Egg Freezing FAQ
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In 2012, the American Society for Reproductive Medicine recommended that the procedure no longer be considered “experimental”– a huge leap forward in terms of public perception. At that point, egg freezing moved onto the list of standard treatments for infertility, alongside IVF, which helped to ignite the growth of egg freezing.
One of the biggest advances in egg freezing is vitrification, a solidification process that eliminates the ice crystals that sometimes formed during earlier methods of cryopreservation, frequently causing damage to delicate eggs. Now, with vitrification, the eggs are stored in liquid nitrogen after they’re speed-frozen, and the potential for damage has been greatly reduced.
Since then, around 20,000 women have frozen their eggs, according to a recent The New York Times article.
• You’re not ready to get pregnant but want to try to increase the likelihood of a biological child down the line.
• You’re not entirely sure you want a biological child or child at all but want the option to make that decision when you’re ready.
• You’re undergoing treatment for an illness that might affect your fertility (like chemotherapy).
Here are the individual tests used to help determine a woman’s OR:
• Day 3 Follicle Stimulating Hormone (FSH): The pituitary – a pea-sized endocrine gland situated right behind the bridge of the nose – is responsible for the production of FSH. High levels of FSH, determined through a blood test, indicate that the hypothalamus and pituitary gland are working overtime to stimulate a depleted egg supply. As a basis of comparison, a normal FSH count is well below 10. Because FSH levels fluctuate month to month, additional testing might be warranted if levels are higher than expected.
• Anti-Mullerian Hormone (AMH): This blood test is considered to be the most accurate predictor of a woman’s egg supply, particularly when compared to FSH, which can fluctuate month to month. Anti-müllerian, a protein hormone, is secreted from small pre-antral follicles located in the ovaries. A higher AMH level is indicative of a larger number of pre-antral follicles and a strong ovarian reserve, while a lower AMH may lead to the opposite conclusion – i.e., a low egg count. Still, a low AMH is not cause for alarm, and recently, the notion that a single hormone can determine one’s ability to get pregnant has been debunked.
• Resting (Antral) Follicle Count: Conducted via a trans-vaginal ultrasound at the start of a woman’s period, this test allows doctors to count the number of resting/unstimulated ovarian follicles. Should the patient have a low number of resting follicles, fertility medication may not be as effective. Healthy women with normal ovarian reserve will demonstrate at least 6 or 7 follicles on each ovary. Good outcomes can certainly be obtained however with numbers both lower and higher than this.
• Estradiol (E2): There are three types of estrogen, all of which are responsible for female sexual development and function: Estrone (E1), Estradiol (E2) and Estriol (E3), and levels are measured by a blood test. Of the three, Estradiol is the most common among non-pregnant women. This hormone is a sign of follicle growth, and is essential to interpret FSH. On cycle day 2 or 3 it’s ideal to have a level < 80.
• They’re looking to delay pregnancy by at least a few years. While egg freezing was once reserved primarily for women with cancer, the user profile has changed dramatically in the past decade or so. Today, she’s likely to be a healthy young woman looking to plan her future family, but may not be in a stable relationship. She’s looking for possibility to become a mother if she finds a partner later in life or to become a single mother.
• They’re open to the investment of time and money needed to freeze. No question, freezing requires a commitment. From start to finish, the process takes at least a month. And in terms of monetary outlay, between egg retrieval and storage, costs may climb to about $15K. This is why Trellis offers Multiple Cycle package for up to 4 cycles or 20 eggs.
While only time will tell whether more women will come back to use their frozen eggs, it’s important that IF you decide to freeze your eggs, to choose a board-credited doctor and lab with significant experience freezing eggs. Across the Integramed network over the last 4 years, we have frozen over 78,000 eggs.
Freezing embryos does in fact give you more information up front. You’ll know how many eggs were healthy enough to fertilize and begin development. But, it also locks you into at least one important decision right now: whose sperm to use.
In 2012, the American Society for Reproductive Medicine recommended that the procedure no longer be considered “experimental”. At that point, egg freezing moved onto the list of standard treatments for infertility, alongside IVF.
One of the biggest advances in egg freezing is vitrification, a solidification process that eliminates the ice crystals that sometimes formed during earlier methods of cryopreservation, frequently causing damage to delicate eggs. Now, with vitrification, the eggs are stored in liquid nitrogen after they’re speed-frozen, and the potential for damage has been greatly reduced. “The success rate of oocyte cryopreservation has risen,” states Oxford University Press, “and the increasing use of vitrification has improved outcomes, with IVF pregnancy rates now similar to those achieved with fresh oocytes.”
When it comes to positive outcomes, the numbers are definitely trending in the right direction. To date, more than 2000 babies have been born, worldwide, using frozen eggs – a number that is only poised to rise, given the inroads in freezing technology gained by vitrification.
The first medication is a hormone (follicle stimulating hormone, or FSH)—or combination of hormones (FSH and luteinizing hormone, or LH)—that gets your ovaries working overtime to produce multiple eggs. This medication is normally started on the first or second day of your egg freezing cycle and is injected once or twice daily for 8–11 days. The second medication is called an “antagonist,” because instead of helping to stimulate your ovaries, it actually prevents you from ovulating early and releasing your eggs before the retrieval. The antagonist is usually injected once daily, beginning mid-cycle. The final medication, known as a “trigger,” is injected 36 hours before the retrieval, prepping your body to release the eggs at just the right time.
Occasionally, egg freezing medications can get the ovaries working too hard, resulting in what’s called “ovarian hyperstimulation syndrome” or OHSS. OHSS is associated with swollen, enlarged ovaries and the collection of fluid in the abdominal cavity. In less than 5% of cases, OHSS can require monitoring or bedrest for a few days; in extreme cases (less than 1% of women taking these medications) OHSS can cause medical complications, like ovarian torsion, that might require surgery.
Risks associated with egg freezing may include:
• Medication Related: Abdominal bloating, weight gain, or fluid retention is common. Pain, bruising or infection from the injection or blood draw sites, breast tenderness, fatigue and mood changes are possible. Ovarian hyperstimulation, possibly requiring hospitalization or surgery is now very unlikely given new protocols for stimulation. Studies so far do not show an increase in ovarian or other cancers caused by stimulation medication.
• Procedural: Like all procedures, there is a risk of bleeding, infection, or damage to surrounding structures. Hospitalization or surgery is rarely required. Anesthetic complication is low.
• Other: Adnexal torsion (ovarian twisting) or cyst formation with possible rupture is rare, less than 1%. Activity restrictions include no heavy lifting or high impact activities (i.e. running/jumping) from the start of injections until after the next period.
1. What hormones are being tracked? • Estrogen, progesterone and LH • At the beginning of the cycle, FSH is also checked to ensure the dosage of medication is sufficient 2. What are their levels vs last time? • LH and progesterone should remain low throughout the cycle • Estrogen should rise gradually and ideally double every 2 days 3. What does this indicate? • If the performance of the hormones is not as expected, the doctor will likely make medication adjustments. If necessary, the doctor may discuss cancelling the cycle.
During the ultrasound:
4. How many follicles do you see on each ovary? • FYI: Ideally, right before retrieval, the doctor will want to see that the majority of developing follicles contain a mature egg. Often follicles are hidden behind others, so it’s not possible to see all of them in an ultrasound. • The number of follicles present isn’t the only determining factor in a successful egg retrieval. The quality of the follicles is equally important. Although quality is notoriously hard to gauge, it is best predicted by estrogen levels, rate of follicle growth and a woman’s age.
5. What size are the follicles? • Resting, non-stimulated follicles on day 2 or 3will be about 5 mm – 10 mm
6. What much have the follicles grown and what does that indicate?
• Most follicles grow with stimulation due to liquid accumulation (“follicular fluid”). They reach ~11-14mm mid-cycle and ~18-24mm at the time of trigger. Follicles grow slowly when they are small and then much faster when after the 12- 14mm range. It may take 5-6 days for an antral follicle to grow to 11-12mm, but then ~1-2mm of growth daily is anticipated.
7. What do each of the medications I’m taking do? • Gonal-F (or Follistim): stimulates ovaries to make more follicles. Sometime Menopur will also be used for the same purpose. • Ganirelix (or Cetrotide): often used starting Day 4 or 5 to prevent the ovaries from releasing follicles prematurely. • Ovridrel (or Pregnyl, aka “hCG”): “trigger” shot, taken 35 hours before retrieval. Triggers ovaries to release follicles. Sometimes to avoid excessive bloating, “Lupron” a leuprolide can be used instead as a trigger.
8. What day do you think I will retrieve? • The goal is to get the majority of the resting antrals to grow. So the number of follicles present in the ovaries prior to retrieval depends on a woman’s ovarian reserve. Trigger is typically timed when the majority of follicles are likely to contain mature eggs. Only the mature eggs retrieved will be frozen, the immature ones will be discarded. • While we are all big planners and want to prep for that day as early as possible, it’s difficult to confirm the exact retrieval date until 2-4 days prior. It’s important to be patient and flexible. Be patient, knowing that our bodies dictate exactly when retrievals should occur.
** Patients should be aware that egg stimulation is a somewhat complex process. The doctor won’t be able to predict exactly how many eggs they will retrieve, or how the patient’s body will react to medications. That’s why patients have repeated monitoring (sonogram and blood tests) to optimize results.
The embryos will be transferred back to your uterus. In a quick non-surgical procedure, a doctor will use ultrasound guidance to insert a soft catheter through the cervix and into the uterus where hopefully, one will implant.
Still, that doesn’t mean drinking fits into a truly healthy, fertility-optimizing lifestyle. According to “Alcohol’s Effects On Female Reproductive Function” by the NIAAA, even light consumption has the power to disrupt blood sugar levels, alter hormone balances and lower a woman’s fertility. Any woman seeking to safeguard her chances for becoming pregnant might want to drastically cut back.
And for women preparing or actually going through egg freezing, our stance is better to swap out the alcohol for a green juice, seltzer water or iced tea.
All hormone-based birth control methods (BCPs; depo-provera; vaginal rings; etc.) need to be discontinued and/or washed out of your system before you start the stimulation medications. The exception to this is your IUD; those can remain in place as they are locally active within the uterine cavity and as such should not exert any effects on the egg freezing process.
• Low dose hCG or Menopur – contains Lutenizing Hormone (LH) used in conjunction with FSH to stimulate multiple eggs to grow
• Lupron, Ganirelix, or Cetrotide – provides spontaneous ovulation before egg retrieval
• Lupron trigger or hCG (Ovidrel, Pregnyl, Novarel) – Medication given about 35 hours prior to egg retrieval; stimulates final maturation of eggs
Nutrition & Wellness
That’s because they undergo a burst of development before they’re released. In fact, eggs don’t actually fully mature until right before ovulation. In short, there’s a lot you can do to boost the quality of your eggs and optimize your chances for as many eggs as possible during egg freezing.
"Human Eggs: How Many and for How Long?"; Go Ask Alice / Columbia University
• Vegetables: Think kale, spinach and chard (green and leafy!), all of which are high in iron, calcium and folate critical for optimal follicle development.
• Fruits: Fruits can contribute loads of key vitamins and minerals, antioxidants and fiber. In particular, berries, citrus and pomegranate are chockfull of vitamin C, a big boost to fertility.
• Plant Protein: Sources like beans, nuts, seeds and hearty grains like quinoa are a much better choice than red meat, poultry and pork. However, low iron can lead to compromised fertility, so the occasional chicken breast or ground turkey can be beneficial. Two to three servings of lean meats per week is plenty.
• Omega-3 Fatty Acid: this polyunsaturated fat is abundant in fatty fish, walnuts and flaxseeds. Since the human body can’t make these fats from scratch, you have to get them from food.
• Water: it cushions and lubricates our tissues and organs and is also the conduit for transporting vital nutrients and whisking away wastes.
• Whole (not Low fat) Milk: According to the authors of “The Fertility Diet,” drinking a glass of whole milk every day “can improve ovulatory function and stave-off infertility.” Many experts recommend whole milk for women looking to boost their fertility and cutting calories elsewhere in their diet. (1)
• Multi-vitamins: In addition to a nutrient-dense diet, women of childbearing age are advised to take a multivitamin / multimineral supplement with folic acid. The goal is at least 400 micrograms of folic acid every day.
• Take plain Tylenol for any headaches or pain; however, avoid ibuprofen (Motrin and Advil) and aspirin during this time frame
• Inform your provider before starting any new prescribed medication
(1) “The Fertility Diet: Groundbreaking Research Reveals Natural Ways to Boost Ovulation and Improve Your Chances of Getting Pregnant.” Jorge E. Chavarro, M.D., SC.D.; Walter C. Willett, M.D., DR. P.H.; Patrick J. Skerrett. McGraw Hill, 2007.
• Animal Protein: As mentioned above – it’s worth swapping out traditional animal protein such as red meat and park for beans, nuts and seeds. Research shows ovulatory infertility was 39 percent more likely in women with the highest intake of animal protein than in those with the lowest. (2)
• “Fast” Carbs: In contrast to complex carbs that are high in fiber such as oatmeal, brown rice and whole grains, carbohydrates that digest quickly – think white breads and bagels, rice and potatoes) destabilize blood sugar levels, spiking insulin. In addition, they can wreak havoc on hormones, and can contribute to an increase in infertility. When sugar is added, as it is with donuts, cake, cookies and other baked goods, it’s even worse.
• Low-Fat Dairy + Other Foods: While we’ve been taught that low-fat milk is better for our weight, it isn’t naturally a boost to our fertility. Research shows consuming one to two servings of full-fat dairy products was linked to increased fertility, while low-fat versions showed the opposite trend. (3)
• Alcohol: the impact of alcohol consumption of one’s fertility is a hotly contested topic and detailed below. While moderate intake of alcohol has not been proven to harm a woman’s chances of become pregnant**, it’s not the smartest thing to do for optimal fertile health. And during egg freezing, we advise NOT consuming alcohol to maximize your results.
• Soda: Duh - loaded with chemicals and sugar that both spikes insulin levels and packs on the pounds – there’s nothing to justify even occasional use of regular (or diet!) soda.
• Caffeinated Drinks: While not advised, less than 300 mg of caffeine a day is safe, but no more.
(1) “Trans Fats May Raise Risk of Infertility”: Harvard Medical School
(2) The “Plant Protein Rules” chapter in “The Fertility Diet” further explains, in great detail, the authors’ rationale for urging fertility patients to bypass animal protein. It’s a highly recommended read.
(3) “About NHS ”: Nurses Health Study
• DO NOT engage in heavy lifting, high impact or strenuous activities
• DO NOT use a hot tub during this time frame or do HOT yoga
• DO NOT take any diet supplements, herbal remedies or “natural” medications during your cycle unless cleared by your provider
Still, that doesn’t mean drinking fits into a truly healthy, fertility-optimizing lifestyle. According to “Alcohol’s Effects On Female Reproductive Function” by the NIAAA, even light consumption has the power to disrupt blood sugar levels, alter hormone balances and lower a woman’s fertility. (3) Any woman seeking to safeguard her chances for becoming pregnant might want to drastically cut back.
And there’s something else to consider about alcohol: the “domino effect” of all the bad health decisions it can lead to.
For example, a young woman decides to meet friends for “happy hour” on a weeknight. She skips a proper dinner beforehand. But she’s a little hungry, so while she’s drinking, she’s gobbling fries, tortilla chips and pizza. That first cocktail leads to 2 more drinks. Once home, she just grabs a little cheese from the fridge and heads to bed.
Because of all the cocktails, she doesn’t sleep well. (Alcohol is a notorious sleep-disrupter.) and skips out her morning workout. Because she’s slightly hungover, she grabs greasy comfort foods that are loaded with fat and calories.
See how quickly an innocent “after hours” drink can wreak havoc on a healthy lifestyle? And that’s just one night!
(1) “Alcohol Consumption and Fecundability: A Danish Cohort Study”: The BMJ (British Medical Journal
(2) “Drinking Levels Defined”: NIH / National Institute On Alcohol Abuse & Alcoholism
(3) “Alcohol’s Effects On Female Reproductive Function”: NIH / National Institute On Alcohol Abuse & Alcoholism
“When you drink coffee, tea or another caffeinated beverage, its caffeine quickly courses through your body. It enters the ovary, uterus, and fallopian tubes, along with just about every other tissue. Caffeine has been found in newly fertilized eggs and embryos. “
The net-net: Consume caffeine with caution.
KNOW YOUR FAMILY HISTORY: No matter how healthy you eat or exercise, genetic factors can make conception more difficult – such as early menopause, or fertility challenges from your family history.
MODERATE EXERCISE: When starting an egg freezing cycle, you’ll need to stay away from most forms of strenuous exercise. However, as part of your general lifestyle, exercise is a huge stress-buster AND keeps your weight in-check. EXCEPTION - “Extreme” fitness – hardcore CrossFit training, or vigorous, Orangetheory-style interval sessions per week – can have an adverse effect on fertility. The loss of loss of too much body fat can tip estrogen scales out of whack and lead to irregular or missed periods.
Other forms of wellness including acupuncture, yoga, and meditation have shown positive results to decrease anxiety,
(1) “Is It Okay To Take Prenatal Vitamins If I’m Not Pregnant?”: Mayo Clinic
* “The Fertility Diet: Groundbreaking Research Reveals Natural Ways to Boost Ovulation and Improve Your Chances of Getting Pregnant.” Jorge E. Chavarro, M.D., SC.D.; Walter C. Willett, M.D., DR. P.H.; Patrick J. Skerrett. McGraw Hill, 2007.