Social Egg Freezing, the Law and Women’s Autonomy: Are We Putting All Our Eggs into One Frozen Basket?

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Image from someecards.

by Virginia Novaes Procópio de Araujo, Dublin City University

Lisa is 37 years old and she has just broken up with her long-term boyfriend. She always imagined that this relationship would lead to marriage and children. Lisa is stable and happy in her career. However, she is now worried that if she does not meet someone new, and soon, her biological clock will be merciless with her and she will be left childless. After a visit to a fertility clinic she decides to freeze her eggs, in order to remove the pressure of having to rush into a new relationship. She wants time and is not ready to date again. She wants to raise a child with a committed partner and believes that freezing her eggs will offer her the best chance of ensuring this.

The story of Lisa is fictional, but reflects the current experience of many women who are availing of social egg freezing.

SPERM, EMBRYOS, EGGS AND THE BIRTH OF SOCIAL EGG FREEZING

Sperm has been successfully frozen since the 1950s using a technique called slow-freezing, and embryo freezing has been an established technique since 1992.[1] On the other hand, egg freezing has been considered experimental until very recently. This was mainly due to the fact that eggs contain a higher amount of water than embryos.[2] The slow freezing of eggs results in the formation of ice crystals, which damage the cell and result in lower success rates.[3] Therefore, historically, egg freezing was only accessible to women with cancer or genetic diseases which cause premature infertility, as a small chance to conceive in the future was better than none at all.[4]

The experimental status of egg freezing was lifted in 2012 in Europe[5] and 2013 in the USA[6] due to advances in freezing methods, particularly a process known as vitrification, which involves rapid cooling of the eggs in liquid nitrogen without the formation of ice crystals. This is highly effective for egg freezing. Therefore, egg freezing began to be offered to healthy, fertile women and social egg freezing was born. This is the idea that women freeze their eggs due to lifestyle reasons, which include: to prevent age-related infertility, to postpone motherhood due to their career, to find a suitable partner, to be financially stable, to be psychologically and emotionally ready to become a mother, and to expand their reproductive autonomy.[7]

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Eggs cryopreserved in liquid nitrogen. Image from Kinderwunsch & Hormonzentrum Frankfurt 

 

LAW, AUTONOMY AND FEMINIST BIOETHICS

My research looks at social egg freezing in Europe from a legal and feminist bioethical perspective. I am assessing the impact of the law on social egg freezing in Europe, particularly in the United Kingdom and Ireland to determine if the law enhances or diminishes women’s reproductive options. For instance, my research has identified that Austria, France and Malta have specific law prohibiting egg freezing for non-medical reasons,[8] diminishing women’s options in those countries.

In the context of autonomy, traditional liberal Bioethics tends to have an individualistic and self-sufficient approach, disregarding the influence power relations (“competing social forces”) can have on someone’s autonomy.[9] In a liberal society, freedom is given to the individual to do as they please with their body, as long as they do not cause harm to others.[10] This highlights the rights of an individual and removes the focus on the responsibilities that may arise from that choice, for example, a child and its well-being.[11]

However, the literature demonstrates that women take their relationships and the power structures that surround them into account when making decisions.[12] For instance, a woman that decides to freeze her eggs is not only thinking about herself, but also about her parents (the future grandparents), her future partner or husband, the health of her future baby (as younger eggs are preferable to avoid chromosomal abnormalities), her finances, her maturity, her employment situation and even society (to increase birth rates in an ageing population). Considering the numerous competing social forces, a woman may feel empowered or oppressed by social egg freezing, and that is why my research adopts a relational autonomy approach from Feminist Bioethics, particularly the theory of self-trust developed by Carolyn McLeod.

Trust is a relational aspect of life involving two people: a patient trusts their doctor on the grounds of an established moral relationship (doctor-patient). Self-trust lacks the two entities, as when one trusts oneself, they are optimistic they will act in a competent manner and within their moral commitment.[13] It is relational in the sense that it is moulded by the responses of others and societal norms, as the other gives a truthful and respectful feedback about yourself.[14] Therefore, if a doctor does not inform realistically of potential risks and future outcomes of egg freezing, a woman may make poor choices.

Research shows that women of reproductive age are misinformed regarding cost, process and effectiveness of egg freezing, and that they want to be accurately informed about it.[15] Further, studies[16] demonstrate that residents and health professionals in the area of Obstetrics and Gynaecology lack accurate information about fertility decline due to age, they have conservative opinions, and are reticent to inform healthy patients about social egg freezing.[17] Medical paternalism could explain this behaviour and it needs to be remedied urgently.

 

EGG FREEZING – HOW IT WORKS

Women need to be aware that in order to freeze eggs, they are collected in the same way as is done for IVF. Women self-inject hormones for approximately 10-14 days to stimulate ovulation and when the eggs are mature, they are collected surgically under sedation, with small risks of infection and bleeding.[18] Hormone injections are not completely risk-free, and although rare, some women may develop ovarian hyperstimulation syndrome (OHSS)[19], characterised by swollen ovaries, a bloated abdomen, pain, nausea, vomiting and, in severe cases, liver dysfunction and respiratory distress syndrome.[20]

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Egg collection and freezing. Image from Clínica Eugin, Barcelona.

Although IVF using thawed eggs is just as successful as using fresh eggs[21], there are no guarantees that if a woman freezes her eggs, she will definitely have a baby – it just increases her chances.[22] That is simply the reality of fertility treatments, and doctors need to be forthcoming with information. Ideally, women will conceive naturally, having frozen their eggs merely as an ‘insurance policy’ and for peace of mind. [23] The age of the woman impacts the quality of the eggs and doctors recommend that egg freezing occurs prior to the late-thirties.[24] There is considerable emphasis on educating young women on how not to get pregnant. Women also need to be educated about their biological ‘clocks’ and the possibilities and limitations of egg freezing.

CAREER AND THE PURSUIT OF ‘MR. RIGHT’ INSTEAD OF ‘MR. RIGHT NOW’

The reasons why women are freezing their eggs also need to be demystified. Baldwin interviewed women who availed of social egg freezing in the UK, the USA and Norway and discovered that they believe that there is a ‘right time’ to become a mother.[25]  This is when, ideally, they are financially secure and in a stable relationship with a man who wishes to raise a child.[26] There has been considerable backlash from the media about social egg freezing, particularly since 2014, when Apple and Facebook offered egg freezing as a benefit for their female employees.[27] It raised concerns that women would be forced into it in order to be considered a ‘team player’ and ascend in their careers, treating motherhood as an inconvenience. However, the main reason why women are freezing their eggs has nothing to do with career advancement, it is actually due to the lack of a suitable partner and to avoid future regret.[28] In fact, one of the women interviewed by Baldwin stated: “I think the media really misrepresent women who have children later. I don’t know a single woman who has put off having babies because of her career, not a single woman I have ever met has that been true for.”[29]

Further, Baldwin and her team coined the term “panic-partnering” to express what future regret meant for the women in the study.[30] This is the fear that they might run out of time and settle for any man, rush into having a child purely to avoid childlessness, and regret this later once the relationship fails.[31] These women also rejected the idea of using a donated egg or having a baby alone with donated sperm, as they wanted the ‘whole package’ – a committed relationship and a father to their genetically-related child.[32] Social egg freezing allows women to ‘buy time’ to find this right partner.

There is ongoing research at the London Women’s Clinic to assess why women are freezing their eggs.[33] Zeynep Gurtin from the University of Cambridge chairs open seminars for single women at the clinic and has identified similar women to those from Baldwin’s research: they are highly educated, in their late thirties and early forties and are “frustrated by their limited partnering options.”[34] These women want to find ‘Mr. Right’, not ‘Mr. Right Now’. Gurtin affirms: “as women become more and more successful in educational and career terms, they have begun to outnumber similarly qualified men, and will need to adjust their partner expectations, embark on single parenting, embrace childlessness, or put some eggs in a very cold basket.”[35]

I recently attended one of these seminars and found the London Women’s Clinic to be a highly positive environment, with counselling and support groups available for their clients. The open seminars are a good opportunity for women to obtain realistic information in clear terms, without it being a sales pitch. Research from the USA[36] affirms that a considerable number of women regret freezing their eggs, particularly if a low number of eggs are obtained. They also complained about a lack of emotional support and counselling.[37] Therefore, it is crucial that clinics offer counselling both during and after egg freezing to ensure that women have realistic expectations as to what the technology can and cannot do.

 

COSTS

Social egg freezing is not covered by health insurance[38] and is therefore a private procedure, costing between £3000 – £3500 in the UK[39] and approximately €3000 in Ireland.[40] This raises questions of social justice and fairness, as only women with greater financial means can access egg freezing for non-medical reasons. Further research focusing on this issue is necessary.

 

FREEDOM FROM EMBRYO FREEZING AND LEGAL DISPUTES

The success of egg freezing expands women’s reproductive autonomy as it frees them from having to freeze embryos with a partner. In 2007, a British case reached the European Court of Human Rights (ECtHR). In Evans v. United Kingdom, the applicant, Natallie Evans, had ovarian cancer and underwent IVF with her partner to create six embryos to be frozen. When the relationship ended, the ex-partner removed his consent for the embryos to be used. The applicant could no longer extract eggs and the six embryos were her last opportunity to have a genetic child. The ECtHR discussed whether there was a violation of article 2 (right to life) and article 8 (right to respect for privacy and family life). It was decided that since embryos do not have a right to life in the UK that there was no violation of article 2.[41] The Court also found that overruling someone’s withdrawal of consent, even in this exceptional case, would not violate article 8 or exceed the margin of appreciation.[42]

In other words, the ECtHR decided that the ‘right not to procreate’ of the ex-partner overruled the ‘right to procreate’ of the applicant and the embryos had to be discarded. Ms. Evans could have created embryos with a donor sperm, avoiding legal disputes. However, as has been demonstrated, women wish to have a partner to raise a child with. The options for women have expanded and if they freeze their eggs it is their sole decision to use them for IVF with a partner or sperm donor, to donate them to another woman, or for research.

 

GAMETE STORAGE AND A CALL TO ACTION

Current technology allows eggs to be frozen indefinitely. In the UK, the Human Fertilisation and Embryology Act determines that gametes can be stored for up to 10 years for non-medical reasons and up to 55 years for medical reasons.[43] This reduces the benefits of social egg freezing. For instance, if a woman freezes her eggs at age 27 to ensure she has the best possible eggs, she will have to use them prior to her 37th birthday. There is no time extension, which could cause a considerable amount of pressure for this woman, who believed she was buying herself extra time.

Kylie Baldwin, one of the most prominent researchers of social egg freezing in the UK, has created a petition to convince the UK Government and Parliament that the law needs to change.[44] Signatures from UK citizens and residents are requested at this moment, prior to the 27th of October 2018, in order to be reviewed by the UK Government. This movement is highly important, and I advise all UK citizens and residents to sign it.

In Ireland, the General Scheme of the Assisted Human Reproduction Bill 2017 also adopts this 10-year time limit for non-medical gamete freezing.[45] If the bill remains unaltered when passed as a law it will raise the same issues that are currently being debated in the UK. Perhaps, there is still time for an amendment in the Irish bill.

 

CONCLUSION

 Social egg freezing is quite a recent development and further interdisciplinary research is required to examine the legal, sociological, feminist and economic implications of it. This is needed in order to gain a complete picture of the technology and the impact it has on women’s lives, relationships and society as a whole. There is a risk that women are gambling with their fertility by ‘putting all their eggs in one basket’. That is why social egg freezing must be approached with caution and with realistic expectations by women in order to avoid potential disappointment. However, it is an exciting opportunity, and it is quite clear that the rights and freedoms available to women in relation to their reproductive autonomy have expanded significantly in the last century. This is further evidenced by the very recent successful result in Ireland’s referendum to repeal the 8th amendment (a constitutional ban on abortion which was introduced in 1983 and which allowed for abortion only where a woman’s life was at risk).

 

I would like to dedicate this post in memory of Grace McDermott, co-founder of Women Are Boring, who I met at the induction of our PhD programme in 2014 and became friends with. She was a wonderful person and I am happy to have had her in my life. I am sure she would have strong opinions about social egg freezing and we would have had some lively discussions about the current state of it.

[1] Valerie L. Peddie and Siladitya, ´Request for “social egg freezing” in Khaldoun Sharif and Arri Coomarasamy, Assisted Reproduction Techniques: Challenges and management options (Wiley-Blackwell 2012) 160 – 161

[2] Peddie and Bhattacharya supra n1, 161

[3] ibid 161

[4] Eleonora Porcu, Patrizia Maria Ciotti and Stefano Venturoli, Handbook of Human Oocyte Cryopreservation (Cambridge University Press 2013) 26

[5] ESHRE Task Force on Ethics and Law, Wybo Dondorp et al, ‘Oocyte cryopreservation for age-related fertility loss’ (2012) 27 Human Reproduction 1231

[6] The Practice Committees of the American Society for Reproductive Medicine and the Society for Assisted

Reproductive Technology, ´Mature Oocyte Cryopreservation: A Guideline`, (2013) 99 Fertility and Sterility 37

[7] Imogen Goold and Julian Savulescu, ´In favour of freezing eggs for non-medical reasons` (2009) 23 Bioethics 47, 47

[8] The ESHRE Working Group on Oocyte Cryopreservation in Europe, Françoise Shenfield et al, ‘Oocyte and Ovarian Tissue Cryopreservation in European Countries: Statutory Background, Practice, Storage and Use’ (2017) Human Reproduction Open 1, 4

[9] Carolyn McLeod, Self-Trust and Reproductive Autonomy (The MIT Press 2002) 105

[10] Catriona Mackenzie, ‘Conceptions of Autonomy and Conceptions of the Body in Bioethics’ in Jackie Leach Scully, Laurel E. Baldwin-Ragaven and Petya Fitzpatrick (eds), Feminist Bioethics: At the Center, on the Margins (The John Hopkins University Press 2010) 72-73

[11] Mackenzie supra n10, 83

[12] Carol Gilligan, In a Different Voice: Psychological Theory and Women’s Development (Harvard University Press 1993) 71; Susan Sherwin, No Longer Patient: Feminist Ethics and Health Care (Temple University Press 1992) 46

[13] McLeod supra n9 103

[14] ibid 37

[15] J.C. Daniluk and E. Koert, ‘Childless Women’s Beliefs and Knowledge About Oocyte Freezing for Social and Medical Reasons’ (2016) 31 Human Reproduction 2313, 2319

[16] L. Yu et al, ‘Knowledge, Attitudes, and Intentions Toward Fertility Awareness and Oocyte Cryopreservation Among Obstetrics and Gynecology Resident Physicians’ (2016) 31 Human Reproduction 403; Désirée García et al, ‘Poor Knowledge of Age-Related Fertility Decline and Assisted Reproduction Among Healthcare Professionals’ (2017) 34 Reproductive BioMedicine Online 32

[17] Yu et al supra n16, 403; García et al supra n16, 35

[18] ESHRE supra n5, 1233

[19] ibid 1233

[20] Michael M Alper and Bart C Fauser, ‘Ovarian Stimulation Protocols for IVF: is More Better than Less?’ (2017) 34 Reproductive Biomedicine Online 345, 348

[21] Joseph O. Doyle et al, ‘Successful Elective and Medically Indicated Oocyte Vitrification and Warming for Autologous In Vitro Fertilization, with Predicted Birth Probabilities for Fertility Preservation According to Number of Cryopreserved Oocytes and Age at Retrieval’ (2016) 105 Fertility and Sterility 459, 459

[22] Ana Cobo and Juan Antonio García-Velasco, ‘Why All Women Should Freeze their Eggs’ (2016) 28 Current Opinion in Obstetrics and Gynecology 206, 206

[23] Zeynep Gurtin, ‘Why are Women Freezing their Eggs? Because of the Lack of Eligible Men’ (7 July 2017) The Guardian <https://www.theguardian.com/commentisfree/2017/jul/07/egg-freezing-women-30s-40s-lack-of-eligible-men-knights-shining-armour> accessed 26 May 2018

[24] Susie Jacob and Adam Balen, ‘Oocyte Freezing: Reproductive Panacea or False Hope of Family?’ (2018) 79 British Journal of Hospital Medicine 200, 200

[25] Kylie Baldwin, ‘’I Suppose I Think to Myself, That’s the Best Way to Be a Mother’: How Ideologies of Parenthood Shape Women’s Use for Social Egg Freezing Technology’ (2017) 22 Sociological Research Online 1, 5

[26] Baldwin supra n25, 5

[27] Mark Tran, ‘Apple and Facebook offer to freeze eggs for female employees’ The Guardian (15 October 2014) <https://www.theguardian.com/technology/2014/oct/15/apple-facebook-offer-freeze-eggs-female-employees> accessed 24 May 2018

[28] Kylie Baldwin et al, ‘Running Out of Time: Exploring Women’s Motivations for Social Egg Freezing’ (2018) Journal pf Psychosomatic Obstetrics & Gynecology 1, 3

[29] Baldwin et al supra n28, 4

[30] ibid 4

[31] Baldwin et al supra n28, 4

[32] ibid 4

[33] Gurtin supra n23

[34] ibid

[35] ibid

[36] Eleni A. Greenwood et al, ‘To Freeze or Not to Freeze: Decision Regret and Satisfaction Following Elective Oocyte Cryopreservation’ (2018) Fertility and Sterility in Press

[37] Ariana Eunjung Cha, ‘Egg-Freezing Regrets: Half of Women who Undergo the Procedure Have Some Remorse’ (18 May 2018) The Washington Post <https://www.washingtonpost.com/news/to-your-health/wp/2018/05/18/egg-freezing-regrets-half-of-women-who-undergo-the-procedure-have-some-remorse/?utm_term=.46f0ecc0afcf> accessed 27 May 2018

[38] ESHRE supra n8, 4

[39] See, for example, current prices at the London Women’s Clinic in London: https://www.londonwomensclinic.com/about/prices/

[40] See, for example, current prices at Sims IVF in Dublin: http://www.sims.ie/treatments-and-services/prices.883.html

[41] Evans v United Kingdom (2007) 43 EHRR 21, para. 54

[42] Evans v United Kingdom (2007) 43 EHRR 21, para. 60

[43] Benjamin P. Jones et al, ‘The Dawn of a New Ice Age: Social Egg Freezing’ (2018) 97 Acta Obstetricia et Gynecologica Scandinavica 641, 644

[44] Petition to extend the 10-year storage limit on egg freezing <https://petition.parliament.uk/petitions/218313> accessed 27 May 2018

[45] General Scheme of the Assisted Human Reproduction Bill 2017, Head 22, 8 (a)(i)

 

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