Skip Notes
*1 Before I tell you more about this part of Sanger’s story, it must be acknowledged that Sanger believed in eugenics—an inherently racist and ableist ideology that labeled certain people unfit to have children—which undermined her movement for reproductive freedom and caused harm to many people. It’s one of many awful examples of how the fight for reproductive rights in the United States has also been marked by an ugly alliance with the eugenics movement.
*2 Prior to FDA approval, when promoting birth control was still illegal in many states, oral contraceptives were prescribed to treat menstrual issues.
*3 In the mid-1950s, Enovid clinical trials were conducted on more than two hundred women living in a housing project in Puerto Rico. The women were not told that the Pill was experimental or that there was a chance of potentially dangerous side effects. Nor were they told that they were taking part in a clinical trial, which was being run by biologist Gregory Pincus and gynecologist John Rock. Three women died, and their deaths were not investigated.
*4 I was glad to see that the Pew report notes that its use of the term “mother” “refers to any woman who has ever given birth, even though many women who do not bear their own children are indeed mothers.”
*5 As a 2023 CDC report noted, “Having a first child at older ages has been associated with a positive impact on women’s wages and career paths, in addition to having a positive impact on their children because they are more likely to have parents with greater family and economic stability.”
*6 The New York Times noted that the rise “subsided in 2020 with the pandemic, when the overall birth rate in the U.S. dipped, but the rate among women in their late forties grew.”
*7 Also, though, increasing numbers of young women under the age of twenty-five—Gen Z women—are opting to freeze their eggs. “The average age of my egg freezing patients is rapidly declining every year,” Dr. Serena Chen, the fertility doctor who spoke at the first EggBanxx party I attended, told Vice in 2023.
*8 As of this writing, the actual number to date of women in the United States who have electively undergone egg freezing is likely closer to 150,000. More on this in chapter 8.
*9 These newer, more upbeat ads have replaced those plastered on buses in major U.S. cities since the early 2000s, like the one featuring an image of a baby bottle shaped like an hourglass, running out of milk.
*10 This is a huge health equity issue. More on this in chapter 9.
4 Hacking Our Hormones
Remy: Egg Freezing Orientation
A little after eight o’clock on a cool Nashville morning, Remy opened the door to her apartment and headed straight to the bedroom. She fell face-first onto her bed, too tired to peel off her scrubs. Sophie, her cat, padded in to greet her. Remy lay on the soft white duvet for a few minutes, eyes closed, hoping to nap. But her racing mind wouldn’t let her. Get up and get it together, she told herself. Her appointment at the fertility clinic was in a couple of hours; she needed to be alert. Just wash your face, brush your teeth, let’s go, let’s go. She took a deep breath and pushed her tall, lean frame to a seated position on the bed.
An anesthesia resident at Vanderbilt University Medical Center, Remy was used to crawling into bed when most people were beginning their days. Night shifts bled into days spent sleeping; weekends were indistinguishable from the Monday-to-Friday hustle. She didn’t mind the relentless routine, really—life was busy, and good—but she found she especially looked forward to her appointments at the fertility clinic, where she would soon be freezing her eggs. The visits reminded her of the future—of her future, and what it held. There’s so much more to come, she thought often.
Remy had made the decision to freeze her eggs a couple of months earlier, shortly after her birthday. Thirty-three had long felt symbolic to her. Unabashedly superstitious, Remy had always imagined having kids at this age. This year of medical residency was going to be her year for children. But things in the love department hadn’t exactly gone as planned, and so now thirty-three was her year for egg freezing.
A broken engagement when she was twenty-five and in medical school. Then: a new flame, a whirlwind romance, a hasty wedding, a brief marriage, and divorce—all before she finished residency. When Remy’s personal life got derailed, she couldn’t help but feel she had somehow fallen behind. She hadn’t thought she’d be single at thirty-three, and she definitely hadn’t expected to have a broken engagement and a divorce under her belt by then—or ever. What she did have was the career of her dreams and an unshakable belief in doing whatever she could to secure the future children—future family—that felt more important to her than anything else.
And egg freezing was the way to do it.
Remy exchanged her scrubs for a long-sleeved denim shirt and faded tan jeans. She looked around for her tall leather lace-up boots, tucked in a corner next to a stuffed brown bear she’d had since childhood. She glanced at her Apple watch. Just enough time to stop for a smoked rosemary latte at her favorite coffee shop before driving south to the clinic.
It was a damp morning in February, the sky a deep gray. Nashville traffic was a pain, and Remy arrived with hardly any time to spare. The clinic’s waiting room was drab. Beige walls, beige carpet, fluorescent lights. Monochrome portraits of babies hung on the wall. Two couples sat waiting to be seen. Remy walked purposefully to the receptionist’s desk and offered a warm hello. The woman smiled brightly, remembering her, and presented a clipboard of forms in exchange for Remy’s credit card.
Checked in, Remy settled into one of the stiff chairs. She rubbed her eyes, feeling tired but calm. She had been too busy at work to overthink today’s appointment, a two-hour session about the hormone shots that were the prelude to her egg retrieval and freezing. For the past month, Remy had been treating pregnant women, her schedule a whirlwind of epidurals and C-sections. Some overnight shifts were so busy she didn’t stop to eat or rest. But she was thrilled to be on OB/GYN clinical rotation this month, of all months; her workdays felt rich with meaning and connectedness. She prepped patients who were about to give birth while her brain buzzed with egg freezing plans and the babies she hoped—she knew—her frozen eggs would someday yield. She closed her eyes and concentrated on turning off her doctor brain and switching to the patient mindset. Here at the clinic, most of the staff didn’t know she was an anesthesiologist, and Remy preferred it that way. She could sit back and be the one taken care of. Here, she was just another woman preserving her fertility.
At her first egg freezing appointment a few weeks earlier, Remy had met the reproductive endocrinologist who would do her egg retrieval. Dr. Ruth Lewis[*1] had walked Remy through the process, the research, some of the risks. She wasn’t particularly warm and fuzzy, but Remy trusted her no-nonsense demeanor immediately. Dr. Lewis explained that she typically didn’t see women having difficulties with fertility until after age thirty-six. Remy was three years shy of that, but she already felt she was losing precious time while she waited to develop the relationship she wanted, to be able to have children with the right person. Or to decide to become a solo parent, a possibility she’d been considering. All her clocks were ticking.
In an exam room, Dr. Lewis had Remy’s blood drawn to test her hormone levels and looked at Remy’s ovaries via transvaginal ultrasound. When her follicles, the fluid-filled sacs containing egg cells, appeared on the monitor, Dr. Lewis counted them: eight follicles on the right ovary, thirteen on the left. Dr. Lewis told Remy she was remarkably healthy, with a good supply of eggs. She was unlikely to face issues conceiving if she tried to get pregnant in the next few years. She understood Remy’s desire for the peace of mind that can come with preserving eggs at an optimal age. But having found no red flags in terms of Remy’s current fertility, Dr. Lewis had told her she might want to reconsider egg freezing, save her money instead. Remy appreciated the doctor’s straightforward way of laying it all out. But she was already committed to freezing her eggs and told Dr. Lewis she wanted to start as soon as possible.
Now she was back for her second appointment. A nurse called Remy’s name and led her to a small exam room. More fluorescent lights and beige. The nurse, nodding toward a chair, instructed Remy to make herself comfortable and left. A few minutes later, there were two curt knocks and the door opened. Dr. Lewis—straightened blond hair, long white coat over a blue floral top, black ballet flats—sat down on a stool, clipboard in hand. She and Remy exchanged hellos, and then Remy introduced me as a friend who was interested in egg freezing and was also writing about it. Dr. Lewis nodded and shook my hand before turning her attention back to Remy.
“Got a lot to cover today,” Dr. Lewis began. “We’ll review the ovarian stimulation process, go over some risks and consent forms, then talk about the egg retrieval. Sound good?”
She launched into explaining the different types of medications that stimulate a woman’s ovaries: carefully timed, self-injected hormone shots phased over about two weeks. During the first phase, the shots would kick Remy’s ovaries into overdrive to produce more eggs. The second phase of shots would prevent immature ovulation, instructing her ovaries not to release the eggs too soon. The final injection, known as the “trigger shot,” finishes off the eggs’ maturation so that they’re ready to be retrieved.
Remy leaned forward, chin in hand and elbow resting on her crossed leg. Her blond hair sat in a messy bun on the top of her head, and silver feather earrings dangled from her ears.
“Now, the trigger shot,” said Dr. Lewis, resting her back against the exam table. “It’s a powder, so you have to mix it. And then, don’t shake it, you just—”
“Reconstitute it,” Remy interjected.
“Reconstitute it gently,” Dr. Lewis went on. “Sometimes it takes a while to clear. And then it’s an IM injection.”[*2]
Dr. Lewis explained that the egg retrieval would be thirty-six hours after Remy took the trigger shot. Describing the retrieval, she said, “It’s a seventeen-gauge needle, one stick per ovary. The risks are small; bleeding, infection, injury to organs is minimal. The embryologist stands next to me while I aspirate the follicle. She looks to see if there’s an egg, and if she got the egg I move to the next follicle. We keep going until we get all the eggs.”
Dr. Lewis shifted on her stool and continued. After the procedure, she explained, the embryologist would determine how many of Remy’s retrieved eggs were mature and thus would be frozen; typically, more eggs are extracted than are frozen (more on this in chapter 8). A nurse would call Remy later in the day to let her know how many of her eggs were successfully put on ice.
When they got to discussing sedation, Remy got excited. This was the aspect of the procedure on which she had a lot of expertise.
“We usually do Versed, propofol, fentanyl,” Dr. Lewis was saying, except she said it in one breath, so it sounded like “Versedpropofolfentanyl.” Most patients undergoing an egg retrieval are put under moderate sedation with IV medications to keep them still and comfortable.[*3] “You can talk to the anesthesiologist, but if people don’t do all three, they tend to move around a lot and it makes it hard for me to get the eggs.”
Dr. Lewis went on, explaining that the retrieval would take about twenty minutes and that the follicles holding Remy’s eggs are quite fragile. As she spoke, I imagined it to be like sticking the tiniest needle into the tiniest water balloon to extract an even tinier particle. “So if I take the needle and you flinch even a little bit, it pops and I miss the egg. So I need you to just not wiggle.”
Remy nodded. “Be in Zen. Got it.”
Listening to Dr. Lewis and Remy discuss egg freezing specifics, I realized that Remy had a leg up thanks to working in medicine. She’d been downplaying being a doctor during her appointments at the fertility clinic but was so clearly in her element here. The two physicians spouted off names of drugs and protocols, abbreviations rolling off their tongues. I scribbled down acronyms and made a mental note to add them to my list of egg freezing terms to look up.
Dr. Lewis looked at the clipboard on her lap, sliding her finger down a list. “Couple more general things to go over,” she said. “Avoid caffeine and alcohol when you start injections.”
