Egg freezing, procreative liberty, and ICSI: the double standards confronting elective self-donation of oocytes

Women's reproductive choice and (elective) egg freezing: is an extension of the storage limit missing a bigger issue?

Egg freezing can allow women to preserve their eggs to avoid age-related infertility. The UK's recent extension of elective egg freezing storage has been welcomed as a way of enhancing the reproductive choices of young women who wish to delay having children. In this paper, I explore the issue of enhancing women's reproductive choices, questioning whether there is a more significant aspect overlooked in egg freezing. While increasing storage limits expands reproductive choices for some women, focus on this extension alone, I argue, misses a fundamental issue with egg preservation that often remains ignored; the importance of effective information on egg freezing and the effect this has on women's reproductive choices. Ultimately, I highlight the crucial role of balanced information in enhancing women's choices regarding egg freezing and argue that focusing on extending and increasing provision may obscure this real opportunity to empower women and their authentic reproductive choices.

Oocytes on ice: Exploring the advancements in elective egg freezing for women

Introduction

Female fecundity decreases significantly after the age of 32, and rapidly so after age 37. There is no treatment to prevent this decline. Furthermore, globally, women are getting married later and the age at which they have their first child is increasing. As of July 2023, elective egg freezing (EEF) or oocyte cryopreservation (OC) for age-related fertility decline, commenced in Singapore. With medical advancements in OC, EEF is no longer considered experimental. The aim of this review is to examine the existing literature around EEF with regard to reproductive outcomes and its safety, to better guide clinicians in counselling young single women.

Method

Published studies were examined to increase understanding on optimal age for EEF, ideal number of oocytes for a live birth, recommended OC protocols, cryopreservation techniques affecting thaw survival or fertilisation, oocyte storage and pregnancy risks.

Results

Models predict that EEF should be performed at age <37 years and to achieve a 70% chance of live birth, women would need 14, 15 and 26 mature oocytes at ages 30-34, 35-37 and >38 years, respec-tively. An antagonist stimulation protocol with an agonist trigger would minimise ovarian hyper-stimulation syndrome and duration of stimulation without affecting outcomes. Oocyte vitrification in comparison to slow freezing increases thaw survival, fertilisation and clinical pregnancy rates. No increased risks exist for the woman, future pregnancy or child when compared with conventional IVF.

Conclusion

EEF is a viable option for single women desiring fertility preservation. Financial costs are significant, but returns are worthwhile if oocytes are utilised.

Social Egg Freezing-A Trend or Modern Reality?

INTRODUCTION

Egg freezing for social reasons is a process in which women who want to preserve their ability to fertilize their own oocytes at an older age freeze their eggs. With the help of in vitro fertilization, the cryopreservation of oocytes for future use is achieved. The aim of this article is to study the reasons, the risks and the effectiveness of the method from a worldwide aspect.

METHODS

A literature search was conducted to evaluate pertinent studies, using data from the search engines PubMed, Google and UptoDate as well as the medical literature.

RESULTS

The reasons for delayed procreation are non-medical, with the lack of an appropriate partner for a family being first on the list. The success rate of this method differs with the age of the woman, the number of fertilized eggs and other factors. Like every medical procedure, this method carries risks that relate to the mother (being of advanced age), the embryo and the procedure of in vitro fertilization. The policies that apply in each country differ depending on respective social, economic, religious and cultural factors. Due to the high cost of the method, its selection remains a choice for only a few, reinforcing social inequality. The question of the medicalization of reproduction remains unanswered in the industry of assisted reproduction.

CONCLUSIONS

In conclusion, egg freezing for social reasons is gradually becoming more widely known, with the United States of America and Israel being at the top the list. Unfortunately, there is no official data registry, and consequently, no statistical results are yet available for Greece, even though it is a method that more and more women are considering. Nevertheless, there is an imperative need for a universal legal framework for all countries with respect for the needs of every woman and different social conditions. More research and data from the literature are needed in relation to the effectiveness of the method from moral and social perspectives.

The making of 'old eggs': the science of reproductive ageing between fertility and anti-ageing technologies

This article proposes going back in the history of reproductive medicine to shed light on the role of assisted reproductive technology (ART) in the making of 'old eggs'. Focusing on two key technologies - egg donation and cytoplasmic transfer - both of which contributed significantly to the production of scientific knowledge about reproductive ageing, the article suggests that ART can be analysed as 'in-vivo models' playing a pivotal role in the shift from age as a demographic variable to ageing understood in biological terms. It will shed light on the role of ART in locating age in the eggs and producing a cellular understanding of fertility decline. It argues that ART not only offers new means of reconfiguring the biological clock by extending fertility, but also reconfigures the biology of reproductive ageing itself. This becomes both the target and the means for new technological interventions, imaginaries and norms, anchored in women's bodies and a more plastic biology, and thereby illuminates hitherto underexplored aspects of the encounter between the science and technology of reproduction and anti-ageing.

Social Freezing: Pressing Pause on Fertility

Increasing numbers of women are undergoing oocyte or tissue cryopreservation for medical or social reasons to increase their chances of having genetic children. Social egg freezing (SEF) allows women to preserve their fertility in anticipation of age-related fertility decline and ineffective fertility treatments at older ages. The purpose of this study was to summarize recent findings focusing on the challenges of elective egg freezing. We performed a systematic literature review on social egg freezing published during the last ten years. From the systematically screened literature, we identified and analyzed five main topics of interest during the last decade: (a) different fertility preservation techniques, (b) safety of freezing, (c) usage rate of frozen oocytes, (d) ethical considerations, and (e) cost-effectiveness of SEF. Fertility can be preserved for non-medical reasons through oocyte, embryos, or ovarian tissue cryopreservation, with oocyte vitrification being a new and optimal approach. Elective oocyte cryopreservation is better accepted, supports social gender equality, and enhances women's reproductive autonomy. Despite controversies, planned oocyte cryopreservation appears as a chosen strategy against age-related infertility and may allow women to feel that they are more socially, psychologically, and financially stable before motherhood.

"It's Just Another Added Benefit": Women's Experiences with Employment-Based Egg Freezing Programs

BACKGROUND

In 2014, companies began covering the costs of egg freezing for their employees. The adoption of this benefit was highly contentious. Some argued that it offered women more reproductive autonomy, buying time to succeed in their careers and postpone childbearing. Others suggested this benefit might place inappropriate pressure on women, unduly influencing them to freeze their eggs to prioritize their career over reproduction. Although ethical problems with this benefit have been explored, there has not been research analyzing the perspectives of women working for companies that offer employer-based egg freezing. Furthermore, existing empirical studies often focus on the experiences of egg freezers rather than the young women thinking about, but not yet using, this technology. Methods: Through in-depth semi-structured interviews, we explore the perceptions and attitudes of 25 women employees of companies with employer-based egg freezing. Results: These women describe delaying childbearing for a multitude of reasons, including not having a partner, and the desire to achieve social and career goals. Many women did not know that their employers covered egg freezing before the interview (44%; 11/24), suggesting this benefit is not essential to their career and family-building decisions. While women did not describe pressure to use this technology, they did describe how this benefit would not solve the difficulties of becoming a mother while excelling in their careers. Conclusion: Although women may not feel pressure to freeze their eggs and delay childbearing, they still feel constricted in their reproductive options. While employer programs may offer women the ability to delay childbearing, many saw this delay as postponing problems with work-life balance rather than solving them. We suggest that sociocultural shifts, such as workplace daycare, flexible workplace hours, and acceptability of non-biological parenthood, might allow women to feel more empowered about their reproduction choices.

Postponing Pregnancy Through Oocyte Cryopreservation for Social Reasons: Considerations Regarding Clinical Practice and the Socio-Psychological and Bioethical Issues Involved

Oocyte freezing for 'social reasons' refers to women of reproductive age who are aiming to prolong, protect and secure their fertility. The term emerged to describe application of the highly promising technique, namely vitrification on oocytes retrieved through controlled ovarian stimulation (COS) from women intending to preserve their fertility for social reasons. These women opt to cryopreserve their oocytes at a point in their life when they need to postpone childbearing on the grounds of so called 'social' reasons. These reasons may include a highly driven career, absence of an adequate partner, financial instability, or personal reasons that make them feel unprepared for motherhood. This is a sensitive and multifaceted issue that entails medical, bioethical and socio-psychological components. The latest trend and the apparent increase noted on oocyte freezing for 'social reasons' has prompted our team of fertility specialists, embryologists, obstetricians, gynecologists and psychologists to proceed with a thorough, critical and all-inclusive comprehensive analysis. The wide range of findings of this analysis involve concerns of embryology and epigenetics that shape decisions made in the IVF laboratory, issues regarding obstetric and perinatal concerns on the pregnancy concluding from these oocytes and the respective delivery management and neonatal data, to the social and bioethical impact of this trend's application. This literature review refers to matters rising from the moment the 'idea' of this option is 'birthed' in a woman's thoughts, to proceeding and executing it clinically, up until the point of the pediatric follow up of the children born. We aim to shed light to the controversial issue of oocyte freezing, while objectively exhibit all aspects regarding this complex matter, as well as to respectfully approach how could the prospect of our future expectations be shaped from the impact of its application.

Oocyte cryopreservation for social reasons: demographic profile and disposal intentions of UK users

A small number of studies from the USA and Europe have provided some data on the profile and characteristics of women who have undergone oocyte cryopreservation for what has been termed elective, social or non-medical reasons; however, little is known in a UK context about which women are undergoing oocyte cryopreservation or their reproductive intentions and actions after the procedure. Drawing on data from an exploratory study of 23 UK resident women who had undergone social oocyte cryopreservation, the demographic profile of these women, their reproductive intentions and actions are discussed, as well as their attitudes and intentions towards their cryopreserved oocytes should they never require them in treatment. The study found that, at the time of oocyte cryopreservation, women were on average 36.7 years of age, were university educated, with 65% of the sample holding further postgraduate or professional qualifications. Fifty-seven per cent of the participants were in professional employment. All participants identified as heterosexual and 87% were not in a relationship at the time of cryopreserving their oocytes. Most (88%) participants stated that they would donate unwanted oocytes to research or to other women for use in fertility treatment should they never require them.

Assisted reproduction: Ethical and legal issues

Since inception, the use of assisted reproductive technologies (ART) has been accompanied by ethical, legal, and societal controversies. Guidelines have been developed to address many of these concerns; however, the rapid evolution of ART requires their frequent re-evaluation. We review the literature on ethical and legal aspects of ART, highlighting some of the most visible and challenging topics. Of specific interest are: reporting of ART procedures and outcomes; accessibility to ART procedures; issues related to fertility preservation, preimplantation genetic testing, gamete and embryo donation, and reproductive outcomes after embryo transfer. Improvements in ART reporting are needed nationally and worldwide. Reporting should include outcomes that enable patients to make informed decisions. Improving access to ART and optimizing long-term reproductive outcomes, while taking into account the legal and ethical consequences, are challenges that need to be addressed by the entire community of individuals involved in ART with the assistance of bioethicists, legal counselors, and members of society in general.

Oocyte banking for anticipated gamete exhaustion (AGE) is a preventive intervention, neither social nor nonmedical

The scope of female fertility preservation through cryopreservation of oocytes or ovarian cortex has widened from mainly oncological indications to a variety of fertility-threatening conditions. So far, no specific universally accepted denomination name has been given to cryopreservation of oocytes or ovarian cortex for the prevention of age-related fertility decline. We argue that the commonly used phrases 'social' and 'nonmedical freezing' to denote the indication for cryopreservation are not entirely correct. We suggest 'AGE banking', as this has not only the advantage of being catchy but also depicts the exact indication for the strategy, anticipated gamete exhaustion.

Freezing the Biological Clock: A Viable Fertility Preservation Option for Young Singaporean Women?

In March 2012, an article in The Straits Times entitled ‘Freezing eggs could reverse falling birth rate’ suggested that employing the latest oocyte cryopreservation techniques could both foster individual women’s reproductive autonomy and impact Singapore’s fertility rate, which in recent years has consistently been among the world’s lowest. The article cited both local and international fertility specialists’ approval of elective oocyte cryopreservation for young women wishing to protect their reproductive potential against ageing and as a potential antidote to the contemporary ‘delay and defer’ model of family-building. Later in 2012, the Ministry of Health announced a review of oocyte cryopreservation policy taking into account related medical, scientific and ethical issues, while the Singapore College of Obstetricians and Gynaecologists endorsed oocyte cryopreservation as an “important, safe and efficient technology”. This paper outlines and analyses the arguments and empirical evidence used both to support and oppose offering elective oocyte cryopreservation as a routine fertility service, before concluding that this remains unjustifiable on the basis of insufficient evidence of its clinical efficacy and safety as regards either pregnancy rates or birth outcomes. If it is to be made available at all for these reasons in Singapore, it should be subjected to rigorous clinic-specific evaluation in accordance with accepted clinical and ethical norms. Key words: Elective oocyte cryopreservation, Outcomes

Is vitrification of oocytes useful for fertility preservation for age-related fertility decline and in cancer patients?

The aim of this review is to provide current knowledge on oocyte cryopreservation, with special emphasis on vitrification as a means to preserve fertility in different indications. Major advancements achieved in the past few years in the cryolaboratory have facilitated major changes in our practice. Areas such as fertility preservation for social or oncologic reasons, the possibility to create oocyte banks for egg donation programs, the opportunity to avoid ovarian hyperstimulation syndrome, or to accumulate oocytes in low-yield patients, or even to offer treatment segmentation by stimulating the ovaries, vitrifying, and then transferring in a natural cycle are some of the options that are now available with the development of cryopreservation. We present general experience from our group and others on fertility preservation for age-related fertility decline as well as in oncologic patients, confirming that oocyte vitrification is a standardized, simple, reproducible, and efficient option.

The status of oocyte cryopreservation in the United States

OBJECTIVE

To determine the current status of oocyte cryopreservation across the United States, and the perceived indications for its use.

DESIGN

Cross-sectional survey of all IVF Centers in the United States.

SETTING

Telephone and fax based survey of all IVF practice or laboratory directors, conducted March to June of 2009.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of oocyte cryopreservation, acceptable indications and age groups, number of oocyte cryopreservation cycles performed and thawed, fertilization and pregnancy rates, number of live births.

RESULT(S)

Of 442 centers contacted, 282 (64%) responded in 49 states. In these centers 143 (51%) programs currently offer oocyte cryopreservation, with a geographic trend toward the western-located clinics. Of all programs, 36% offer oocyte cryopreservation only for cancer patients or as an alternative to embryo cryopreservation after IVF, whereas 64% of programs offer it electively in women of advancing maternal age. For elective indications, 87% of programs accept patients aged 35-37 years, 49% consider age 38-40 years as acceptable, whereas only 26% of programs cryopreserve oocytes beyond age 40 years. Three hundred thirty-seven live births resulting from 857 thawed cycles (39.3% pregnancy rate [PR]) were reported across all centers.

CONCLUSION(S)

Oocyte cryopreservation is offered in more than 50% of ART clinics in the United States. Most programs that perform oocyte cryopreservation for cancer indications offer it for elective delay of childbearing as well. These data suggest a growing acceptance for this technology within our field.