- Fertility Drops off a Cliff at 35 and Other Myths
- How Effective is Egg Freezing?
- The Financial Costs of Egg Freezing
- What About the Health Costs to Mother and Risks to a Baby?
- Avoiding Buyer’s Remorse with Your Egg Freezing Experience
- Special Considerations with PCOS and Endometriosis
- No Wrong Answer, Just a Deeply Personal Choice
I am a 35 year old woman who lives in New York City. I am single. And I do have a history of suspected endometriosis and suspected PCOS, although I’m not sure if that’s 100 percent correct. And I have been thinking about freezing my eggs, because I have not found a partner yet, not sure if I ever will find a partner. But I’m curious as to your thoughts about if it’s too late, if it’s the best health move, knowing I have those conditions, if that affects it, and just in general if you feel like it’s a good approach for somebody who is unsure about their future. It is expensive, from what I understand, in New York City. I would love to hear anything that you can offer me here, as I’m getting a little concerned as I grow older.
First, Victoria, thank you for sharing this question that I promise, you are not alone in asking!
Some history: The first successful pregnancy from a previously frozen egg happened in 1986 – so it’s a relatively new phenomenon. The option was originally used primarily by women with cancer or other medical diagnoses who wanted to save their eggs before receiving medical therapies that could destroy their fertility. In 2013, the American Society for Reproductive Medicine (ASRM) lifted the ‘experimental’ label from the procedure and since then the procedure has rapidly become more widely used. Between 2010 and 2016, the number of American women freezing their eggs skyrocketed 880 percent.
Today, the vast majority of women who freeze their eggs are not facing any immediate threat to their fertility due to a medical condition, but rather are doing so proactive to protect their future options for becoming pregnant, in anticipation of the natural decline in fertility as we age – which is known as elective, social, or planned egg freezing. According to the Society for Assisted Reproductive Technology (SART), in 2020, 12,438 healthy women froze their eggs, up from 7,193 in 2016. While media coverage of the trend often suggests women are turning to egg freezing to delay childbearing in order to focus on their career in their thirties, most women who pursue egg freezing report that the main reason is that they haven’t found a suitable partner, or want to protect their eggs against future medical issues that may affect their fertility.
Fertility Drops off a Cliff at 35 and Other Myths
It is true that fertility declines as we approach menopause. Known as “age-related decline in fertility” in the medical literature, this occurs because our innate supply of eggs declines in both quantity and quality over time. We start life with approximately 1 million to 2 million eggs in our ovaries and lose them steadily every cycle. Further, as we approach menopause, remaining eggs are more likely to have abnormal chromosomes, increasing the risk of miscarriage and genetic conditions.
However, there’s also lots of fear-mongering about this decline. Fertility, in fact, does not “drop off a cliff” at 35. Rather, around age 30, it starts to slowly decline and by mid-30s the rate of decline increases. A 2016 US study that followed women trying to conceive found the chance of pregnancy after 12 months was 87% for women aged 30-31. This dropped to 76% at age 36-37, and 54% at age 40-41. Another study found that when the woman was in the 35-39 age range, 82 percent of couples had conceived within a year of trying and 90 percent had after two years. But most do eventually conceive – it may just take longer than expected.
How Effective is Egg Freezing?
While egg freezing hasn’t been labeled experimental since 2012, the technology is still new, and we don’t yet have a lot of research on, including about the most basic question of how many women succeed in having a baby using their frozen eggs. In 2021, the ASRM reviewed the most recent literature and published an evidence-based guideline on planned egg freezing, concluding that there wasn’t enough evidence to predict live birth rates after egg freezing. In fact, guidelines from the American College of Obstetricians and Gynecologists state that there is not enough research to recommend egg freezing solely to delay having a child at all.
The main reason for this knowledge gap is that while increasing numbers of women have frozen their eggs, most of them have not yet returned to thaw and actually try to use them. Although the number of egg freezing cycles each year in the US increased from over over 2,500 in 2012 to over 13,000 in 2018, the number of egg thawing cycles during that time rose from over 300 to about 1,800.
When fertility clinics cite success rates, they’re usually based on mathematical models using data on IVF or egg donation and neither of these groups are exact apple-to-apples comparisons to women undergoing planned egg freezing. Plus, much of the data has included women freezing their eggs for medical reasons like cancer. This means that it’s difficult to say what the odds of success are for women who are freezing their eggs solely because of age-related fertility decline.
In the last few years, however, a couple major studies have shed some light on the question. In 2022, a study analyzing 15 years of data from over 500 patients who froze their eggs at a fertility center in NYC was published. This was the largest US study of outcomes from egg freezing performed for age-related fertility decline to date, and it provided some “sobering” results that suggest egg freezing is not, as many assume, an “insurance policy” that guarantees a baby in the future.
In the study, the average age when the women froze eggs was just over 38. On average, they waited about four years to thaw and fertilize their eggs. The data underscored that the odds of successful pregnancy seems to depend a lot on how young women are when they freeze them and how many eggs they freeze. The overall chance of a live birth from the frozen eggs was just 39 percent. But the birth rate was over 50 percent among those who were younger than 38 when they froze their eggs. Across all age groups, patients who thawed more than 20 eggs had a 58 percent chance. And it rose to 70 percent if women younger than 38 also thawed 20 or more eggs.
The study also found that the duration that the eggs had been frozen didn’t matter – all that mattered was how old a woman was when she froze her eggs and how many she froze. That’s in line with data from other fertility clinics. In a 2021 study, only about one-third of those women who thawed their eggs were able to have a baby. Interestingly, that study didn’t find that outcomes were significantly different in women younger than 38 years at time of freezing and those over 38. But it did find that none of those who froze their eggs at age 40 or over were successful in having a baby with their eggs.
Another major study came out in 2021. SART released an analysis of all the outcomes of egg freezing in the US reported to SART’s surveillance program. About 90 percent of fertility clinics report their data to SART, so this was the first time we got some sense of the national trends in egg freezing in the US.
Overall, the data revealed that pregnancy rates with frozen eggs were similar to the rates for women in the same age group undergoing IVF with fresh eggs. In other words, a 40-year old trying to get pregnant with eggs she froze at age 35 had about the same odds as a 35-year old undergoing IVF with her current eggs.
The most “striking” finding according to the researchers was just how many eggs were needed to achieve one successful birth among older women: They calculated the number of eggs that needed to be thawed for one successful live birth at different ages. For women who froze their eggs when they were younger than 35, they ended up thawing 15 eggs per birth. For women over 40, it was a whopping 55 eggs.
So what’s the takeaway here?
First, it’s important to keep in mind that while egg freezing may give you a better shot at having a baby at an older age than you otherwise might have, it is not a guarantee. Unfortunately, it seems that some women aren’t being given realistic expectations by providers. In one survey, 6 percent of women, who were between roughly 34 and 41 years old when they froze their eggs, estimated a 100% likelihood of having a baby with their banked eggs.
Second, from the limited data we have, it does seem that the younger you are when you freeze your eggs, the better your odds. And, unsurprisingly, the more eggs you retrieve, the better your odds, especially if you’re older.
The Financial Costs of Egg Freezing
As my caller today points out, egg freezing is usually quite expensive. Health insurance policies sometimes cover at least part of the costs, but many do not. More and more companies, like Facebook and Apple, are covering egg freezing as part of their benefits packages, (of note, in cases like these, it has been thought that this does speak to companies placing covert pressure on female employees to delay childbearing). As of 2020, almost one in five large US employers offered egg-freezing benefits. But for most women who are paying out of pocket, the costs add up quickly.
Each egg retrieval cycle can cost $10,000 and the number of eggs retrieved during each varies, so women may need to do more than one cycle in order to have enough eggs for a good shot at a pregnancy. Storing the frozen eggs until you’re ready to try to get pregnant can cost $500 to $1,000 a year. If you decide you do want to use them, it costs another $5,000 to $7,000 to thaw and fertilize the eggs and transfer the embryo into the uterus. It can cost $3,000 to test embryos tested for chromosomal anomalies, which many choose to do. So we’re looking at a $20,000 to $35,000 cost.
Determining whether it’s “worth it” to freeze your eggs is a difficult personal decision, especially because the majority of women who pay to freeze and store their eggs end up not even trying to use them, often because they get pregnant on their own or with the help of conventional IVF. A recent Belgium study, one of the largest European studies on the topic, followed women who had frozen their eggs (at an average age of 36) between 2009 and 2019. By 2022, just 27 percent had returned to the fertility clinic to try to have a baby (at an average age of 40). Among those who did return, only around half ended up using their frozen eggs and about a third used their own fresh eggs.
Of course, if you do end up struggling to get pregnant naturally and turn to conventional IVF to conceive, multiple rounds of IVF is also very expensive. Some researchers have used mathematical models to try to determine under what circumstances egg freezing is cost-effective compared to traditional IVF.
In a 2018 study, researchers mapped out different strategies for a hypothetical 35-year-old woman who plans to delay having a baby until age 40. They concluded that the most cost effective strategy was to undergo 1.2 cycles of egg freezing at age 35 (that’s the average number of cycles required to get 16 eggs at that age) and then at 40, attempt to conceive naturally for 6 months, and then do 2 cycles using her stored eggs if needed. They determined that this strategy was most cost-effective up until age 38. But for women age 38 and older, it was most cost-effective to forgo egg freezing and just try to to get pregnant at 40 year for 6 months and then undergo 2 rounds of conventional IVF with fresh eggs if needed.
What About the Health Costs to Mother and Risks to a Baby?
There’s a significantly high knowledge gap when it comes to the risks of the egg-freezing, thawing, and pregnancy, especially long-term risks. In 2018, the ASRM Ethics Committee urged providers to ensure that women are informed about the uncertainty around the efficacy, safety, benefits, and risks of egg freezing, including the unknown long-term health effects for the offspring conceived with frozen eggs. They called for more data and research to help inform patient decision-making.
When it comes to the short-term side effects and risks, most of them are similar to conventional IVF because, except for the freezing, the procedures involved in egg freezing are largely the same for ovarian stimulation and egg retrieval. Women inject themselves with hormones once or twice a day to stimulate the ovaries to grow multiple follicles. Once the follicles reach a certain size, the doctor will retrieve the mature eggs by inserting a small needle through the vaginal wall into the ovary, and then flash-freeze them.
Women often feel somewhere between unwell and miserable in the days prior to the retrieval. The stimulation drugs cause extremely high estrogen levels, which cause mood swings in some women. Bloating from the enlarged ovary is common and can be uncomfortable. The most serious immediate risk is ovarian hyper-stimulation syndrome, which occurs in roughly one percent of women who undergo egg freezing. It is more common in those with polycystic ovary syndrome because PCOS can increase the risk of developing too many follicles. Other immediate risks from the stimulation and retrieval process include bleeding, infection, and complications from the anesthesia.
From the limited data we have now, it also seems that immediate health outcomes for babies conceived from frozen are similar to those conceived via IVF with fresh eggs. For example, there doesn’t seem to be any increased risk of congenital abnormalities in infants from frozen eggs compared with other IVF babies. But when it comes to the long-term health of babies conceived with frozen eggs, it’s too early to have any data and we just don’t know.
Further, although over 10 million children have been conceived via assisted reproductive technologies since the eighties, there are big gaps in our knowledge of the health of children conceived via assisted reproductive technologies like conventional IVF too, especially long-term. In the US, we have not been systematically tracking the long-term health of IVF babies. There’s also an inherent difficulty in studying the topic: since couples who turn to IVF are experiencing infertility or “subfertility,” it’s difficult to disentangle whether any increased health risks are due to the IVF procedures or related to the underlying infertility – or even simply due the fact that the parents tend to be older than average.
Some epidemiological studies have shown that compared to children conceived spontaneously, children conceived through assisted reproductive technologies are at increased risk of a range of health problems – including low birth weight, preterm birth, birth defects, and cardiovascular and metabolic abnormalities, like high blood pressure, later in life. Again, it’s uncertain if these are due to the IVF procedures or other parental factors. Still, research on animals – including studies on healthy, fertile animals, so the confounding variable of infertility is removed – suggest that there may indeed be differences in the physiology of offspring conceived by IVF.
Research on the possible risks to the women who undergo IVF is even harder to come by. Studies suggest that women who conceive via IVF are at a somewhat higher risk of pregnancy complications like postpartum hemorrhage, gestational diabetes, and pre-eclampsia. It’s important to keep in mind that the absolute number of women who develop these complications remains quite small. And again, it’s not clear if that’s due to the IVF procedures or if the increased risk is simply a reflection of those who require infertility treatment.
There has also been some concern raised that exposure to the medications used to stimulate the ovary could increase women’s lifetime risk of cancer, especially those cancers which are known to be hormone sensitive. A 2017 review concluded that, while the data are limited and we need more long-term studies, most studies do not show a significant risk of breast, endometrial and ovarian cancer with the use of fertility medications. Some studies, however, have shown a possible increased relative risk of borderline ovarian cancer.
Avoiding Buyer’s Remorse with Your Egg Freezing Experience
Most studies have found that few women who freeze their eggs regret the decision – even if they don’t end up using their stored eggs. In a 2020 UK study, over 90 percent had no regrets over their decision to undergo egg freezing, even though only 20 percent of the women in that study have successfully had a baby or were currently pregnant. But in one 2018 US study, almost half of women who’d frozen their eggs subsequently experienced some regret about their decision, especially those who ended up with fewer eggs and those who said they received inadequate information or emotional support.
Many women have accused fertility clinics of engaging in biased advertising that seeks to persuade, not inform, emphasizing the benefits for egg freezing services while minimizing risks and the low chance of successfully bringing a pregnancy to term. There are plenty of heartbreaking stories of women who were given the impression that freezing their eggs was a guarantee, giving them a false sense of security about their ability to have kids in the future, only to find that none of their eggs survived the thawing and implantation process, leaving them forking over even more money for conventional IVF to conceive or, in the worst case scenario, being unable to get pregnant at all.
If you decide to explore egg freezing, experts say make sure you do your homework and find an experienced fertility doctor. They advise asking how long the clinic has been performing the procedure and steer clear of those who have only recently adopted the practice. According to ASRM, studies indicate it takes experience to become skilled at egg freezing and thawing, so patients deserve to know their provider's level of experience.
Ask for data on the clinic’s success rates. General statistics can only tell you so much—you want to know your particular clinic’s rates when it comes to egg survival after thawing, successful pregnancies, and number of successful live births. Be sure to ask for the data for your age group. And remember, even with good stats, there are no guarantees.
Special Considerations with PCOS and Endometriosis
If you are planning to freeze your eggs and do have PCOS, or any other gynecologic condition, it’s important to be aware of additional risks to you, and anything that might prevent successful egg retrieval or later pregnancy.
As mentioned earlier, women with PCOS may be at increased risks of ovarian hyperstimulation, which can be a severe complication. One study suggests that women with PCOS undergoing ovarian stimulation will have higher egg retrievals, but still have lower pregnancy rates for unknown reasons, though a variety of causes have been speculated including problems with implantation to increased rates of early pregnancy loss. Interestingly, a 2023 study supports the use of many of the supplements I discuss in this article, not only for PCOS improvement, but specifically for improving outcomes with …
A study published in Clinical Obstetrics and Gynecology in September 2017 suggests that 30 to 50 percent of women diagnosed with endometriosis also struggle with infertility, and many consider their options for treatment, particularly when they reach their mid-30s. Decreased ovarian reserve and risk of tissue damage to the ovaries sometimes associated with endometriosis may increase your desire to preserve fertility via egg freezing, however, having a physician skilled in both egg retrieval and endometrial changes to the ovary becomes all the more important for your safety and the success of the procedure, particularly in the setting of ovarian endometriosis (OMA), as hyperstimulation may also be more likely in this group. Additionally, even with successful egg retrieval, pregnancy success rates are unclear.
We do know that IVF success rates are lower, particularly the more severe the endometriosis. A 2018 study in Human Reproduction reported a 24 percent lower live birth rate after undergoing IVF compared with those with unexplained subfertility, though “extensive laparoscopic surgery when performed by an experienced multidisciplinary surgical team” for the endometriosis lesions may improve the live-birth rate with IVF.
No Wrong Answer, Just a Deeply Personal Choice
The decision to freeze your eggs is a deeply personal one, and it's essential to approach it with a clear understanding of both the benefits and limitations involved. By considering your unique circumstances, goals, and timeline, you can make an informed choice that empowers you to take significant control over your fertility journey.
Freezing your eggs can offer hope and flexibility, providing a sense of security for the future, while removing both real – and the externally driven pressures of a ‘biological clock.’ While it doesn't guarantee a successful pregnancy, it may increase your chances of having a child when you decide the time is right. But it’s also not without financial and potentially medical costs. With the support of a qualified fertility specialist, you can create a tailored plan that aligns with your individual needs and preferences, and optimize safety and success.
Regardless of the path you choose, remember that your story is unique, your future is filled with possibilities, and remember, you are not alone on this journey.