Putting your eggs in one basket

Concerned they may have hit the snooze button on their biological clock one time too many, more women hearing the motherhood alarm are turning to egg freezing.

By ORIT ARFA
The process of extracting eggs in a lab in a fertility clinic. (photo credit: REUTERS)
The process of extracting eggs in a lab in a fertility clinic.
(photo credit: REUTERS)
Since biblical times, fertility has been a sensitive topic for Jewish women, with motherhood an iconic Jewish longing.
Sarah despairs at her inability to conceive with Abraham, until she finally laughs when her prayers are answered at the ripe old age of 90. Only after Rachel’s true love, Jacob, procreates with her sister and handmaidens to ensure his progeny does Rachel finally give birth to Joseph.
Childless Hannah cries and prays at Shiloh, pledging her unborn son to the service of God; he answers her with the birth of the prophet Samuel.
Then there’s pain in childbirth, thanks to Adam and Eve’s original sin, which also ushers in the first real battle of the sexes.
The modern Jewish woman can, of course, always turn to God, but more and more women are also turning to doctors when God is not answering their prayers fast enough – not only for their soul mate, but for the child they hope to bear him.
Egg freezing (oocyte cryopreservation) is emerging as a viable yet chancy option for women over 35 who are concerned they may not meet their life’s partner, as their ovarian reserves lose stock in both quality and quantity. A woman’s womb, on the other hand, is capable of carrying an embryo even after menopause.
In 2011, Israeli law permitted women between the ages of 30 and 41 to harvest up to 20 eggs within four cycles of egg freezing, for what is characterized as “social reasons.” Up until then, egg freezing was allowed only for medical reasons, such as cancer patients whose eggs risk damage during chemotherapy treatments.
In recent years, the rapid “anti-freeze” method called vitrification supplanted the slow-freezing method, drastically improving chances for eggs to thaw intact and hence be fertilized.
Indeed, in 2012, the American Society for Reproductive Medicine gave egg freezing a vote of confidence by proclaiming it was no longer “experimental.”
The treatment received a marketing boost when Facebook and Apple made the controversial announcement in October that they would offer this expensive treatment as a perk to their female employees. In Israel, meanwhile, the treatment costs anywhere from NIS 12,000 to NIS 20,000 – about half of what it would cost in the US.
These factors have led to a growing trend of egg freezing among Israeli women over 35, despite cautions from the medical community that the procedure will not necessarily hasten or provide the realization of a woman’s prayers.
TAMMI, 39, fits the profile of the typical egg-freezing candidate, going through the process for “social reasons.”
Despite her best efforts, she has not found a husband, citing fear of commitment, fear of divorce, lack of readiness to start a family and the proverbial “pickiness.” She agreed to be interviewed in person at a Tel Aviv café, albeit anonymously, because she wants more women to be aware of the option.
Tammi heard about egg freezing by chance last year, when she saw a segment about it on television; the next day, she called her gynecologist. Three months later she began the process, with the support of her friends and family, of injecting the hormones that stimulate the ovaries to produce more than one egg for extraction and cryopreservation.
“I didn’t feel, and I still don’t feel, that I could bring up a child alone,” she says. “My state of mind is not ready for it. Yet I didn’t want to give up on my desire to raise a family. So I said, OK, what can I do? To have a child alone – that’s not what I want. This is the best option for me, or I can do nothing and pray to God that it will happen. So I decided to do it.”
A women’s fertility begins to decline at age 35, with a freefall after age 40. At 38, Tammi hoped she’d be an exception. She’s in good physical shape, has regular menstrual periods and comes from a family of prolific women.
In the end, six eggs were harvested – fewer than the recommended number needed for a reasonable start for a trial, which varies from 10 to 40, depending on a woman’s age and what medical data are referenced.
Tammi would do another cycle if not for the cost; fertility treatments whose aim is immediate pregnancy, such as intrauterine insemination (IUI) and in vitro fertilization (IVF), are included in Israel’s public health basket, but egg freezing is strictly out-of-pocket.
While egg freezing could be a lucrative business, directors of IVF units at major hospitals across Israel did not evince enthusiasm about it among women in their late 30s. Pregnancy success rates are inconclusive, given the relative newness of the procedure among this population in Israel; since the law permitting egg freezing went into effect only three years ago, most of the women who have had their eggs frozen have not yet come back to redeem them.
Dr. Hananel Holzer, head of the IVF unit at Jerusalem’s Shaare Zedek Medical Center since September 2014, provides an optimistic estimate, suggesting that at least 10 frozen eggs offer a reasonable start for a trial. Prior to joining Shaare Zedek, he served as medical director at Canada’s McGill University Health Center’s Reproductive Center. An initial study at McGill on egg freezing showed a success rate of about 40 percent, yet the sample of over-35 patients was not large enough for this figure to be anywhere near informative.
While, due to vitrification, the pregnancy success rates of egg freezing and IVF are evening out, artificial insemination is still a viable option to achieve pregnancy for those who would consider being a single parent. Holzer, in an interview in the Canadian media, once said, “Fresh is always better,” and it quickly turned into a slogan relating to a woman’s fertility. Still, he realizes that artificial insemination through a sperm donor negates the dream of having a child with the choice father, and may not fit someone’s cultural, philosophical and/or religious values.
“Psychosocially, it’s a very complex issue,” he says. “We want the patient not to have false expectations, and to be aware that egg freezing is not a guarantee for a future live birth. They should be ready for a possible disappointment and try to have a plan B.” Holzer considers this elective procedure a luxury, noting a higher percentage of Jewish and Asian professionals seeking it out.
Prof. Ami Amit, head of the IVF unit at Tel Aviv’s Sourasky Medical Center, recommends 20 eggs as a reasonable minimum – the number allowed by Israeli law. “But if you can collect 40, it’s better.”
His IVF unit boasts one live pregnancy from a batch of five frozen eggs. A woman who froze her eggs in London had them transferred to Ichilov Hospital for fertilization; two were successfully fertilized, and one embryo successfully implanted. Still, each case is so individual, women should not pin their hopes on one success story.
Prof. Joshua Dor, director emeritus of the IVF unit at Tel Hashomer’s Sheba Medical Center, tells of a more disappointing result. A woman who performed the procedure at a top-notch clinic in Spain transferred the frozen oocytes to Sheba for fertilization. Among the batch of 30 eggs, 23 thawed successfully and 14 fertilized, but none yielded a viable embryo after implantation. The woman subsequently became pregnant via IVF.
“I’m a bit afraid that women will have misconceptions about it,” Dor cautions.
“First of all, the attitude is directed to women who want to postpone childbirth for many reasons – either they don’t have a partner, or they’re busy with work. And they sort of say, ‘Oh, we can freeze our eggs, and it’ll be okay if we don’t deliver at age 36, 37 or 38, but we can postpone it to 44.’ I think that’s a mistake.”
In one case, he even discouraged a successful 36-yearold from freezing her eggs. He recalled telling her: “If you want my treatment, OK; I earn my living from it, but I don’t want to do it for you. Go find a partner and make a baby now, before it’s too late.”
Turns out, she met her husband at a party not long after and came back to his office to show off her pregnancy, five months along. At 39, she now has two children.
Dr. Shai Elitzur, head of the IVF unit at the private Assuta Medical Center, has seen an increase in the number of women coming in for egg freezing consultation.
He too advises women in their late 30s to get pregnant, or first freeze their eggs and then get pregnant.
Among older women, he notes, pregnancy rates are still higher for frozen embryos than for frozen eggs; women over 40 are also more prone to high-risk pregnancies.
“The younger the woman is, the more successful it is,” says Elitzur. “It’s true that the law allows it from age 30 until 41, but in medical terms, we’d be happier it if was from 27-28 to 37-38.”
All of the doctors interviewed look askance at Facebook and Apple’s egg freezing benefit.
“If you ask me, I think a company and society should put more efforts and money not into freezing eggs and delaying motherhood, but in helping young women raise children,” maintains Elitzur.
Holzer says the move could be perceived as “Orwellian.”
“Companies are ‘asking’ their employees to freeze oocytes instead of getting pregnant. Not speaking as a physician, I think society should focus on making pregnancy work for a mother and father rather than asking women to preserve their fertility.”
AS AN orphan, Galit, an Anglo immigrant who works as an office manager, is committed to having a family. Realizing egg freezing has a better chance of succeeding the younger the age, she started the process at age 35 and is currently in the preparation stage for harvesting her eggs for cryopreservation; this involves daily hormonal injections for 10 to 14 days culminating in the outpatient harvesting procedure, usually performed under general anesthesia.
“I haven’t met ‘the one’ and want to be a mother one day – but not a single mom,” she wrote in an online chat, requesting anonymity. “I’m not freezing embryos because I want to choose the father. I want to take the pressure off dating but still have an investment for the future.”
She hopes to produce at least 20 eggs – but also hopes she’ll never have to use them. “I’m happy I’m doing it; it’s the right decision for me. Not happy, actually, that I don’t have a family yet, but that I’m investing in my future.” (At press time, Galit updated the Magazine that she had harvested four eggs.) At the same time, the conservative prognosis of doctors and the costs have deterred Anna, a 37-yearold employee at a Tel Aviv biomedical company, from freezing her eggs. She has been a “serial dater” for the last few years – seeking a partner through dating websites, parties and set-ups – with no luck.
“My doctor told me it’s better I just get pregnant,” she says. “It’s very expensive. There’s no guarantee, and I don’t want to live with the idea that I could hold off pregnancy until I’m in my 40s,” she says. In her purse is a referral for a blood test that will measure her hormonal levels to better gauge her chances of conceiving, but she’s postponing the test for another reason: She’s afraid of confronting her biological clock.
“I’m in denial.”
At the hospital, the medical staff encouraged Tammi to get pregnant, but she insisted on freezing her eggs.
“The whole point is that I want a partner, and I want a child with that partner. So to go to a sperm bank and receive a donor and get pregnant – that’s a completely different process.”
The one time Tammi experienced acute regret about her life’s path was in the middle of the process, when doctors feared she would produce only one or two viable eggs.
She describes the procedure as more trying emotionally than physically; she wished doctors and nurses had been more comprehensive in their explanations of what to expect.
Now, her only regret is not freezing her eggs sooner.
“I wish the health system would understand that it’s better to encourage this process when women are young, and it will also raise the chances for women to get pregnant,” Tammi says. “At the end of the day, it would save money – because now they’re wasting money on free IVF for women until age 45, and most of them don’t get pregnant.”
ACCORDING TO Dor of Sheba Medical Center, younger women, in large part, do not come in for consultations, since they don’t believe they will need it.
“Imagine a woman is now 32, 33 years old – she has a nice career, she’s educated, she’s still optimistic she’ll have a partner soon and do it by herself.
“They’re a bit scared of the whole procedure.”
This summer, Tammi is turning 40. She has no deadline for when or if she’ll attempt to fertilize her eggs – either fresh or frozen. “A lot of people have asked me how long I want to wait. I can’t really answer that. I think if in another year nothing happens, I’ll have a child on my own. I prefer to do it with a friend and not from a sperm bank, because I want a father for the child at least. But it’s not something I can say; I have to feel it.”
Among Orthodox women over 35, traditional marriage and the accompanying religious lifestyle are the preferred options, so egg freezing is generally more desirable than getting pregnant via insemination through donor sperm.
“In terms of Jewish law, there is no prohibition against egg freezing,” says Rabbi Dr. Baruch Finkelstein, co-author of The Third Key: A Jewish Couple’s Guide to Fertility. Rabbinic debates on fertility treatments usually relate to legalities, although a rabbi’s ethical biases may at times guide legal erudition.
“The ethical debates that accompany practices like insemination are not exclusively Jewish,” explains Finkelstein, “they have a universal interest. Single motherhood by choice carries substantial concerns that are relevant to every woman.”
Ruthie Katzburg Kadosh, head social worker at Shaare Zedek’s IVF unit and a couples and family therapist, has noticed a considerable spike – in just the last month – of women aged 35 to 40 coming to the religious hospital for egg freezing. In some cases, this is the first time they have inquired seriously into their gynecological health; some, as religious women, are virgins. It’s a process fraught with questions and uncertainties.
“They come here with a feeling of ‘Why am I even here?’” says Katzburg Kadosh. “Where did I go wrong to even think about egg freezing? If I’m here, it means I failed in relationships.”
She soothes them by highlighting their ability to take steps towards ensuring their future by creating a “savings plan,” despite the lack of any guarantees. She recommends that they not go through it alone, but find trusted friends and family members to join them at doctor visits and certainly at harvest time.
“They’re still praying and hoping, and have faith that they’ll get married; once they do have children, they’ll have a reserve,” Katzburg Kadosh says.
Holzer cautions women against panicking. “People should be aware of their declining fertility, but they shouldn’t walk around feeling there is a sword of Damocles hanging over their heads.”
Since starting the procedure, Tammi has noticed a difference in how she approaches dating. “When I saw a man as sperm, it was bad,” she says. “When I look at a man, I want to see a man – not sperm; a human being; a partner; then a father.”
She definitely feels more relaxed but still prays, as in the past.
“On the one hand, even if you are pressured, that’s not good,” she says. “If you’re in a relationship and you’re stressed to have a child, it won’t work; it’ll negatively influence the relationship and the chances to get pregnant. You just have to relax and hope for the best.” Tammi points to the sky. “In the end, it’s not really up to you.”