TMRW works with more than fifty clinics across the country, some of which operate networks of multiple centers, who have or are in the process of ditching their dewars for TMRW’s CryoRobots and automated system. The company is expanding overseas, too. It’s also developing several regional bio-repositories that it plans to use, in addition to its New York facility, to store gametes and embryos from patients around the country. Patients can store with TMRW through their fertility clinic or individually; the company charges individual consumers about $600 a year, as of this writing, to store with TMRW directly, which is on the lower end of average annual storage costs.[*5]
TMRW begins its pitch by predicting that between two hundred million and three hundred million IVF babies will have been born by the end of this century. Some fertility experts find that number too conservative, actually, but TMRW’s point is that most of these IVF births will rely on tens of millions of frozen eggs and embryos—a mind-boggling amount that would quickly overwhelm the current IVF infrastructure. TMRW sees itself as the solution for the hundreds of thousands of fertility patients requiring frozen gamete storage in coming years. And we do need a solution. In the wake of the 2018 tank failures and as embryo mix-ups make headlines with more frequency, patients have every reason to be scrutinous about how their frozen reproductive tissue is handled. Joshua Abram, TMRW’s founder, likened the catastrophes to the sinking of the Titanic. “When we think about the Titanic on its inevitable path to the iceberg, it’s clear now that the failure was in not having enough lifeboats—and in not having the foresight to see issues before they become problems,” said Abram when we first spoke. “That’s a fairly apt metaphor for what’s happening in fertility clinics today. The risks are hidden most of the time.” Hidden though they may be, risks should be planned for, before they lead to devastating consequences—as indeed they have. TMRW hopes to preempt the extreme headlines as well as the day-to-day fertility clinic lab errors that go unseen, making the loss or mixing up of eggs and embryos never-events.
Tara Comonte, who served as TMRW’s CEO until June 2023, came to the femtech start-up from Shake Shack, where she was president and chief financial officer. Like many women in the fertility technology space, Comonte is also an IVF mom; she had her daughter when she was in her early forties. The five frozen embryos left over from her IVF cycles are housed at TMRW’s cryobank at its Manhattan headquarters, to which, in early 2023, Comonte moved them from the clinic where she’d undergone fertility treatment. “We’re in a whole new generation of patient transparency and I think it is overdue,” said Comonte, who is fifty, when we spoke a few weeks after my visit. “[Most] patients have no idea how outdated the processes are for storing their precious eggs and embryos. And I think there will be shock and reality checks when it’s realized how many decades the storage process has sat unchanged.”
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A few months later, I spoke with a woman whose story was one of several I’d heard that made the need for more reliable storage options for reproductive cells painfully clear. In June 2022, Danielle was eight months pregnant and scrambling to figure out how to move her and her husband’s remaining frozen embryos out of Texas. Roe v. Wade had just been overturned, and Danielle, like many people across the country living in more restrictive states who have eggs and embryos left over from fertility treatment on ice, was afraid of how the ruling would impact her embryos. She and her husband decided to move them to a different state; they’d travel there to use them if they chose to have another child.
When Danielle called her fertility clinic to ask about moving her embryos, she was told the clinic didn’t know where they were. The clinic eventually located them, but Danielle was shaken. “It was something I never questioned until now: where my embryos are, who’s watching them, and how safe they are,” she told me. I was reminded of how most fertility patients have no good alternative with regard to storing their genetic material once they choose a clinic and are locked into their facility’s storage methods and prices. Then, on social media, Danielle learned about TMRW and reached out right away. She was the first individual patient whose embryos TMRW arranged to transport to its New York facility.
Of course, there are risks to replacing humans with digital machines as custodians, but the likelihood of human error surpasses that of a CryoRobot confusing barcodes on petri dishes. The more I considered TMRW’s revolutionary technology, the worse the fertility industry’s status-quo method of storing and monitoring reproductive tissue seemed. What kind of investment—which frozen eggs and embryos certainly are—can you never see, check up on, verify? When do you ever spend thousands of dollars and not receive reassurance that what you paid for and entrusted the safekeeping to has gone unharmed? It seemed so obvious, the fertility industry’s need for a long-overdue redo of a faulty system. But even obvious deficiencies take time to fix.
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Groundbreaking reproductive technology lingered in my mind in the weeks after my TMRW trip. A crucial component of cryopreservation’s future, it was clear, is automation. Scientists will continue to shape the future of fertility, of course, because they’re the ones who’ve brought us the techniques we have today. But egg freezing isn’t the only innovation changing ART’s landscape. “The ability to fertilize an egg outside of a woman’s body, without sexual congress between two human beings, has led to a host of other advances and reproductive improvisations that can extend and expand the scope of possibility for when and with whom (if anyone) we can have children,” writes Rebecca Traister in her book All the Single Ladies. Entire texts have been written about what’s on reproductive medicine’s horizon, but a few of the discoveries and technologies in development are too wild for me not to mention.
Ovarian tissue freezing could be the next egg freezing. The procedure’s experimental label was removed in 2019, and as the technique has continued to advance, hundreds of live births have resulted. Doctors surgically remove a woman’s ovary, or part of it, then freeze the egg-producing portion of the ovary—the outer layer of ovarian tissue that contains the follicles. When the woman is ready to try to get pregnant, the strips of ovarian tissue are thawed and transplanted back into her body to restore fertility and endocrine function.[*6] The procedure has mostly been performed on prepubescent girls about to undergo chemotherapy to treat cancer who want to preserve their fertility (egg freezing isn’t an option for them). But it can also be—and is being—used by adult women who don’t have time to freeze eggs before cancer treatment, transgender men hoping to retain the chance to have biological children, and women wanting to delay menopause. In this case, a woman has slices of her ovary taken out (as with egg freezing, the younger she is, the better) and, once she enters menopause years later, doctors graft the tissue back into her body, thereby restoring her sex hormones, which pauses menopause and its unpleasant side effects.
Uterine transplants. In December 2017, in Dallas, Texas, a woman who was born without a uterus gave birth. That landmark event, part of an ongoing uterus transplant clinical trial at Baylor University Medical Center, was the first of its kind in the United States. “When I started my career, we didn’t even have sonograms,” said Dr. Robert T. Gunby Jr., the OB/GYN who delivered the baby, in an interview with Time. “Now we are putting in uteruses from someone else and getting a baby.” While uterine transplants likely won’t become mainstream—there’s no need for them to—it’s a revolutionary procedure for the right type of patient, and a big breakthrough for reproductive science.[*7]
Drugs that could prolong female fertility. Ovarian aging has long been an understudied field, but that’s starting to change, as experts studying reproductive longevity attract more funding and attention for their efforts to figure out how to make ovaries work for longer. Their research could lead to learning how to extend a person’s reproductive years, and potentially life span, by delaying menopause. Scientists have also identified a drug that prolongs egg viability in microscopic roundworms—their unfertilized eggs show an age-related decline in quality similar to that of human eggs—which could theoretically extend women’s fertility by three to six years. Drugs that slow down menopause and prolong the ovaries’ natural functioning are already in development.
Artificial intelligence is helping embryologists better select embryos most likely to result in a healthy birth. On a larger scale, the ability to more precisely pick viable embryos to implant could improve success rates, reduce the risk of pregnancy loss, and bring IVF costs down. Also in the works: editing eggs and sperm to rid them of diseases.
Artificial wombs. Researchers have developed rudimentary artificial uteruses, proving that it’s possible to separate natural gestation from the process of having biological children. And human embryos have been grown in ectogenesis, the process of human or animal gestation in an artificial environment, for several years now. Although years away from being a reality, complete human ectogenesis and the potential for “motherless births” will have myriad moral and legal implications, particularly with regard to abortion rights.
Ovaries grown in a lab. In 2021, five years after successfully converting skin cells from a mouse into fertile eggs, two Japanese reproductive biologists constructed an ovary organoid—a mini organ-like structure—made entirely from stem cells in mice. The pair of scientists are now trying to repeat the construction of mini-ovaries with human stem cells, also with the goal of using them to grow an egg. New ovarian stem cell discoveries have researchers working on building an artificial ovary that could produce eggs and jump-start hormonal function for cancer survivors, as well as potentially delay menopause.
Egg-making technology. IVG, or in vitro gametogenesis, refers to converting nonreproductive adult human cells into artificial gametes. The emerging technology involves custom-making human eggs and sperm in the laboratory from any cell in a person’s body. For fertility patients, IVG would solve the problem of not having enough eggs, because there’d be no need to harvest them. And if lab-made eggs and sperm could be derived from a person’s stem cells to create embryos, solo parents could create a child on their own and same-sex couples could have biological children that share the genes of both partners. Finally, this technology could remove, or at least dramatically reduce, the concerns about exposing young, generally healthy women to the high doses of hormones that are currently necessary to stimulate egg production. IVG “is on the precipice of materialization,” a reproductive biology specialist told NPR in 2023. “And IVF will probably never be the same.”
Researchers have also spent years exploring how to mature eggs that have been extracted from the body. This process, called in vitro maturation, or IVM, is when a woman’s immature oocytes are extracted and then “ripened” outside the body. The ASRM recently declared the technology to be nonexperimental. IVM, which eradicates the need for most of the self-injected, ovary-stimulating drugs and thus requires less medication, money, and time than conventional IVF and egg freezing, is the primary focus of Gameto, a biotech start-up founded in 2020.[*8] The company, which hopes to make fertility treatment safer and more widely accessible, was co-founded by Martin Varsavsky—who, you’ll recall, founded Prelude, the nationwide fertility clinic mega-network.
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Fertility treatment for women has been focused on making the best possible use of whatever women have left. That will change when we discover a way to regenerate human eggs via stem cell technology, perhaps the most consequential of the on-the-cusp technologies mentioned above. Part of the future of fertility will lie in developing new procedures and techniques—but part of it lies in better understanding the technologies we already employ. When the Italian doctors who developed egg freezing technology started working together in the 1980s, they never envisioned egg freezing as a way to fulfill women’s desires to “have it all.” Except that’s precisely how we’ve come to view it—and we’re rapidly embracing egg freezing without pausing to consider, for one thing, how society is changing as more and more people postpone childbearing. Or what it means—what it says about our modern culture, about us—that so many women, myself included, do not feel free to be pregnant when we are fertile and young.[*9]
Revolutionary technology is by nature bound up with contentious benefits and repercussions, as well as terribly exciting implications. And the fact that it is now possible for almost anyone with adequate resources to become a parent is terribly exciting. When you stop to think about it, it’s wild that humans are reproducing in ways that would have been unimaginable just several decades ago. As social ideas about coupling, mating, and parenting continue to change, the pioneering technological developments in the works mark the beginning of a new era of reproductive medicine, with major implications for fertility research and beyond.
Medicine, Morality, and the Pursuit of Parenthood
Around this time, I caught up with my cousin Bridget. Needing to start cancer treatment immediately meant she couldn’t freeze her eggs beforehand. Instead, she received monthly Zoladex shots—a type of hormone therapy that stops the release of LH, so that her body stopped producing estrogen—which effectively shut down her ovaries during chemotherapy, the aim being to help preserve her fertility.
When Bridget woke up after her mastectomy in more pain than she has ever experienced before or since, her first thought was: I never want my daughter or granddaughter to go through this. She and Chris knew it would be a while before she was cleared to try to become pregnant, but they started to delve into family planning options, aware of the 50 percent chance that their children would inherit the gene mutation. They decided that if her fertility held up and if they could afford it—two very big ifs—they would genetically test their embryos and select the healthiest one to get pregnant with via IVF. They’d use PGT-M, a test performed on embryos that looks for the presence of a specific, disease-causing gene, making it possible to identify which embryos do not have a BRCA gene mutation.[*10] By now, Bridget was confident she was going to survive cancer, but she was consumed with worry that it was going to prevent her from having a healthy family. Of course I’ll beat cancer, she wrote in her journal the week she was diagnosed. But to think that this may rob us of the ability to have a family is something that I can’t get over. At Chris’s graduation from business school, Bridget sat in the audience crying, thinking about how in a different version of life she’d be sitting there with their toddler, instead of wondering if she’d ever have one.
When Bridget’s period came back a few months after she finished chemotherapy, her oncologist told her she had “very strong ovaries.” She was elated. While she waited for the okay from her doctors to begin freezing embryos, she did what she normally does in stressful situations: making to-do lists. She researched insurance options, joined online support groups, and stared at her and Chris’s savings account balance.[*11] Roughly two years after she was diagnosed and six months after completing cancer treatment, Bridget underwent her first egg retrieval, fertilizing the eggs with Chris’s sperm and genetically testing the resulting embryos. Over the next three years, she raced the clock, undergoing six egg retrievals in an effort to get as many BRCA1-negative embryos on ice before needing to have her fallopian tubes and ovaries surgically removed.[*12] Because of IVF and the ability to genetically test and select embryos, Bridget was freed from the worry and guilt of potentially passing on BRCA1 via a spontaneous pregnancy.[*13] Using her and Chris’s chromosomally normal frozen embryos, she gave birth to a son when she was thirty-three and, later, a daughter. Neither child has the BRCA1 mutation.
“I feel overwhelmingly grateful that science allows us to make this choice to give the rest of our family a little bit of a safer life, and that we have had the insurance coverage to do it,” Bridget told me.[*14] People with fertility-threatening medical conditions often struggle to cobble together funding from various sources to preserve their fertility, which adds significant financial pressure to an already stressful situation. The current political climate surrounding reproductive rights has made her gratitude swell, too. “When I needed an abortion, I almost immediately got a safe and legal appointment at a clinic less than three miles from my house,” she said. “I could afford it. I think about this a lot: how many women and couples, especially now, who have to make the same heartbreaking decision we did, don’t have the access or means to give themselves the best possible chance to treat cancer. How infuriating that is. How that’s the opposite of ‘pro-life.’ ”
Genetically testing embryos is complicated, and there are certainly drawbacks in addition to the many positives. But Bridget’s story is a clear-cut example of the power of both IVF and genetic testing. As I reflected on all she’d gone through, I was once again struck by remarkable science and technologies that enabled her to have biological children—why such technologies were invented and what they make possible, as well as all they were leading to. ART has already changed millions of lives for the better. It will continue to do so. But I also understood another, more dispassionate, perspective: Just because we can make a baby using certain tools does not mean we should. Biological boundaries and ethical guidelines demand that we consider the question that’s on the tip of our tongues: Just how far can science push the boundaries of human fertility? Just how far should it?
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Our field, more than ANY field in medicine, has the ability to literally change society as we know it, the text on my phone screen read. It was from Dr. Anate Brauer, director of IVF at Shady Grove Fertility New York. I’d been pinging her with questions about the implications of the latest biomedical technologies I’d been learning about. Fertility doctors like Dr. Brauer, I knew, had long been weighing the potential ramifications of these newer ART developments, and my recent conversations with her and other experts had helped me to clarify some of their moral and ethical implications.
As genetic testing becomes more sophisticated and commonplace, decisions about screening embryos and making disposition choices about them will become more difficult. It’s a slippery slope. IVG could supercharge the path to designer children. DNA editing in human embryos raises ethical questions about the prospect of controversial gene-editing techniques being used clinically to correct defects in, or even enhance, embryos. Such a laboratory process would also permit unfettered genetic editing with DNA engineering tools such as CRISPR,[*15] which is already sharpening some of the old tensions that came with IVF: the specter of selective abortion and eugenic selection of offspring. Before this happens, though, advances in human genetic engineering are likely to play out through preimplantation genetic testing. As geneticists become more proficient in mapping out DNA sequences that correspond to specific human attributes, PGT—which already allows sex selection, used by IVF patients in the United States all the time—may be increasingly used to screen embryos with far more detail, including for intelligence and even cosmetic traits. For people like Bridget, PGT is life-changing, making it possible to have children without passing on certain debilitating gene mutations, but it’s not difficult to imagine the procedure becoming another form of ART adopted for elective, widespread use by the public.
And so the ethical and philosophical debate about the reproductive revolution rages on, bringing us back to the lack of regulation in ART and how that lack has contributed to the fertility industry growing rapidly, without many legal or ethical constraints. To that end, the authors of the book Babies of Technology have outlined what it would look like to create a federal administrative agency that would be responsible for maintaining a database of all ART cycles and use of eggs and sperm in the United States. Advantages of having such an agency, the authors say, include monitoring advertisements for fertility clinics to ensure accuracy and—arguably most important—assuring equal access to fertility treatments for people of all socioeconomic levels. This regulatory body could also establish detailed rules governing how clinics operate and provide consequences for those that do not comply. It’s a compelling vision—and a shame nothing like this is in the works yet.
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More broadly, these scientific developments point to a future in which reproduction is moved entirely outside the body. In The End of Sex, the Stanford bioethicist Henry Greely writes about the coming obsolescence of sex for the purpose of conceiving children. He contends that the technological developments within genetics and stem cell research mean that, in the near future, “humans will begin, very broadly, to select consciously and knowingly the genetic variations and thus at least some of the traits and characteristics of our children.” So we’re dealing with a real beast here, a fact I did not fully grasp or appreciate until well into this journey. The more I learned about how technology is fundamentally altering reproduction, the more enthralled I’ve become with the inefficient, complex, impossibly random act that is creating human life. I have also grown quite fond of my single ovary and would like for it to someday produce an egg that meets a nice sperm to grow in a welcoming nest of a uterus inside me. Most women are still having babies the old-fashioned way. But if Greely’s prediction is accurate and the act of sex to make a baby is going by the wayside, well, I look forward to a ride at the carnival before it closes.
A few years ago, on the day after Christmas, my brother and sister-in-law pushed a holiday card across the dinner table for my mother to open. Inside was a sonogram, the expected due date handwritten on the back. My parents beamed—their wish to be grandparents was coming true—and I burst into tears that were partly from shock and partly from joy, completely overwhelmed with emotion. My brother and sister-in-law’s first child, a healthy baby girl, was born several months later, in the middle of the pandemic. It was a humbling reminder that, for all we try to anticipate and control, choices around some of life’s biggest moments unfold differently for all of us.
Throughout the pandemic, I found myself thinking about how I felt after Ben and I broke up: unsure of so much, except for knowing that something fundamental was missing from our relationship—a mutual deep level of trust and respect, I realized only in hindsight—and how, without it, I couldn’t move forward, couldn’t make it work in my head or my heart. I now felt a similar way about egg freezing. For a while, I couldn’t trust whatever decision I made or unmade about egg freezing unless I was sure I’d done my due diligence to understand every aspect of it. And so as my journey progressed, I went farther and deeper to find the answers I sought, trusting the world—science, stories, stone-cold facts—more than I trusted myself. But the farther afield I went, the more I realized that the answers to this particular search lay closer to hand. It was an inkling I’d first had on a trip to Italy, not so long ago—a moment when everything shifted.
Skip Notes
*1 Name has been changed.
*2 Now, however, Dr. Shahine is more optimistic. She feels people are more aware about egg freezing’s lack of guarantee these days, as well as about the procedure’s pros and cons. She’s less worried today than she was when egg freezing cocktail parties were all the rage years ago. And she’s heartened by the increasing number of people who share their egg freezing stories—not just successes, but failures, too. “People are much better prepared for egg freezing’s [various] potential outcomes,” she said. I can’t say I fully agree with her, but her changed stance made me feel more hopeful.
*3 Researchers are working on tools to help people considering egg freezing make the right decision for them. I’m hopeful that this represents a move toward more openness about the real costs and benefits of egg freezing.
*4 One dewar—the type typically used at fertility clinics—can usually hold the specimens of about two hundred patients. TMRW’s machine can hold about twenty times more.
*5 TMRW offers discounts if a patient prepays for multiple years of storage. ReproTech, a large network of cryobanks, offers patients similar prepay discounts, and also has lower-than-average storage prices. Generally speaking, a patient can often bring down their egg storage costs—sometimes by half—if they arrange to have them moved from the clinic she froze at to an offsite storage facility.