Why do I believe that this sex education problem isn’t likely to change anytime soon? Because regardless of the science, sex ed is political. In the United States, it is extremely difficult to pass legislation to improve states’ sex ed curricula; many have tried and failed. But if we can’t teach young women and men about their bodies and sex—comprehensively and transparently—in school, then where? There is no forum for teenagers to talk about sexual development, self-exploration, or how bodies actually work. No place, really, to learn about masturbation or the female orgasm. No safe space in which to shake the shame that society promotes by using euphemisms for genitals.[*4]
One girl I spoke with told me she thought she was dying when she first got her period. Another said the first person to touch her clitoris was somebody else. Yet another believed something else Coach Carr said in Mean Girls to be true—“If you do touch each other, you will get chlamydia and die”—until she contracted chlamydia in her late teens and did not, in fact, die.
I thought about these anecdotes and the myriad forces shaping sex ed policies while I sat inside the gym that morning, scanning the roomful of fresh-faced teenagers. I couldn’t get over how young they looked. I thought about all that they were not learning that day. Boys clueless about condoms. Girls thinking STIs could kill them.[*5] I worried about how misguided our priorities are when it comes to educating young people about their bodies and shaping their ideas and attitudes about sex, and how the patchwork quilt of sex ed laws across the country means that many, many kids receive either abstinence-only lectures or nothing at all. The truth is, if the goal of sex ed is to prepare young people for real-world activities and decisions, it seemed pretty clear that we were failing.
Eggs and Female Gonads: A Primer
It’s not rocket science to figure out that there is a direct connection between understanding our bodies and understanding our reproductive choices. The disturbing thing is that the fuzziness with which we stumble around, sorting out a few of the basics early on, here and there—“What’s a cervix?” the girl had whispered—sticks around, like a layer of dust on an out-of-reach shelf, well into adulthood. Our practice of more or less ignoring sex education in schools has resulted in a nation of young people who aren’t adequately informed about reproduction and fertility, and then as adults they are making choices about their lives—in particular, putting off having children while they pursue careers, degrees, relationships—without understanding the limits of their biology. Meanwhile, reproductive technologies that young people may or may not want to avail themselves of, now or in the future, continue to evolve and change. As Jess, a young woman I interviewed soon after she graduated from college, put it: “Knowing reproductive options leads to big decisions. And if we aren’t educated about these options, then how can our big decisions be truly informed?”
Numerous studies over the past two decades have determined that many young women know very little about the limits of their reproductive systems. One, a 2020 U.S. Department of Health and Human Services report that summarized findings from a survey of three thousand people between the ages of eighteen and twenty-nine found that fewer than half of the women respondents knew that the ovaries do not keep producing new eggs until menopause, and only 65 percent were aware that women’s fertility declines sharply after their mid-thirties. The authors noted that the respondents’ lack of knowledge “may have grave implications for their ability to plan their fertility” and that some of the topics about which the respondents were mistaken “may lead women to delay getting pregnant to a time when they may be at high risk of infertility and possibly involuntary childlessness.”
Other research focused on fertility awareness has borne out the argument that young adults of reproductive age want to have children but are not sufficiently informed about age-related fertility decline and infertility risk factors. They also tend to seriously overestimate fertility potential and chances of conceiving, both naturally and through assisted reproductive technologies; on top of the misconceptions they have about age and fertility, many women also believe that medical treatments can dependably extend the biological clock into a woman’s forties and fifties. That, as we’ll see, is hardly the case.
The reason researchers are beginning to look closely at how young people think about fertility is, in part, because of another trend: Women don’t tend to seek help for infertility until they’re in their late thirties, by which point their chances of getting pregnant and having a healthy baby are already diminishing. And this translates into the fact that women know very little about a crucial component of female fertility: their eggs.
—
“If you have never had trouble with your eggs,” writes Natalie Angier in Woman: An Intimate Geography, “if you have never had to worry about your fecundity, you probably haven’t given your eggs much thought, or dwelled on their dimensions.” Tiny but fierce, human eggs are powerful pieces of biological tissue. An egg, or ovum, to use its more scientific name, is the female reproductive cell. It’s the largest cell in the human body, even though it’s barely a tenth of a millimeter across—roughly the size of a grain of sand. An egg is also about thirty-five times the width, and ten million times the volume, of a sperm cell (a fact that I think women ought to brag about more often, considering how many men take great pride in their—eye roll—“seed” and strong and agile “swimmers”). Boys don’t make sperm until they reach puberty, at which point they begin producing fresh sperm every few months; most men create around two trillion sperm cells in the course of their lives. Contrast that with baby girls, born with one million to two million egg cells in their ovaries—but that’s all they get.[*6]
Human egg cells, or oogonia, as they’re called when they start to develop, begin their formation while the fetus is still in the uterus—specifically, in the ovaries of the female fetus, at about seven weeks’ gestation—and start maturing individually in adolescence. By puberty, a young woman has about 25 percent of egg cells remaining of the couple million or so she was born with.[*7] Over her reproductive lifetime, beginning with puberty and ending with menopause, she’ll release one egg per month for some five hundred months.[*8] Her eggs are kept within a vault in her ovaries, where they grow inside little fluid-filled pouches called follicles, one egg per follicle. Every month or so, an exquisite scientific selection takes place deep inside her body. In one of her ovaries, a single dominant follicle begins to develop, and the immature egg cell—an oocyte—growing inside it is anointed The One. As the follicle gets bigger, the oocyte nestled within transforms into a full-fledged mature egg—or ovum—and, through a complex hormonal chain of events, is solicited for ovulation, which is when the follicle bursts and the egg is released.
But what about all those potential eggs that are not chosen as The One? Throughout a woman’s youth and early middle age, a proportion of her oocytes are neatly destroyed through a process of programmed cell death called apoptosis. With the start of her menstrual cycle and until menopause, approximately one thousand oocytes die every month—with only one of those thousand destined to ovulate. The average woman has between three and five hundred thousand oocytes remaining when she reaches puberty. By age thirty-seven, she has approximately twenty-five thousand, and as she approaches menopause, very few oocytes remain. Of all these immature eggs, however, just five hundred or so become mature eggs—normally one egg per month that’s released through ovulation, as I mentioned—with baby-making potential.
So, women are overbudgeted with eggs; they are born with a huge surplus and most eggs just sit there in the ovaries, aging. Nonetheless, eggs are finite, and as a woman gets older, she starts running out of functioning ones. There isn’t any rollover; at the end of the fiscal period, management says buh-bye to assets that don’t get used. This phenomenon, the degrading and dying, is completely natural, and independent of any hormone production, birth control pills, pregnancies, nutritional supplements, or health or lifestyle components. It’s just what happens when Nature does her thing. “The eggs do not simply die—they commit suicide,” Angier writes. “Their membranes ruffle up like petticoats whipped by the wind and they break into pieces, thence to be absorbed bit by bit into the hearts of neighboring cells. By graciously if melodramatically getting out of the way, the sacrificial eggs leave their sisters plenty of hatching room.” By the thousands, the eggs make their graceful exit. It is a choreographed dance of coming into and out of being. A ritual as old as time.
—
Eggs were on my mind when, not long after I’d sat in on the sex ed class, I met a friend for happy hour. She was twenty-eight, had a master’s degree from an Ivy League university, and worked in the publishing industry. We ordered appetizers and got to talking about some of my recent research and reporting. “Wait,” my friend said, putting her glass of wine down sharply in surprise. “You’re telling me I have thousands of potential eggs? Like, right now, in my body?”
“Yep,” I said, reaching for a Parmesan crisp.
She stared at me, eyebrows raised in shock. “I honestly thought I had four or five—total,” she said.
“Hmm,” I replied. “I think you’re thinking about ovaries? Most women have two of those.”
“No, I know about ovaries,” she said. Her face brightened. “Whoa. I can’t believe I have thousands of eggs. This is exciting!” She picked up her wineglass and took a big swallow.
As empowering as it feels to be born with so much potential life nestling in our bodies, women should keep in mind that the ovary is the first organ to age in such a profound, literally life-changing way—at least twice as fast as other organs in the body. And while that fact spurs a wide range of emotions for many women, it’s simply an objective biological truth. Here’s another: A woman’s fertility is determined by the quantity and quality of her eggs. As she gets older, her reproductive system slows down and both her egg quantity and egg quality diminish, as the number of egg-containing follicles in her ovaries undergoes a steady decline. Fewer eggs means fewer chances to conceive each month. And older eggs have more chromosomal abnormalities, making it increasingly difficult to become pregnant. So, a woman’s age is the most important predictor of her ability to get pregnant. By her mid-forties, her chances of having a pregnancy without assisted reproductive technology are exceedingly low.[*9]
While all that may sound alarming, fertility decline over time is less of a cliff than it is a hilly terrain—with a few peaks and valleys, fluctuating periods of fertility and infertility—that gradually gets steeper, particularly in a woman’s mid- to late thirties. “There’s no one age where a woman turns into a pumpkin,” said Dr. Anne Z. Steiner, a reproductive medicine specialist and professor of obstetrics and gynecology, in an interview with The New York Times about a study she published on measuring female fertility decline. “The difference between 30 and 33 is negligible. But the difference between 37 and 40 is going to be pretty drastic.”
You can see why it’s a problem, then, that many women postpone childbearing in their most fertile years, and then expect to be able to successfully conceive as soon as they try—and, if they can’t, that fertility treatment will be a cure-all. When I asked Arthur Caplan, a bioethicist at NYU Langone Medical Center, about this, he said as much: “There is this notion that you can get pregnant whenever you want—the technology is here, we’ve got the answers, it’s in your control. But spending your twenties thinking just about not getting pregnant is not consistent with how your eggs work.”
Preventing pregnancy is fear-based dissuasion, as we’ve seen, rooted in our school health classes. The messaging we experience as we grow up directs us toward other worthwhile pursuits: education, work, travel. Starting a family is an undertaking for later. And then all of a sudden—at least that’s how it feels—we’re in our late twenties and early thirties and besieged with warnings about our fading fertility. There’s very little breathing room between these polar opposite messages of “prevent pregnancy” and “preserve fertility.” As a modern American woman in the heart of this demographic, I can’t help but feel confused. And frustrated. I see mixed messages everywhere. I’m told to lean in. I’m told to quiet down. I’m told I should want to have it all. I’m told I can’t. I grew up using various forms of contraception, spending the majority of my fertile years avoiding pregnancy, and then, after I am “launched” into a fledgling career and relationships, I learn that my eggs have a shelf life, may even be nearing their expiration date, and I should seriously consider freezing them—yesterday.
Egg Freezing Appointment #1
EggBanxx had made an effective pitch. Only two weeks after their egg freezing party, I was sitting in the waiting room of a New York City fertility clinic, filling out a long questionnaire. The morning of the appointment, I woke early. In the shower, I rehearsed my answers—and explanations for not having answers—for questions I knew I’d be asked: Date of your last period? Why are you interested in egg freezing? Ah, you only have one ovary? Tell me about that. I shampooed my hair, already feeling mildly exasperated about telling yet another doctor the serpentine story about my ovaries.
I took the subway to Grand Central and walked several blocks northeast to NYU Langone Fertility Center. On a corner near the clinic’s entrance, I paused. It was a crisp, sunlight-streaked morning, the kind that lifts the mood of the whole city—and mine, too. I took a deep breath.
In the waiting room, I completed the new-patient paperwork and signed my name what felt like a dozen times. I expected to be taken to an exam room when my name was called, but the nurse led me to a fancy office and instructed me to wait. I sank into an overstuffed chair and looked around. Taped to the wall above the desk was a piece of pink construction paper with purple flowers drawn as tall as trees. “Dear Nicole,” it read, in a child’s scribble. “Thank you for helping me be born.” Next to the drawing was a plaque announcing Dr. Nicole Noyes as New York magazine’s Doctor of the Year. This was the fertility doctor who had handed me her business card at the EggBanxx party. When I made the decision to make an appointment to discuss egg freezing, I’d dug up her card from the goodie bag I’d stashed in my closet. This initial consultation, at least, would be covered by my graduate student health insurance plan.
NYU Langone’s was one of the first egg freezing programs in the country—it began offering the procedure for non-medical reasons[*10] in 2004—and Dr. Noyes was one of its pioneers. After this appointment, I’ll hear and see Dr. Noyes’s name everywhere—in newspaper articles, on panels at reproductive technology conferences, in conversation with other fertility doctors, from women whose eggs she had frozen. That morning, though, all I knew was that she was kind of a big deal.
Dr. Noyes walked into the office, having just finished a conversation with a nurse in the hall. “Hello, hello,” she said, holding out her hand for me to shake. She had short brown hair, bangs, fashionable glasses, a white coat. In her fifties, if I had to guess. I was immediately struck by how hip and smart she seemed, fiery and cool at the same time. She sat at her large desk and began peppering me with questions about my life—my education, my writing, my aspirations. She made a few nice comments about my accomplishments and told me I was impressive. We discussed aspects of my medical history in detail. The surgeries, all the scares. She asked me if I wanted biological children someday. “More than anything,” I replied. My voice came out soft and I suddenly felt self-conscious. That feeling of high stakes was back. “But after I lost my ovary—after the unilateral salpingo-oophorectomy…,” I said, the o’s rolling off my tongue before I realized I was trying to sound smart. What was I trying to prove?
“Are you nervous?” Dr. Noyes said abruptly.
“No! I mean—well—” I stammered. I tried to explain that I’d come to believe my two unrelated ovary emergencies happened for a reason. That I thought it was perhaps not a coincidence I was sitting in her office. If there was a silver lining to my surgeries, I said, it was that I’d been forced to confront my fertility before it was Too Late. Dr. Noyes pushed her glasses to the top of her head and studied me. The all-business, no-nonsense demeanor from the EggBanxx event had faded some; something in the way she was asking so much about my life, and not just my reproductive system, felt…human. “It’s rare for someone your age to have had two major surgeries like the ones you’ve had,” she said. “It’s pretty hard for an ovary to do a full twist. And torsion—that’s a real fierce pain.” I nodded. I thought about how, in the days before my first surgery, when I was twelve and the pain was most acute, I’d get down on my hands and knees, pounding the floor as I cried.
Dr. Noyes and I started talking about birth control and women postponing motherhood. “We’re basically blocking our biology,” Dr. Noyes said. “We get this big message like it’s wrong to have a baby when you’re most fertile—and what women do with that information, I think, is critical. You can’t just turn a blind eye and say, ‘I’ll just deal with it when I’m ready.’ The fact is, you’re fertile from, like, sixteen to thirty-eight. Everything after forty is a gift.”
She flipped through pages of health records I’d brought along. When she got to my visit with the fertility doctor who told me I had a “lovely” ovary, she furrowed her brow. “ ‘Lovely’?” she said, glancing up at me. “That’s not a medical term.” I half-shrugged, feigning ignorance, choosing not to gush to this cool doctor about just how much that comment regarding my ovary had meant to me back then—and still did now.
We talked about my irregular periods. “It just bleeds, gets confused,” said Dr. Noyes, referring to my ovary. “You’re probably not ovulating, not releasing eggs. That’s good—more for me.” She wet her finger and continued turning the pages of my chart. Almost to herself, she murmured: “We can also sew it to the wall to stop it from moving.” I had no idea if she was joking or not.
“I’m not concerned you’re going to lose the ovary,” she said, looking up at me again. “I don’t want to understimulate you and only get, like, five eggs. I want to get at least ten.” I blinked. Another sharp turn; we’d arrived at egg freezing. Dr. Noyes continued: “And you’re at such a good age. You have so much ahead of you.” She took her elbows off the desk and for a moment I thought she was about to clap. “It’s gonna be awesome,” she said. “Just awesome.”
Dr. Noyes didn’t explain egg freezing in detail to me that day. I took notes while she glossed over the basics, and I filled in the holes with my own research later. The procedure has multiple steps: ovarian stimulation, egg retrieval, and freezing. A woman getting ready to have her eggs retrieved must first give herself shots of hormones to ramp up her ovaries, coaxing them to grow more eggs to maturity than the usual one per month. More on the specifics of fertility drugs later, but here’s the gist: In a normal menstrual cycle, remember, a single follicle containing a single egg bursts at ovulation and releases the egg. With egg freezing, the self-injected drugs hyperstimulate the follicles in the ovaries so that a couple of years’ worth of immature eggs—upward of a dozen or more—mature in a single month, with the hope that all or most that are extracted will be frozen.
A woman injects herself daily in the comfort of her home—or vacant conference room at work, or restaurant bathroom, or wherever—over the course of ten to fourteen days. Throughout the days of shots, she returns to the fertility clinic every few days to have the size of her follicles monitored and for blood work to check her hormone levels. Then, when her ovaries are plump and ripe, teeming with what the doctors hope are dozens of eggs, she is put under sedation in a private room at the clinic and her eggs are surgically removed, in a “no scar, no stitches” procedure that takes less than half an hour. During the egg retrieval, a doctor, guided by ultrasound technology, pierces the vaginal wall with a long, thin needle and pushes through to the ovary, maneuvering the needle to puncture one follicle after another. One by one, the doctor draws the follicular fluid into a test tube using light suction. Floating within the fluid are the eggs. Once extracted, the eggs can be frozen unfertilized, or they can be injected with sperm and made into embryos, which can then be either frozen and put in cryogenic storage or else transferred to the uterus right away.
Learning about the procedure from start to finish reassured me. I was already beginning to be swayed by egg freezing’s hope, by how well it seemed to fit into my plans for organizing my life and planning for the future. Also, though, I suspected the process was expensive—possibly prohibitively so—as well as unpleasant, and not without its risks.
Dr. Noyes said she wanted to run blood work and a few tests. Amazingly, once I was in the exam room, I relaxed a little. These uncomfortable surroundings, at least, were familiar. The stirrups, the overhead lights, the flimsy gown. I climbed onto the padded table, the tissue paper crinkling beneath me, and let my knees fall to either side. As she nosed the ultrasound wand inside me, Dr. Noyes peered between my legs and motioned to the screen to my left. “Your left ovary is quite active,” she announced. I smiled. Medical term or not, I felt proud. It was lovely, my active ovary. Good job, you. I left the clinic with an ultrasound image of my ovary and a strong recommendation to freeze my eggs. I stepped out onto East 53rd Street, clutching the small picture in my hand as I made my way to the subway. The sun warmed my cheeks. Nearby, the East River glistened under the vivid blue sky. I straightened my posture and tightened my backpack straps around my shoulders, walking a little taller. I realized I was grinning, for no particular reason except I felt pleased that a renowned doctor thought I was a good candidate for egg freezing. I knew more about my fertility than when I’d woken up that morning, and this struck me as significant.
Back at my apartment, I taped the black-and-white picture of my ovary and follicles to the fridge. There it stayed, an image that came to be the Rorschach inkblot it resembles. I could feel its significance gathering inside of me, this Polaroid-sized printout—and, later, ones just like it—that represented what fertility and motherhood had come to mean to me: all that I’d lost, or almost lost, and all that I had to look forward to.
