The Italian newspaper Domani and The Why Wait Agenda are continuing their collaboration with a series of reports on the issue of choosing to have children. This fifth article was published in Italian in Domani in May 2023.
Stopping time is one of humanity’s longest-held dreams. Slowing down ageing, circumventing the laws of biology. That is limited to the realms of science fiction for now, but something similar does exist. Reproductive cells can be taken out, frozen, and used in a pregnancy at a later date.
With the delay in the age at which people start a family, this possibility becomes even more relevant. Sometimes, the desire to have a child comes late, and fertility problems, especially for women, become more common because of aging. As the years pass, the quantity and quality of eggs (technically referred to as oocytes) diminish. So, science can preserve them when they are “young” and use them once financial and professional stability is attained, or the right partner is found.
Hardly anyone freezes their eggs But the truth is that only a thousand women in Italy have opted for so-called “social freezing” so far, which involves freezing their eggs without a health-related reason, at a time in life when they do not want or cannot have children. According to unpublished data from the Italian National Institute of Health, only 909 women have done so between 2015 and 2020. In 2020, for instance, only 147 women opted for this “elective” oocyte cryopreservation, voluntarily placing a total of 992 ova under liquid nitrogen. Why hasn’t it caught on? «Because there is a complete dearth of information about this technique and the possibility for young women to delay the timing of motherhood», states Giulia Scaravelli, the head of the National MAR Registry (Registro nazionale Pma) at the Italian National Institute of Health. Gaining time
Among the very few in Italy who have opted for this route is F., who was already 38 years old when she gave it a try, being single, to grant herself some additional time to find a partner or with the notion that if she didn’t find one, she could pursue MAR - Medically Assisted Reproduction - overseas. However, it didn’t work out for her: ‘You have to do it much earlier. When you’re twenty-five, maximum thirty years old,’ Otherwise, it may be the case that there aren’t enough eggs formed, or that the frozen ones aren’t of good quality.’”
On the other hand, S. and her husband had been trying to conceive for a few years. They were under the care of a fertility centre but were still at the initial stage - medication for her ovulation, follicle monitoring, targeted intercourse during the right days. Her husband was unsure about pursuing in vitro fertilisation.
At the age of 34, S. receives a recommendation from her gynaecologist: ‘Since he is uncertain, you could move forward with fertility preservation.’ S. decides to do it at her own expense, «regardless of what would happen later. With assisted fertilisation, you extract the eggs to fertilise them; here, to freeze them». The story has a happy ending as a year later, the husband finally makes up his mind, the eggs are thawed and fertilised, and the first attempt is successful: a baby is born who is now five years old.
Other types of freezing
If the husband hadn’t wavered, and if they had immediately opted for MAR, S. could have had her eggs frozen for free as part of the MAR process they were going through. This specific area is not rigorously tracked, but according to the Italian National Health Institute, «it is hypothesised» that between 2005 and 2020, «around 40,000 women may have engaged in this practice».
In this scenario, the freezing of eggs takes place while women are actively pursuing pregnancy. The decision to freeze is not theirs but that of the doctors, who, if a high number of eggs is obtained following ovarian stimulation, sometimes prefer not to fertilise them all and instead freeze the excess ones. Furthermore, since MAR has an average success rate of only 30 percent, freezing the eggs allows for the possibility of pursuing additional attempts, if needed, without subjecting the woman to the stress of another stimulation.
The preservation of fertility in cancer patients should also be mentioned. In Italy, there are 3,646 women who have frozen their eggs, mainly between 2010-2020, before undergoing chemotherapy, radiation therapy, or other treatments. Here, of course, there is nothing “elective” about it. «The cryopreservation of gametes is suggested prior to commencing therapies that could potentially affect fertility, whenever workable», says Luca Gianaroli, Vice President of the Pma.Italia Foundation and Director of Global Educational Activities at the International Federation of Fertility Societies: «Tumours are the diseases most frequently associated with a decline in fertility for both men and women. While many treatments offer good odds of surviving, they can affect fertility in younger patients».
How it works
These are completely different circumstances compared to freezing the eggs of healthy individuals when they are still of high quality – typically under the age of 35 – and then using them in the future if necessary. It’s akin to an insurance policy for one’s fertility.
But there are some drawbacks. First is the cost: it can amount to thousands of euros – covering medication, egg retrieval, and freezing, along with an annual fee for storage, and an additional charge for thawing – which in Italy can vary in private clinics from 4,000 to 8,000 euros.
And it is, after all, a surgical procedure. Preliminary tests are needed, plus stimulation through ultrasound monitoring and hormone measurements, and the actual retrieval, which «involves puncturing and aspirating the eggs vaginally under ultrasound guidance», Gianaroli explains. «It is a real operation carried out in the operating theatre under anaesthesia».
The risks are minimal, but it is not guaranteed that the first retrieval will be enough: «It is necessary to have a good number of eggs at hand, as not every egg automatically produces an embryo, and not every embryo develops properly and implants», the gynaecologist adds.
«I, for example, had plenty of follicles, but in reality, when it came to extraction, only five were mature», S. recounts. When she and her husband proceeded, «we thawed and fertilised all five, but only two were viable. We implanted both». However, only one was successful.
Without forgetting that hormonal stimulation itself «has a major impact on many women, both physically and psychologically», stresses F. There is, however, another aspect that poses a challenge: access to MAR is only available to heterosexual couples in Italy. So, a single or lesbian woman «can proceed with cryopreservation», confirms Gianaroli, «but they cannot use the frozen oocytes within the context of assisted reproduction treatment», unless they have a male partner or go abroad. This existing state of affairs naturally discourages many Italian women. Shifting society
Critics suggest that egg freezing could be a contributing factor in women putting off the thought of motherhood. It is important to remember that freezing is not an absolute assurance of successfully conceiving with those eggs in the future.
But if it were to become a widespread practice, would the average age at first childbirth become irrelevant? «It might carry less weight», concedes Gianaroli, «but there are still biological factors that make pregnancy risky and not recommended after a certain age. We mustn’t make the mistake of believing that this solves all problems and that it offers an unlimited amount of time».
Some companies provide egg freezing reimbursement as a benefit to their employees, but behind this generosity, there could be the implicit message “Don’t have children now.” Wouldn’t it be better instead for companies, and society as a whole, to support women in having children when it is biologically easier?
The decision to freeze one’s eggs is a tremendous opportunity, if it remains firmly rooted in freedom and self-determination. In order to address the declining birth rate, young people should be made aware of this possibility, and it should be reimbursed by the state: «It should be seen as an investment in a national strategy for fertility preservation,” suggests Gianaroli.
«When I was 25 years old, this option didn’t even exist», reflects S. «But today, I would recommend it to a 25-year-old. I wouldn’t tell her she has to do it, you know. But I’d say: even if right now you think you don’t want children, consider it».