Lifestyle

The Ethics of Egg Freezing and Egg Sharing

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Illustration: by Simoul Alva

Dean Pfeiffer always wanted to be a parent. At first, as a queer woman, she figured adoption was her only choice. Then, maybe a sperm donor? When she was 22, a friend of hers presented her with another way: He told her about a lesbian couple his mom had worked with at a clinic in California who had done reciprocal IVF, in which each woman carried an embryo made with her partner’s egg. That sounded like a dream to her — an expensive one. Pfeiffer, then a senior at East Tennessee State University, planned to become a doctor, so she knew she’d be spending most of her 20s accumulating student debt. “I was like, okay, well, I’m gonna be poor around the time that I’m expecting to do this,” she says now. “So hopefully my partner has money, or I’ll go into debt, or I’ll just skip it entirely and just adopt.”

Then she met Anna Lyon, her current partner, a repeat egg donor who recently completed her doctoral thesis on gamete donation at the University of Texas, Austin. Around a year ago, on their first or second date, Lyon told Pfeiffer about the money one could earn from egg freezing — between $10,000 and $15,000 per egg-donation cycle, in Lyon’s experience. A few dates later, the topic came up again. (They talked about other stuff, too, including their favorite composer, Dmitri Shostakovich; their shared love of reading; and the joys of a Costco membership.) Lyon mentioned a variation on egg donation, known as a “freeze and share program,” in which a donor shares the batch of eggs retrieved from her (following a cycle of hormonal stimulation and an operation done under anesthesia) in exchange for getting to freeze her half of the eggs for free.

Yet another option — perhaps the best one yet.

Even though she and Lyon were just getting to know each other at the time, Pfeiffer couldn’t help herself, thinking, Hypothetically, if she did that, and I did that, then we could swap and I could have my dreams — and it would be free!

Freeze-and-share programs offer young women a way to freeze eggs without ponying up the $10,000 to $15,000 the procedure costs. Alternatively, they can be seen as a way to ensure donors don’t find themselves needing donor eggs ten or 15 years down the line. Dr. Aimee Eyvazzadeh, a reproductive endocrinologist in San Ramon, California, who is working with both Lyon and Pfeiffer, said she was inspired by a patient who had donated eggs at 20, only to return 20 years later in need of donor eggs herself. (Giving away half of one’s eggs doesn’t completely obviate the costs of care: Dr. Eyvazzadeh’s clinic, for instance, offers five years of free storage, then charges $275 per year, which means if a patient freezes eggs at 20, then decides to try to get pregnant at 35, she’ll have spent nearly $3,000 before the costs of doing in vitro fertilization, or IVF. The total price of IVF averages somewhere between $15,000 and $20,000 in large U.S. cities.)

There are no official estimates of how many freeze-and-share programs exist in the U.S., but scholars who study reproductive technologies say they started popping up around 2014, two years after the “experimental” label on egg freezing was lifted by the American Society of Reproductive Medicine, and around the same time that tech companies like Apple and Facebook started offering insurance coverage for egg freezing to their employees. In the U.K., clinics have been offering shared in vitro fertilization cycles (in which an egg donor gets one cycle of IVF for at reduced or no cost in return for splitting her retrieved eggs with a paying patient) for more than 20 years.

Eyvazzadeh says she has informally offered this option to donors since 2008, when she first opened her fertility practice (she later trademarked the website freezeandshare.com). “You’re going to run out of eggs,” Dr. Eyvazzadeh tells potential donors. “Every single woman does, and sometimes they run out before they’re done having kids.”

The fear of running out of eggs has intensified as the average age at first birth in the U.S. creeps higher, from 21 in 1970 to 27 in 2017. In big cities, it’s even higher: 31 in New York City, and 32 in San Francisco. Although the thousands of women who freeze their eggs each year is still a tiny share of the tens of millions of reproductive-age women in the U.S., uptake is growing at a rapid clip, with over 16,000 freezing cycles performed in 2019, according to preliminary data from the Society for Assisted Reproductive Technology — up 24 percent from the prior year. The longer would-be parents wait to conceive, the more demand there is for new donors. Eyvazzadeh estimates the average age of her female patients is 41, and around 20 percent of them require donor eggs in order to get pregnant.

Most recently, doctors reported higher-than-normal interest in egg freezing as the pandemic continues to screech all sorts of life plans to a halt; Eyvazzadeh says she had around 100 inquiries for the freeze-and-share program specifically last year and completed ten cycles (it often takes several months or more for her to match a donor to the right family), compared to about five completed cycles in a normal year.

“The problem that we recognize is that we don’t have enough egg donors to meet the demands of our patients,” says Dr. Peter Klatsky, a reproductive endocrinologist and infertility specialist who co-founded Spring Fertility, a network of fertility clinics in Vancouver, New York City, and across Northern California. In 2016, he started a freeze-and-share program to help meet that demand. But to his surprise, the program wasn’t very popular: Most people who freeze their eggs want to keep them all for themselves, he says, especially since his clinic offers a no-interest payment plan to help patients spread out the $13,000 to $15,000 up-front cost at his clinic over several years.

The average egg donor — as in, not the average egg freezer — is in their early 20s and typically financially motivated, says Diane Tober, a medical anthropologist and associate professor at the University of Alabama who has interviewed over 200 egg donors. Historically, women freezing eggs are typically in their mid- to late 30s, when they also have more resources to pay for it (some employers, mostly in high-skilled sectors, increasingly cover egg freezing as part of their benefits packages). However, as egg freezing becomes increasingly mainstreamed and companies target women in their 20s on social media, patients may get younger.

Michelle McGowan, a bioethicist at Cincinnati Children’s Hospital Medical Center, notes that freeze-and-share programs bridge the gap between these two distinct patient populations: traditional donors (who tend to be younger, financially and altruistically motivated, with a more detached attitude toward their eggs) and egg freezers (who tend to be more invested in their own fertility and a genetic connection to a future child). A freeze-and-share donor has elements of both patient populations — the investment in her own fertility but the financial need to be a donor. McGowan worries this could potentially create a “cognitive dissonance” for freeze-and-share patients.

In her research on egg donors’ assessments of their donation experience, McGowan has found that when traditional egg donors experienced infertility later in life, the question of whether there was another child of “theirs” walking around while they could not have their own child “raised a lot of angst for them.” This angst could be more intense for someone who is both freezing and donating her eggs at the same time: She may value that genetic connection more than a donor, who may see the egg as merely a cell.

Elizabeth Reis — a professor of medical ethics at Macaulay Honors College at the City University of New York who has criticized egg-freezing companies for using aggressive marketing (with slogans such as “Preserve your options” or “Freeze time,” and little mention of possible side effects from hormone stimulation) to “create patients” — says the donation aspect of freeze-and-share programs adds another layer of complexity. “It’s not just freezing your eggs. It’s like sperm donation — there’s going to be a baby with your genetic material out there in the future,” she says.

Sometimes unexpected scenarios arise. Anna Lyon, Pfeiffer’s partner, provided eggs for compensation five times in her 20s as she made her way through a master’s degree and then her Ph.D. When the child born from her first donation was a toddler, she received an email, stripped of identifying information and forwarded through the egg-donation agency. It was the toddler’s parent, asking for her permission to donate the remaining embryos that had been made with her eggs. “That was kind of the first moment when I realized, This isn’t like they tell you at the agency, where you complete the cycle, and then your contract terminates, and then it’s over,” Lyon says. After the donation, she hadn’t expected to hear from them again: The agency she had worked with left her with the impression that under anonymous donation, she should never go looking for the parents, and they would never come looking for her, so the email about what might become of these leftover embryos “caught me off guard,” Lyon says. That’s when she realized a donation isn’t so cut-and-dried. “This is going to continue to affect me for the rest of my life,” she says.

Freeze-and-share programs create other lingering obligations, too. Even though they offer up-front savings on the cost of egg freezing, there are other financial costs that will arise in the future, such as storage costs and the price of doing IVF to attempt to have a baby.

“It costs a lot to use your egg later — you’re going to have to go through IVF,” says Arthur Caplan, a bioethicist and director of the division of medical ethics at the NYU Grossman School of Medicine. That can cost at least $10,000 to thaw, fertilize, and transfer, according to data collected by FertilityIQ, a website that collects pricing and patient-review data for fertility centers across the U.S. That leaves open the possibility that, after all this, someone who froze and shared their eggs with another patient won’t be able to use them when they’re ready. While these costs might not be a barrier to, say, medical students who go on to high-earning jobs, many of the donors in Dr. McGowan’s study were in the gig economy when they donated and were still in financially unstable situations when they were surveyed years later.

“If you’re poor, what chance do you have of using it if you’re still poor later?” Caplan asks.

For Dean Pfeiffer and Anna Lyon, these future costs are already weighing on them in the present. Lyon has some savings put aside for the fertilization and implantation half of her IVF treatment (the first half, the extraction of the eggs, has now been completed for free during the freeze-and-share process), but it’s a “fraction of the cost.” She is currently teaching middle-school English, and Pfeiffer will be graduating medical school with significant student loans. So how are they planning to pay for these procedures? They are looking at fertility loans to cover the cost of IVF when the time comes, Lyon explains.

Compared to IVF, which is more than 40 years old, egg freezing is a relatively novel technology, and data on success rates is scarce due to the small number of egg-freezing patients who have returned to use their eggs. In one study of 137 patients at a network of Spanish clinics, just under 30 percent of patients gave birth, although the success rates were higher for women in their 20s and early 30s.

During shared IVF cycles, when donors and patients share a batch of eggs while each pursues IVF at the same time, it’s not unheard of for the intended parent to get pregnant while the donor’s IVF cycle fails. Surprisingly, donors do not always find this devastating — some reported being happy their donation yielded something positive, says Zeynep Gurtin, a lecturer at Women’s Health at University College London who has studied these programs. But she worries that solidarity between patients is less prominent in the absence of the temporal simultaneity that characterizes a shared IVF cycle. “With a freeze-and-share, you may not have a sense of reciprocity,” Gurtin says.

Furthermore, the asynchronous nature of the freeze-and-share model means a donor will only learn much later if she is unable to get pregnant with her own frozen eggs. Within any given egg-retrieval cycle, perhaps only one or two out of ten or 20 eggs will yield a live birth, notes Catherine Waldby, a sociologist at the Australian National University and author of The Oocyte Economy: The Changing Meaning of Human Eggs. “There’s no way to tell until you fertilize it” whether the egg is viable, Waldby says. “Giving away a proportion of your eggs might mean that you give the one single egg that is actually going to get you pregnant.” Lyon had already been aware of this possibility from her previous donation cycles; as part of the psychological counseling, a donor is told this and evaluated to ensure she is giving true informed consent. Both Lyon and Pfeiffer worry more about the opposite outcome: if the intended parents were unable to get pregnant, while she — the theoretically younger and more fertile party — would have additional time and options to pursue. Pfeiffer adds that “it would be better to find out that a live birth wasn’t possible for me after already having my eggs frozen for free, rather than in another scenario where I begin my fertility journey on my own paycheck.”

And for Lyon, having half a batch of frozen eggs is still preferable to having none. Now 30, she underwent a sixth cycle this year as a freeze-and-share with Dr. Eyvazzadeh, who encourages donors and recipients to meet and get to know each other. Based on her research and her own experience, Lyon believes open donation is preferable to anonymous donation for both donors and the children born through donor conception, many of whom seek information about their donors as they get older.

When it comes to her first five donations, which were all anonymous, Lyon says, “My gut and my heart just tell me that I should have insisted on an arrangement that would have made me more accessible to the kids if they need anything.” “In my research, everyone I interviewed who had an open relationship with their recipients was happy about it and none regretted it,” Lyon continues. “On the other hand, many who had donated anonymously reported that they were wishing for more information or connection with their recipients. All signs point to openness being healthiest and most ethical, in my opinion.”

She adds that as an anonymous donor, she did not always feel that her health was prioritized by the clinics where she was treated, in contrast to Dr. Eyvazzadeh, who has more of a stake in her own well-being. “I’m going to come back to her someday as a patient, right?” Lyon says.

It’s also worth noting the concern that while freeze-and-share programs aim to increase accessibility, dictates of the market may mean some donors are still more “desirable” than others. In the donor-egg market, agencies take into account factors such as race, ethnicity, physical appearance, skin tone, and educational background, says Daisy Deomampo, a medical anthropologist and associate professor at Fordham University who has researched donor egg markets. These same factors can determine compensation. “Once a person decides to ‘share’ their eggs in order to offset egg-freezing costs, they effectively become egg ‘donors’ who are subject to the same market forces that determine whose eggs are ‘desirable’ and whose are not,” Deomampo says. “Less ‘desirable’ donors may find themselves without potential recipients and unable to access more affordable egg-freezing procedures.”

Dr. Eyvazzadeh screens according to health criteria, she says: Under 34 years of age, BMI under 30, certain levels of fertility-related hormones (measured from a blood sample), no known fertility issues or psychiatric conditions, and a follicle count of 15 or higher.

Perhaps the freeze-and-share model is most perfectly suited for someone like Ryan Moody, 29, a Los Angeles–based engineer who works in green energy. By the time she was in her mid-20s, Moody was fairly sure she did not want to become a parent herself. So when a friend who was looking into being an egg donor asked if she wanted to try it alongside her, Moody figured, why not? She had no agenda for her eggs. And how hard could it be? As simple as handing over the contents of a menstrual cup, right?

Then Moody, a self-described “woman of science,” went on a research binge. (Turns out, the process looks more like: shots of hormones to stimulate the growth of egg follicles, frequent ultrasounds and blood work, a commitment of two to three weeks in all.) As part of her research, she joined Facebook groups for people conceived from donor eggs to hear their perspectives; she learned that some of them felt their lives had been commoditized. She decided that if she donated eggs, she did not want to be compensated. “The idea of a child feeling like they had been bought and sold, especially given that I’m Black and come from ancestors who were enslaved, that was just something that I was not willing to be a party to,” Moody says.

Still, she did think she should be recognized for the medical risk she was undertaking. The hormones used to stimulate follicle growth, in rare cases, result in ovarian hyperstimulation syndrome, which involves painful abdominal bloating. She learned about Dr. Eyvazzadeh’s freeze-and-share program through her podcast, The Egg Whisperer Show.

This alternative form of compensation appealed to Moody. While she had no interest in becoming a parent at the time, she wasn’t sure how she’d feel in ten years. “It would be foolish for me to assume what future Ryan will always want,” she says. “So I try to protect her desires as much as I protect my own desires.”

She did one freeze-and-share cycle last summer, after having a two-and-a-half-hour video call with a couple in Northern California with whom she had immediately clicked. On a recent work trip to San Francisco, she stayed on an extra day to meet them and their new baby, who had been born thanks to her donation. Moody was surprised that she felt very little connection to the baby by virtue of their shared genetics. “I kind of thought that I might feel some sort of kinship with their child, and I really didn’t,” she says. Instead, the feeling was closer to seeing friends of hers who really wanted to be parents finally get their wish. “Like, man, I’m really excited for you to get what you want.”

https://www.thecut.com/2021/12/egg-freezing-and-egg-sharing-cost-ethics.html The Ethics of Egg Freezing and Egg Sharing

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