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.
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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.
The idea of women freezing their eggs no longer seems futile or dangerous, yet in truth a lot of the enthusiasm around the procedure is still premature. The marketing is ahead of the reality, and in some cases it’s just plain deceptive, like calling egg freezing an insurance policy—which I’d like to say a final word about, in an effort to put this all-too-common comparison to rest. A 2020 Fertility and Sterility study stated plainly: “Data suggest that to virtually guarantee one live birth (97 percent likelihood), a woman would need to freeze about forty oocytes.” That would require about three or four cycles, which is both incredibly expensive and would necessitate a lot of fertility drugs. The paper continues: “If a woman younger than 35 years were to undergo one cycle and retrieve an average number of mature oocytes, she would have a 75 to 80 percent chance at one live birth. Although these odds are relatively favorable, they do not provide the kind of guarantee that the word ‘insurance’ brings to mind.”
The fact remains that egg freezing is still a technologically advanced process riddled with risks. And yet, even though more data on the risks and success rates has been slow to emerge, and concerns about the aggressive sales culture and operations at some of the glitzy, newer fertility clinics seem to be well-founded, the medical community—especially the thousands of fertility doctors at this conference—acts as confident as ever.
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I left the convention center around eight in the evening. A long day. I walked on faux-cobblestone streets to the Tower of the Americas, the sounds of late summer in Texas washing over me: chirping crickets, a large fountain, big cars starting in a nearby parking lot, children still outdoors playing. I looked up at the lights on the tower and remembered hearing that the observation deck was closed for a private cocktail hour hosted by Progyny. I recalled something a man from a digital marketing company had told me after a session earlier that day: “If you knew how hard these doctors partied at conferences like this, you’d never want them doing things to your ovaries.” He was half-joking, but the underlying bit of truth pointed to the confluence of forces—money, medicine, marketing, motherhood—at play here. And it worried me.
Plot Twists and Tangled Webs
One evening, a month after the ASRM conference, I received an email from my cousin Bridget, who was living in Washington, D.C. Subject line: “Some bummer news.” Breast cancer. She’d just found out. There was no history of it in our family. She was twenty-nine years old.
She’d discovered a lump, had a biopsy, and was diagnosed with an aggressive form of breast cancer, stage III. She would undergo chemotherapy, have surgeries, and dutifully do as her doctors said. She might also freeze eggs or embryos—she and her husband, Chris, newly married, wanted children. That’s in part why she wrote to me, to ask about egg freezing and urgent fertility preservation. Her email concluded: “Please make a calendar reminder to do a monthly self-exam.”
Then, an excruciating plot twist: Bridget was pregnant. When she went in for the biopsy, there were signs all over blaring Tell your doctor if you’re pregnant. She and Chris had recently started trying, and she hadn’t gotten her period that month—she was expecting it later that week—so she informed the doctor doing the biopsy she might be pregnant. The doctor called the next day to tell Bridget she had cancer, and then said, “You really don’t want to be pregnant right now.” Bridget took three at-home pregnancy tests—all immediately positive—then confirmed it with a test at her OB/GYN’s office. That night, after she hosted her book club—the shock propelled her into a discombobulating autopilot mode—she and Chris googled “pregnancy + cancer treatment” and cried. Theirs was a pregnancy that was planned and very much wanted.
I closed my computer screen. Elbows on desk. Head in hands. I was in upstate New York, about halfway through a ten-week writing residency. Most days, I wrote in the mornings, sifted through research and reporting in the afternoons, and spent the evenings trying not to think about Ben. My belongings were in Colorado, part of my heart was still in Houston, and every day I wrestled with concentrating on my work. The residency was an incredible opportunity, one I didn’t want to squander with the nagging anxiety I felt about returning west to live with my parents until I figured out my next move. But all that felt trivial compared to what Bridget was going through: learning that she had breast cancer and that she was pregnant on the same day. Forty-eight hours after being diagnosed, Bridget was thinking not about her body but about her future babies. Babies she had always been sure she’d have. Cancer means chemotherapy and chemo threatens fertility. We take it for granted, all of it, until one day there’s a lump and a biopsy and suddenly you are a recently married woman on the cusp of thirty, with a job you love and a cat named Nancy Drew and a pregnancy you’re longing for, and cancer growing in your chest.
After getting the okay from Bridget, I called my mother and told her about Bridget’s diagnosis. We talked about breast exams and how radiation can damage ovaries and scar the uterus. I felt a newfound personal appreciation for ART and the scientific capability that existed and that would, I so deeply hoped, preserve my cousin’s fertility, her ability to have biological children, the family she had always wanted.
Bridget’s oncologist recommended she start chemotherapy as soon as possible; triple-negative breast cancer grows fast. Bridget and Chris met with a surgeon, who explained that options for breast cancer treatment in the first trimester are limited. If Bridget’s health was the top priority, she couldn’t be pregnant when she started chemo. Then they visited a reputable fertility center and learned Bridget couldn’t start the process of an egg retrieval until at least six weeks after ending a pregnancy, because it would take time for the pregnancy hormones still in her body to normalize. She and Chris made the devastating decision to terminate the pregnancy, and a week before starting chemotherapy, she had a D&C.[*6]
Ultimately, Bridget wasn’t able to harvest eggs from her ovaries before starting chemotherapy. Her tumor had already grown quickly; there wasn’t time to delay treatment for several weeks. The awful irony is that if she hadn’t been pregnant, she most likely would have been able to do an egg retrieval. But needing chemo right away meant she couldn’t safely stay pregnant, and terminating the pregnancy meant she didn’t have time to undergo fertility preservation before starting treatment.
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A month after starting chemotherapy, Bridget’s genetic testing results came back: She was BRCA1 positive, which made her more susceptible to getting certain types of cancer. Our family later learned that Bridget’s father—my mother’s brother—also had the gene mutation. He’d never had cancer, and neither had his siblings, but he urged them to get tested. The child of a parent with the BRCA1 mutation has a 50 percent chance of inheriting the variant, and having a mutated BRCA gene greatly increases a woman’s chance of developing breast and ovarian cancer and a man’s chance of developing prostate and male breast cancer. Our family was worried: If my mother tested positive for BRCA1, it would mean my siblings and I each had a 50 percent chance of having inherited the mutation, too, as Bridget had.
During those long weeks of waiting and worrying, I did another egg freezing one-eighty. There was no question that I would freeze my eggs as quickly as possible if I learned I was BRCA1 positive. I was so relieved when my mother learned she didn’t have the mutation. But the waves that Bridget’s cancer sent reverberating through our family—the females, in particular—lingered, and in my case they forced me to think anew about egg freezing in the face of yet another potential threat to my fertility. Life went on, but a new realization crystallized: Fertility-related decisions do not exist in a vacuum. The journey to figure out and make decisions about my fertility was, it turns out, inextricably tied up with my love life, career, physical and mental health—areas of my life that, often despite my best intentions, cannot be neatly compartmentalized.
I remembered something Lesley, the nurse who was diagnosed with breast cancer not long after freezing her eggs, told me: how she wished she had dedicated more time to understanding the procedure in detail. “I didn’t have any questions,” she told me, “so I just went for it.” But, barring an urgent medical need like Bridget’s, egg freezing isn’t always an easy or simple decision. That, at least, I now knew with certainty. I also understood that most potential egg freezers had neither the time nor the desire to spend months or years studying the nuances and underlying questions. For better or for worse, though, that’s what I’d decided to do, and by now I had researched the whole process long enough to go well beyond its shiny surface. At the core of my analysis paralysis was the realization that the decision to freeze was wrapped up in a tangled web: motherhood, marketing, medicine, money, and, now, even mortality. I couldn’t know what might happen in the future. Cancer. Infertility. More romantic disappointments. A career that sputtered and fizzled out. Never feeling financially secure. But I knew I wanted to have a say about a lot of it. I wanted to control what I could.
Skip Notes
*1 The hefty profits are in part because many patients pay for treatment out of pocket. So clinics often receive cash directly, rather than seeking reimbursement from health insurance companies, which tend to negotiate down the costs of services.
*2 When I asked Kindbody about this in April 2022, a spokeswoman for the company relayed: “We’ve had ten oocyte thaw cycles from eggs that were frozen at Kindbody. Only one patient has had a transfer as of now and she is pregnant.” (When I reached out in October 2023 for an update, the company’s response was that the ten oocyte thaw cycles was the most current figure they could offer.) This doesn’t mean that Kindbody, or any newer clinic, is less adept at freezing eggs, necessarily; it just means they don’t yet have the pregnancy rates from women who’ve frozen eggs with them to point to as a proven measure of success.
*3 One ironic example of this: Last Valentine’s Day, I received an email from a prominent national chain of fertility clinics with a discount code for 20 percent off an egg freezing cycle. The subject line read: “Here’s a special gift in honor of self-love.”
