|From left, Rabbi Dr. Zalman Levine, Dr. Kenneth Prager, and Rabbi Kenneth Brander talked at a panel discussion on the technology, morality, and halachic implications of freezing eggs. Dr. Miryam Z. Wahrman|
Should young women freeze and bank some of their eggs so some day they can conceive children?
With improved technology, elective egg freezing has become a viable possibility for women from 16 to 42 and holds out hope that women may prolong their fertility. A panel called “A Timeless Mother,” held on April 28 at Congregation Ahavath Torah in Englewood, discussed the “social, ethical and halachic” implications of egg freezing.
In October 2012 the American Society for Reproductive Medicine announced that egg freezing, or cryopreservation techniques, had advanced to the point of “acceptable success rates in young, highly selected populations.” Because of these advances, the society’s practice committee decided that egg freezing no longer should be considered experimental. It recommended that the technique’s use be limited to infertility cases involving donor eggs, fertility preservation for women undergoing chemotherapy, certain genetic conditions, and some in vitro fertilization cases where sperm are not readily available.
“It’s a frontier topic in reproductive medicine. It’s becoming a major issue, and more and more of a global issue,” said Rabbi Dr. Zalman Levine of Teaneck, the panelist who provided medical background on the topic. Levine, who was ordained by Yeshiva University’s Rabbi Isaac Elchanan Theological Seminary, is a trained specialist in reproductive medicine. He described how the cattle farming industry was instrumental in developing methods to freeze animal sperm in the 1940s. Levine explained that when living cells are frozen they can develop ice crystals that will damage the cell structure. “You must dessicate, or dehydrate the cell and replace with cryoprotectants, to protect the cell from the freezing process,” he said. Then the cells are frozen in liquid nitrogen, which maintains a temperature of -350 degrees Fahrenheit. “Glycerol was originally used to dehydrate. Now DMSO or propanediol are used.” The latter is a chemical that is used as an antifreeze. The freezing process must be done slowly, lowering the temperature of the cells at a constant rate of one degree per minute.
Levine said that the first successful human pregnancy from frozen and thawed sperm was reported in 1953. Other milestones in the field include the first IVF, or test tube baby, Louise Brown, who was born in 1978. Since the IVF process frequently results in the collection of multiple eggs, and typically more embryos are made than can be used in one cycle, the process of embryo freezing soon followed. “In 1984 the first pregnancy from a frozen and thawed embryo” was accomplished, Levine said, adding that freezing embryos is very successful and now considered routine.
“Eggs are a different story from embryos in terms of freezing,” he said. There are two reasons that eggs are more challenging to freeze than embryos. One is that unlike other cells, which are 60 to 70 percent water, eggs have a water content of about 90 percent. “If you try to dessicate or dehydrate the egg you are essentially replacing the entire contents of the cell [with antifreeze chemicals], and that can be toxic,” Levine said.
The second reason is that the human egg at that stage is in the middle of a cell division process called meiosis, when the chromosomes are lined up on a very fine structure of fibers called the spindle. “The fibers are very susceptible to damage from freezing. If disrupted, the egg is finished,” Levine said. The first report of a human pregnancy with a frozen egg was in 1986. “It took several hundred eggs to get it to work,” he said. It was considered experimental for decades, as researchers struggled to increase the success rate. It was only when a new freezing approach, called vitrification, was introduced that egg freezing became more reliable. “Vitrification involves flash freezing; you precipitously drop the temperature of the cell,” Levine said. “Within less than one second the temperature is dropped to -350 degrees Farenheit. It does not allow water in the egg to form ice crystals so there’s much less of a chance to disrupt the spindle.”
Although the ASRM has removed the designation of experimental, Levine cautioned that data on the egg freezing procedure still is limited. “Most of the data involves freezing eggs for very short term, one to two months,” he said. “Also the egg freezing data is in young women who don’t have fertility problems,” he continued, referring to the women who typically serve as egg donors. “There is no data on freezing eggs from older women.”
Potential applications for egg freezing include egg donation, as the ASRM recommended. When egg donors are used for infertile couples, the donor and the recipient must be synchronized so the recipient’s uterus is primed to receive the embryo. With donor eggs this is not a problem; the eggs are readily available when the recipient is ready.
Another application, according to Levine, is if a couple is undergoing IVF and on the day of the egg retrieval “the husband has no sperm. We can just freeze eggs for another day when we have a better sperm count.”
Then there are cases where the couple would not want to freeze the embryos for religious reasons. “In Catholic teaching, human life begins at conception,” Levine said. “The embryo has full status of a human being.” But that is not true of eggs, which “are pre-fertilization and don’t have the status of a full human being.” He explained that in Italy it is against the law to freeze embryos. “You can go to jail for freezing an embryo,” he said. It is not surprising, therefore, that “much of the research into egg freezing comes from clinics in Italy.”
A further application the ASRM recommended is for women who are undergoing treatment for cancer that could damage or destroy their eggs. For these patients, egg freezing is a form of fertility preservation. Levine added that Ashkenazi Jewish women who harbor BRCA 1 and 2 mutations are at risk of ovarian cancer. If the oncologist recommends prophylactic oophorectomy – ovary removal – eggs can be removed and frozen so those women can have children in the future. In addition, some genetic conditions such as fragile X Syndrome can lead to premature ovarian failure in very young women. Those women also can freeze their eggs for later use.
The ASRM practice committee does not encourage the final application, elective fertility preservation. Its report raises concerns about the lack of data on the safety of the technique, its efficacy and value, and the emotional risks involved. According to the report, “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing. Patients who wish to pursue this technology should be carefully counseled.”
Levine similarly advised caution for women who are considering egg freezing for that purpose. He said that egg freezing, like IVF, does involve a tremendous investment of time, money, discomfort or pain, and health risks. The woman must undergo two weeks of hormone treatment, with from one to three injections per day. She must visit the clinic every one to three days to monitor egg growth. Egg retrieval is done under light general anesthesia, using a needle through the vaginal wall, to reach the ovaries and remove the eggs one by one. The risks include ovarian hyperstimulation syndrome, internal bleeding from the egg retrieval, or infection from the procedure.
Levine reported that costs range from $10,000 to $15,000 for one egg retrieval, plus costly medications, as well as storage fees of $600 to $1, 200 per year.
The biggest risk, said Levine, mirroring the ASRM statement, “is the risk of creating false hope.” He said that there is a 90 to 97 percent chance that an egg will survive the freeze/thaw process; a 70 to 80 percent chance of that egg being fertilized, a 15 to 30 percent chance of implantation and early pregnancy, but a disappointingly low 3 to 4 percent chance of a live born baby from the frozen egg. Levine contrasted that success rate with the success rates for typical IVF, which ranges from 20 to 30 percent for a live born baby per cycle (when three embryos are transferred).
Levine, who practices at the Fertility Institute of New Jersey and New York in Westwood, conducts IVF and related techniques, including embryo freezing. His clinic does not yet do egg freezing; he refers patients to New York University Fertility Center, which has an active egg cryopreservation program.
According to NYU’s website, its clinic recommends that eggs be frozen “when they are of the best quality possible. For instance, eggs frozen at the age of 35 are more usable than fresh oocytes produced at 43 years of age.” It reports on its website that “more than 1000 women have chosen to freeze their eggs with us; 80% were for the purpose of deferred reproduction and 20% for medical indications.” It claims recent success rates that are much higher than quoted by Levine, similar to those seen with general IVF patients. NYU Fertility Center reports a whopping 60 percent success rate (in 20 cycles, 12 women gave birth to 16 babies) in cases that used frozen eggs from young donors. Since the number of cases is still low, it is prudent to interpret those figures cautiously.
“Frozen eggs are kind of a backup,” Levine concluded. “But we do not want her to freeze her eggs with the thought that this will ensure having a genetic child.”
Rabbi Kenneth Brander, dean of the Yeshiva University Center for the Jewish Future, tackled some of the halachic [Jewish legal] issues involved. Fertility treatment is halachically permissible, he said. “Anything that comes to us through science, embrace it. Please use fertility options in a responsible fashion, but it is not mandated to do so. The couple is not forced to go to such lengths to have children.”
“Rav Mordechai Eliyahu” – a former Sephardic chief rabbi of Israel – “at one point in time was very against freezing eggs. He was concerned about creating the social dilemma of single parent homes,” Brander said. He cited other rabbinic sources that endorse oocyte cryopreservation when necessary to deal with certain issues. For an example, he cited “elective preservation when using gonadic toxins, so the woman doesn’t have to worry that in the process of saving her life that she won’t be able to have children.”
Brander discussed the issue of using egg freezing to delay childbearing. He cited the dramatic increase in the average age of marriage in the past 40 years as a factor that makes egg freezing more compelling. He said that in 1970 the average age of marriage for women was 20.8 years and for men was 23.2 years, compared with 2010 figures of 26.1 for women and 28.2 for men. When women get married later, and delay motherhood until their 30s or later, fertility is compromised. “Will oocyte preservation relieve stress about dating?” Brander asked. After all, if a woman freezes some eggs when she is in her 20s, then perhaps she can delay marriage. “She won’t have to settle” for an unsuitable partner, he said.
Brander has been active in developing the Y.U. Connects program, which, according to its website, “conducts educational studies and develops programs that foster healthy meeting opportunities and relationships toward marriage.”
Calling Y.U. Connects the “most challenging program I’ve ever worked on,” he reported that “there are men who say ‘I won’t go out with anyone over 25.'” With that kind of attitude, it is easy to imagine that women who do not find a partner when they are in their early twenties may feel pressure to freeze some eggs away.
“Oocyte preservation has to be used responsibly,” Brander said. “Is it going to be used to establish more single parent homes? Recognize that halachah will look at this through the prism of social issues. It has value if it can create psychological security for the young men and young women so they feel they do not have to settle.”
On a related issue, Brander noted that “eight years ago, genetic testing done on Orthodox college students was minimal. Eight years later, it’s unheard of at Y.U. not to do genetic testing.” He reported that “all the rabbis signed a document encouraging open testing. Now we have information and with information there is power.” This example shows that technology can be embraced and used in positive ways, within the bounds of halachah, and that within a short period of time attitudes towards technology can change.
The Yeshiva University Student Medical Ethics Society sponsored the program to address pressures faced by older women who have not found a partner. Its brochure suggests that the technology could enable older women “to date men their own age.” On the other hand, “the trend could very well create yet another impossible standard” – that is a pressure on women to freeze eggs.
Chana Herzig of Monsey, N.Y., the MES’s secretary, voiced her concerns. Egg freezing “is less of an option than I thought,” she said. Herzig, 20, who is a junior at Stern College, was surprised to learn that the chance of a successful pregnancy from a frozen ovum is so low.
Dr. Kenneth Prager, Columbia University Medical Center’s director of clinical ethics, moderated the discussion. “There might be a misuse of this technology,” Prager said. “One of the problems with technology is that the public will see it in its simplistic form. You hear about the low likelihood of being successful, and the risks.”