‘Banking time’: egg freezing and the negotiation of future fertility

Catherine Waldby* 2014

http://dx.doi.org/10.1080/13691058.2014.951881

Non-medical egg freezing has only been available for about the last five years, as new vitrification
techniques have made the success rates for actual conception more reliable than the earlier method of
slow freezing.

the advent of in vitro fertilization (IVF) in the late-1970s offers some methods for prolonging
fertility

The core business of the fertility clinic sector is assisting women over 35 to conceive
children, as more women delay motherhood in order to establish careers and household
stability.

the technique of IVF itself is only one among many other strategies to reorder human
reproduction in the laboratory (Thompson 2005). Thompson, C. 2005. Making Parents: The
Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press.

private tissue banks allow clients to preserve their own tissues for future use (Healy 2006).

A significant segment of private tissue banking is focused on reproductive tissues and the
preservation of personal reproductive capacity through time. Women may variously bank
their child’s cord blood (Brown and Kraft 2006), their IVF embryos (Nisker et al. 2010) and
their breast milk (Ryan, Team, and Alexander 2013), while men may bank semen, if, for
example, they are facing a tour of duty in the military or a gonadotoxic cancer treatment
(Johnson et al. 2013).

practice of elective egg freezing, where women bank their eggs for later use in conceiving a
child

‘Social’ egg freezing, as it is sometimes called, has only been available for about the last five
years, as new vitrification techniques have made the success rates for actual conception
much more reliable than the earlier method of slow freezing. As I describe in detail in the
next section, the uptake for this new kind of private tissue banking is set to accelerate with
the recent publication of peak medical guidelines (ESHRE Task Force on Ethics and Law et al.
2012; American Society for Reproductive Medicine 2013) declaring the practice no longer
experimental.

cryobiology, the cold storage of living tissues so essential to the history of biomedical
innovation (Radin 2013) Radin, J. 2013. “Latent Life: Concepts and Practices of Human Tissue
Preservation in the International Biological Program.” Social Studies of Science 43 (4): 484–508.

‘tissue economy’ approach (Waldby and Mitchell 2006).

The idea of a tissue economy is that donated human tissues (e.g. blood, embryos, organs,
sperm, oo ̈cytes) have a productivity that can be ordered in different ways. While still inside
the donor’s body, tissues are part of the self and help to sustain the person. Once donated,
they can sustain the life and health of the recipients (for example blood and organ
donation), they may be banked for future use (for example cord blood) or they may become
elements in laboratory research (for example embryonic stem cell lines). Waldby, C., and R.
Mitchell. 2006. Tissue Economies: Blood, Organs and Cell Lines in Late Capitalism. Durham: Duke
University Press.

Oo ̈cyte banking is of particular interest to considerations of tissue economy because, as I

will describe in the next section, oo ̈cytes are historically very difficult tissues to manage
compared to human semen, for example, because they have proved so resistant to freezing
and banking.

While oo ̈cytes have been donated between women since the early-1980s (Trounson et al.
1983), their extremely rapid loss of fertility once outside the body has meant that donation
involves very careful coordination and the co-presence of donor and recipient, in the same
clinic at the same time. The capacity to freeze tissue, and hence to preserve it through time
and transport it through space, is perhaps the single most important technical consideration
for the malleability of a tissue economy, because it dramatically expands the possible uses
of the material and hence its clinical and commercial value (Waldby and Mitchell 2006).
Waldby, C., and R. Mitchell. 2006. Tissue Economies: Blood, Organs and Cell Lines in Late Capitalism.
Durham: Duke University Press.

Cryobiology, the science of tissue freezing and thawing, has been part of the infrastructure
of the biological sciences since the mid-twentieth century.

Cryobiology has since become a central technique of the contemporary life sciences, as
more and more kinds of tissue and cellular material can be frozen and thawed without loss
of vitality.

As Hannah Landecker (2005) observes, biotechnology does not simply change what it
means to be human, it changes what it means to be biological. In that sense cryobiology: the
ability to freeze, halt, or suspend life, and reanimate, [is] an infrastructural element of contemporary
biotechnology. In short, to be biological, alive, cellular, also means (at present) . . . to be suspendable,
interruptible, storable, freezable in parts. Landecker, H. 2005. “Living Differently in Time: Plasticity,
Temporality and Cellular Biotechnologies.” Culture Machine 7.
http://www.culturemachine.net/index.php/cm/article/ view/26/33

In order to freeze her eggs, each woman was obliged to have what is termed an ‘ovarian
reserve’ test. The test comprises a set of procedures that detect the number of primordial
oo ̈cyte follicles in the ovaries. Follicle count decreases steeply with age, accelerating in the
late-30s, and the test provides a guide to overall fertility (Barad, Weghofer, and Gleicher
2009). Barad, D. H., A. Weghofer, and N. Gleicher. 2009. “Comparing Anti-Mu ̈llerian Hormone (AMH)
and Follicle-stimulating Hormone (FSH) as Predictors of Ovarian Function.” Fertility and Sterility 91 (4,
Supplement): 1553–1555.

While women in IVF treatment have already endured many unsuccessful attempts to
conceive or to carry pregnancies to term, for the women seeking egg freezing, the ovarian
reserve test is often the first objective indication of their fertility. They generally have no
direct experience of attempted or failed conception to draw on, and only population
statistics to give them an idea where they may sit on a probability curve.

In the Hodes-Wertz (2013) study, 20% of women reported that they used egg-freezing to
manage workplace inflexibility. These studies describe a group of women whose
demographic characteristics are broadly similar to the women interviewed for this study.
Hodes-Wertz, B., S. Druckenmiller, M. Smith, and N. Noyes. 2013. “What Do Reproductive-age Women
Who Undergo Oocyte Cryopreservation Think about the Process as a Means to Preserve Fertility?”
Fertility and Sterility 100 (5): 1343–1349.e2.

Interviewer (I): how were you aware about fertility decline in the second half of your 30s?
Participant (P): I think actually it’s something that’s generally spoken about, and I think I didn’t really
know a lot. It was just something I had heard. . . . . I have friends who’ve had children in their 40s and
I’m kind of aware that that’s the last window. One of my really good friends, actually, she’d gone
through IVF at the age of 44, and because of her age she actually went for egg donation, and she went
to Cyprus last year to do it, and she asked me to be her support person.

I: Oh! Did you go to Cyprus?

P: Yes. In summer last year, and that was really good, I think, for opening my eyes about how the
procedure worked. . . . [and] last year I went to a few information evenings, and I didn’t know the
actual statistics until they were put in front of me, and I just thought, ‘Oh, my god, that’s so scary!’
Like, every year matters, you know? (Phoebe, late-30s, Environmental Engineer)

Here we see Phoebe referring to the statistical analysis known as the ‘fertility cliff’. This
analysis demonstrates that the probability of conception falls away sharply after the mid-
30s. It has its origins in mathematical modelling of the rate of loss of ovarian follicles (the
biological structures that produce oo ̈cytes), which shows accelerated exponential loss after
the median age of 37 (Faddy et al. 1992). This truncation of fertility in the late-30s was felt
to be quite out of step with their sense that they themselves were not ‘old’:

I thought about it [egg freezing] maybe for half a year, and I was 39 then. I’m now 40, and I
thought, ‘Well, I read that by 40 your fertility’s declining’. . . . My grandma, she had a child
in her 40s. So I’m not concerned about myself – I wasn’t – but I thought I’d just go and see
someone. . . . when you turn 40, even though I don’t feel 40, it is kind of a society
[pressure], I think it was more outside influences than an internal thing, ‘Oh, I’m getting old!’
It was more like that thought, ‘Well, I’m told I’m getting old, so I better do something now!’
(Melissa, early-40s, media producer)

The ovarian reserve test: calculating fertility futures

n order to freeze her eggs, each woman was obliged to have what is termed an ‘ovarian
reserve’ test. The test comprises a set of procedures that detect the number of primordial
oo ̈cyte follicles in the ovaries. Follicle count decreases steeply with age, accelerating in the
late-30s, and the test provides a guide to overall fertility (Barad, Weghofer, and Gleicher
2009). While women in IVF treatment have already endured many unsuccessful attempts to
conceive or to carry pregnancies to term, for the women seeking egg freezing, the ovarian
reserve test is often the first objective indication of their fertility. They generally have no
direct experience of attempted or failed conception to draw on, and only population
statistics to give them an idea where they may sit on a probability curve. Most waited
anxiously for the test results:

I: OK. So, were you – did you feel kind of anxious waiting for the test results? Or were you fairly calm
about it?

P: Uh . . . yeah, a little bit, I suppose, because, well, things like the ovarian reserve, it’s quite a big
determining factor of your future, isn’t it. It’s one of those things that you can’t really change. So I
have to get on with it. Yeah. It was nice, actually. It was good news when it came through. (Meredith,
early-30s, occupational therapist)

Phoebe reports similar feelings of trepidation:

I: Did you have the test when you presented to the clinic to tell you what your fertility level was?
P: [Yes the] AMH test that you can get. It came back really low. I was like, ‘Oh, damn. I’m too old, I
waited too long.’ I’ve had one egg collection so far, and they got about 13 or 14 eggs. (Phoebe, late-
30s, engineer)

In the clinical setting, the ovarian reserve tests are designed to give patient and clinician a
metric for future fertility and to introduce a degree of calculative rationality into what until
then had been experienced as incoherent anxiety and a subjective sense of lost time

The future family and generational time

At one level, egg-freezing is a highly rational strategy for management of the life trajectory.
In one light, it could be framed as a form of instrumental consumer risk calculation, another
example of the entrepreneurial subject of commercial medicine (Rose and Novas 2004;
Waldby 2006).

I: Did you ever think about a donor egg?

P: I just don’t think there would be any point – I can’t see the point. I mean, you might as well adopt. . .
. You don’t know what you’re going to get, do you. [laughs] You don’t know what you’re going to get
with yourself, at the best of times! So no, I wouldn’t do that. I mean, I’m not having a child – I’m not
having it just to have a designer child. I’m doing it because I would like a child myself; I think most
women . . . would have chosen their own egg over a donor. [I think] ... genetics play quite a strong part
in personality and character. It’s

fascinating. Which is why I wouldn’t have a donor. (Jennifer, early-40s, company director)

Jennifer wants to conceive with her own oo ̈cytes because she wants to maintain the genetic
relation with the future child, as well as the gestational relationship. She cannot see the
point of maintaining the genetic legacy of another, unknown woman.

A demographic projection of the contribution of

assisted reproductive technologies to world
population growth
Malcolm J Faddy a, Matthew D Gosden b, Roger G Gosden c,* 2018
Enormous unmet needs for infertility treatment exist because access to assisted reproductive technologies is demographically
skewed. Since the first IVF baby in 1978, the number of people conceived by reproductive technology has grown much faster than
expected, reaching several million today and rapidly approaching 0.1% of the total world population.

When the first babies were conceived by IVF nearly 40 years ago after a long struggle to develop the technology, it
was widely assumed the procedure would remain rare. But in subsequent decades there has been an explosion of
fertility services, and what were originally aimed at unblocking Fallopian tubes have been extended to almost every
cause of female and male infertility through a family of assisted re- productive technologies (IVF, intracytoplasmic
sperm injection [ICSI], frozen embryo replacement, egg/embryo donation, in-vitro matura- tion and preimplantation
genetic diagnosis/screening). From world reports and taking account of missing information, it was estimated there
were 5 million people conceived using assisted reproductive technologies by 2013 (Adamson et al., 2013; IFFS
Global Reproductive Health Surveillance, 2016; Sullivan et al., 2013), and from this base we have projected growth
to the end of the century.

Adamson, G.D., Tabangin, M., Macaluso, M., de Mouzon, J., 2013. The number of babies born globally after treatment with the
assisted reproductive technologies (ART). Fertil. Steril. 100, S42. http:// www.fertstert.org/article/S0015–0282(13)02586–7/fulltext.
(Accessed 10 October 2017).
Involuntary infertility is common and regionally variable (Mascarenhas et al., 2012), but affordability and location
are major barriers to access for treatment. Some poor countries have no assisted reproductive technology clinics,
or only one, and across 62 countries where data exist there is a strong correlation between the number of clinics
per million and per capita income in US$ purchasing power parity (R 2 = 0.66) (IFFS Global Reproductive Health
Surveillance, 2016; World Bank, 2015).

At present, assisted reproductive technology services are skewed towards high-income Westernized countries
where growth has con- tinued more or less linearly or has stabilized in the aftermath of the global financial crisis of
2008 (CDC, 2014; HFEA, 2016). After lagging, services are now rapidly expanding in populous nations like India and
China (IFFS Global Reproductive Health Surveillance, 2016), but in places where they are still scarce or absent only
privileged people can afford to access them, which often requires crossing national borders. The heterogeneity of
fertility services is compounded by the uneven evo- lution of clinical practices to embrace the care of previously
untreatable conditions and for increasing live birth rates.

The assisted reproductive tech- nology subpopulation was projected to the year 2100 for four levels of increase:
from conservative values of zero and 10,000 to more speculative 20,000 or 30,000 additional births per year. An
annual in- crease of 10,000 is a rough figure for countries where assisted reproductive technology is widely
available, considering recent UK and US data (CDC, 2014; HFEA, 2016).

These striking projections offer numbers for the first time instead of what was previously only guesswork. The
fraction of assisted re- productive technology-related individuals could eventually approach one in ten in countries
where service needs are saturated, and by the end of the century their total number is likely to exceed the size of
the current population in Russia, and possibly even the USA.

Although demographic projections have been surprisingly accu- rate in the past, there are more pitfalls in our era of
economic and social insecurity, where fertility rates are also in flux. The propor- tion of people who owe their
existence to assisted reproductive technologies could be underestimated if world population growth slows more
than expected or if prosperity grows and is distributed more equitably. Africa is a special case as the most under-
served conti- nent with the greatest potential for growing fertility services if economic conditions improve, because
it has a young age profile and a wide- spread social stigma associated with childlessness. There is less sympathy for
infertile people in countries with the highest natural fer- tility (even if in decline) because contraception is regarded
as a priority, but more affordable assisted reproductive technology protocols might one day offer access for millions
of additional patients in developing countries (Van Blerkom et al., 2014).

Despite many cautions and qualifications, we can still be confi- dent in predicting that, barring a global
humanitarian or economic catastrophe, hundreds of millions of people will be alive later in the century whose
existence will have depended one way or another on reproductive technologies.

Assisted Reproductive Technology and Newborn Size in

Singletons Resulting from Fresh and Cryopreserved
Embryos Transfer
Galit 1,2 2 3 2 2
Levi Dunietz *, Claudia Holzman , Yujia Zhang , Nicole M. Talge , Chenxi Li , David
2 3 4 3 5
Todem , Sheree L. Boulet , Patricia McKane , Dmitry M. Kissin , Glenn Copeland , Dana
6 7
Bernson , Michael P. Diamond 2017

Assisted Reproductive Technology (ART) is an infertility therapy that involves the handling of
both gametes in the laboratory to achieve pregnancy. ART-conceived singletons have an
increased risk for low birth weight (LBW) compared with singletons in the general
population. [1–9] LBW has long been used as an indicator for child health, however, its
interpretation is unclear because LBW may be related to short gestation, small newborn size
or their combina- tion.[10–12]

Previous reports suggested differential birth weight for ART singletons conceived with fresh
versus cryopreserved embryos, with smaller newborn size for the former. [20–22] In
contrast, one cohort study associated lower birth weight with ART singletons from
cryopreserved embryos transfer. [23]

The inconsistent findings across studies of ART and newborn size warrant addi- tional
investigation.

We found that the risk of smaller newborn size was higher in ART singletons from fresh
embryos transfer and lower in ART singletons from cryopreserved embryos transfer
compared with non-ART singleton infants. Although statistically significant, the magnitude of
excess risk among ART singletons from fresh embryos transfer was small, which is
reassuring. Similarly, the excess risk of smaller newborn size within ART subgroups defined
by infertility source (male, female), was not large. Greater subgroup heterogeneity in
newborn size may be detected if assessed by underlying infertility causes and ART therapy
subtypes; our future work will investigate this potential heterogeneity.

Assisted reproductive technology in

Europe, 2013: results generated from
European registers by ESHRE†
‡
The European IVF-monitoring Consortium (EIM) for the European
Society of Human Reproduction and Embryology (ESHRE)
1,2 2,3 2,4 2,5
C. Calhaz-Jorge , C. De Geyter , M.S. Kupka , J. de Mouzon , K.
2,6 2,7 2,8 2,9 2,10
Erb , E. Mocanu , T. Motrenko , G. Scaravelli , C. Wyns ,
2
and V. Goossens 2017
Data on ART were collected in 38 European countries, covering IVF, ICSI, frozen embryo replacement
(FER), egg donation (ED), IVM, pooled data on PGD and PGS as well as frozen oocyte replacements
(FORs). In add- ition, data on IUI using husband/partner’s semen (IUI-H) and donor semen (IUI-D) were
also included.

he present report is the 17th consecutive, annual European report on ART data. Taken together, these
reports cover more than 7 million treatment cycles from 1997 to 2013 and 1 308 289 infants.

Assisted reproductive technology in Japan: a summary

report for 2015 by The Ethics Committee of The Japan
Society of Obstetrics and Gynecology
 Hidekazu Saito1 | Seung Chik Jwa2,3 | Akira Kuwahara4 | Kazuki Saito5 | Tomonori
Ishikawa5 | Osamu Ishihara2 | Koji Kugu6 | Rintaro Sawa7,8 | Kouji Banno9 | Minoru
Irahara 2017
1
Since the first baby was born as a result of in vitro fertilization (IVF) in the UK in 1978, assisted reproductive technology (ART) has
been used as infertility treatment globally. More than 1 million babies worldwide were reportedly born as a result of ART between
2
2008 and 2010.

3
In Japan, the first baby born after IVF was reported by Tohoku University in 1983. increased dramatically and Japan has reportedly
2
become one of the largest contributors of ART worldwide in terms of the annual number of procedures done.

References:

Dunietz GL, Holzman C, Zhang Y, Talge NM, Li C, Todem D, Boulet SL, Mckane P, Kissin DM,

Copeland G, et al. Assisted Reproductive Technology and Newborn Size in Singletons Resulting

from Fresh and Cryopreserved Embryos Transfer. 2017;12(1).

Faddy MJ, Gosden MD, Gosden RG. A demographic projection of the contribution of assisted

reproductive technologies to world population growth. 2018;36(4):455–458.

Gliozheni O, Calhaz-Jorge C, Geyter CD, Kupka MS, Mouzon JD, Erb K, Mocanu E, Motrenko T,

Scaravelli G, Wyns C, et al. Assisted reproductive technology in Europe, 2013: results generated

from European registers by ESHRE. 2017;32(10):1957–1973.

Saito H, Jwa SC, Kuwahara A, Saito K, Ishikawa T, Ishihara O, Kugu K, Sawa R, Banno K, Irahara

M. Assisted reproductive technology in Japan: a summary report for 2015 by The Ethics

Committee of The Japan Society of Obstetrics and Gynecology. 2017;17(1):20–28.

Waldby C. ‘Banking time’: egg freezing and the negotiation of future fertility. 2014;17(4):470–482.