In June 2017, Karissa Chen flew from the United States to Taiwan with one purpose: to freeze her eggs. Chen first learned about mature oocyte cryopreservation (as the procedure is officially known) from a friend when she was 28 years old, but six years passed before she considered doing it herself. Now 37, Chen regrets waiting so long. Over time, she’s become more aware of the impact age has on fertility.
“I wish I had received more information about my own body years ago and made a more informed choice ahead of time,” Chen says over the phone from Taiwan, where she has since moved to teach creative writing. “If you think about it, the numbers [and quality of eggs a woman produces] aren’t as good as they used to be [when I was younger].”
Concerns about her personal fertility peaked a year earlier, when Chen had walked away from a five-year relationship. The decision left her acutely aware that, by doing so, she was leaving behind any ideas she may have had about starting a family in the near future.
“I’d envisioned sports practices, museum visits, and, sometimes, I could practically hear the sound of little hands pattering on the congas that my partner loved to play,” she recalls in ‘My Fertility, My Future,’ a regular column in web-based magazine Catapult, which Chen began writing in early 2019 to share her reproductive experiences.
When she finally made the decision to freeze her eggs, Chen felt relieved and empowered, as if she was defining pregnancy and motherhood on her own terms: “I suddenly felt like Superwoman,” she writes. “I was proud of myself. I had already proven I was capable of more than I thought. I was taking control of my life.”
At the same time, Chen was well aware that this back-up option isn’t foolproof: “The chances of getting a viable baby from frozen eggs is pretty slim. It’s a last resort.” It’s also not without its drawbacks, from emotional and physical challenges to prolonging gender inequality in the workplace.
A Growing Trend
For the IVF market, women like Chen represent a huge opportunity. Experts say the industry anticipates a 9.8 per cent compound annual growth rate for the next six years, bringing the market value to US$38.7 billion by 2026.The egg freezing industry in the US alone is estimated to be valued at US$4.3 billion.
“You can imagine, it’s big business,” observes Professor Ernest Ng, a specialist in assisted fertility at The University of Hong Kong. “Around 15 per cent of couples will have problems conceiving and go for IVF. Egg-freezing has much bigger potential, particularly if you can persuade younger women to do it.”
Indeed, egg-freezing has become more popular in high-income countries, where an increasing number of women are choosing to start families later in life. According to a study by the Organisation for Economic Co-operation and Development (OECD) Social Policy Division, in most OECD countries, the average age of first-time mothers is 30 or above, representing an increase of two to five years in several countries since 1970. In Hong Kong and Singapore, it’s 29.8, while Hong Kong has also seen a 90 per cent surge in the number of women aged 40 or older giving birth in the last decade.
Experts attribute this change to the increasing emphasis on a woman’s career development and the absence of support for childcare – in policy and in employment practices. A comprehensive 2018 report by the Hong Kong Federation of Youth Groups, entitled “Improving incentives for Women’s Employment,” found that most Hong Kong residents believe women should take care of children on a full-time basis, creating a tension between employment and family responsibilities. According to the 2016 census, the labour force participation rate of single women is 65 per cent, but only 44 per cent for married women.
In terms of fertility success rates, the chances of pregnancy from frozen eggs has increased substantially since the procedure’s first live birth in 1986 globally. In 2008, a study by the Valencian Institute of Infertility in Spain found no notable difference between fertilisation rates of fresh and frozen eggs, with both methods seeing over 75 per cent success rates. Subsequent studies confirm these findings, and many private clinics have since advertised rates in the region of 80-90 per cent.
However, these often quoted fertilisation rates do not necessarily result in successful pregnancies. “If you’re approaching 40, freezing your eggs is technically possible and you may be able to finance it, but the chances of getting a live birth further down the line are pretty low,” says Ng. “The best time is when you’re in your early 20s, but at this age women may not have the funds and don’t see the need: They’re still confident they’ll find Mr Right.”
“It’s important for a woman to understand that her individual success rate depends on a number of factors,” adds Dr Patrick Chan, a Hong Kong-based obstetrician and gynecologist. “First and foremost, there’s egg quality, which depends on a woman’s age at freezing [the younger, the better], but also the sperm quality, her uterine conditions [such as the uterus lining], and other questions relating to her gynecological health [such as fibroids or endometriosis].”
‘Freeze Your Future’
Commercial clinics in the US are increasingly targeting women in their 20s, with invitations to “freeze for your future” and warnings that “eggs are a nonrenewable resource.” Some companies have also started offering egg freezing as an employment benefit. Both Facebook and Apple, for example, offer egg-freezing coverage up US$20,000.
“The cost of egg-freezing can be prohibitive, and it’s nice to have the option. But it’s not ‘no strings attached.’ It’s because they want you to work harder and longer,” says Chen. “It seems to be pushed as some sort of insurance for women who are focused on their careers or haven’t found their partners.”
What seems like a win-win situation on the surface may end up benefiting companies and clinics rather than women. As Dr Jude Browne of the University of Cambridge Centre for Gender Studies points out, egg freezing gives working women the option to become mothers later in life, and yet does little to fix the systemic problems that hamper women during their career-building years, which coincide with their natural child-bearing years.
Few, if any, companies in Asia offer egg-freezing as part of their employee benefits packages, but it is an increasingly available option for women who can self-fund the procedure. In Hong Kong, both single and married women may freeze their eggs, but they must be married under Hong Kong law to harvest them, a restriction that poses a barrier for both single women and same-sex couples.
The same restrictions apply in Taiwan, so Chen would have to ship her eggs to the US to be able to implant them if she is single upon retrieval. In Singapore, you can only freeze your eggs if certain medical conditions ‘justify’ it, such as the need for chemotherapy in cancer patients, which can damage a woman’s eggs. In China, you need a marriage certificate to qualify.
Freezing your eggs by choice, often referred to by practitioners as ‘elective’ or ‘social egg-freezing’, as opposed to being offered the option due to medical conditions, is also available in Thailand, Malaysia, India, Japan, and South Korea. In 2016, the Japanese city of Urayasu, east of Tokyo, began to subsidise the cost to boost the country’s low birth rate as the population rapidly ages.
Depending on where a woman lives, it sometimes makes sense to schedule the procedure abroad. In Chen’s case, she chose Taiwan because it was more affordable than in the States where retrieving eggs for freezing costs US$8,000 or more, sometimes with multiple cycles in order to obtain a sufficient quantity of mature eggs, plus fees for testing and medications. On top of these initial fees, storage costs around US$600 per year.
Chen’s total bill for the medications, testing, and procedure in Taiwan, by comparison, came to US$4,400, while storage costs roughly US$200 a year. It’s a cost she plans to carry on paying while she splits her time between New Jersey and Taipei.
“I would rather conceive naturally, without using those eggs, if I can. The clinic would never get rid of them without my permission, so at least I know they’re there as long as I need them. I can budget a couple of hundred dollars a year for this. It does offer me some measure of security,” she says.
Yet despite the glowing promises offered by the IVF industry, physical and mental health tolls of egg-freezing are largely absent from promotional literature. When Chen arrived in Taiwan, she began taking hormonal medications about 10-12 days ahead of the egg-freezing procedure. These included Duphaston, a hormonal stimulant, and self-administered injections of follicle-stimulating hormones, such as Elonva and Merional, to encourage healthy ovulation.
Injected fertility drugs are associated with more severe side-effects than those taken orally, with common reports of bloating, headaches, breast tenderness, stomach issues, hot flushes, and mood swings during the prescribed treatment cycle. Chen at first felt a sense of fatigue, which quickly descended into total exhaustion as her body directed more resources into producing eggs.
“I felt like a heavy cloak had been draped over every single one of my cells,” she says.
She also suffered from a heavy emotional toll. At her first ultrasound appointment in Taiwan, doctors assessed the volume and viability of her egg follicles (small fluid sacs in the ovaries full of potential eggs). Chen had a relatively low number of visible follicles, which meant that she may need to undergo several retrieval attempts in order to collect enough eggs.
Chen went home with a to-do list designed to boost her chances of a successful egg-retrieval procedure. She had to change her hormone medication, eat more protein, drink more water, and get lots of rest before attempting to freeze her eggs. “Over the next week, my life consisted only of sleep, clinic visits, hot pot, injections, crying, more sleep. I was always hungry but had no interest in food.”
There are only a handful of studies detailing the impacts of fertility treatment on women’s mental and physical health, let alone egg-freezing in particular. A 2004 study in Taiwan examined the prevalence of anxiety and depression amongst a small group of 112 women seeking assisted reproductive technology. Researchers found 26.8 per cent had a depressive disorder while 28.6 per cent of the women had an anxiety disorder, echoing previous research which found high frequencies of such disorders among women in assisted reproduction clinics. For comparison, a much broader study of general medical outpatients found 16 per cent had a depressive disorder and only 11 per cent had anxiety.
Besides the physical challenges – painful injections, cramps from swollen ovaries, spotting, fatigue – Chen also suffered from severe loneliness. In the IVF clinic in Taiwan, she recalls being surrounded by couples, and her earlier sense of ‘superhero’ independence crumbled under the weight of feeling completely alone. “Something about egg freezing made it seem easy, aside from the financial aspect, which is prohibitive for many… It was actually a lot harder than I had expected.”
Three days after the procedure, Chen says she “crashed into inexplicable despair” and entered a depression that lasted several months. “I no longer had the energy to be angry about anything. I was tired, I was lonely, and I was sad in ways I didn’t know how to explain.”
While postnatal depression is widely researched and acknowledged, with support systems in place, ‘post-extraction depression’ (a term Chen coined) is not. There are currently no studies on the issue, but there is substantial anecdotal evidence across personal blogs and news articles that many women experience anxiety and depression following egg-freezing procedures.
In addition to the impacts of hormonal stimulants, the invasive nature of the procedure and the sense of loneliness that she felt, Chen also wonders whether anxiety could be aggravated by the prolonged uncertainty, the lack of closure, that accompanies egg-freezing: There are no immediate results beyond a number of eggs in storage.
After her procedure, Chen says she was not offered any professional support or guidance, nor did she seek it out. “I didn’t necessarily expect the clinic to offer a therapist, but I wish I’d been counselled on the impacts of the hormones, and the emotionally taxing nature of egg-freezing before doing it.”
Perhaps, were the mental and emotional impacts more commonly discussed, she might have been more proactive herself: “I don’t know how many women feel like I did, but just as people watch for signs of postpartum depression, maybe there needs to be a practice.”
New frontiers of fertilisation
Some women have attested to a sense of panic as they move through their 30s and 40s, due to two generally accepted facts: fertility is finite and egg quality declines with age. According to widely cited medical research, an average woman at puberty will have around 300,000 eggs, but only one-tenth will be left by her mid-30s, and none by the time she reaches 51 – the average age of menopause.
Egg quality also declines with age, affecting a woman’s chances of a successful pregnancy. Chromosomes are particularly affected: If an egg has too few or too many chromosomes, it may fail to implant in the uterus and lead to a miscarriage. At the age of 25, around 75 per cent of a woman’s eggs are chromosomally ‘normal’, compared to just 10-15 per cent by the age of 40.
The combination of egg quality and quantity means that a healthy 30-year-old has a 20 per cent chance of getting pregnant each cycle, but by 40, her chance is less than 5 per cent. However, conflicting research also points towards healthy, if diminishing, rates of conception for women in their late thirties.
Those like Dr Patrick Chan believe new advances in technology could challenge these natural laws of aging. He points to ongoing experiments to improve egg quality through the transfer of mitochondria (the power generators of a cell) to help more eggs reach maturity. The process, called in vitro follicle activation, could be commercially viable in the near future.
Ovarian tissue freezing is another emerging solution that may become mainstream in the next decade. By harvesting small amounts of tissue from a young woman’s body via fibre-optic surgery, freezing it, and transplanting it later, women could regain fertility later in life.
Over the past decade, stem cell researchers have also challenged nature through experiments that create reproductive cells from ordinary tissue cells. In this procedure, doctors take a non-reproductive cell, such as a blood or skin cell, and inject it with genes to transform it into a stem cell. The stem cell is then capable of becoming a gamete, or reproductive cell.
While infinite fertility and super-charged eggs are a long way from the mainstream market, women will have more choices when it comes to reproduction in the future. For Dr Chan, these emerging possibilities raise difficult questions: “Are we encouraging women to have children at a very advanced age? In theory we can impregnate a 50-year-old woman, but what about the risk of complications in pregnancy? What about social taboos?”
Chen welcomes the growing pool of options but says it’s important for society to value women beyond their capacity to become mothers. “We emphasise the child, but we don’t always emphasise the person bringing the child into the world, and how to make it work for her. Or if a woman chooses not to become a mother, we should value the myriad contributions she makes to society.”
After her personal experience, Chen wishes the focus was not on women getting pregnant but on a better understanding of biology and its impact on fertility, so women can make informed choices and take more control over their lives.
Egg Freezing in Hong Kong
Who can freeze their eggs? Any woman can freeze her eggs, but only women in heterosexual marriages can harvest them.
How long does it take? An egg-freezing cycle takes approximately four to six weeks. Often, multiple cycles are recommended to increase the number of eggs harvested, and the chances of fertilisation.
How long can you store them? Frozen eggs may be stored up to 10 years or until the patient reaches age 55.
What does it cost? Costs range from HK$30,000 to HK$100,000, including all testing, monitoring, and the first year of storage.
Up for Discussion
Many medical journals circulate anxiety-inducing statistics about women’s fertility. But as a 2013 article by The Atlantic argues, those fears may be outdated: “The widely cited statistic that one in three women between the ages of 35 to 39 will not be pregnant after a year of trying, for instance, is based on an article published in 2004 in the journal Human Reproduction.
Rarely mentioned is the source of the data: French birth records from 1670 to 1830. The chance of remaining childless – 30 per cent – was also calculated based on historical populations.”
A more recent study published in 2014 by Obstetrics & Gynecology found that, amongst 770 European women, the fertility rates of those in their late 30s was nearly identical to those in their late 20s and early 30s. A 2013 Dutch study published in Fertility and Sterility and a US study by the University of North Carolina School of Medicine that same year also found that fertility rates do not drop off dramatically until a woman enters her 40s.