WUNRN
New Republic - http://www.newrepublic.com/article/120077/dangers-and-realities-egg-freezing
IS FREEZING YOUR EGGS
DANGEROUS? A PRIMER
By Josephine
Johnston and Miriam Zoll
Photo: Shutterstock.com
When news broke several weeks ago that tech giants Apple and
Facebook were offering female employees elective egg freezing benefits, much of
the commentary criticized the decision, interpreting it as a message to women
that they should postpone motherhood in favor of advancing their careers—or
perhaps their company’s bottom line. Few articles, however, addressed the fact
that experts do not view this as a procedure that should be encouraged.
The American College of Obstetricians and Gynecologists (ACOG) does not endorse egg
freezing for the “sole purpose of circumventing reproductive aging in healthy
women.” Two years ago, the American Society for Reproductive Medicine (ASRM), a
membership organization representing roughly 500 fertility clinics in the U.S.,
lifted the “experimental” label from the procedure, but stressed
that its decision was not an endorsement for healthy women to freeze their eggs
for future use.
After reviewing 981 fairly small studies, of which only 112
addressed safety and efficacy concerns, ASRM’s practice committee wrote:
“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.” Citing
the critical lack of medical evidence and potential emotional risks the
committee cautioned:
“Marketing this technology for the purpose of deferring childbearing may give
women false hope.”
Prior to these recommendations, a 2010 study
reported that of 442 fertility clinics surveyed, 283 were already
providing expensive “experimental” freezing services: one-third offered it to
women with cancer, while two-thirds offered it “electively to women of
advancing maternal age.” It is not clear how many of these clinics were
providing these services under an experimental protocol overseen by an Institutional
Review Board, as was recommended by ASRM at that time. Today, far more clinics
are disregarding ASRM’s most recent guidelines and offering elective egg
freezing as a top-tier item on their menu of services.
This eagerness to push forward with non-medically necessary egg
freezing services raises an important question: How safe and effective does a
technology like this need to be before it is sold to young, fertile women?
How Did Egg Freezing Arise?
Oocyte cryopreservation—the technical name for egg freezing—is a
young and tenuous science. While frozen sperm and embryos have routinely been
used in reproductive medicine since the 1950s and ’60s, egg freezing has only
been used since 1986 and is more technically complicated. Human eggs contain a lot
of water, and during the freezing process ice crystals can rupture the egg’s
delicate structure and disrupt the chromosomes inside it.
Only recently has a new
flash-freezing technique known as vitrification improved
“freeze-thaw” rates to a point where between 90 to 97 percent of eggs survive.
Far fewer, however, result in the birth of a baby following in vitro
fertilization (IVF) procedures. The Society for Assisted Reproductive
Technology reports
that only 2 to 12 percent of thawed eggs lead to a live birth in women age 38,
and the most comprehensive study to date suggests live birth failure rates as
high as 76 percent in women age 30 who attempted more than one cycle with
thawed eggs. In women age 40, the rates of failure are 91 percent and higher.
Is Egg Freezing Safe?
Egg freezing isn’t the first innovation to shift from being a
strictly medical treatment—primarily for cancer patients—to an elective or
“enhancement” procedure. Cosmetic surgery developed out of treatments for
wounded soldiers, and drugs approved for conditions like narcolepsy, ADHD, and
heart failure, are today being used to improve human performance.
But as the debate over these so-called “enhancement therapies” has shown,
making the leap from medical intervention to elective procedure is tricky. For
one thing, healthy end users generally have less to gain and more to lose.
Like those who sell their eggs or undergo IVF, women using egg
freezing services must submit to ovarian hyper stimulation and egg retrieval
procedures. Both techniques carry risks, but with no mandatory national U.S.
registry tracking the health of patients or consumers undergoing these
procedures, it is impossible to know exactly how many women actually experience
problems. One voluntary data-collection effort is the Infertility Family Research Registry,
housed at Dartmouth-Hitchcock Medical Center. Unfortunately, fewer than 100 of
the 500 infertility clinics in the country actively encourage patients or
consumers to join and share their health experiences, or those of their
offspring.
So how does the process actually work? Drugs known as gonadotropins
are used to hyperstimulate women’s egg production from one or two eggs (during
a normal monthly cycle) to upwards of a dozen or more. During egg retrieval, a
surgeon, guided by ultrasound technology, pushes a long needle through the
vaginal wall and into the ovary. Once the needle punctures the ovary, it is
maneuvered to pierce one follicle after another, and suction is then applied to
draw the follicular fluid into a test tube. Floating within the fluids are the
oocytes—the eggs.
There are many safety concerns:
potential pelvic and abdominal pain, injury to the bladder, bowels or
blood vessels, pelvic infection, and damage to the ovaries that are punctured
during retrieval. Doctors treating egg donors, in particular, have been known
to hyperstimulate their patients to the point where many routinely generate 30
or 40 eggs, and sometimes even more. Some donors have reported
becoming infertile or experiencing early menopause after exposure to the drugs
or retrievals that can leave behind damaging scar tissue. In other instances,
their ovaries have swelled from the size of walnuts to that of grapefruits,
indicating a not-so-rare condition known as Ovarian Hyper Stimulation Syndrome
(OHSS).
Depending on the woman and the drug dosages, mild OHSS can
manifest as bloating and abdominal pain that goes away on its own, but
sometimes symptoms are more serious. Severe cases
of OHSS may require hospitalization for bleeding, severe fluid buildup and pain
in the abdomen and lung area, difficulty breathing, decreased blood flow to the
kidneys due to blood thickening, and in the most critical cases, even stroke or
death. Patient follow-up studies from Canada indicate
that about one-third of women who undergo ovarian stimulation suffer “mild”
OHSS. In a British study
tracking 339 women, roughly 14 percent were hospitalized for OHSS after
stimulation cycles yielded more than 20 eggs.
Though most babies born through freezing methods that also
required IVF appear to be
healthy, more long-term data on developmental outcomes is needed
before safety can be adequately and responsibly evaluated in children. There is
not enough
medical evidence to know whether the liquid nitrogen and other
chemicals used in the new flash freezing technique are toxic to embryos and how
they affect cell development.
The most recent national summary available from the Centers for
Disease Control and Prevention indicates
that 46.4 percent of all babies born through assisted reproductive technologies
(ART) were high-risk twins, triplet or higher order births, and costs for their
care far exceeded earlier estimates of one billion dollars annually. Though
often underreported in the media, additional risks linked to children born
through ART include
higher instances of preterm birth, low birth weight, stillbirth, neurological impairments
like cerebral palsy, and increased associated risks of up to 28 percent of
certain birth anomalies, especially of the eyes, neck, heart, and urogenital
tract.
Despite All This, Egg Freezing Is Being Aggressively Marketed
Healthy and presumably fertile women in the U.S. are being told
that egg freezing is as revolutionary and liberating as the Pill. The most
dramatic campaigns have come from egg freezing brokers—businesses that act in
partnership with drug companies and fertility clinics. An especially egregious
example is EggBanxx, which hosts
“Let’s Chill” egg freezing cocktail parties, several sponsored by the drug
company EMD Serono, Freedom Fertility Pharmacy, and three New York City-based
ASRM member clinics.
The invitation for its September 2014 event at a posh Manhattan
hotel highlighted the “Three F’s: Fun, Fertility and Freeze.” Guests who
attended told us that EggBanxx presenters did not discuss high failure rates or
alarming gaps in safety studies, but they did pitch financing options and
offered $500 and $1000 discounts through follow up emails several days later.
With a perpetual media and marketing blitz, and clinic websites touting slogans like
“set your own biological clock” and “take control of the calendar,” many
healthy young women might think they are being negligent if they don’t sign up
to “insure” their chances to become a mother in the future.
This kind of dreaming and imagining is lucrative. Egg freezing
service providers charge anywhere from $7,500
to $10,000
for one freeze cycle—and upwards of $30K for the three cycles they recommend to
find that “one good egg.” Tabulate additional cash-layouts for annual storage
fees ($500-$1000), drugs per cycle ($2,500 - $7K)
and later, at least one but likely multiple IVF cycles minus the egg retrieval
($12K per cycle),
and you’ve conservatively topped out at an estimated $45K—with no guarantee
that a healthy baby will be born.
Weighing the Bioethical Risks
Women facing the specter of chemotherapy and radiotherapy know
that their fertility will be seriously compromised, if not destroyed. In these
patients, the argument can be made that egg freezing is safe enough and
effective enough to be a reasonable option. Indeed, this is what ASRM’s
and ACOG’s practice committees concluded. Yet these same committees determined
that existing research did not adequately meet the medical or safety standards
needed to endorse egg freezing in the general population.
Unlike cancer patients, healthy, young women don’t face an
immediate and unavoidable threat to their fertility. The threat they do
face—time—is certainly real, and can feel overwhelming. But egg freezing, and
all the risks it entails, may not be the most effective way to respond to the
ticking of the biological clock. If women rely on this technique and it fails
years later, they may have lost their reproductive window of opportunity
forever. From this vantage point, healthy young women have more to lose
than cancer patients.
Commercial interests are erroneously marketing egg freezing as
an “insurance plan for motherhood.” Like IVF, egg freezing is more like a
gamble or a wager than insurance. “You put down $15,000 or $30,000 dollars and
you might be able to preserve your fertility,” says Karen Maschke, a
political scientist and research scholar at the Hastings Center, “but there are
no guarantees.”
Why Informed Consent is Crucial—But Not Enough
There is no question that women who choose to freeze their eggs
are legally entitled to balanced and comprehensive information about the
medical, ethical, and psychological risks and concerns associated with egg
freezing—including what is not yet known about its safety and efficacy.
But informed consent alone—which is often surprisingly difficult to
obtain—cannot resolve the ethics of elective egg freezing. As scholars in
bioethics have argued, an overreliance on informed consent can blind us to the
cultural, economic, and political contexts that often pressure patients and
customers into believing that they have little choice but to agree to medical
interventions that do not necessarily meet their needs or align with their
values.
We must ask why women who want to have children fear that, for
professional or personal reasons, they will be unable to do so during their
safest and most fertile years. If we fail to ask that question, we inevitably
endorse a world in which the very real forces that create this fear and reality
are not held to account. In this world, “responsible” women freeze their eggs,
and the complicated societal problem of reconciling work and family is theirs
alone to resolve.
Josephine Johnston is the director of research and a research
scholar at the Hastings Center, a bioethics and policy institute in New York.
Miriam Zoll is the author of Cracked Open: Liberty,
Fertility and the Pursuit of High-Tech Babies (2013) and a member of the
board of the women’s health organization, Our Bodies Ourselves.