Should you consider freezing your eggs? What is involved and how much does it cost. We talk with Dr. Taraneh Nazem, Board-Certified Reproductive Endocrinologist with Reproductive Medicine Associates of NY.
In this episode, we cover:
Female Fertility
Fertility Preservation
Egg Freezing
This podcast is produced by www.CreatingaFamily.org. We are a national non-profit with the mission to strengthen families. Creating a Family brings you the following trauma-informed, expert-based content:
· Weekly podcasts
· Weekly articles/blog posts
· Resource pages on all aspects of family building
Creating a Family also has an active presence on many social media platforms. Please like or follow us on Twitter, Facebook, LinkedIn, and Pinterest.
Please leave us a rating or review RateThisPodcast.com/creatingafamily
Should you consider freezing your eggs? What is involved and how much does it cost. We talk with Dr. Taraneh Nazem, Board-Certified Reproductive Endocrinologist with Reproductive Medicine Associates of NY.
In this episode, we cover:
Female Fertility
Fertility Preservation
Egg Freezing
This podcast is produced by www.CreatingaFamily.org. We are a national non-profit with the mission to strengthen families. Creating a Family brings you the following trauma-informed, expert-based content:
· Weekly podcasts
· Weekly articles/blog posts
· Resource pages on all aspects of family building
Creating a Family also has an active presence on many social media platforms. Please like or follow us on Twitter, Facebook, LinkedIn, and Pinterest.
Please leave us a rating or review RateThisPodcast.com/creatingafamily
Please forgive the errors. This is an automatic transcription.
0:00
Welcome, everyone to Creating a Family Talk about Infertility. I am Dawn Davenport, your host and the director of Creating a Family. Today we're going to be talking about fertility preservation and egg freezing with Dr. Taraneh Nazem. She is a Board Certified reproductive endocrinologist with Reproductive Medicine associates of New York. Welcome Dr. Nazem. to Creating a Family, we are so glad you're here today to talk to us about fertility preservation as well as egg freezing.
0:30
Thank you so much for having me, Donna, I'm excited to be a part of this very important conversation.
0:37
This will be part one female fertility.
0:40
Okay, I want to start, we always try to start at the beginning. Right, that makes sense. We're gonna start with an overview of female fertility because if we're going to be talking about fertility preservation or female fertility preservation, we need to understand female fertility in general. So just give us kind of the crib note the basic version of, of female fertility, how it works, just basically from a biological standpoint. Oh, absolutely. And I completely agree, I think it's always good to start from the beginning. And, you know, fertility preservation while it doesn't always go hand in hand with female infertility or fertility, it, it sort of all stems from the same place, so it's a good place to start.
1:26
So pretty much in order to have successful reproduction, there are several different components that are important both on the male and female side that we always want to make sure are functioning from the female side, we need to make sure that women are oscillating regularly, meaning that they have regular menstrual cycles, and that the ovaries are functioning properly, that they're releasing one egg every single month in a timely fashion, and that they have a good quantity and quality of eggs. Interestingly, women are born with all the eggs they're ever going to have. And so that is the sort of rate limiting step of reproduction in general. And it's something I'm sure we're gonna dive into in more details, we talked about fertility preservation. And so the quantity and the quality of eggs over time declines. And so it's important that a woman has not only a good quantity, but good quality of eggs, because without a good egg being released every single month, it's pretty hard to reproduce. So that's sort of the ovarian piece of reproduction and fertility may ask a question, at what age is a woman the most fertile? It's a tough question specifically to answer by a number, but we usually look at it over a woman's, you know, reproductive lifespan being from puberty to menopause. And within that timeframe, it's really in a woman's less, sort of when they're a woman is less than 35 years old, is her prime peak fertility. And the reason is because the quantity and the quality of the eggs are at their best in that age category, starting around the age of 35, it's not something that just happens instantaneously on your birthday. But around that time, that we start seeing a more rapid decline in both the quantity and the quality. And we see it happen around 35, but really much more significantly after 37. And as we inch closer and closer to 40, it becomes really rapid. So when we look at quality, for example, under the age of 35 80% of the eggs that a woman has in her body are chromosomally normal. And when we talk about normal, we're really worried about the chromosomal content of the egg.
3:42
After 35, that percentage, slowly slowly starts to decrease. And by the age of 4080 to 90% of the eggs are abnormal. And so that's really the the challenge with reproduction. And I think it's something that actually a lot of people don't learn about and don't know about most women are not aware at how quickly this process happens. And then the rate at which the quantity decline is very person specific, but it's also during that same 35 plus range when the quantity is decreasing.
4:16
So anything else on the the biology of female fertility we need to cover before we move on to what impacts Absolutely. So the other components in order to have successful reproduction is we have to have functioning fallopian tubes. This is the conduit path, Byrd obsoleted egg to meet sperm in the fallopian tube and implant in the uterus. We also need to have a healthy, you know, area in the uterus where where implantation can occur. And so, it's important that a woman doesn't have something like you know, large fibroids or dimitra polyps or something like that that could interfere with successful implantation. And then you know, the final piece is on the male side we have to have viable healthy sperm
5:00
Better modal and access to that sperm ultimately, to have successful fertilization and implantation. So, you know, these are all the these are the main four components that we evaluate when we're looking at someone's overall capacity to get pregnant. And there's a lot of testing that we can do to look at each one of these reproductive systems. So you've been talking in generalities of female fertility, but what factors impact a woman's fecundity, a woman's fertility, just in I'm speaking in general now, what factors impact beyond just the anatomy?
5:38
Right. So you know, there are obviously a lot of other things that can impact one's ability to get pregnant. And a lot of it really stems from overall health and wellness, several medical problems can interfere with a person's ability to become pregnant. So generally, it's important that that somebody is in good health, they have a good healthy BMI or weight, women who are obese, or have had significant fluctuations in their weight, either major weight losses or weight gains, these things can interfere with the menstrual cycle, that can interfere with the ability to get pregnant. And of course, any kind of toxic behavior or exposure could impact fertility. So things like smoking and excessive alcohol use can impact one's fertility, or, you know, maybe a past history of being exposed to a lot of toxic chemicals or radiation, things like this. So there's quite a lot that can impact fertility, but sort of the rule of thumb is is general, overall health and wellness is is the best way to be and everything in moderation. And you've already mentioned probably the number one factor that influences fertility, and that is age, especially for women female fertility annually, and it it affects it negatively by both affecting the quality and the quantity of eggs. How does it affect the quality describe the quality, the quality, because it's chromosomal abnormalities that increase significantly with age, but how does it affect the the number of eggs we have other than the fact that we're releasing eggs every month? It's
7:20
a really interesting phenomenon. So we're born women are born with one to 2 million eggs. And already by the time they get to puberty, that is down to maybe 500,000 eggs. So start at the start of our reproductive years, we're already you know, working with much less than what we were born with. And little by little over the course of every single month, there's a release and loss of eggs that happens. So even though we think that there's only one dominant follicle that oscillates every single month, there's actually a whole group of eggs, along with that dominant follicle that get released and actually disappear at the same time as population. And so there is an attrition of eggs over the course of our lifespan, you know, just naturally that happens. And the issue is, is that that that number of eggs that are lost, and the pace at which they're lost, increases rapidly after the age of 35. And that's why it can potentially impact fertility, it only takes one egg to get pregnant. So you know, you might ask, so why do I care if I have so many eggs or not, but it's a matter of having the availability to release a normal one every single month and when there's fewer eggs to work from? It becomes harder over time.
8:43
Okay. All right.
8:46
Let me pause for a moment to remind you that this show is brought to you in part through the generous support of our partners. These are organizations and clinics that believe in our mission of providing unbiased medically accurate information to the patient community. We could not be doing what we do without their support, and we thank them.
9:08
One such partner is Cooper surgical fertility and genomic solutions. Cooper surgical fertility and genomic solutions are global leaders in IVF and reproductive genetics, Cooper genomics offers PTT, a PTT, PTT ESR and E RP, which is an individual receptivity testing for those who are pursuing IVF Cooper genomic genetics test screen and embryos genetic health to help your care team select the best embryo for transfer and improve your chances for achieving a successful pregnancy.
9:44
Part Two, fertility preservation.
9:48
In part one, we did an overview of female fertility. In part two, we'll be talking about fertility preservation.
9:58
You mentioned that at the beginning that
10:00
The fertility begins to decrease at around significantly, I assume it's decreasing on a on a steady path from our early 20s. On but that angle starts increasing the decline starts increasing at around 35. And more specifically around 37. Is that correct or incorrect? Okay. But some women, their decline they, at a much younger age have significantly less ovarian reserve than then you would be but be the average. What is that called and and how is it diagnosed and what causes it.
10:39
So, we call it diminished ovarian reserve. And that's a diagnosis that's based off of a woman's age and her assessment of her ovarian reserve. ovarian reserve, really is just an assessment of the quantity of eggs that a woman has not just per month, but overall left in her body. And there are a couple of ways that we can evaluate that. One is doing an ultrasound within a transvaginal ultrasound, which is an internal type of ultrasound, we can take a look at the ovaries and the number of follicles, which is the fluid that surrounds the eggs that a woman has in her ovaries per month. Counting that number is one way to assess what a woman's ovarian reserve is relative to her peer group. The second way is through blood tests. The main blood test that we use is called anti mullerian hormone or a m h. And m h is a test that that quantifies the amount of eggs that are left that are remaining in the body overall in storage, not just how many eggs have been brought to the ovaries that month. And that's also based off of a normal gram somewhere between the range of zero to four being the values that we look at. And it's also interpreted based on a woman's age, the main cutoff that we use is the value of one. So if your age is above or below one, it's it signifies a diminished versus a normal ovarian reserve. But generally, this innate value in a vacuum is not an easy thing to interpret. And it's something that generally a fertility specialist should help you to understand if it's something you've done for yourself or one of your patients to to really interpret based on your age and and also your ultrasound findings.
12:31
How can a woman How might a woman know that she has diminished ovarian reserve and
12:38
it's not something that you can feel or know inherently about yourself, it's something that you would only find out if you went and sought out this kind of evaluation from a doctor. And it's something that most women don't really discover about themselves until they're going down the path of either fertility preservation or trying to reproduce, and maybe that they've hit a roadblock that they've been trying for several months and no luck. So it's not a part of a routine health maintenance exam. And it's not something that in general, the field of fertility, you know, doctors and reproductive society, we don't recommend that it's done routinely. Because I think that it's a it's not a predictor of your ability to get pregnant. It's really a marker of ovarian reserve. But is it a predictor of how long you should wait before you start trying to get pregnant?
13:30
Not quite. It's, it's something that that has been used for that purpose for some providers and some patients, but it's not really for that purpose. Because it's not a predictive value. It's a snapshot in time. It's telling you this is the quantity of eggs that you have today. It doesn't tell you at what rate that's going to change. And it does not predict your ability to get pregnant because like we said, it's it's really just takes one egg to get pregnant. But it is something that's helpful if you're going through fertility treatments to guide fertility treatment medication, especially for fertility preservation purposes. And also if you know for family building purposes might be something that's important as you are embarking on you know building your family for example, if you found out you had a really low ovarian reserve, and you want to have a very large family in the future, that might influence some of your decision making about whether or not fertility preservation would be good for you.
14:31
So although it is not predictive and you're not recommending it, if a woman is in her 20s and is for whatever reason hasn't found a partner or is embarking on a long degree program, or is starting off in a career that she knows is going to She needs a fair number of years in advanced to gain seniority before she hasn't family. Is there anything since we're talking about four
15:00
fertility preservation and aspect of that is understanding how you should approach family planning. If you have that option, and some women obviously do not, is there anything a woman can do when she is younger, and her most fertile? Other than we're going to move into talking about fertility preservation and egg freezing? Other than that, is there any way to know how long she has to wait? If she needs to alter her plans? If having a family is in having biological children is important to her?
15:33
It's a really important question when you're asking but unfortunately, the answer is there is no other real treatment besides fertility, preservation and fertility preservation has been a game changer for this exact reason. It's allowed an opportunity for women to sort of stop their biologic clock, you know, to to do other things in their life before they build their family. But, but less than that, no, there isn't any specific natural way or, you know, other medical way to preserve our fertility or or stop our clocks. And there's there's no way also of predicting how our, you know, reproductive journey is going to go when we're in our 20s. There's no specific diagnostic test or, or thing that we can discover about ourselves that would that would tell you, okay, this is the year that you need to start trying to get pregnant, or you only have X number of years left, I have a relatively easy conception, right? Unfortunately, we don't have that I wish we did. And if I could invent it, I would.
16:39
But unfortunately, we don't have a way of predicting that beyond just what we know about general population statistics, and looking at age and fertility rates. And you know, a woman in her 20s really should be okay, in trying to conceive. Whereas if, you know, I was starting this conversation with somebody who was already in her mid to late 30s, we might be having a different conversation. But that's all just based on what I know about the
17:03
reality. Yeah, it's not because the diagnostic test or some sort of algorithm that we have. Okay, so since we're talking about fertility preservation, before we move in to discussing egg freezing, let's talk about what women can do to who are women, younger women, by women in their 20s and 30s. What they can do to support their fertility and maintain optimum fertility for as long as possible. I think the number one thing in terms of maintaining good potential for fertility and reproductive potential is just maintaining a good healthy lifestyle. If you have medical problems, keeping them well controlled, keeping your BMI at a normal level, being active, healthy, eating healthy, you know, doing staying away from really toxic behaviors, like smoking, excessive drinking, illicit drug use, avoiding any major exposures that might harm your reproductive system. I'm sure a lot of your listeners are in medical professions or have exposure to radiation, or toxic chemicals, be careful, you know, those are the things that we know are going to impact your fertility and, you know, being extra cautious about that can make a difference. But beyond that there's no specific medication, vitamin or major, you know, treatment that will you know, preserve your fertility in a in a bottle. What about birth control? We get this question a lot. Is there a form of birth control that could either help your fertility or harm your fertility, there's really no type of birth control that's harmful to fertility. And there's many different obviously types of birth control. But in general, when we talk about birth control, I think a lot of people are thinking about the birth control pill, and other suppressive hormonal suppressive treatments, they're not harmful. And in fact, there's a lot of medical benefits to being on on birth control, you know, reduces your risk of ovarian cancer and has a lot of positive side effects like lightening your menstrual flow, and minimal cramps and great skin changes and things like that. But it's not harmful to your fertility. It only suppresses your ovulation while you're on it. For some women who have been on birth control for many years, sometimes upwards of a decade, they can have, it might take them longer once they've stopped their birth control to resume their normal menstrual cycle. But that's not a harmful side effect. It just takes it means it's taking a little bit longer for your hormones to normalize after going off of birth control. Birth control simultaneously does not necessarily, you know prevent the loss of eggs over time, just because it's suppressing your population. It's not decreasing that attrition that happens over time. So I get this question a lot about well, I've been on birth control for all these years. I haven't been oscillating for all these years. 100
20:00
lose all those eggs, right? It's still happening anyway. And so it's not like it's a preventative treatment, or it's going to preserve your fertility by being on birth control. Long term I wish but unfortunately not. So the number of each month even if you're not ovulating, you still are having attrition that diminishment of your eggs and, and even realistically, if you've got if you started at a half a million, and we're only talking for a month, even if you were preventing from losing those for a month, you're still not that's not a drop in the bucket. Right, exactly. I mean, and but there are women who say, well, I've been on birth control since I was, you know, went through puberty. And so How come I've still lost eggs, they're still losing them month to month, it's a pop ptosis of the of the oocytes. And that's, that's beyond our control with any hormonal birth control, or non hormonal? Well, let's talk about some non hormonal IUDs, which could be both, but there is some concern that we hear from patients about it, could the IUD have scarred my uterus? Or make it more difficult for the uterine lining to become an inviting place for an egg to land? Is there any evidence with IUDs? one way or the other? No, there isn't. You know, the IUD is a really effective form of birth control, and it's a temporary thing. So it's long acting, but it's temporary. And when it's removed, usually your fertility goes right back to where it should have been. It is not harmful to the uterine lining, it does not cause scarring of the uterine lining unless you were one of the rare people who had to have a very complicated, you know, removal of your IUD did the IUD get embedded in the uterus and need to have a surgical procedure or something to remove it is a very rare occurrence. And even so, a lot of women who undergo additional procedures, remove IUDs still have completely normal fertility going forward. So there is not evidence to suggest that an IUD is harmful to your fertility at all. Okay, so birth control is not an issue that either it's not in the plus column or the negative column when it comes to a woman's fertility. Absolutely. And I and I strongly encourage women before they're ready for those reproductive years to be on birth control, it is the healthiest, safest way to prevent pregnancy when you're not ready.
22:23
And the last question that we receive a fair amount is, Will is there evidence that exercise will increase our health preserve your fertility, we hear a number of women be surprised when they're in their 40s they just ran a marathon I am in peak health I have never been, I have never been more fit than I've ever been. So how can I be having reduced fertility.
22:48
But we hear that also from women in their 30s. So what is the relationship from physical fitness or exercise and fertility?
22:58
So I think being in good physical fitness is a key component to fertility. Like I said, maintaining a healthy weight and being active and having good cardiovascular health. All of these things ultimately will contribute to your ability to reproduce carrier pregnancy and have a successful delivery. And so these are things that I encourage with all of my patients and and to take into consideration as I am getting to know my patients. That being said, exercise and being healthy isn't the the main component here. And it does not change the aging process of the ovaries and the eggs. And so, you know, whether you're in your 20s or your 40s, and you're equally fit, you're still combating the same reproductive aging that happens to all women and and so that exercise doesn't necessarily change that factor. It's good for your overall health and what's good for your overall health is good for your fertility, but it's not a magic bullet. Is that a good sign? Exactly, exactly.
23:57
Thank you.
24:00
Part Three, egg freezing. In part one, we talked about an overview of female fertility in part two, we talked about fertility preservation. In part three, we will be talking about egg freezing.
24:15
Let me pause for a moment to remind you that this show is brought to you in part through the generous support of our partners. These are organizations and clinics that believe in our mission of providing unbiased medically accurate information to the patient community. We could not be doing what we do without their support and we thank them.
24:37
One such partner is Reproductive Medicine associates in New York. They are a full service Fertility Center specializing in in vitro fertilization, egg donation, egg and embryo freezing LGBTQIA family building, reproductive surgeries and male reproductive medicine. highly individualized patient care is offered through 13 reproductive
25:00
chronologist, fertility specialist and a urologist as well as a full support team. By combining the latest innovations in reproductive sciences with compassionate and customized treatment plans, RMA of New York is able to provide the very best possible care.
25:19
All right, Alright, now let's move on to talking about egg freezing, who should consider freezing their eggs who are the prime candidates that you would think should consider this option? Honestly, and maybe it's coming from a biased place, I think everybody should consider it at some point or another. And when I say consider it, it doesn't mean do it. But I think it should be a conversation for every single woman at various time points in their life. And I have noticed, actually, that a lot of gynecologists have made this a part of their routine health maintenance discussions with their patients, which I think is fantastic. When it comes down to it, there's a lot of different reasons to pursue fertility preservation with either egg or embryo banking. And what I see is women coming to do it for medical reasons, meaning that they're planning, you know, a surgery, and they're concerned that that might impact their fertility in the future, and they want to preserve their fertility before they do it. Or they have a significant medical condition, which means that they're not going to be able to get pregnant in a timely fashion. And so they want to preserve their fertility. Before it's too late, for example, somebody who has a cancer diagnosis and needs to have chemotherapy and will lose their fertility. As a result. These are women who always pursue fertility preserved, well, not always, but very often presumed fertility preservation before going undergoing treatment. But then there's a lot of people who just elect to do it for personal reasons, because they're in a professional career that they want to throw themselves into and dedicate themselves to, and, and not necessarily start their family just yet, or because they're concerned because other family members that they know have struggled with infertility, and they're afraid there might have the same. There's a multitude of reasons. I mean, the list could go on for days and days. But it's for this exact reason that I think it's a good conversation to have with oneself with one's doctor, and just explore what the process is like, which hopefully will explain a little today and see whether or not it's the right fit for you. At what age should a woman consider freezing her eggs? Both ideally? And realistically?
27:26
Yeah, good question. So, you know, I'd say that the prime time to pursue egg freezing is really in one's 30s, you know, in the early to mid 30s, is probably the sweet spot. The reason being that I'm sort of saying this for not just for the people who are considering it medically, because medically it's for a little bit different. This is more for people who are elected. Yeah, let's definitely take up because they don't have a choice. Right, exactly. Like they get a mental diagnosis when they're 22. That's when they're doing it. We're not we're not waiting. But when we're talking about women who are just electing for personal reasons to freeze their eggs or make embryos, generally in the 30s, early to mid 30s is the prime time to be doing this, because that's when women are sort of a little more settled in their life, they they sort of know their their trajectory, studies have shown that women in their 20s who do egg freezing are a lot less likely to come back and use their eggs because they generally end up finding a partner and having a family naturally on their own. And so it's not as cost effective.
28:38
And then when we look at it from a medical standpoint, that that's the time in the early to mid 30s when the egg quality and the quantity is really at its peak in terms of, you know, timing, past the 20 year old, you know, timeframe. And so you're going to get probably the best yield if you do an egg freezing cycle at that time in your life, because the quantity and the quality both matter when it comes to using those eggs in the future.
29:09
All right, now let's talk about the egg freezing process, what do what is involved.
29:16
So the process starts just with a simple consultation meeting with somebody like me, a fertility specialist, just talking through what your history is, what your goals are, and coming up with a plan. During that consultation, I usually do an ultrasound to evaluate a woman's ovarian reserve as well as the anti mullerian hormone or a MH blood test, which also helps me to understand what would be a reasonable expectation for one cycle of egg freezing. And at the end of that consultation, I like to sort of set a goal and a plan for for the process. And so that's that's really where it all starts a simple consultation and that's still that's information
30:00
Gathering session for you, as well as for your provider to figure out if it's the right thing for you. And then once if you're ready, and once you're ready to start, the process is about a two week process all in, it starts and it's scheduled on your menstrual cycle. So usually starting day three of your menstrual cycle, a woman will take injectable medications, which are hormonal injections for about nine to 12 days, they're very small, thin needles that are injected into the belly fat. And this is something that every single person is taught how to do, we make it as user friendly as possible. And while you are doing those injections, you will have to go in for for monitoring, with an ultrasound and blood work about every other day for those those nine to 12 days. The reason is, is that it's important for your provider to be able to evaluate how you're responding to the medications. And the way that they evaluate that is by looking on the ultrasound at the size of the follicles, which is the fluid that surrounds the egg, which correlates the maturity of the eggs, the quantity of eggs that are responding. And also looking at your hormone levels to see whether we're where you are in your response. And so that way they have the ability as the process goes along to adjust your medications as you go to optimize your response. And ultimately, at the end of those nine to 12 days based on your monitoring evaluation, your provider will decide whether or not it's time for your egg retrieval. The egg retrieval is a procedure that's done under sedation. It's not general anesthesia, it's an IV is placed in the arm and some medication is placed in the IV that's very mild and just puts the puts the woman to sleep for 15 minutes. While the eggs are being retrieved from her ovaries. The egg retrieval is done magically. So there's no belly scars or incisions, it's not a major surgery. And a needle is used to just go across the vaginal wall into the ovary and suction out every single egg possible. So section all the follicles and the eggs come along with it. An embryologist evaluates the eggs as they're being removed from the ovaries, and they're cleaning the eggs evaluating for the maturity of the eggs, and they're ultimately going to freeze those eggs that are retrieved. And then ultimately, after the egg retrieval, about an hour later, women go home and they do fairly well. They may have some spotting some cramping, but but nothing too remarkable or too painful to recover from. It's the one day that I tell my patients just take off, take it easy, no working, no major decisions. But the next day they're back at work and sort of business as usual. And generally they're able to work and function in their regular lifestyle all throughout this process. And that's sort of the end of the process at about two weeks later, they'll get a period and you know, regroup with their with their doctor and figure out how they did feel how they feel they did and you know, do they want to do it again, or was that enough? And that's something that's person specific. So what are the short and long term risks of the fertility medication needed for egg freezing or egg retrieval for those eggs to be used for freezing. So the short term is really just side effects. It's you know, feeling what I think is extreme PMS, so feeling crampy and bloated, tired, fatigued, maybe some breast tenderness, some moodiness, that extra vaginal discharge. And these are all symptoms that ultimately resolve by your next period. There are some rare complications with the egg freezing process and that some women can be overstimulated, it's a big reason why women generally are told to come in to be evaluated on a frequent basis, so that we can reduce that risk of happening. There's also the very rare complication of having an ovary twist on itself, because the ovaries become so enlarged. It's why I advise my patients while they're going through this process, not to do any high intensity or high impact exercise, because all of that jostling about can potentially twist the ovary. but less than that, really the short term is is really short term and resolvable and people do very well. Long term, there's very minimal impact. I know a lot of women are very concerned about hormonal exposure and risk of breast cancer. There has been actually some great longitudinal studies that have looked at women who have done IVF or ovarian stimulation for a multitude of different reasons, whether it be infertility or egg freezing, and they have not found an increased risk of breast cancer compared to the general population. And I think a big part of the reason is because it's a short term spike in your hormones that quickly resolves by your next period, your hormones are right back down to normal, and you're hopefully not doing this for so many cycles. So you're not having repeated exposure over time. Okay, I was gonna ask about that. That So, because we're gonna be talking
35:00
Just a minute and about how many cycles one needs to do. Do you need to have if you're using an IUD as for birth control? Do you need to have that removed in order to go through an egg retrieval process? No, you don't we do the egg retrieval process with IUDs. Whether it's the copper IUD or the hormonal IUD in place, it's completely fine. It does not impact the outcomes from these cycles. Okay. And that makes sense, actually, do you need during the egg retrieval process to be careful not to be having intercourse? Because you don't want to be exposing all these eggs to sperm?
35:38
Absolutely. Right. So for two reasons, I recommend abstaining from intercourse during this process. The first is, is that I just said it's really not advisable to do anything high intensity, high impact, it's actually quite uncomfortable to have intercourse when your ovaries are so enlarged. So that's part one. And Part two is is that in the rare, rare, rare circumstance that you happen to ovulate through the egg freezing process, if there was exposure to sperm, there is a high risk of pregnancy and a multiple pregnancy which we want to avoid at all costs. Yeah. And it would be substantially it could be a high order multiple multiple pregnancy, right? Correct. We're not talking twins. We're talking, you know, optimum level. Yeah. Yeah, certainly, we certainly want to avoid that. Right. Right. Very situation. Yeah.
36:30
So one of the, you know, the $64 million question, both literally and figuratively, is how many eggs? Do you need to freeze to provide a decent chance of having a baby? And then the the corollary to that question is, so how many cycles does one need to be prepared to do? Because this is not a free procedure? We'll talk about that in a minute. So Alright, so how many eggs Do you need to freeze?
36:56
So this is an extremely important conversation, and it is a big part of the consultation that I have with each one of my patients, before we embark on an egg freezing cycle, because it is a very person specific answer. It has to do with age, it has to do with the egg quantity that you have already in your ovaries, and what's reasonable. So when we look at women under the age of 35, I usually recommend that 10 to 15 eggs is more than enough to secure them at least one live birth in the future. It's very important to know as you sort of embark on this process that there are absolutely no guarantees. But based on the few, you know, studies and the outcomes data that we have so far, there's a good chance about a 70 to 80% chance of having at least one child from 10 to 15 eggs when you're in that sort of younger age category. And that shifts over time, as a woman gets older, and the quality of her eggs declines the quantity that she needs varies. I also like to say that you know it, it has to also do what your personal with what your personal goals are. Are you looking to bank for a large family? Are you looking to bank just to have a little backup for maybe one child and and that also goes into that final assessment and setting of goals. So I know that I'm supposed to try and give you an exact number of for everybody listening? I'm sorry, I can't it's not a canned answer. But it is something that's important to to determine for you based on your evaluation with your doctor. And then the number of cycles that you need goes hand in hand with that. So if for example, just I'll just throw an example out there, let's say I'm seeing a 34 year old woman who has, it looks like a antral follicle count. So the number of follicles in her ovaries looks like it's about 12 follicles. What I'll say to her is okay, your goal will probably be something like 10 to 15 eggs, let's say she just wants to bank for maybe one child, I'll say 10 to 15 eggs. And in one cycle of IVF we may achieve the 10 eggs, but we may not. And depending on how we do in that first cycle, we will regroup and decide whether or not she needs a second cycle. And a lot of that also has to do with her personal feelings and how she felt the cycle went and how important it is for her to have the highest possible percentage of odds going forward. And then also their financial considerations. And I know we'll talk about as as we go through it.
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So it is really person specific. It has to do with how many eggs you can possibly achieve in one cycle and how many eggs you want to achieve for your family building goals.
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Are women with low HDL levels a good candidate for egg freezing?
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Yes, they are. I know that there is some there are some people who say well, it's just not worth it. I have had women who've had low MHS who who have performed very well, that the difference is that it may take more cycles to achieve the same goals.
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As somebody who has a higher aim age and one cycle and and so it's just a matter of your level of determination and persistence to achieve what you set out for yourself. So how long can eggs remain frozen?
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indefinitely, we have improved our freezing technology, we now do fast vitrification, which is the super fast cooling system, that's not damaging to the eggs. Once they are frozen, they are frozen in time, and they do not get damaged while they're in the freezer the entire time. So you can come back and use your eggs many, many years after you froze them.
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Yeah, okay. So they're that length of time is not going to be hurt hurting. Okay.
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All right, does freezing damage the eggs? It is not. There used to be an older technology called slow freezing that we used to do an egg freezing was first being developed, we do not use that anymore, because that was slightly damaging to the eggs. vitrification, which is a fast cooling system that we use. Now, across the board. Everybody uses vitrification for a freezing is not damaging to the eggs. What percentage of eggs survive the fall? So that has to do with wherever you're going to do your egg freezing. So these are important questions to ask during your consultation, because it has to do with the specific statistics of the laboratory that you are going to be using. So in our laboratory, about 80% survive the thaw. And so we do fairly well with our egg freezers who come back to use their eggs. Okay. And I've read varying statistics on of the women who freeze their eggs, what percentage come back to ever use those eggs? That's a tough question. I have to go back and see exactly what our stats are. I'm sorry, you stumped me on that one. That's all right. It's a I think, from what I have seen, it is highly dependent, as you mentioned earlier on the age of the woman, when she is freezing her eggs. I mean, a lot of it also has to do with the fact that egg freezing became FDA approved in 2013. So it's a relatively new technology. And there's not a lot of people who did it right from the outset that we've we've seen a surge in it in the past few years. And a lot of the people who just froze their eggs will not be coming back to use them probably for another few years. Yeah. So it's not super high numbers just yet. But there have been actually, you know, there have been there have been a bunch of people have come back to you. I just don't know what the number is off the top. Yeah. And I think that that the bottom line is that it's a little too early to know, for all the reasons you just said it is coming into acceptability more and more, but the women who are freezing their eggs currently, they're freezing them for the future. And so we won't know until the future but generally speaking, we we do the assumption is that younger women will be more likely to not use them simply for the reasons you mentioned, that their life plans will have changed along the way. All right. So we we all know that are maybe we we don't all know. But egg donation, the person who donates an egg there you can be paid and the money would go a long way towards recouping the cost of of egg donation is there a way if you want to do one of two things either want to have the option if you do not end up needing your eggs to donate them and be able to recoup some of your costs or to go into egg freezing some for you for fertility preservation and some to donate, or any of those options feasible are something that women should consider. Some of them are, I'll say that the egg donation process, if that's something a woman is interested in, is a little more stringent than the egg freezing process. Meaning that since you'd be donating tissue to another individual, there's a screening process that needs to occur to make sure that it's safe to donate that tissue to somebody else. And so when somebody comes to freeze their eggs for themselves, we don't do that same screening process because it's intended for your use in the future. So donating your eggs that you spontaneously chose to freeze doesn't necessarily always work for the egg donation process unless you want to donate it to like a family member or a friend or something like that. It's very rarely done, let's just put it that way. But if you're somebody who knows that you want to do both, maybe freeze a cycle for yourself and freeze the cycle to donate. Then going through the whole egg donation screening process first would be advisable and then figuring out the logistics Second.
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Okay, we have been freezing embryo for a very long time. And if you go back and include veterinary medicine where the technique was first perfected even longer, so
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We have a proven track record with freezing embryo with great success. And, as one reproductive endocrinologist mentioned, said one time, it's not the freezing, it's a problem. It's the thawing. So freezing and thawing successfully embryos for a very long time. So what is the what is the calculus for the women that you consult with on whether or not to freeze their eggs or to go ahead and create embryos and then freeze the embryos? Because I suspect that the fall rate, the successful fall rate is higher for frozen embryos it? Well let's put this way successful fall rate and implantation rate would be higher for frozen embryos. I don't know that, but would be higher for frozen embryos and frozen eggs. Yeah, so this is a really important question. I'm glad you asked it and actually just recently wrote a blog, which is on the army of New York website to anybody who wants a deeper dive into the into this question, because it comes up quite often. And there are pros and cons to both. When we break down egg versus embryo banking. There's a couple of main components that differentiates the two and I'm going to wait to answer your question about success rates, because there's some other things that go into decision making before that. The first and most important thing is is deciding whether or not you want reproductive independence, or if you're willing to have joint custody of your tissue with somebody else. And making making eggs keeps you completely reproductive independent, they are yours and yours only. And you can do whatever you want with them in the future. What if and when you find the sperm source of your choice, whereas if you make embryos, you are attached that sperm source, whether it is donor sperm, or a person that you're in a relationship with, and you either have sole custody or joint custody of them, but you can't really do much else with them. Right? It is wed to that person. So I'd say that that is the number one decision that needs to be made before embarking in this process. Now there are a lot of people who are kind of in between where they're in a serious relationship, they're not sure what they should do. And then this question really comes up. So one of the advantages of embryo banking is that the egg has been fertilized, it's gone through a lot of steps to become an embryo. And so it's very clear from the quantity of the eggs that were retrieved, how many are going to ultimately have the potential for viability and implantation. Additionally, we have the option with embryo banking, to test the embryos for their chromosomal makeup through what we call pre implantation genetic testing, where we take a biopsy of a few cells of the embryo in the area that's going to become the placenta, and we find out is it 46 x y 46 x x or does it have an irregular number of chromosomes in which case would not be compatible with a successful pregnancy. And that gives a major advantage to embryo banking over egg freezing because the unfortunate part about egg freezing is we don't have a way of testing what the chromosomal status of the eggs are, and what the likelihood of success will be with those eggs, except for based off of population statistics. So embryo banking has that advantage. And that's why success rates with embryo banking can sometimes seem much better, because we know exactly what we're what we're transferring, and what the odds of implantation are of those embryos. And so when somebody does an embryo banking cycle, and they see how many embryos they have at the end, then they really know, do I need to do another cycle or not? Because you can really very accurately give a sense of likelihood of live births based on that. With the egg freezing process, we cannot do that until after we've thought the eggs fertilized them. And then we can still do that testing on the you know, resulted embryos, but it's at a stage where you're obviously older than when you froze them. And so the options for you know, recourse are a little bit less, the ability to thaw eggs and embryos is almost the same. So we had said, you know, for our egg saw success rates is about 80 to 90% at RMA of New York, and our, our embryo thaw rates are about 95% at RMA of New York, so it's almost comparable. Yeah, it's really not a huge attrition rate. In terms of the number of eggs frozen to thawed, eggs are a little more fragile. frozen eggs are a little more fragile than fresh eggs. And so you know, it's it is possible that maybe the fertile is the fertilization rate is just slightly lower instead of 80% at 70% are frozen eggs. But generally people do very well with frozen eggs. And I think it's more important to make the right decision based on your personal circumstance, then based on statistics, because it's really splitting hairs. Both are are fairly successful processes. When you were talking about reproductive freedom, that whether or not you are the sole decider of what happens to the
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agar the embryo
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I think you were assuming and perhaps I'm wrong that, that if the the sperm would be coming from a partner, and you would be, but this donor, yeah, but a donor sperm, you would still be able to maintain. Exactly right. Yeah. So if you use donor sperm to create embryos, which many women do, then you have sole custody of those embryos, they, there's nobody else who has a claim to them. Whereas if you make it with a partner that is involved in the process, then it is it can be joint custody unless you fill out paperwork for a different nature. Okay, we make sure to go through all of this with our patients. So I that's part of this whole process of an egg and embryo banking is is going through, you know, the consent process and making sure that you know, all of these things are clarified before you embark on process. Yeah, exactly. It may seem intimidating, but the reality is, there are there, there are questions that can be asked that help lead you to the right decisions. So it's not quite when you're actually doing it, it's probably less overwhelming than what it feels like right now. When you're listening. Right, right. My intention is not to scare anybody away from it. No, you're not guy that Yeah, life a lot easier in the future. But you're you said it so perfectly, which is that it also it the questions elicit the right plan? Yeah, exactly. All right. Now, let's talk about cost. Because the reality is unless you work for a company that provides the benefit of egg freezing, which is extremely rare right now, although increasing, I will add, but it is not generally, yeah, thankfully. But it is not the norm. So having said that, insurances most likely not going to cover this, it's an elective procedure. So what I'm going to break the cost into three sections, because I think it's helpful for people to that for a couple of reasons, I think that is helpful. I want to talk about the cost for the initial egg retrieval, which is the process that you have described of, of Avi latorre, stimulation, and then retrieval, and all of that, and the medication involved with that, because the medication is a substance can be a substantial part of that. Then I want to talk about the cost for freezing your egg, freezing your embryos or eggs, in this case, most likely cryopreservation storage fee. And then if you're going to come back and use your embryo, you're going to have a frozen egg IVF cycle, and there's a fee for that as well. So let's talk about and you can you can talk about national averages are in any way you want. But let's first talk about the initial egg retrieval process, including the medication and that will have to be an average because medication, of course, is dependent on many factors that are that really fluctuate. I'm gonna, I'm gonna preface all this, which is, I am not the financial expert. And so I actually have a financial coordinator that I have every single one of my patients meet with that knows this all inside and out, I'm sorry, I'm not going to be as eloquent as she is. But that's also part of that initial consultation because I am not naive to I get it. This is a big part of the decision making process. The other thing I wanted to address in sort of the preamble to this is that there is more insurance coverage now than there used to be for egg freezing. But you are correct in that most elective egg freezing is not covered. There are some circumstances where you might have actually a medical indication you didn't know about that we can appeal insurance to cover egg freezing for. So for example, there's a lot of women who have endometriosis and need to have surgery or they have fibroids or their stuff. And these things ultimately do end up getting coverage for and so it's something that you should explore. Just don't automatically assume you can't get it. But yes, it is on the more rare side that you will get insurance coverage for this. And if you're not somebody who works like a tech company that has great benefits, you're probably thinking unless you have a metal if you're I do not want people who are undergoing a let's say cancer diagnosis and they're going to go through treatment. That is often a very different thing. So that is what we're talking about now is elective egg freezing, and the
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But absolutely, I have so many patients who did not ask their employers and found out later that there were benefits there are a lot of companies do not speak about it. They don't publicize it. So if you're thinking about doing this, please ask your HR department and you might find you might find that especially at this past year, a lot has changed and a lot of people are sort of a lot of companies are being pressured to incorporate some sort of fertility benefit into their benefits program. So definitely
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We asked, now, let's say you did all of that, and there's no coverage whatsoever, what's it going to cost? Okay, so yes, there are averages, there's a wide spread. There are some places that do this on the cheap. And some places that, you know, sort of have standard rates, I'd say standard rates for all in for one cycle of egg freezing is somewhere between 10 to $15,000. And that includes the medications and the retrieval process. The medications are usually about half that cost, but it varies. So if you are somebody who has a really high ovarian reserve, and may not need as much medications, as somebody who has a low ovarian reserve, your costs might be on the lower end. That's why there's such a big range. And then if you're doing embryo banking, then the cost goes up a little bit more and ranges more like 15 to 20,000, depending on what procedures are being done and all that kind of stuff. But these are really crude numbers. Yeah, we know that. Yeah. We're not expecting this is a ballpark? Yeah. Okay. How about cryopreservation storage fee, the fee for keeping them frozen, not as familiar with, I think it ranges from like about, you know, I think you had said something is based on how many years or whatnot, I think the annual fee ranges somewhere between 200 to $1,000 a year, depending on where you where you store them.
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And it's somewhat dependent, usually get a reduction for X number of years, and most women are able to say, I'm not going to use this, you know, I'm doing this because I'm not planning on using them for the next three to five years. And so there usually is a reduction anywhere, you know, 2500 to 3000 would be a five, just roughly a five year range. And I know at army of New York, when somebody does an egg freezing cycle, the first year of storage is complimentary, and we just included is a part of, you know, the process that you went through. So we don't start storage fees until after the first year. Okay. And I think that probably is many places, and you can often get, if you store off site, you can sometimes get reduced rates. So anyway, just something to think about. Yeah. Again, some research before you go through this process. Yeah, exactly. The main reason to talk about it now is so that you know that that is a cost that you need to be factoring in. All right. Now, let's say you come back three years later to to fertilize your if let's assume you only froze eggs. So you're going to go through the fertilization and then frozen embryo. Yeah, at that point you'd be? Well, I guess it'd be a frozen egg IVF cycle.
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So what's the process? At that point? We know the cost? Oh, well, ha. No, actually, I think it's a valid question. Let's now the point. Let's say we haven't talked about the, let's say, five years later, you come in, and you say I want to throw all my eggs. And I want to fertilize them. And I want to have them transferred with the hope of a pregnancy. What would be the what was the process then? So we first figure out how many eggs Did you freeze and in some cases, if you froze a lot of eggs, we're not going to sell all of them right away. We might just a few of them at a time. We thought the eggs we fertilize them and we fertilize them through the use of xc intracytoplasmic sperm injections, we inject the sperm into the egg that helps to overcome sort of the fragility of the of the egg. And then we let them grow, then generally, I think most places, grow them until they're a blastocyst, which is day five of development, meaning a very expanded embryo. So it goes from being a two cell fertilized egg to almost 100 to 200 cells. At that point, either you undergo an embryo transfer of one good embryo or depending on your age, maybe two, or you decide that you want to do the chromosomal testing, we talked about the pre implantation genetic testing of the embryo in which case they biopsy the embryo they refreeze the embryo and wait for the results to come back before thawing and transferring the chromosomally normal embryo. Both are options, and it's just a discussion with your doctor about what's the right thing for you to do. And that's sort of the process in a nutshell, I have to say this part, I really don't even know where to give you the cost up because it has to do with just what procedures you're doing in the lab, the embryologic procedures, preparing for an embryo transfer cycle is really on the order of maybe a couple $1,000. It's not a very expensive process. So this is much more minor compared to the stimulation of making the eggs is where the big cost comes in. But it depends on whether you're doing PPC, exactly whether you're doing the genetic testing, right, because the cost of the biopsy and the cost for the testing and then the extra thawing and freezing like those all it's like just depends on what procedures you're doing. Right. That's a fair assessment. Okay. Well, thank you so much. This has been fascinating. The fertility preservation is going to increase
1:00:00
recently become a topic that, that women or couples, the men and men need to be thinking about for the future. And thank you so much, Dr. darnay Nazim for talking with us today. And again, she is a Board Certified reproductive endocrinologist with RMA of New York, our reproductive medicine associates of New York. Thank you so much for being with us today to talk about this topic. And thank you so much for having me. I'm so passionate about this. I think this is such an amazing way for women to take control of their reproductive journey. And I hope I answered some of the Hot Topic conversation topics and questions that have come up. But anybody who wants to know more, please either follow me on Instagram or check out the RMA website. Come in for a consultation. I'm happy to see anybody who wants to learn more. Thank you so much, and everybody else, let me remind you that the information presented at this show is for general advice to understand how it applies to your specific situation, you need to work with your infertility professional. Also, the views expressed in this show are those of the guests and do not necessarily reflect the position of creating a family, our partners or our underwriters. As you know, the mission of creating a family is to provide unbiased, accurate information to help you create the family you've always wanted. And this podcast, the one you're listening to right now is the prime way we accomplish this mission. Please tell others about this podcast so that we can help more people. You have so many options for letting the world know social media posting about an episode you liked or texting a friend that you think would benefit from this show, sharing it with someone in person or Heck, you could even call someone on the phone and tell them we would appreciate your help however you decide to do it. Thank you everybody, and I will see you next week.
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