We've Gotta Have it
How Ovarian Tissue Freezing May Help Women Better Time Children with a Career
Ovarian tissue freezing can extend fertility and delay menopause
As recently reported on ABC News, the total fertility rate in the US is at a 30-year low, as women are having children later in life. “We are seeing more and more women pursue higher education and enter the job market and establish a career before they have children,” explains Professor and Vice Chair of Education at the Johns Hopkins Bloomberg School of Public Health Donna Strobino.
Not only are more women pursuing graduate degrees, but they are also entering graduate school later, after a few years of travel and work experience, alongside their male classmates. At Harvard Business School, for example, new entrants are 27 years old on average, compared to 24 a generation ago. This shift in age has implications for the female graduates who want to have both a career and their own children. By delaying the launch of their formal careers, female graduates actually shorten the window of time they have to climb the career ladder before their biological clock slows down and they have potential fertility issues. Generally, after age 35 a woman’s egg supply and quality of eggs deteriorate, and she is classified as having an “advanced maternal age.”
Melissa, for example, graduated from Stanford at age 30, and took a job for newly minted MBAs at one of the FAANG companies on the West Coast. She married at 33 and wanted to spend the next few years giving her all to work so she could be promoted. At the same time, Melissa’s doctor gave her a stark warning. He cautioned her that if she delayed getting pregnant until she was 35 or older, she would have fewer eggs and her eggs would have a higher chance of chromosomal damage. Also in the back of her mind was the fear that she could be one of the unlucky few to have a premature menopause. Many of Melissa’s friends faced a similar dilemma: during their most fertile time, they believed they needed to work long hours, pay dues, and travel in order to advance their careers.
While Melissa had seen some of her friends freeze their eggs during this time, she realized this procedure was not as straightforward as sometimes portrayed. In reality, her friends and their partners went through emotional and physical stress with egg harvesting, and they often had to repeat this process several times to be able to freeze a sufficient number of eggs for later IVF.
A New Way to Extend Fertility
Now there is a new option for Melissa and her generation of women: ovarian tissue freezing, which is also referred to as ovarian cryopreservation. News coverage of the procedure has focused primarily on the technique’s ability to delay menopause. But it can also help women who are concerned about early career and family trade-offs or premature menopause (which affects less than 5 percent of women) to extend their period of fertility. Ovarian cryopreservation has been used selectively for over two decades for cancer patients to preserve their fertility before undertaking chemotherapy or radiotherapy, and it is now becoming available for healthy women of childbearing age in specialty clinics around the world, such as the US, the UK, and Israel.
Like egg freezing, this procedure involves microsurgery. But instead of removing eggs, surgeons can now remove one third to one half of one ovary. The tissue is then sliced, frozen, and later reinserted when needed. Later in life, this procedure can boost a woman’s natural hormone production and egg supply and deliver her own hormones according to her body’s own rhythms. Ideally, the tissue is removed before age 35 for use in enhancing fertility, and before age 40 if one is looking to delay menopause.
A major benefit of ovarian cryopreservation over egg freezing is that it allows a larger number of eggs (hundreds, even thousands) to be captured by freezing ovarian tissue for future use, compared to approximately 10 eggs per cycle for egg freezing. And it does so without the large doses of artificial hormones required for egg harvesting. Ovarian cryopreservation is also likely to be less disruptive, as it normally requires one microsurgery, as opposed to the multiple ones egg freezing typically requires.
At a minimum, it is reported that ovarian cryopreservation has a similar pregnancy rate to egg freezing. For women who want to conceive children with their own eggs (as opposed to donor eggs), conception rates with ovarian cryopreservation for cancer patients with mixed ages average around 30 percent, compared with 18-27 percent for egg freezing and later IVF, although some experts claim that success rates for both procedures are significantly higher. The efficacy of both procedures is likely to improve significantly with advances in technology and when more younger women, with healthier eggs and egg reserves, decide to go through these procedures to protect later fertility.
Costs vary for both procedures, particularly for egg freezing. In the US, a good baseline for egg freezing with IVF is upwards of $10,000 per cycle. But the costs can easily skyrocket from there. Dr. Sherman Silber, a fertility specialist at the Infertility Center in St. Louis, cautions that clinics often “add one test after another, and although the cost might not initially seem that much ….. if the clinic is not careful the cost could be $20,000-$25,000 per cycle.” Most importantly, women need at least two cycles, if not three, in order to procure and freeze a sufficient number of eggs. Dr. Silber explains that the total bill “could add up to $50,000 or $80,000, and totally break a couple’s savings.” Ovarian cryopreservation costs around $15,000-$20,000 for the tissue to be removed, stored, and reinserted. Insurance coverage is generally not available for either procedure, although a few states (such as Maryland) require coverage for egg freezing, and a small number of companies provide it for their employees.
Are there Drawbacks?
As does any new procedure, ovarian tissue freezing has many unknowns. While there is a track record with patients who have been diagnosed with cancer, extensive data backing its use in the general public doesn’t yet exist. The proponents of ovarian cryopreservation predict that if the procedure works on women with medical issues, it should logically work even better on healthy women.
However, many experts have their doubts. Some fear that the removal of part of one ovary could put undue pressure on the other ovary. However, Professor Simon Fishel, chief executive and founder of ProFaM and one of the pioneers of IVF who facilitated the birth of the world’s first IVF baby (Louise Brown), claims “there is no evidence of this.” Paul Wood, the president of the European Association of Paediatric and Adolescent Gynaecology, warns about “the risk of adhesions or scar tissue on the ovary from the microsurgery.” Professor Adam Balen, a consultant in Reproductive Medicine at Leeds University Teaching Hospitals and former chair of the British Fertility Society, maintains “removing ovarian tissue will inevitably have a negative impact on future fertility…. the more ovarian tissue you remove, the more valuable hormone- and egg-containing tissue is lost, thereby hastening the age of the menopause.” Balen asserts that, in contrast, egg freezing “doesn’t exhaust the supply of eggs or ovarian reserve for the future.”
Additionally, no one knows for sure what the long-term impact on women could be if they produce hormones at a premenopausal level for longer. As Balen emphasizes, “the prolonged use of HRT is associated with an increased risk of breast cancer etc. …” and he questions whether the use of natural hormones to delay menopause might have similar risks. But on the flip side, as it is known from women who take HRT, hormones can protect women from other physical and emotional side effects associated with menopause, such as severe mood changes, risk of colorectal cancer, and cardiovascular disease.
Although there’s an obvious concern that such fertility enhancements could usher in a generation of pregnant women in their 50s and 60s, Professor Fishel and other practitioners are preventing this by using the same parameters for ovarian cryopreservation as indicated for IVF — both fertility procedures are available only to women who are 50 or younger. For women over 50 who want to use their preserved younger tissue to delay menopause, the regrafting will be done far away from the reproductive system, such as under the arms, in order to disable its reproductive use. Ovarian cryopreservation, egg freezing, and IVF allow more women to have children in their 40s, and the long-term impact of older parents on children and families, and the risk of using older sperm, exist for all of these fertility techniques.
While ovarian tissue freezing is often described as an experimental procedure, Professor Fishel thinks the objections are neither problems nor reasons to hold back — there is evidence from thousands of ovarian surgeries that removal does not affect fertility. And he believes “the risks of microsurgery, with a highly skilled and experienced surgeon, are no more risky than surgical procedures carried out by a dentist.” He recommends, at a minimum, that women who are already having procedures in the reproductive area, such as surgery for fibroids, endometriosis, ovarian cysts, or even a Caesarean, freeze part of an ovary to protect themselves against future fertility issues. He refers to this as “opportunistic surgery” — the risks are already there from the primary surgery. Fishel aims to generate a larger data pool and provide benefits to more than just cancer patients. “I’ve been involved in IVF since the beginning, and there were colleagues and Nobel laureates all saying we should never offer IVF. If we had listened to them, we would not have 40 million parents today with IVF children,” he says.