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Social egg freezing: Who chooses and who uses?

Published:August 20, 2018DOI:https://doi.org/10.1016/j.rbmo.2018.08.003
      Forty years ago this year the birth of Louise Brown – the pioneering achievement of Patrick Steptoe and Bob Edwards – was greeted with near universal joy and wonder. Childless women with inoperable tubal disease could finally be offered the chance of ‘genetic’ motherhood. It must be remembered, however, that not everyone was delighted by the advent of IVF. Some sceptics initially declared it was fraud, others pointed to the ‘low’ success rates (105 embryo transfers before a healthy birth), and many commented on the high financial cost, which would inevitably limit access to the wealthy few in the richer countries. Some religious authorities forbad its use for their adherents, claiming that it was ‘unnatural’ and morally repugnant. Some social commentators considered it to mark another potential slip down the ‘slope’ that led to the commodification and commercialisation of human reproduction. Perhaps the cruellest response was from those that claimed the infertile should ‘just accept their fate' as the world was over-populated already. In all this furore, the women's opinion was rarely sought.
      The current intense debate about the role of ‘social’ egg freezing reprises many of the assertions made initially about IVF itself. Women who wish to freeze their eggs for their own future use face many hurdles. Far from social egg freezing being ‘oversold’ as a technique, women are repeatedly warned that the success rate is very low. When presented as babies born per egg frozen, success rates are indeed low, but we don't present IVF success rates as babies born per egg retrieved. Vitrification of oocytes and the experience of frozen donor egg banks has shown that ‘young’ frozen eggs have the same reproductive potential as ‘fresh’ eggs when thawed, fertilised and transferred as blastocysts (
      • Cobo A.
      • Kuwayama M.
      • Pérez S.
      • Ruiz A.
      • Pellicer A.
      • Remohi J.
      Comparison of concomitant outcome achieved with fresh and cryopreserved donor oocytes vitrified by the Cryotop method.
      )
      Women who seek ‘social’ egg freezing are not doing so because they have other life goals and will ‘get around’ to motherhood when the time is right, but because they have a highly conventional view of parenthood and because they want to have the opportunity to become a mother in a supportive, long-term relationship. (
      • Baldwin K.
      • Culley L.
      • Hudson N.
      • Mitchell H.
      • Lavery S.
      Oocyte cryopreservation for social reasons: demographic profile and disposal intentions of UK users.
      ). To suggest that women who freeze their eggs are likely to be too ‘choosy’ to find a suitable partner in time is demeaning to women who decide to avail themselves of this technology.
      In this edition of RBMO Professor Zion Ben-Rafael proposes another reason to attempt to dissuade women from social egg freezing, namely that the usage rate is too low to make it ‘cost effective’ (
      • Rafael B.
      The dilemma of social oocyte freezing – Usage rate is too low to make it cost effective.
      ). He argues compellingly, if a little harshly, that if women are waiting until their late 30s or early 40s to find a husband to use their frozen eggs to parent with, they are likely to be unlucky in finding their man. Historically, it was the case that husbands were usually older than their wives, but this trend is reducing in a world where many couples meet as peers at college or even on-line! He argues that if women freeze their eggs while young (the optimum time for future successful use) then they are unlikely to need to use them, whereas freezing them at an older age gives disappointing results.
      However, a very low usage rate is not necessarily an indication that the policy is flawed. If a woman does achieve the number of pregnancies she desires, either naturally, or with more conventional fertility treatments, then her frozen eggs may be discarded or donated. But if she does not, those frozen eggs offer a chance of achieving her heart's desire. After all, we do not counsel people against taking out fire insurance because the chance of their house catching fire is very low.
      It is quite clear that at the present level of efficacy of oocyte freezing, the analogy with ‘insurance’ should not be pushed too far. Moreover, it is vital that women, especially if they are over 35, are made aware that their frozen eggs cannot represent a guaranteed insurance policy against age-related infertility. However, the vitrified ‘clutch’ of 35-year-old eggs is much more likely to produce a healthy baby than the few, probably aneuploid eggs that would be obtained from the same woman 10 years later undergoing IVF.
      The ‘reproductive life-span’ inequality between men and women has long been regarded as regrettable but inevitable. But it need not be so from now on. With women's longer, healthier life span, using their own frozen eggs to achieve a pregnancy at a time of their choosing would seem to be no more ‘unnatural and undesirable’, than making a woman go through an ICSI cycle because her partner has obstructive azoospermia or testicular failure. Governments have tried frightening, cajoling and even bribing couples into have children when younger, but the age of first birth continues to rise inexorably and with it the rise of ‘uncompleted’ families. A woman who has a first child in her mid-to-late 30s is very unlikely to be able to have a sibling unless she had her eggs frozen. (
      • Habbema J.D.F.
      • Eijkemans M.J.C.
      • Leridon H.
      • te Velde E.R.
      Realizing a desired family size: when should couples start?.
      )
      ‘Social’ egg freezing developed from work to preserve the fertility of young women undergoing potentially sterilising chemotherapy, surgery or radiotherapy. In practice, the distinction between ‘social’ and medical freezing is increasingly difficult to maintain as significant gynaecological pathologies such as endometriosis or a strong family history of premature menopause may also represent a compelling argument for oocyte freezing. In the UK, women diagnosed with premature and irreversible infertility may have their eggs frozen for up to 55 years. However, it is quite clear that the passage of time is just as destructive as chemotherapy to a woman's fertility prospects and yet the legislation for ‘social’ freezers in the UK limits the storage period of these eggs to only 10 years. This time limit is totally arbitrary, unscientific and rather cruel. It has the paradoxical effect of encouraging women to delay having their eggs frozen beyond the point at which the process is most effective. Those who do choose to freeze at the best time under 35 (or even earlier) can be faced with the intolerable dilemma of allowing their eggs to perish or creating embryos with donor sperm, which may then be stored for a further ten years! A society which permits women to achieve a pregnancy up to the age of 50 using donor eggs, should surely allow women to keep their own eggs ‘on ice’ for more than 10 years.
      Apart from the willingness of employers such as Facebook and Apple to pay for ‘social’ egg freezing for their female employees, ‘social’ egg freezing is paid for privately. Such is the desire of some parents to be grandparents one day that there is an emerging trend for the parents of single ‘thirty-something’ daughters to fund their egg freeze cycle for them. In a society that accepts privately funded fertility treatment, it should not be necessary to justify privately funded ‘social’ fertility extension or preservation. Moreover, it may render ‘social’ egg freezing more acceptable since no added financial burden for society is involved.
      Evidence about the ‘usage’ rate of socially frozen eggs is difficult to obtain as most data sets do not distinguish between the various reasons why eggs have been frozen. It is, however, the experience that women either return within a few years to use their eggs (often with donor sperm), or never return at all. We may speculate that this is because they have achieved a pregnancy naturally, or they have never met a suitable partner to parent with. Data from the Brussels Centre for Reproductive Medicine presented at ESHRE in 2018 revealed that only 7.6% of 563 women who had their eggs frozen for social reasons between 2009 and 2017 returned to use their frozen eggs for fertility treatment. The majority had found a suitable partner with whom to pursue motherhood and one third became pregnant (De Vos et al., 2018). Further interesting and confirmatory data is presented in a paper by Balkende and colleagues in this issue of RBMO (Balkende et al., 2018), which followed a cohort of over 300 women who froze eggs for either social reasons (44%) or prior to gonadotoxic therapy (39%). A reassuring 65% of respondents became pregnant, but only 7% (6 women) by utilising ICSI with their vitrified-warmed eggs.

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