Another egg freezing obstacle that had stymied scientists was that sperm ordinarily cannot penetrate an egg that has been frozen and thawed. But a new method, called intracytoplasmic sperm injection, or ICSI, in which sperm is injected directly into eggs, had recently been introduced. ICSI is similar to conventional IVF insemination in that, after eggs and sperm are collected from each partner, the eggs are fertilized and, hopefully, become embryos that are transferred to a woman’s uterus and develop into a fetus. But the method of achieving fertilization is different. Conventional insemination entails placing the eggs in direct contact with sperm—mixing them in a petri dish in the laboratory—so that large numbers of sperm can swim around and ultimately one fertilizes the egg; basically the “best sperm wins” dynamic of natural conception. ICSI takes a more hands-on approach: An embryologist uses a needle to inject a single sperm into each egg. Dr. Porcu began experimenting with injecting sperm directly into frozen-then-thawed eggs. In 1997, just a few years after ICSI was developed and after the Italian doctors had been working together for a decade, Dr. Fabbri and Dr. Porcu were the first to report a baby born from a frozen egg using ICSI.
By building on the techniques of other doctors and their own discoveries, the Italian doctors had changed the destiny of egg freezing. The altered cryoprotectant solution and the use of ICSI together had made all the difference, resulting in the first pregnancy of its kind in the world. In 2001, Dr. Fabbri received a worldwide patent for her novel method and solution for cryopreserving human eggs. On the heels of her team’s breakthrough, three further significant developments would kick off the egg freezing revolution.
Game Changer #1: Vitrification
By the early 2000s, scientists managed to conquer the cryoprotectant solution problem, paving the way for bettering the method the Italians had developed that had improved frozen egg survival rates. Technological advances now gave scientists the ability to flash-freeze eggs using vitrification, which made the freezing process more reliable. Until 2003, when it was proven that vitrified eggs could successfully yield live births, the only way to freeze eggs was through slow-freezing, a method that often produced the harmful ice crystals I mentioned earlier. Vitrification, on the other hand, chills the eggs to –196 degrees Celsius in a fraction of a second. The ultra-rapid cooling technique prevents ice crystals from forming more reliably than the Italian doctors’ novel cryoprotectant discovery had. Vitrification significantly improved egg survival and pregnancy rates: Flash-frozen eggs have an 85 to 95 percent survival rate, compared to a 60 to 80 percent survival rate for slow-frozen eggs. The improved technique quickly became a firmly established technology, and is the current cryopreservation method the vast majority of fertility clinics rely on.
Initially, egg freezing was done only for reasons of medical necessity. The first women to take advantage of the Italian doctors’ promising flash-freezing method were cancer patients who froze their eggs as a way to save their fertility before undergoing treatments known to harm reproductive organs and fecundity. Some chemotherapy medications destroy eggs, and eggs are exceedingly sensitive to radiation; both treatments can leave a woman sterile. For a young woman diagnosed with an aggressive form of cancer, the ability to preserve her healthy eggs outside of her body can mean everything. But it didn’t take long for egg freezing to move beyond the “for medical reasons” realm. The possibility of extending the shelf life of one’s eggs was enticing, and before long, healthy women began raising their hands to freeze their eggs.
Game Changer #2: No Longer Experimental
In 2012, the American Society of Reproductive Medicine (ASRM), the fertility industry’s principal professional organization, lifted the “experimental” label on egg freezing. This was a big deal. A big-tent membership organization covering all areas of reproductive biology, ASRM was founded in 1944 by a small group of fertility experts to address the need for more research into infertility and more widely disseminated information on the subject. When the ASRM decided egg freezing should no longer be considered experimental—despite the lack of quality research on the procedure—their declaration raised eyebrows.
ASRM is governed by a rotating board of directors, a group of about twenty MDs and PhDs. Like other multidisciplinary professional associations, ASRM is a long-standing unified forum for debate within its field and wields a lot of influence. Fertility doctors and clinics pay close attention to what it does and does not advise when it comes to the ethics and efficacies of reproductive technologies. So when the organization changed its stance on egg freezing and issued a report to practicing clinicians across the country, the U.S. fertility industry leaned in with perked ears.
More than nine hundred babies had been born from frozen eggs by 2008, the year ASRM labeled the procedure as experimental. With that designation, ASRM approved the use of egg freezing only in clinical trials overseen by an institutional review board. Despite the society’s recommendation, many clinics offered egg freezing outside of this framework, as a clinical service for a fee, without securing informed research consent from patients, which is required for any experimental procedure. Ethically problematic, to be sure, but for at least one subset of egg freezing patients—women with cancer, desperate to preserve their fertility before undergoing chemotherapy or radiation—there wasn’t time for long clinical trials. One reason ASRM wanted to take a fresh look at the process was to make it easier for doctors to freeze the eggs of these cancer patients without the obstacles of informed research consent.
That was all well and fine, but after reviewing nearly one thousand egg freezing studies, the ASRM committee stopped short of giving egg freezing for non-medical reasons the green light. “There are not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women,” the report stated. While early studies on egg freezing proved reassuring—largely due to the improved freezing and thawing techniques—there wasn’t yet enough to go on for women who wanted to freeze their eggs simply to delay childbearing. So ASRM lifted the experimental label, but with a caveat, concluding there were still too many questions about the procedure to warrant its use in women beyond those with cancer and other fertility-threatening medical conditions. Other prominent associations agreed. The American College of Obstetricians and Gynecologists (ACOG) joined ASRM in discouraging egg freezing for non-medical reasons because, in addition to the lack of data and research, too little was known about its personal, social, and scientific ramifications.
When the 2012 report was published, Dr. Samantha Pfeifer, ASRM committee chair at the time, reiterated the committee’s decision: “While a careful review of the literature indicates egg freezing is a valid technique for young women for whom it is medically indicated, we cannot at this time endorse its widespread elective use to delay childbearing,” she said. “This technology may not be appropriate for the older woman who desires to postpone reproduction.” ASRM’s position was clear. But the caveat was quickly downplayed by clinics eager to market this new offering. In the end, removing the experimental label opened the door to a much wider audience.
To some degree at least, ASRM understood the impact that upgrading non-medical egg freezing from experimental to standard would likely have. It certainly knew that many women were interested in this emerging technology, because the association had actually said so in its 2008 report maintaining that egg freezing was not an established medical treatment. The 2012 report, in which ASRM reversed its stance—egg freezing was now an established medical treatment—took its cautionary tone regarding egg freezing’s potential widespread use up a notch, then up again. Scientific advancements such as egg freezing may allow women the opportunity to have biological children later in life, the report said, but “while this technology may appear to be an attractive strategy for this purpose, there are no data on the efficacy of oocyte cryopreservation in this population and for this indication.” And then the committee took it even further with a warning: “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing.”
Game Changer #3: Apple and Facebook
Yet two years after the ASRM decision, in October 2014, Apple and Facebook announced they would help cover the cost of egg freezing for female employees, offering up to $20,000 per person. The news that some of the biggest companies in Silicon Valley were now subsidizing the procedure for women with no known fertility issues as part of their benefits packages immediately set off a controversy, and debate ensued. Employers paying for non-medical egg freezing applies even more pressure on women to keep working while putting their personal lives on the back burner, went one argument. This levels the playing field for women, went another. I followed and joined the debate along with my feminist friends, and considered what such a benefit said about how companies regard young female employees and how we as a country treat mothers. That was a larger and ongoing conversation, I knew, one I was becoming increasingly attuned to as my thirties loomed. But, frankly, I was more interested in the practical, achievable aspects of this new technology, especially since now I no longer felt like such an oddball for seriously considering undergoing egg freezing myself.
While IVF has been around for decades, it was only since the mid-2010s that egg freezing really took off. Of the five hundred or so fertility clinics in the United States, almost all offer egg freezing. At these clinics, between 2009 and 2022, nearly 115,000 women opted to freeze their eggs,[*8] and the number of procedures to freeze eggs quadrupuled between 2015 and 2022. That growth was spurred in part by Apple and Facebook’s announcements, which in turn ushered in the benefit at an increasing number of large companies (more on that in chapter 9).
The night the news broke—spokespeople for both Apple and Facebook told an NBC News reporter about their companies’ new perk—I happened to be at another egg freezing event in New York City. Now that I knew more, and had learned I was a good candidate, I wanted to see how I’d feel about it when I heard the pitch again. It was a cool autumn evening, and inside the Harvard Club, the mood was light and full of intrigue. Women sipped wine and crunched on veggies they’d piled onto cocktail napkins. Again I was several years younger than most of the women in the room. Again I couldn’t help but think of Carrie Bradshaw. I wore my blue-light glasses so that I would look older and not attract as many stares as I had at that first EggBanxx event, the looks that said, You and your young eggs don’t belong here. Drinks in hand, we took our seats under a glistening glass chandelier and listened to doctors sing the praises of egg freezing.
A few days later, I saw my first egg freezing ad on the subway. “To Emma (Age 42). Love Emma (Age 30),” the blue-and-pink poster on the Q train read. “If you are not ready to have a baby, freeze your eggs now and give yourself the gift of time.”[*9] And then I began to notice targeted ads on my social media feeds. One, sponsored by a boutique fertility clinic in Manhattan, featured a pink illustration of a sperm wiggling its way into an ovum. “When you freeze your eggs, you #freezetime,” the ad read. “How often do you get to do that?” The ads, in combination with the celebrity endorsements and new employer-covered fertility preservation perk, shimmered with the illusion of control. That powerful idea: control. Until I saw egg freezing ads on the subway and my Instagram, I wasn’t aware that my fertility—present, future, or otherwise—needed to be controlled. Or that it was something I was supposed to be controlling. And control doesn’t come cheap. The answer to “How much does egg freezing cost?” requires an involved discussion we’ll get to in chapter 9, but the average cost of one egg freezing cycle in the United States is roughly $16,000, which includes the doctor visits, the medications, and the average number of years of egg storage—and most women do more than one cycle. Insurance rarely covers it. Some employers do, as I said, but most women pay for it themselves.[*10]
The Apple and Facebook announcements would prove to be a watershed moment, helping to mainstream both the concept of egg freezing and the conversation around it. Egg freezing, it seemed, was suddenly everywhere. Meanwhile, the confluence of two trends—older parents and increased insurance coverage for IVF—meant that demand for fertility services continued to rise. But questions lurked. What do fertility preservation technologies actually offer women, and what are our fantasies surrounding them? Is egg freezing a genuine help and good investment, or is it merely a bad bet laced with hope? And: how to judge whether or not the potential future upsides are worth the expense, yes, but also the consequential risks—of which there are several, I’d come to learn.
One thing I was crystal clear on after this second egg freezing event was that the pressure to procreate has a timeline and echoes warnings: “Before it’s too late” and the tick-tock, tick-tock of our uteruses. A week or so after the event, I called Barbara Collura, executive director of RESOLVE: The National Infertility Association, a nonprofit advocacy organization, to seek her advice about where to start in my quest to find objective answers about egg freezing. “I wouldn’t even know where to tell you to go to get really great, unbiased information,” she said. “There’s nothing out there for women. You want a third-party, credible source—and not to be tied to somebody who’s trying to sell you on doing this—and it doesn’t exist.” At first, I felt pretty deflated hearing that. But her declaration also stirred in me a quiet defiance to prove her at least partially wrong; surely there was some helpful, scientifically sound information about egg freezing out there for women.
Pros and Cons
Late one October evening in my Brooklyn apartment, I sat cross-legged in bed, eating salad out of a Tupperware container. It was my third semester of graduate school. A string of delicate paper-lantern lights bordered shelves brimming with books. On my bedside table, a scented candle burned. My journal lay open in my lap. I needed to clarify some basics; lists are good for that. I flipped to a blank page and scribbled: What egg freezing is:
A back-up plan
Hope and peace of mind—I think?
Promising technology; keeps getting better over time
Supported by lots of big companies
A very good option for many women What egg freezing is not:
An insurance policy—right?
Risk-free
Inexpensive
A guaranteed way to prevent my fertility from fading
A very good option for many women
I studied the lists. I finished my salad. On my desk lay a faded, two-pocket folder labeled “Surgeries.” Tucked inside were medical records, copies of doctor’s notes, pamphlets on egg freezing, and a handful of Polaroid-sized pictures of my ovary. From my perch in bed, I reached for the folder and lifted a recent ultrasound image from one of the pockets. I held it up to the light. In the narrow white space beneath the fuzzy picture, I had written: Just me and my ovary, giving this all we’ve got.
I sat wrapped in a patchwork quilt I had made out of T-shirts I’d collected as a child and teenager. Running my hand across the soft cotton squares, I smiled, recalling nicknames and jersey numbers, celebrations and milestones. When it comes to having children and being a parent, I am drawn to the ineffable mystery of motherhood, the seductive veneer that nothing has been able to penetrate—at least for me, and, I believe, for many women—despite how much and how fervently motherhood and all it entails is discussed and picked apart in our culture. My mother’s experiences being pregnant and giving birth have a lot to do with my romanticizing early motherhood. She talks about it in a way she doesn’t talk about anything else—not her decorated career as a U.S. Army officer and government lawyer; not the few dozen countries she’s visited; not even her forty-five-year-long marriage to my father. She has also made giving birth sound easy and joyful (yes, really). My mother is not a martyr, nor does she have an unusually high tolerance for pain. But she did birth three babies, all without epidurals, IVs, or pain meds—not even Tylenol. (She wasn’t opposed to medical intervention had something gone wrong; she just hadn’t needed it.) And when she talks of nursing my siblings and me, her normally rapid-fire voice slows and she sighs in satisfaction, in reverence, as if she’s sharing a secret about some magical land she once visited. “Breastfeeding my babies is the single most satisfying and wonderful experience of my life,” my mother has told me more than once. She says it triumphantly and I believe her completely.
Perhaps the in-my-heart certainty is a seed watered by my mother’s stories. I am her firstborn daughter. It would not be until years later, when my friends began having kids, that I would come to realize that, for many women, pregnancy is not easy or joyful, epidurals are a polarizing topic, and breastfeeding is not something that all women love or even want to do. Even so, where my mother’s tales of pregnancy and childbirth left off, I want mine to begin. Of course, I have no way of knowing if I will one day have the unmedicated, low-intervention birth experiences she did, but I can’t help but imagine I might. And, also like her, I want to have children with a person I love and am committed to. I have always wanted this. I have always planned on it.
A few weeks before that list-making night in my apartment, I’d returned home after being out of town for my brother’s wedding. I took the subway from the airport and by the time I arrived at my street it was quite late. I pulled my purple suitcase along the sidewalk and wondered how many times I’d done this exact thing, returning home alone after a trip. A fierce loneliness took hold. As I walked, I felt as if a hole in my heart was growing bigger, block by block. Inside my empty apartment, I unpacked, made a ham sandwich, stood at the kitchen island, and cried. Then I shook my head hard, as if to fling off the sobs. Stop it, I berated myself. You’ve lived on four continents and traveled all over the world. You’re close with your family. You’re earning a master’s degree from one of the top journalism programs in the country. My life was full—but I felt deeply alone. I wanted to lug my suitcase next to someone else lugging theirs, then climb the stairs to my fifth-floor walk-up together. I wanted to make this ham sandwich for someone else.
My last serious relationship had ended two years earlier. I hadn’t had much time or energy to devote to thinking about a new one since moving to New York, but now that I was feeling settled, I was ready to not be single anymore. I wasn’t yet facing the intense time pressures I knew single women in their thirties often feel, and I wasn’t old enough to worry about the expiration of my fertility. But my missing ovary was beginning to haunt me, saying otherwise. It used to remind me of painful surgeries and hospital stays; now it reminded me of too-close calls and the quiet ticking of my biological clock, of egg freezing and my forever desire to have a family.
A few months before the Apple and Facebook news broke, Bloomberg Businessweek reported: “Not since the birth control pill has a medical technology had such potential to change family and career planning.” The questions were coming faster now: Was egg freezing really the next revolution for women’s reproductive lives? Did it give women real agency, or just the illusion of it? Would I be among a generation of women buying into a grand experiment? As I sat on my bed that night, I realized I was almost certain I wanted to freeze my eggs. But I needed to do something about all these questions and figure out why egg freezing was being so readily and widely embraced and if in fact it was, or could be, as good as it sounded. To better understand the nuts and bolts of egg freezing, I decided, I needed to go back to the science, and lay out all the facts and implications as best I could.
That sounded like a lot of work. And many more lists.
Maybe there was a better place to start.
Maybe I could find someone who had decided to do it.
