I’m Dr. Monica Pasternak, Medical Director at Spring San Francisco, a best-in-class fertility center that puts patient care first.
In the second post of the three-part series, we answer your questions about family planning, egg quality, the “best” age for egg freezing, and more.
If you missed the first part, don’t worry, you can find it here.
Q from @Lucile76: What’s the best age to do egg freezing for the majority of women?
A: Best is a tough word in medicine. A woman’s eggs are highest in quantity and quality when we are young, number of eggs begins to decline in our twenties, the quality of our eggs (meaning, the chance that any one egg can successfully develop into a healthy baby) begins to decline rapidly in our mid to late thirties. In general, there isn’t a dramatic change in either of these until our mid to late thirties.
An important consideration is “how likely are you to need to go through IVF in the future.” For example, if a woman knew that she would have to go through IVF, then we would recommend freezing eggs the younger the better. For example, if you know that your fallopian tubes are blocked or damaged, if you have a genetic mutation that you will want to screen for to have a healthy child, or if you have a medical condition that will preclude carrying your own pregnancy (therefore requiring IVF with a gestational carrier), we would recommend freezing eggs as early as possible in order to optimize your chances.
Most of the data on using frozen eggs comes from women under 38. We see that eggs frozen after age 35 seem to develop at a lower rate than younger eggs and that those embryos tend to be abnormal.
For most women, there is not a big difference in outcome between freezing your eggs at 28 or 34. So our answer here, every woman should consider her goals with egg freezing and decide when is the best time for her as life events, travel, school, and finances weigh differently for people. Interestingly, the average age women were freezing their eggs 5 years ago was 37-38, today, the average age of women freezing their eggs at Spring Fertility is 33.
Q from @lexiyan: What would you recommend for someone who knows they want to have kids and is in their late 20s, but doesn’t have plans to have kids in the immediate future?
A: For most women, there is no pressure or need to preserve fertility in your twenties. It's always a good idea to get an initial test of your ovarian reserve with an AMH blood test. REMEMBER: Having a low AMH does NOT have any relation with your natural fertility. Women with a low AMH can achieve a pregnancy as easily as women with a normal or high AMH. But it may mean that their follicle count is lower and that they will produce fewer eggs through the egg freezing or IVF process (if they needed it). Thus, an initial AMH can be helpful to guide your own timeline in considering egg freezing. These will help you and your physician make a timeline.
The primary downside to freezing your eggs when you are younger is the annual storage fees, which vary regionally, but can typically cost from $60 to $100/month.
Q from @SenZhan: I just turned 38, and for most of my life I was on the side of not having children, so I didn’t explore egg freezing options earlier. Now I’m with a wonderful partner, and if I were ever to have children, it would be with him. But as much as I would love for him to have kids, I’m still not ready or sure about my own desire or capacity to be a mother [...] I was told by my gynecologist that egg freezing at my age would not necessarily improve my chances of a successful pregnancy down the line once I’m ready, compared to if I just went for trying to get pregnant now. But buying myself time would be worth it for me, even if the chances of success with egg freezing don’t improve, but match the probability of success as trying to have a child now. What would you suggest for me? Does egg freezing make any kind of sense? Is there a different frame of mind I could try on that would help me to think about things differently?
A: Fertility preservation does not need to be limited to egg freezing. In your case, it sounds like you met your life partner and only want to have children if it is with him. You just don’t want to have them now. You may want to speak with a fertility specialist about EMBRYO freezing. This is highly effective (more than egg freezing) and ideal for a committed couple that wants to have children together in the future. If you create a chromosomally normal embryo, you can expect an approximately 60-70% chance of a live birth with each genetically “normal” embryo.
Q from @Rae79: When I was 30, my endocrinologist told me I’d better hurry up and freeze my eggs because over 30 the procedure would be less effective. Now I know people being told it’s still a good idea to freeze eggs at age 37. I guess science may have advanced, but cynically I see this and assume clinics figured out that women 35+ can better afford the hefty price tag of the procedure.
A: We generally advise patients with a good ovarian reserve that before 35, they do not need to rush to freeze their eggs. If this is something you are interested in, find a time that works for you. If you DO decide to freeze your eggs, there are many studies showing meaningful year-to-year declines in success rates after age 36. But the goal is to feel empowered with knowledge and then choice. If you feel that your provider is pressuring you to do this, we’d recommend leaving that provider.
Q from @Rae79: I froze my eggs when I was 30, and 19 were retrieved across 2 cycles. Although I've heard tons of IVF success stories, I've never actually heard anecdotes about women who used their frozen eggs. How does it usually go? When I've looked into this in the past, I've been told that egg freezing only became popular within the past decade, so there isn't enough data yet to draw any conclusions about success rates when the eggs are used across different ages. I've heard it's good to use them within 10 years, but even that sounded like a guess.
A: The uncertainty about outcomes is one of the hardest things for women freezing eggs. Egg freezing was introduced clinically in 2012 (was no longer considered experimental). And we are still learning about the success rates. Much of our data comes from women who use frozen donor eggs to healthy pregnancies by using frozen eggs from younger women. These have high success rates and function similarly to “fresh” eggs if they survive the freezing process.
REMEMBER: Egg freezing is still a manual process and it is arguably the hardest thing we do in the IVF lab (reserved for our most senior embryologists). There is a lot of variability in outcome between patients and also between clinics. We recommend doing it somewhere with good experience and you should ask your provider for their clinic’s
- Survival rates of warmed frozen eggs, and
- Blastocyst development rate of those eggs, at your age
One clarification: there is no truth to the statement about using them within 10 years. This was an arbitrary time frame set by regulatory authorities in the UK. They have since rescinded that recommendation as more data have consistently shown that eggs, sperm, and embryos do not degrade based on time that they are cryopreserved. You can storage your eggs for as long as you’d like. The primary risk is the momentary process of cryopreservation and the momentary process of the thaw.
Q from @iammyr: Is there specific steps/analyses/monitoring that you recommend one should ensure our doctors do perform, before and after frozen embryo transfer, in order to raise the chances of success as much as possible?
A: Before an embryo transfer, it is a good idea to evaluate the uterine cavity. Leading up to the transfer, it is standard to monitor the uterine lining development. How often you go in will vary across clinics, as well as the need to check bloodwork. It's always a good idea to ask the clinic how they are using the bloodwork or tests. After transfer, some clinics will check hormone levels prior to a pregnancy test, others won’t. The key here is that you understand what your clinic will do and why and to understand their rationale.
Q from @iammyr: If one was to travel to a different country for the FET, how much time would they need to spend in this other country before all checks and procedures were completed?
A: Before a Frozen embryo transfer, one typically undergoes a saline sonogram to make sure the uterus has no addressable obstacles to implantation. Once we have initial bloodwork and a saline sonogram, it is possible that a patient on a medicated or “controlled” protocol for a frozen embryo transfer, may only need to visit their clinic for the day of a transfer (if their doctors accept remote monitoring). Every clinic will have different requirements and slightly different protocols, so the time in country for the transfer might range anywhere from three days to one month.
Q from @codev91: What is the typical cost of freezing eggs for someone in their early thirties? My doctor said the "ballpark" cost is $3k-5k / round (I live in Boulder, CO) + ~$200 / year for storage, but I have heard a lot higher numbers from friends who have had it done (though they also live in other cities). I'm also not sure what the typical number of rounds is for someone in their early thirties. How hard is this process on your body? Would it be difficult to work while undergoing egg freezing?
A: Regarding the process, prices vary by clinic and location (remember cheapest to freeze may not be the cheapest in the long run if the outcomes are worse). Most of our patients continue to work during the process and may only miss one day of work for the egg retrieval.
Q from @iynna: I hear and I see that egg freezing is crazy expensive, but I actually don't fully understand how women are being charged and how much on average would the treatment cost (let's assume all out of pocket)? Are you familiar with other countries that have more favorable terms for women (e.g countries where healthcare is not as expensive as the US)? Along the same wavelength, any countries that are known to provide quality care? How long is the process of freezing eggs? I have heard the process is difficult on the women's body, is this true? What could be the cons of doing it (from a health perspective)? Can women have irreversible side effects? It's known that Black women are most prone to death during childbirth, any similar studies with regard to egg freezing?
A: The costs are egg freezing vary a bit by region, in general range is 7-15k. The process takes about two weeks. How each woman reacts to egg freezing is different. In general, the more eggs you have growing the more side effects you experience, like bloating. Side effects are reversible and normal-when something increases in size (an ovary), you feel heavier because in that moment you are. I am not familiar with studies suggesting black women have higher complication rates from egg freezing.
Q from @Rae79: My doctor told me to do the egg freezing procedure ASAP because my fertility would decline rapidly after 30. And then a few years later, the same clinic I used told my 35-year-old friend that it was a good idea for her to do the procedure too (and I think they even told her there was no rush). Based on what they told me (that it was a HUGE rush), it seems like they should have told my friend in full disclosure that the procedure had really low odds of being successful.
A: It can be frustrating hearing different advice from different providers. It's always reasonable to ask your provider for data on this too. Our best understanding of the data is that egg QUALITY, and therefore naturally fertility, does not decline too much before age 36. It is true that the number of eggs one can obtain declines linearly, and this decline begins in ones mid 20s. That said, declining number of eggs typically occurs slowly. The average number of eggs retrieved per attempt declines by about 1 egg per year of age.
Helpful data slides that we use from published studies are included below:
Rate of decline in number of usable eggs retrieved per IVF cycle (Attempt):
Decline in quality or chance that an embryo has a normal chromosome number over time:
Old study looking at how many eggs were used per live birth at different ages (from 2005-2010 in clinics across Belgium and The Netherlands):
Q from @innachilik: I am 37 and have been told that I have decreased ovarian reserve (low egg count). Does it make sense to still go for egg freezing? And what would that mean for me (aside from increased costs and the need for several cycles of egg extraction)? Secondly, according to my doctor, the chances are higher to impregnate the egg after the hormone treatment rather than freezing them first and creating an embryo 1-2 years later (and also cheaper apparently). Since I am not ready to become a mother just yet, would my chances significantly decrease if I chose to pause the process and do egg extraction (and potentially IVF) next year when I am 38?
A: It may be helpful to view some of the data slides we shared. What is clear is that fertility declines quickly after age 36. So 37 is actually a good time to freeze eggs as the changes over the next two years will be significant.
If you have already identified your life partner (or sperm source), then freezing embryos, instead of eggs, makes sense. If you freeze eggs, you preserve your opportunity to choose your sperm source later. The cost of the opportunity to delay committing your eggs to one sperm source is that eggs do not all survive the freezing process. It's appropriate to assume that 10-20% of the eggs frozen, may not survive that process. When we freeze embryos (fertilized eggs), 99% survive.
Q from @Ingeborg96: I've heard about higher risks for certain medical diagnoses like autism etc. if you give birth after the age of 36. I'm curious about the reality of these risks versus how much is hearsay. I'm also curious whether freezing eggs at 36 would do anything then to support lower risks around these, or whether if you're freezing eggs past 36 it comes with the same risks.
A: Eggs that are retrieved from younger women are more likely to produce genetically normal pregnancies. So if you intend to use your eggs to conceive, frozen 36 y/o eggs are more likely to develop into healthy pregnancies than older eggs, HOWEVER, this refers primarily to risk of Downs syndrome, Turner’s syndrome and miscarriage. Maternal age is NOT related to conditions like Autism, schizophrenia or other conditions that are not linked to chromosome number. Interestingly, the MAN’S age may play a role in risk of autism, schizophrenia and neuropsychiatric conditions. So far paternal age has been associated, but is not definitively causal in these conditions. Maternal age, or egg age, data is centered around genetic abnormalities.
Q from @Monet87: I am 30 and married, but ideally, we don't want to have kids right now. We want to figure out our careers, travel, and buy a house which will all take a few years. What should I be doing now to prepare us for fertility? What data should I be gathering to make informed decisions? I am scared we will wait until it's too late and then have regret.
A: Fortunately, 30 is considered young in our field. I think since you have already identified your sperm source (or life partner), you can hold off until 34 before seriously considering whether to pursue fertility preservation techniques. Or maybe you are starting a family at that time. The critical consideration is, “how old do I anticipate being when I want to be having my LAST child?” If the answer to that is over 40, then it may be prudent to learn more about fertility preservation.
Q from @Mistie8: If one wanted more than one child from frozen embryo transfer, how much time should one consider in between one eventual pregnancy+delivery and the next?
Timing between pregnancies after IVF: There is one study that suggests waiting a year from delivery to embryo transfer will be most beneficial (in terms of birth weight and length of gestation) for your second child. We encourage women to wait at least 10 months from their last delivery and if possible to wait a year.
Q from @iammyr: Do multiple cycles of IVF/ICSI carry any health risk or decrease of fertility level? Does the time distance between one and the other affect this risk, at all?
In general, we do not see much risk of multiple cycles of IVF or egg retrievals. There is a small increased risk of borderline ovarian tumors that has been reported in women after undergoing SIX retrievals, but the absolute increase in this risk remains very low at less than 1%. The timeline between cycles does not increase your risk of adverse outcomes.
👀 Curious to learn more from the team at Spring Fertility? Check out part 3 of the series.