Dr. Paula Brady joined Columbia endocrinologist Dr. Hyesoo Lowe on an episode of Columbia Surgery’s podcast Conversations and Curbsides to discuss everything from fertility evaluation to egg freezing.
Dr. Brady is an Assistant Professor of OB-GYN at Columbia, and is fellowship-trained in Reproductive Endocrinology, with a special interest in fertility preservation. She is the Director of the Oncofertility Program at the Columbia Fertility Center.
The following is a transcription of the discussion, and is loosely edited for context and clarity.
Jump to a Section:
- Who Should Seek A Fertility Evaluation And When?
- What Is The Process Of Fertility Evaluation?
- What are Fertility Planning Options for LGBTQ+ and Single Persons?
- Fertility Preservation Overview
- Freezing Eggs: Specifics
- Egg Freezing: the Process
- Egg Freezing: Costs
- Final Thoughts
Introduction
Dr. Hyesoo Lowe:
Let's just plunge right in. I've noticed that egg freezing has increasingly entered into many of my conversations with patients. And I wanted to just explore that a little bit more.
So, to break down our conversation today, I think maybe let's start with discussing the patient who desires a pregnancy immediately and how that evaluation might go. And then sort of turning the main part of our conversation to fertility preservation, that is, helping patients who desire a pregnancy in the future.
Who Should Seek A Fertility Evaluation And When?
Dr. Hyesoo Lowe:
So, let's start with part one. Who should seek a fertility evaluation and when?
Dr. Paula C. Brady:
That's a great question. So, when to seek evaluation depends a little bit on how long someone has been trying and their age. When a woman is under age 35, the recommendation is to seek evaluation if they've been trying for a year, with regular periods. So, pretty much trying monthly for 12 months, not pregnant, that would be a time to come see a fertility specialist.
For women over age 35, the recommendation is six months. If they're not pregnant within six months, they can come see someone like me.
And for women who are in their 40s, it's reasonable to have an evaluation up front. We tend to be more proactive in the 40s because the number and quality of eggs has changed, so we want to maximize our options.
There are a few reasons to be seen earlier. So, if folks are having irregular cycles, which makes it difficult to try on their own, that would be a reason to see us sooner. For folks who are known to carry a genetic condition or have a strong family history of a genetic condition, that would be a reason to be seen sooner. We do have capability of screening embryos for disease-causing genetic conditions. So, that is an option that we can explore.
For folks who have other known GYN issues, like fibroids, that can warrant evaluation sooner. And also folks who've been trying and gotten pregnant, but had pregnancy losses, if that's happened two or more times, that's a reason to see us sooner as well.
Dr. Hyesoo Lowe:
Great. And that's very helpful because people who are perfectly healthy may think that they should keep on trying on their own for a good amount of time and when, in fact, age really does matter. So, even in prior healthy patients, it's something to really keep in mind and certainly other medical conditions as you alluded to.
What Is The Process Of Fertility Evaluation?
Dr. Hyesoo Lowe:
What happens after you've investigated all the causes and sort of taken care of reversible causes? What would happen next?
Dr. Paula C. Brady:
So, the basic evaluation is blood work, looking at what we call ovarian reserve, which is egg supply. We check a hormone called anti-müllerian hormone, or AMH, which is a hormone produced by early eggs in the ovaries. And it comes back as a single number.
The higher, the better. And we would correlate that with an ultrasound, which shows us what's called antral follicle count, ultrasound markers of early eggs in the ovaries, and the more of those we see the better. Ultrasound will also allow us to evaluate the uterus for issues like fibroids or other structural issues.
We would also check thyroid function, which is very important in all of this, evaluate a few other reproductive hormones, make sure someone's not anemic, kind of a bunch of blood work.
We would also check a semen analysis for a male partner, for which we have specialized kits. Male partners drop their sample off at the clinic, and we confirm whether there's enough sperm and whether they're moving okay.
And a final part of the evaluation for a female patient is something called an HSG, which is essentially like an x-ray, to make sure that the fallopian tubes are open. Sometimes, fertility specialists will do those. A lot of times radiologists will do those. But essentially, it entails using a little bit of dye and taking an x-ray to make sure that the tubes are open, which is a very important part of this, essentially making sure that the ovary and the uterus are connected and that egg and sperm can meet.
What are Fertility Planning Options for LGBTQ+ and Single Persons?
Dr. Hyesoo Lowe:
What would be some considerations for same-sex couples or single persons wanting to conceive?
Dr. Paula C. Brady:
That's a great question. And there are a lot of options. We frequently do consults for these reasons. It depends a bit on the scenario.
So, for single folks who are looking to conceive, it depends. We have lots of options for donor gametes, donor eggs, donor sperm, depending on what the situation entails. And we can take patients through screening and selection of, and utilization of those options.
For male same-sex couples, or patients who aren't able to carry a pregnancy themselves, there is also an option of gestational carrier, which we can help patients with as well. New York State previously had some restrictive laws on the books for a long time that were recently opened up. So, we have a lot more options, and we can definitely help patients through that process.
And for utilization of donor egg or donor sperm, it totally depends on the scenario. So, we can do donor sperm inseminations, essentially just timing an insemination of a thawed donor sample. And I should say that gamete donors can be known to patients, so friends or family members that we screen and cycle, or there are a lot of anonymous donor gamete options that we can also help patients navigate.
But we can do donor sperm inseminations. We can do IVF with donor sperm or with donor egg, with or without gestational carriers.
So, there's a lot of permutations, depending on what patients want and need. So, we definitely welcome patients to come have a consultation and kind of see what the options are for their specific situation.
Dr. Hyesoo Lowe:
That's very, very helpful to know that there are so many options out there. And the key is, come in and talk about it because there's no other way to know, other than when you get to discuss everything according to your own situation, so that's very helpful. Let's turn over to fertility preservation.
Fertility Preservation Overview
Dr. Hyesoo Lowe:
Who should think about egg freezing? And by that, I mean, is this something for healthy patients who just sort of don't see themselves getting pregnant now, but want to optimize their chances later? Should they be thinking about that? What kind of illnesses might be involved in patients who need to think about this earlier, rather than later?
Dr. Paula C. Brady:
That's a great question, and definitely on a lot of patients' minds these days. So, there are several reasons to consider fertility preservation.
One, and kind of the most pressing reason, would be if patients are going to be receiving chemotherapy. Those medications will affect the number of eggs in the ovaries. So, we encourage patients to see us before that, in the hopes of retrieving and freezing eggs, that can then produce a pregnancy once the acute medical illness is dealt with.
Patients who will be having extensive gynecologic surgery, maybe having an ovary removed, or are known to have severe end endometriosis, which is when the types of cells that line the uterus end up in the abdomen, can cause pain and infertility. If there are acute gynecologic issues or surgery planned, that would be a reason to have an evaluation and potentially consider freezing some eggs.
Most patients don't fall in that category. Most haven't found their person yet or they have, but they aren't ready to conceive for a while, due to career, travel, or other things they have going on.
So, when to see a fertility specialist? Generally, the sooner, the better, just to hear about the process. And studies have evaluated the most effective or cost-effective time to freeze eggs. One study suggested age 34. One suggested age 37. It's really patient-specific.
We know that the quality of eggs—that is, the proportion of eggs that are genetically normal and able to make a healthy baby—starts to change in the mid-30s. And it's not a cliff. Age 35 is not a cliff, after which fertility drastically changes, but it's a progressive change.
So, generally, I would say, if patients know that they want to have a family and know that they probably won't be trying until their late 30s or even into the 40s, ASAP is the right time to be seen. I'm seeing more women in their early 30s.
And it's really a conversation about balancing the cost and effort of freezing eggs, against what is the likelihood that you'll need to use them. And it also involves having a realistic conversation about the likelihood of having a baby from frozen eggs, which is not a sure thing, but essentially a back-up plan. As with many things, it's not guaranteed, and the more eggs we can freeze, the more likely we'll be successful.
Freezing Eggs: Specifics
Dr. Hyesoo Lowe:
Okay. And how many eggs in one cycle is considered an optimal number?
Dr. Paula C. Brady:
It's a good question. We want to get as many as we can in a single cycle, as many as we can safely, I should say.
The national average is around eight to 10 in a cycle, because there's a limit to how much the ovary can respond to these medications. So, eight to 10 is around the average. Some folks with lower egg supplies, which can be genetic or age-related, may get one egg. Some may get 20 eggs. It really depends on age and genetics and egg supply.
The important statistic is the live birth rate per egg, so from one frozen egg, the likelihood of having a baby is about five to 10%, at most.
The further we are beyond our mid-30s, and particularly into the 40s, the quality of eggs is also something to consider, though we have no direct tests for that. We know it's related to age. So, the older we are, the more eggs we need to have frozen.
In the youngest patients, at least 10, ideally 20, but that might be two cycles. So, it is important for patients to be aware that it may require more than one stimulation and retrieval to get a sort of satisfactory number of eggs.
Dr. Hyesoo Lowe:
How do those numbers compare with the non-frozen egg, the menstrual cycle, and natural conception?
Dr. Paula C. Brady:
Again, it depends on age. Per month, when folks are trying to get pregnant, it's about, at most, a 20% pregnancy rate per month.
So, it is normal for it to take some months to conceive because many things have to go right, in each month of trying, for a pregnancy to result.
As we get into our 40s, though, the monthly success rate is more like 5%, because the quality of our eggs is different in our 40s, but, at most, it's about 20% per month.
Dr. Hyesoo Lowe:
That is very, very helpful. And just curious, does it matter how long an egg has been frozen, in terms of the success rate of pregnancy?
Dr. Paula C. Brady:
That's a great question. Frozen eggs and embryos have no expiration dates. So, there's no demonstrated change in quality over time. They can be frozen indefinitely.
A few years ago, a baby was born from an embryo that had been frozen for 20 years. So, yeah.
Dr. Hyesoo Lowe:
That's amazing. Technology, everyone.
Egg Freezing: the Process
Dr. Hyesoo Lowe:
So, you have a patient who has basically decided to move forward. What's the process? What are the nuts and bolts of what they might have to do to start the process?
Dr. Paula C. Brady:
We would do an initial evaluation of ovarian reserve. That helps us know which medications to use and how much.
Ultimately, a cycle will start when a woman gets her period. We would see the patient for blood work and ultrasound in the first couple days of their cycle. We call the first day of bleeding cycle Day One.
So, we usually see patients cycle day two, three, or four for blood work and ultrasound. And we're basically making sure that hormones are at the right place to start the medications.
Then patients will start using the self-administered injectable medications that stimulate the ovaries. It sounds scarier than it is. The needle is very small. It's what's called an insulin needle, so super tiny, really doesn't hurt. It's just about feeling comfortable handling the medications, which we help patients do.
Patients will self-administer these injections for about eight to ten nights, on average, and come into the office, not every day, but every couple of days, for blood work and ultrasound.
We essentially watch their estrogen level rise, which indicates eggs are growing. And on ultrasound, we're watching the follicles. (Follicles are the cyst-like appearance of growing eggs, because we can't see the eggs themselves. They're microscopic, but we can see kind of broadly on ultrasound, how things are going and roughly how many we might get).
So, based on blood work and ultrasound, we know when to schedule the egg retrieval. On average, it's after about eight to 10 nights of injections. The egg retrieval is done under anesthesia. So, patients will get medication in an IV so that they're totally asleep for about five to 10 minutes.
It's a quick procedure. There's no breathing tube. And we essentially use an ultrasound-guided needle, transvaginally, to retrieve the eggs. It's sort of like an ovarian biopsy. It's minimally invasive. It's quick. And our embryologists, our egg and embryo specialists, will go through the fluid that is suctioned from all of the follicles and count up the eggs.
Before patients go home, we're able to tell them how many eggs were retrieved. And a majority, though usually not all, of those eggs will be mature (which means having fully responded to the medications) and can be frozen or fertilized, depending on the plan. So, the eggs will be evaluated for that after a patient goes home.
The recovery from the procedure's pretty quick. Folks have some cramping, like a bad period, that day. Some bloating, which resolves in the days after the procedure. Usually, folks just need Tylenol or ibuprofen and are generally back to work the next day, and so the recovery is quite quick from there.
Egg Freezing: Costs
Dr. Hyesoo Lowe:
Fantastic. And you mentioned earlier that freezing the eggs is a bit of a cost. And that certainly does enter into the decision sometimes. So, what are we talking about? What are the types of costs, maybe annually, that are involved?
Dr. Paula C. Brady:
Yeah. So, some insurance companies or employers will cover this. So, I do encourage patients to explore their insurance benefits or even talk to their HR because they may not be aware they have these benefits.
All in, between the procedure and the medications, a cycle will realistically cost at least $10,000. The annual storage fees vary around the city from high 100s to a little bit over that. It's New York City real estate! But it's billed usually month by month, and they can be stored indefinitely, as I said.
Final Thoughts
Dr. Hyesoo Lowe:
I think this is something that has been in a lot of conversations in the last several decades. And I think it's sort of one of these wonderful innovations in medicine, where patients who may have never hoped to become pregnant because of various situations in their life, various medical conditions, what have you, now have a completely different option that's available to them.
So, I find that absolutely amazing. So, Dr. Brady, any final thoughts or advice to patients seeking egg freezing?
Dr. Paula C. Brady:
Basically, information is power. So, it never hurts to have a consultation and do some initial testing just to kind of get a lay of the land and understand the options. And it doesn't commit you to doing anything, but at least you have all the information. And yeah. We're always happy to talk with patients about this option.
Dr. Hyesoo Lowe:
Fantastic. Thank you so much for joining us today.
Dr. Paula C. Brady:
Thanks for having me. This was great.