the embryo had been frozen for two months, quite a brief period of time compared to how long embryos stay on ice now. In 2022, healthy twins were born to a Portland, Oregon, couple from donated embryos that had been frozen for thirty years—likely the longest-frozen embryos to ever result in a successful live birth.

Revolutionary, indeed.

The next day, I arrived at the convention center early for my meeting with Louise. I sat on the floor in a side hallway and installed fresh batteries in my recorder. Louise had given hundreds of interviews over the years, and I knew there was probably very little I might ask her that she wouldn’t have been asked before. Still, I was excited to meet ART’s poster child one-on-one. Half an hour later, we sat in a drafty room in a quiet section of the convention center. Louise wore a white ruffled top with pastel hummingbirds, her gray-blond hair loose. We started talking, and I forgot all about the questions for her I’d written down. At some point I broached the topic of puberty and asked her when she had first become aware of her body and self as a young woman. I couldn’t have been more delighted by her response. “That’s one I’ve never been asked before!” Louise laughed, before launching into a story of menses-meets-fish-and-chips. “It was a Friday. I can’t even remember what age I was, but on Friday evenings we’d always have fish and chips,” she said. But she felt too sick to eat it. “My God, it’s happened,” she recalled thinking when she realized it was her period. How did getting her period feel? I asked. “It put me off my tea, put it that way.”

As we joked and chatted, I thought about how, well, normal Louise was. After all I had read about her and her influential birth, I’d half-expected the first-ever miracle of reproductive medicine to present as the celebrity she was to fertility doctors and infertility patients across the globe. But she struck me as your average middle-aged woman. And that was maybe the point. Assisted reproductive technologies such as IVF symbolize an unconventional road that leads—some of the time—to a conventional end. Louise, now in her forties, lives in England with her husband and their children. She’s had a few jobs over the years, from nursery nurse to postal worker to freight forwarder. She likes to sing karaoke—Madonna songs, mostly, and sometimes “Total Eclipse of the Heart.” At eighteen she had her belly button pierced, and at twenty-one her tongue. At one point during our conversation she started talking about her tattoos and, one by one, showed them to me: a purple butterfly on her ankle; a Muppet in honor of her half sister who’d passed away; a rose and a heart with “Mum” and “Dad” written in; Tweety, from the Looney Tunes cartoons; Chinese characters that she’d forgotten the meaning of. She’s also the mother of two boys. She and her husband conceived children naturally; she’s never needed IVF.

“I’m pretty boring, really,” said Louise, grinning. “Well, apart from how I was conceived and born.” She said she’d grown used to being hounded by journalists and almost never answered her cellphone if she didn’t recognize the caller. Her entire life, she’s had to be careful about what she says in public. “As a teenager, I used to think, ‘Why me?’ ” she said, explaining that she was at once proud to be the world’s first IVF baby and eager to assert herself as normal. “Now I’m quite proud of it.”

Money, Marketing, and Medicine: A Perfect Storm

On the third day of the conference, I braved the convention center’s Expo Hall, a sprawling high-ceilinged space, map in hand. I walked around in a slightly stunned daze. At one end of the hall, a giant sperm poised to fertilize an ovum, which was the size of a small weather balloon, rotated above a booth promoting egg banking services. An enormous mobile composed of more sperm and eggs—this time wearing eerie human faces—grinned down from the rafters. When I found the restroom, I noticed posters for injections and devices plastered to the mirrors above the sinks.

Big banners and flashy signs announced the Expo Hall’s different booths. At first, I couldn’t tell which were the names of pharmaceutical companies, or procedures, or something else. Good Start Genetics. Celmatix. Fairfax Egg Bank. Fertility Drug Calculator. Center for Drug Evaluation and Research. Even Panasonic had a booth. There was fresh popcorn, just like there was at that first egg freezing event I attended years earlier in Manhattan. Another booth was handing out stress balls with unmissable squiggly tails, while attendees crowded around an arcade game for the chance to win T-shirts stashed inside—what else?—golden eggs. I wandered the maze, nibbling on popcorn and marveling at all the gimmicky gametes on display. I paused next to something called the Simulation Pavilion, where physicians could observe various virtual-reality procedures simulating things like embryo transfers. At Prelude’s booth, I picked up mint-green paper cardboard squares with messages like Let’s talk about sex in huge dark letters and, in a smaller font, and the alternatives you have if it doesn’t get you pregnant. A poster advertised a conference session titled “Fertility Preservation Patients: How to Re-engineer Your Practice to Accommodate Them.” It was being conducted not by a physician with an MD but by someone with an MBA.

—

Today, there are some five hundred fertility clinics scattered across the United States—employing more than fifteen hundred reproductive endocrinologists and seeing hundreds of thousands of patients per year—all competing for business. Private equity companies are pouring money into the for-profit fertility industry, a trend in line with what’s been happening a lot in medicine since the 1990s. The ART industry in the United States has two things investors like most: scale and growth. Fertility clinics are very profitable and have high margins.[*1] Many have doubled down on practicing and promoting egg freezing, with specialized egg freezing start-ups in particular receiving hundreds of millions of dollars of venture capital and private equity. Writing about the financialization of fertility in her book Freezing Fertility, sociologist Lucy van de Wiel, whose research focuses on reproductive technologies, says: “These investments materialize the promise of egg freezing as a growth technology that may increasingly be targeted at a wide group of younger, fertile women, who may or may not want to have children in the future—a far greater segment of the population than those currently accessing IVF.”

As I stood in the Expo Hall, I realized I was witnessing a perfect storm: the confluence of ticking biological clocks, investor money, and a shaky foundation of reliable basics. I thought about Kindbody and Prelude, companies that want to be global brands, one-stop solutions for all things fertility-related. NYU Langone Fertility Center, where I’d had my first few egg freezing appointments, was now a Prelude Network clinic. Kindbody doubled its already massive footprint when, in 2022, it acquired Vios Fertility Institute, a large fertility network with several clinics throughout the Midwest. It also has its own genetic testing division, called Kindlabs, as well as its own gestational carrier agency and egg and embryo donor program. By bringing these major and typically outsourced ART services in-house, Kindbody was—and this is an impressive feat—well on its way to achieving its goal of delivering end-to-end care to fertility patients. Which, if you squint, resembles an empire.

And my former fertility doctor, Dr. Noyes, one of egg freezing’s early and best-known pioneers and who had co-founded NYU’s egg freezing program, was now at Kindbody. One of the most senior and experienced reproductive endocrinologists in the business now worked at an egg freezing start-up—one with a minimal track record and little data on pregnancy success rates.[*2] A New Yorker article about new fertility entrepreneurs explains that Dr. Noyes “credits private equity and venture-backed firms with spreading the word about egg freezing and other fertility care, both in the media and in the employer market,” where company-sponsored egg freezing remains on the rise. But when the profit model is “volume-driven,” she said, “it’s like driving a car faster and faster. Okay, you’re going ten, you can go twenty, you can go thirty, you can go forty—but when is it not safe?”

Meanwhile, the market continues to soar, backed by millions of dollars in capital, creating an endless feedback loop between egg freezing and young consumers. The more money invested, the more marketing dollars are thrown at selling women on the procedure. The public, though, isn’t aware of these financial machinations—mostly because no one involved wants to talk about them. During my reporting trip to California, I’d asked Marcy Darnovsky, executive director of the Center for Genetics and Society, about this when we met at her Berkeley office. “Because we’re so queasy about talking about babies and commerce in the same breath, the commercial dynamics that are often at play escape our notice,” she’d said. “We’re putting young women at unnecessary risk. A combination of the marketing persuasion on the part of these companies and cultural and social pressures make women afraid they’re going to be infertile.” So, fear, in part, fuels the business of egg freezing. Another issue, to state the obvious, is misinformation. Studies in the United States, United Kingdom, and Australia have shown that fertility clinic websites tend to be more persuasive, rather than informative, in their language, emphasizing the benefits of egg freezing while minimizing the risks and costs. Some clinics even fudge the numbers somewhat when it comes to describing the success rates of their procedures.

Ours is a capitalist society; money is a driving force behind so many decisions. The fact that women are patients but also customers is an uncomfortable notion, even if it’s the reality of capitalism. They are being sold to, and many believe they’re investing in a procedure that guarantees a future baby. And the people doing the selling are savvy salespeople. I know this firsthand: Before I ever seriously discussed egg freezing with a doctor, I learned about it from a company eager for my business. It was so easy to drink the Kool-Aid at the fancy egg freezing cocktail parties I attended—marketing events focused on the importance of persevering fertility while women like me are still in our “prime.” And it’s still easy. Egg freezing is now spoken about less like a medical advancement and more like a new tech product. It’s even being marketed as a form of self-care.[*3]

Given the number of women who may never need to use their frozen eggs, fertility clinics and egg freezing companies are profiting hugely off of women who freeze eggs, while also—depending on how one assesses the paltry data—putting them at risk for future cancers. Arthur Caplan, the NYU bioethicist, argues that market forces are distorting our ideas about fertility in troubling ways. “The consumer doesn’t know what’s going on, and the provider has every reason to sell it to you and make a lot of money,” he told me. “It’s not a good market—the consumer is disadvantaged and often desperate to do something. And there doesn’t seem to be any inclination to regulate any of this.” He’s right, and we’ll unpack that shortly. The bigger, unsettling point here is that the lack of consensus on how ART is regulated in the United States means we’ve by default agreed to let the market drive how such technologies are used and who can access them. But a uterus isn’t Uber. Letting the market decide—instead of, say, well-studied public policy considerations—is not the best way to make a fundamental shift in our species’ procreative habits. And on a more personal level, it’s harder for women to make decisions about their bodies when they are not thoroughly counseled—about the actual need for the eggs they freeze or the actual success rates, both of which are difficult to quantify for a given woman—and when the doctor-patient relationship is too easily influenced by a profit motive. A large portion of fertility doctors’ bonuses are directly tied to metrics like patient conversion rate—how many consultations they were able to convert into treatment. “[Fertility companies] want customers, and they’ll advertise accordingly. But that’s not necessarily appropriate for a sensitive medical area like infertility,” said Caplan. “They make me nervous.”

A very profitable marketplace has shaped up to provide egg freezing, even though there is no guarantee of success down the road. Demand is high and competition between clinics is fierce. The marketing drives women to the newer clinics, which offer a more inclusive and feel-good patient experience and tend to charge less for freezing eggs, but lack solid track records in thawing them. This should be a red flag to a woman considering fertility preservation, in my opinion, but it’s tough to care about cost and quality equally; a lower price tag often trumps an established reputation. Several reproductive endocrinologists I spoke with worried that these rapidly expanding, egg-freezing-focused clinics—which face increased pressure to generate revenue—also don’t have enough physicians with the necessary experience to perform the delicate procedure well and, in some cases, have implemented cost-cutting measures that affect lab quality as well as patient care.[*4]

Their concerns, it seems, are valid. A major story about Kindbody published in Bloomberg in October 2023 found that, “Beneath the firm’s Instagrammable aesthetic lies a bonus-driven business model, a number of understaffed clinics, and instances of inconsistent safety protocols that have plagued some operations and contributed to errors,” according to three dozen current and former employees and patients. The article described how the company’s efforts to make fertility treatment more accessible and offer services at lower price points than its competitors led to difficulties running its labs at the level needed to safely handle eggs and embryos. “Kindbody’s challenges underscore the risks facing an industry that, on one hand, focuses on expensive, painstakingly precise biological procedures while at the same time pursuing a growth path funded by investors intent on an eventual return on their money,” the article said. One of the more harrowing incidents described was a flood at Kindbody’s Santa Monica clinic that affected lab operations.[*5] Since 2022, at least four of the company’s senior lab directors have quit, more errors have started surfacing, and some of Kindbody’s clinics are losing money.