To Freeze or Not to Freeze: Elective Fertility Preservation and Egg or Embryo Freezing

In honor of National Infertility Awareness Week #NIAW2022 and the reality that ONE in FOUR female physicians will face infertility, we're sharing information on egg and embryo freezing or cryopreservation. These are very personal decisions, and there is NO RIGHT ANSWER. Our goal is to empower women to make the decisions that are "right" for their personal lives - allowing them to choose both career and family if they so desire. We aim to provide information to help future generations of female physicians make choices so that they can have their "all" in life.

As a Reproductive Endocrinologist (RE) who has been treating Infertility patients for over 13 years, the idea that women, particularly female physicians or physicians to be should be proactive about their reproductive health is very close to my heart. As we approach National Infertility Awareness week, it is worthwhile to highlight the fact that Infertility is a very common issue affecting 1/6 couples in the United States (Reuters Health). Infertility affects up to 15-20% of the general population.* (This is Canadian data. US data typically quotes 12.1%) Women are typically taking longer to find the right partner, longer to get married and longer to have kids and as a result, fertility doctors like myself are seeing that most women are over 35 when they try to have their first child, and a significant rise in consults for single women who are interested in evaluating their fertility, freezing their eggs or conceiving on their own as a single mother by choice.

Women, who pursue specialty careers like medicine, are at higher risk given the delay in childbearing due to higher education, intense training in med school, residency and fellowship and oftentimes delay in finding the right partner. In a recent article published in the New York Times in September 2021 that highlighted the increased incidence in physicians pursuing a medical degree, a staggering statistic revealed that “nearly one in four MDs who had tried to have a baby had been diagnosed with infertility — almost double the rate of the general public.”

We are fortunate, however, to practice in an age of advanced technology, particularly in the field of Assisted Reproduction as well as an age that is focused on health and wellness and empowerment of women to take charge of their fertility and child-bearing goals while pursuing their professional and academic goals in unison.

The big question I get asked by women who come see me is “Are my eggs OK?” As females in health-care, we are all cognizant of our health, we drink cold-pressed juice, workout on the Peloton 7d a week, take vitamins (when we remember!), and practice a healthy diet and lifestyle. Many physicians in training are on some sort of hormonal contraception to regulate their cycles. My mantra is “it’s never to early to have a fertility evaluation and consider egg or embryo freezing” and it is actually very easy!

Most fertility doctors and clinics can do a consult and evaluation as a “one-day workup,” which includes a consult where you and the fertility doctor will discuss your medical history and childbearing plans, when you would like to ideally conceive and potentially ideas on how many kids you would want. Your partner is welcome to that consult. The work-up includes:

• Bloodwork including reproductive hormones, thyroid, prolactin and an AMH level (egg fertility test, a hormone Anti-Mullerian hormone that is secreted by follicular cells surrounding the egg (oocyte). Disclaimer: AMH levels in patients who do not have infertility should be taken with a grain of salt. While used as a guide to determine treatment options, low or high levels do not necessarily predict chances of conception or treatment success!

• Pelvic ultrasound and antral follicle/egg count (AFC)

• Semen analysis (if you have a partner)

Once these results are back, you can have a discussion with the fertility doctor about next steps which include:

• Following ovarian reserve testing (typically every 6m-1year)

• Trying to conceive sooner whether with partner or donor sperm

• Egg or embryo freezing ***

For physicians in training, definitely a shout out should be made for the third option of elective fertility preservation and egg or embryo freezing. This gives you options, to conceive no or later and takes the pressure and burden off having kids while going thru rigorous training or expediting the path to finding a partner (with all the stress that comes with it!)

Who do I recommend elective fertility preservation to and is it right for you?

• If you are single, and don’t have a partner and are likely delaying having kids for at least a few years

• Ideally women under 36 who have good ovarian reserve parameters (younger is always better and data supports that the younger you are when you freeze eggs or embryos the higher the success rate when you use them, mostly due to lower risk of genetic mutations in the eggs or embryos and better response to stimulation).

• You are in a relationship but are delaying having kids due to professional or other goals

• You want more than 1 or 2 kids and may not start trying till you are over 35 and ovarian reserve may be lower.

• You are undergoing medical treatment (i.e. medications or procedures that can impair fertility) and want to freeze eggs or embryos before doing so.

These are just some of the reasons to go ahead with elective fertility preservation.

The medical process usually takes approximately 2 weeks. Starting on day 2 or 2 of menses, you take hormone injections (gonadotropins FSH and/or LH) for 10-12 days with monitoring every few days with bloodwork and ultrasound at the clinic followed by egg retrieval thru the vagina under conscious sedation in the clinic (30-minute low-risk procedure, low complication rate), and follow up to make sure there is no evidence of ovarian hyperstimulation (OHSS). Sometimes 2 cycles are required to get to the right number of eggs (typically 15-25 for highest success) or embryos. Can this be managed during your training? Most RE’s are very sympathetic to making the process work for their patients especially female MDs! Talk to your doctor but if they are like me, we try to make things as easy and seamless as possible for women with busy schedules and can accommodate early appointments etc. as needed.

On a personal note, as a physician who always wanted 3 kids and who was in a rigorous and long specialty, knowing it would take 7 years of training after med school to become a Reproductive Endocrinologist, while I did not freeze my eggs in med school or residency, early on in my career I opted to pursue IVF (when I was under 35). This allowed me to create surplus embryos that I would eventually use over 40 to have my 3rd child, an opportunity I would have never had if I had not moved forward with IVF sooner to preserve extra embryos at a young age.

I encourage women in medicine to take their fertility and reproductive health and goals seriously! All it takes is a consult and a discussion to explore your fertility choices and to have options for now and later.

#physicianinfertility

#NIAW

#infertilityawareness

Dr. Prati A Sharma is a Reproductive Endocrinologist who practices REI (Repro Endo and Infertility) in Toronto, Canada. Originally from NJ and trained in NYC at Cornell and Columbia University, she is very familiar with how women can struggle to find the right balance to achieve their personal and professional goals especially when it comes to having kids. She is a huge advocate for early fertility evaluation and consideration for egg and embryo freezing in young women to help ease stress and allow them to pursue their academic and career goals without sacrificing their wish to have a family now or later. She is on multiple Advisory Boards including Lilia, a company geared to making access to fertility care easier and readily available, OVRY a company specializing in easy at-home fertility products, the Canadian Fertility and Andrology Board of Directors and author of The Conception Diaries, a fertility blog designed to provide useful, evidence-based information for women and men interested in learning about their Reproductive health (www.theconceptiondiaries.com).