*8 In contrast, several other countries have national ART regulatory agencies. The best known is the Human Fertilisation and Embryology Authority, the United Kingdom’s independent regulator overseeing the use of sperm, eggs, and embryos in fertility treatment and research.
*9 There’s also a murky third: the Clinical Laboratory Improvement Amendments (CLIA), passed by Congress in 1988 and administered by the Centers for Medicare and Medicaid Services (CMS). CMS, FDA, and the CDC have joint responsibility for the law, which requires that all diagnostic lab work performed on humans (in a fertility patient’s case, semen and blood testing) adhere to quality standards. But CLIA doesn’t extend to embryology, which involves the retrieval of eggs, their fertilization, and the transfer and storage of eggs and embryos. These procedures do not fall under CLIA’s mandate.
*10 The tanks are considered medical devices, which the FDA does regulate—but it doesn’t regulate the use of the tanks. The agency does not, for example, ask clinics to disclose how often tanks malfunction or how many specimens have been accidentally destroyed.
*11 ASRM acknowledges that if fertility clinics and doctors were required to follow ASRM guidelines, it “might improve the uniformity of practice nationwide.” Even so, ASRM maintains that ART is highly regulated in the United States. But the examples it points to supporting this assertion all have caveats—the ones I’ve dug into here.
*12 Save for their patients, which nearly all of the fertility doctors I spoke to in the course of reporting this book consider an important responsibility.
*13 Most clinics require that couples sign a contract prior to creating embryos that states their agreement about the fate of any remaining embryos after undergoing IVF.
*14 Reflecting on how Arizona’s law gives the court guidance on how to award frozen embryos when there’s a dispute during divorce proceedings, Cathi Herrod, president of the Center for Arizona Policy, said: “Just like a judge will decide when there are disputes over property, disputes over who gets the family dog—now, who gets the family embryos—will also be decided by a judge according to the law.”
*15 The party/spouse who’s against the reproductive use of the embryos is usually absolved of legal parental responsibility for any resulting children. But they’re still being forced by the state to become a genetic parent against their will.
*16 Most clinics require patients to sign a contract stipulating their frozen specimens be stored for a set number of years, and after that period of time patients can renew their contract.
*17 Especially when I zoomed out from frozen eggs and considered that there are studies showing that children born with the help of fertility treatments face various increased health risks. See the Notes section for examples.
*18 Name has been changed.
*19 Especially because, as she noted, the women freezing their eggs now are much younger than the first wave of egg freezers, of which she was part; they’re also waiting longer before attempting to use their frozen eggs.
*20 Freezing eggs at an older age, it bears repeating, increases the likelihood of their being chromosomally abnormal, which is a reality of age and genetics. And, again, the freezing and thawing processes carry their own risks.
*21 A different and more pragmatic half that’s also important to see: Brigitte pointed out the importance of considering and learning about actually using the eggs you’ve frozen. It’s quite involved, as we’ve seen, and as she said, “If you’re going to spend all that money on the first part—the freezing—you also have to know what goes along with that, especially cost-wise, to make a baby from those frozen eggs.”
*22 For more on choosing a fertility doctor and the importance of the lab, I recommend FertilityIQ’s five-module course on the subject (there’s a fee, but it’s worth it): fertilityiq.com/the-ivf-laboratory/introduction-to-the-ivf-laboratory-and-course-plan.
15 Reproduction Reimagined
Inconceivable
The beginning of the pandemic fell at the blurry line between late winter and early spring in Colorado. We didn’t know anything about the coronavirus or how long we’d be hunkered down for. All we really knew, in those first months of 2020, was that a plague was upending the world. Covid-19 deaths mounted, the numbers unfathomable. New normals rearranged themselves in our homes, our grocery stores, our lives. We began wearing masks everywhere. We grew more afraid. We doom-scrolled. We settled in. I waited to feel anxious about spending so much time alone in my apartment. I thought I would resist the stillness, find ways to distract myself from quieting down. I’m good at drumming up noise when I fear solitude. Instead, as the weight of the days changed, as I felt time slow, I slowed with it. I learned the sounds of my neighborhood, the small slice of downtown Boulder I call home. I felt both opened up and tucked in; tender parts were exposed, but I wanted to keep them nestled. I walked the streets at dusk, struck by the hush, the empty sidewalks. I lay on the living room floor and hugged my legs to my chest, marveling at what it felt like to not be doing and going every minute of every day. I spent days with only myself and enjoyed it. I remember how that felt like a small miracle.
One thing I did not do during the pandemic that scores of other women did was freeze my eggs. In the context of a global pandemic, fertility preservation took on a new, urgent meaning. The number of women freezing their eggs had already been increasing year over year at fertility clinics across the country, and the uptick continued during Covid—despite the fact that most clinics were forced to shut down and suspend fertility treatments during the pandemic’s early months. There was an overall 39 percent increase in egg retrievals compared to pre-pandemic levels and, interestingly, a notable increase in egg freezers under age thirty-five, as well as a significant decrease in time between patients’ initial consultation and their egg retrieval. Between August 2020 and October 2021, Shady Grove Fertility, which has more than forty locations across the country, saw a 95 percent increase in women freezing their eggs compared to the same fifteen-month period pre-Covid. Kindbody quadrupled its revenue and tripled its number of clinics in 2021. NYU Langone Fertility Center saw almost three times the number of women—overall younger patients—starting egg freezing cycles in 2022 compared to 2019. And in the United Kingdom, where egg and embryo freezing cycles are the fastest-growing form of fertility treatments, clinics saw a 60 percent increase in egg freezing from 2019 to 2021, which experts said was in part prompted by the pandemic.
At first, I was amazed by the extent of the pandemic’s impact on the egg freezing market. Then I spoke with a few reproductive psychologists and understood the larger context that such a seismic event had on how people thought about fertility and family. For many women, myself included, as life became quieter, our eggs became louder. The pandemic gave us the opportunity to reconsider so much: where we live, how we work, whom we date, and what kinds of families, chosen and biological, we want to cultivate. Amid the anxiety of Covid, and the dating drought that it precipitated, many of those who could afford it—or who still worked for employers that pay for it—invested in egg freezing.
There were practical reasons for why many women felt that the pandemic offered them more of a window to pursue egg freezing. Thousands of them suddenly found themselves with more time, working remotely and traveling less. Many had more funds available since they were spending less money. Others, who combated isolation by moving back in with their families, had more emotional support as well. Existential reasons played a role, too. Sharon Covington, director of psychological support services at Shady Grove Fertility, told me that as many women sat at home, unable to date, considering what they most valued in life, “they realize that time is ticking. They feel extremely alone and isolated and think, ‘Well, I don’t know if I’m going to find a partner, but I know I want to have a family and I want to keep that option open.’ And so they decide to pursue egg freezing.”
This was true for Fatima,[*1] who told me the pandemic prompted her to freeze her eggs in September 2020, when she was thirty-six. Originally from Pakistan and now living in Los Angeles, Fatima told me about the pressure she’d felt from cultural norms to get married and start a family in her twenties. She’d wanted to be a mother for a long time, but in her thirties she began to make peace with not having biological children when she realized she was one of the last of her siblings and cousins to not have kids. But then the pandemic brought on an overwhelming sense of grief that she might be out of options if she did decide to one day have children. Then her employer—she works in the education sector—started offering fertility treatment coverage through Carrot, a fertility benefits company. “The pandemic made me feel such a lack of control over everything in my life,” said Fatima. “There’s so much uncertainty and ambiguity. Freezing my eggs was something I could have control over. And that felt really empowering.”
—
You would think, perhaps, that in this context—when life is on hold but eggs continue aging, as they are wont to do—I, too, might have decided to do it. It was, on paper, an extremely appropriate moment. I was thirty now. I wasn’t dating; no one was, really, and our social lives were on hold for the foreseeable future. I sometimes caught myself mulling over the prospect of children with more urgency than I ever had before. You’d think it would be easier for me to rationalize egg freezing in the absence of the “right” partner. And so you might think that, more than at any other point in my journey, this was the opportune time to freeze my eggs. You’d probably be right on all counts. But as logical as it very well might be, I couldn’t seem to make the logic work. I’d done the research, thoroughly examined all the angles. And yet I still didn’t arrive at the conclusion I’d thought I would, the one that would allow me to freeze my eggs and sleep at night, confident in my decision.
I am not alone in not knowing how to navigate this moment, I thought what felt like a thousand times during the pandemic. Control was on my mind in a different way now, my brain ablaze with the frustrated urge to “take control” that had come to dominate my and so many others’ lives during this unprecedented event. How do we navigate the loss of control? My answer, at least in part, was to throw myself into learning about what the future might hold for egg freezing—the final puzzle piece of my quest.
—
One aspect of egg freezing that had not changed during the pandemic, despite the droves of women doing it, was the fear that the technology would ultimately not deliver on its promises. Perhaps it was naïve of me to think the data on success rates would have materialized by now, but for the most part, they hadn’t.
“I really believe that the generation of women now who are freezing their eggs are trailblazers,” said Dr. Shahine, the reproductive endocrinologist in Seattle, on a video call in April 2020. “And these are the people who, in five or ten years, will help us find out really how well it works for people. Because, right now, we just don’t have the data.” Through my computer screen, I noticed her face showed real concern. I wasn’t used to seeing her brow furrowed; on Dr. Shahine’s educational TikTok and Instagram videos, which are famous in the fertility world, she’s usually lighthearted and sarcastic, in a funny way. “I worry that there’s going to be a huge backlash against my industry and the doctors,” she went on. “That when people come back to use their eggs and they don’t work, they’re going to be really angry because they’ll feel like they weren’t counseled well.”[*2]
Deborah Anderson-Bialis, of FertilityIQ, had mentioned this potential backlash to me a while back. “I think it’s inevitable that a large number of people will be disappointed when their eggs don’t work,” she said. “There will be a reckoning. And I believe that will make the places that are marketing this as a very easy quick fix and a guarantee look bad—and I don’t think that’s a bad thing.” In a 2021 New Yorker article, Peter Klatsky, a San Francisco–based reproductive endocrinologist and co-founder of Spring Fertility, put it more strongly: “When women come back for their eggs, it’s going to be a nightmare,” he said. “It’s going to be really bad for our whole field. It could make people say, ‘Well, egg-freezing doesn’t work,’ because there’s massive variability” in outcomes between clinics. The experts I spoke with agreed that it was a matter not of if an egg freezing backlash would occur but when. One way to mitigate it: more honest and educational conversations now about the likelihood of using frozen eggs successfully.
In the several years I’d been researching and reporting on egg freezing, two major changes had transpired: one, the decreased stigma surrounding egg freezing, and two, the massive jump in employers paying for it—although accessibility and affordability remained major issues. Soon, hopefully, we’ll be able to add increased transparency and realistic expectation-setting to that list, as potential egg freezers become better informed.[*3]
As I continued to think about the technology’s flaws, I also kept dwelling on how the dawn of egg freezing coincided with a relatively novel sentiment: For many women, being able to have children when they want them is the ultimate sign of independence. This symbol of autonomy is more central to a modern woman’s sense of self than perhaps anything else. We may look back and be able to say egg freezing was the next revolution for women’s reproductive lives. But even if it’s not—even if it doesn’t end up affording women the chance to recalibrate their baby-making timelines the way they hope it will—we will almost certainly acknowledge egg freezing’s powerful role in changing how we think about fertility, family, and feminism over the past decade.
Then, while sitting at home during the pandemic thinking about the many women rushing to freeze their eggs and wondering why I wasn’t, I learned about a fertility technology company that had the potential to, at long last, solve one of the industry’s biggest problems: the protection and well-being of eggs and embryos on ice. As soon as it was safe to do so, I got on a plane to see for myself.
Fertile Ground
In April 2022, I flew to New York City to visit TMRW Life Sciences, a biotech start-up whose technology automates reproductive tissue’s storage and management. All the buzz I’d heard about the company—backed by Peter Thiel, Google Ventures, even Amy Schumer—had me thinking that this cryostorage venture was the future of fertility in the way that mattered most.
Walking up to the company’s U.S. headquarters in Lower Manhattan, I passed kids playing dodgeball in the sun next to a school, the sort of normal scene that now, two years into the pandemic, struck me as precious. I rode an elevator up to TMRW’s main floor and was escorted to a small room where I took off my mask and took a rapid test, per the company’s Covid protocols. Several minutes later, Cynthia Hudson greeted me. With her pearl studs, gray loafers, and collared shirt under a blue half-zip pullover, Hudson gave off both scientist and corporate vibes, which was fitting, since she’s TMRW’s vice president of clinical strategy and an embryologist with more than two decades of experience. She led the way to a massive room on the street level, where TMRW’s white, sleek cryogenic freezers—the company’s CryoRobots—are kept. The company’s latest model, the CryoRobot Select, looked as if Apple had made a super-sophisticated extra-large ATM machine that stored and dispensed frozen eggs and embryos.
Of the many advancements ART has seen since the beginning of human IVF nearly fifty years ago, one major facet has remained mostly unchanged: the shockingly analog method of storing frozen reproductive tissue. Founded in 2018, TMRW is changing that with what it calls “the world’s first automated platform” of integrated software and hardware that digitally tracks frozen embryos, eggs, and sperm. The software developed by the company uses radio frequency identification, or RFID, an identity management coding system. RFID, which works similar to the way a car’s VIN number or a book’s ISBN number does but also uses tags and readers, replaces the handwritten labels that most fertility clinics use to identify patients’ gametes and embryos. The wireless system also records an audit trail, which automatically captures the data of who did what and when and constantly monitors tanks’ levels and temperatures. The company’s hardware is the CryoRobots, which are similar to the storage tanks, or dewars, that most clinics use to store frozen reproductive cells. Traditional dewars, though, resemble old-fashioned metal milk cans that you might find on a farm; TMRW’s tanks reminded me of a refrigerator-sized R2-D2, the Star Wars droid, for their technology-powered capabilities.
With the TMRW’s FDA-cleared system, when a patient is ready to use their eggs or embryos, a robotic mechanism picks the specimen and delivers it to the embryologist, as a vending machine might. Sensors within the CryoRobots conduct thousands of automated checks daily to monitor the safety and well-being of the tissues inside. (The company’s motto: “TMRW never sleeps so you can.”) This is especially impressive considering that the only way to check on a person’s eggs or embryos with the current method of frozen tissue storage is to manually open the tank and lift them out of the liquid nitrogen, which disturbs other patients’ specimens unnecessarily.[*4]
As we stood talking next to one of the massive freezers, Hudson alternated between standing with her hands tucked in the pockets of her dark jeans and excitedly demonstrating to me how the CryoRobot Select’s iris-scan security feature worked. As a seasoned embryologist, Hudson knew firsthand how unsustainable the current low-tech and human-error-prone systems used by most of the country’s fertility labs were. “These are incredible professionals,” she said, referring to embryologists, “but we’ve got to arm them with better tools. And I think patients are very quickly going to start insisting on that, as soon as they know that they’re an option.” Maybe Hudson’s passion was contagious, or maybe it was remembering what it felt like interviewing patients at the cemetery in Ohio after the tank failures and seeing dewars lined up wall-to-wall and shoved under desks in the back offices of fertility clinics I’d visited, but as I peered inside a CryoRobot, I felt a rush of excitement, convinced I was looking at one of the fertility industry’s biggest advances in decades.
If Kindbody is the SoulCycle of fertility, TMRW’s monitoring system is the industry’s Google Nest Cam meets ADT Home Security, providing real-time information about frozen specimens and identifying issues before something happens. The command center manages data from every TMRW CryoRobot in the country, remotely monitoring clinics’ systems through its predictive analytics. Eventually, patients will be able to check in virtually on their eggs or embryos, too, via TMRW’s app (which is still in development). A pre-baby baby monitor, one might say.
