Knocked Up Podcast - What you should know before freezing your eggs
Deciding to freeze your eggs can be a big decision, we ask Dr Raelia Lew how we should be informed.
Deciding to freeze your eggs can be a big decision, we ask Dr Raelia Lew how we should be informed.
What tests do you recommend your patients undergo before freezing your eggs?
What factors could affect a patient’s eligibility for egg freezing?
How long does the entire process take?
Will I need to take time off work whilst freezing eggs?
What are the potential side effects of the medications and procedure?
Are there any long-term health risks?
What are the success rates with egg freezing and subsequent thawing?
How many eggs do you recommend freezing to achieve a live birth?
What is the survival rate of eggs during the thawing process?
How long can my eggs remain frozen?
What happens if I want to use my eggs in the future?
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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TRANSCRIPT
Jordi Morrison:
You are joined as always by me, Jordi Morrison, and Doctor Raelia Lew, CREI fertility specialist. Welcome, Raelia.
Dr. Raelia Lew:
Hi, Jordi.
Jordi Morrison:
How are you?
Dr. Raelia Lew:
I'm great. Thank you.
Jordi Morrison:
Today, Raelia, we're talking about what you need to know before freezing your eggs. We've spoken a bit before about egg freezing. It's a favorite topic of yours.
Dr. Raelia Lew:
I love oocyte cryopreservation or egg freezing as a topic because it is one of the great liberating things that I can do to help people have a better prognosis in the future.
And I'm so excited to let you know that I did a pregnancy scan. It's one of my last patients yesterday for one of my patients who came back to me in her early forties to have a baby. And we had frozen eggs for her in the very early, twenty twenties mid pandemic.
Jordi Morrison:
That's right.
Dr. Raelia Lew:
And, you know, and she was kind of, you know, mid to late thirties at the time without a partner at that point and not came to be a single mom by choice. And when she came back to me with a partner in her early forties, they tried naturally first, didn't work. They wanted to try IVF with their own eggs now, didn't work. And so finally and and slightly reluctantly, I warmed four of her frozen eggs and she's pregnant.
And we still have other eggs in the freezer, so we kept quite a lot of them.
And that that's one of the things that I like to do when I warm eggs. I batched them. There is just logically a better prognosis for patients when we minimize the amount of rephrasing, rewarming of embryos made from frozen eggs because they've already been frozen once as an egg.
Dr. Raelia Lew:
And it's one of the most beautiful things about using frozen eggs. It's like the perfect scenario in IVF that we never get to have.
It's a fresh embryo from a frozen egg into either a natural or just hormone-only perfected lining.
And, when it works, it's amazing.
Jordi Morrison:
Amazing. Very exciting.
I've got a few questions all organized for you to help our listeners understand what they need to know before they get pregnant using their frozen eggs.
When you start fertility treatment or fertility exploration, there's some tests to do.
Someone who's wanting to freeze their eggs, what sort of tests would they be doing?
Dr. Raelia Lew:
Well, look, we cast a very wide net.
So we wanna figure out many things about you so that we can work out how to treat you and also how to counsel you, you know, to let you know what's possible and what isn't.
There's a whole, you know, the movie, as you know, I love — I love eighties movies.
I love, you know, When Harry Met Sally, and, you know, there's the famous scene in When Harry Met Sally, where she's faking an orgasm in a café and the lady next to her says, “I'll have what she's having.”
There's a little bit about that with egg freezing that resonates in that, you know, someone's best friend might get 20 eggs at an egg collection, and you're talking to a patient in front of you who maybe you've done some tests and you've checked their ovarian reserve, and they've got a lower ovarian reserve.
And you need to really communicate kindly, empathically, but also realistically and honestly to that patient that no matter what we give, no matter what drug regimen we choose, that's gonna, you know, perfectly suit and, you know, make her ovary perform to the best of its ability — she's never gonna be able to get 20 eggs in an egg collection like her girlfriend because she doesn't have the same ovary, and so she can't.
Dr. Raelia Lew (continued):
And I always say to patients, you can only stimulate the follicles you have.
You can only collect the eggs that are there that month, and we've gotta get our head around what our own potential is.
And that helps us reflect and plan.
And some people, it means planning egg freezing as a series of treatments over a series or a number of months or a period of time so that we can work with what they've got and get them a great prognosis gradually.
And for other people, it might be, yeah, you're the perfect candidate for egg freezing. One cycle, terrific. You're happy.
And the combination of factors that really influence that: the potential of an individual and their biological potential, which is very genetic and very uncontrollable. So it's kind of the cards you're dealt with.
And also the thing that we can control is when we do it. And the age is important because our eggs are better when we're younger.
And so you don't need as many eggs when you're younger because you've got good eggs. Whereas when you're older, unfortunately, eggs go off with age, and that is what happens.
And when we get older, we don't make new eggs. We've still got the same eggs we used to have, but they're just older, and they just can't do as much. They're not as metabolically fit.
Dr. Raelia Lew (continued):
And they've been waiting a long time and they're tired and they make errors.
And we know that when we're older, the proportion of eggs that turn into babies is less.
And so when I counsel somebody in their over 35, I have to be realistic because what I don't want is patients being disappointed or unhappy if they come back to use a limited number of frozen eggs and they don't get pregnant — because some will and some won't.
And my patient that I described at the beginning of this episode, it was — it's good planning, obviously — but also she was lucky. She was incredibly lucky because some of what happens in the making of a baby happens by a series of complex events going right, one event at a time.
And every developmental milestone in an embryo is contingent on the previous milestones all going right.
And even an embryo with the right DNA information, the correct chromosomes, that looks fabulous — an AA embryo as a microscopic blastocyst — still has to do everything right to make a baby, and it's not guaranteed that it will.
It's only 50% of the best embryos that will make a baby.
Jordi Morrison:
So one of the things that we have to do is do a thorough assessment of someone's potential so that we can counsel them realistically and strategize individually to get them their best outcome — or, if they decide that it's not for them, to make sure that there's no decision or regret because they've thought about it with the right information.
Dr. Raelia Lew:
So that — that's kind of what I'm aiming for.
Dr. Raelia Lew:
And then there's all these other tests that I do, which are really to help me predict difficulty or correct things that can be optimized so that I can get the best outcome for the patient, avoid complications of treatment.
So those kinds of things are what I'm talking about when I'm doing investigation. So I'll do things like an anatomical survey, a pelvic ultrasound to check the anatomy of the patient — to ideally confirm that they're low risk for egg collection or to identify if they're high risk and why — and address any factors that can be modified.
And then, also, I want to look at a lot of different tests opportunistically, because people who are thinking about freezing their eggs are maybe not immediately, but at some point, thinking about having babies.
So we want to really check for things like their immunity to rubella and chickenpox and some other things that we just, opportunistically as a health promotion activity, can optimize by vaccination to give them immunity if they don't have it.
Jordi Morrison:
What I find so interesting about your response just then, Raelia, is that my next question for you is: What factors could affect a patient's eligibility for egg freezing?
And you kind of answered that when you were talking about the test. And I think it just goes to show the importance of the individuality of the person and the counseling they receive.
Dr. Raelia Lew:
Yeah. Well, that's right.
So I'll give you another example. I've had this happen many times in my career — that a patient is sitting, you know, kind of opposite me, and they've got a really good egg count and everything on paper checks out, but they're in their forties.
And they say, you know, "Raelia, why can't we freeze my eggs?" And we can is the answer, and I will help patients if they want to do what they want to do.
But it's my job to make sure that they are not misled in their opinion of what those eggs mean. They need to be realistic. They need to understand what those eggs mean.
When we are freezing eggs at an older age, we are freezing eggs that are compromised. And so the chance that those eggs will actually translate is less, and we need to know that.
We need to know that our efforts may be in vain.
And look, they may translate and come through, and we may be very happy we did it.
Dr. Raelia Lew (continued):
But when we freeze eggs for young women, the vast majority — if they need to use them — will ultimately be successful statistically.
So what we're doing... they may not need the eggs. They may have babies in other ways. They may decide not to have babies.
But if they need the eggs, they're likely to succeed. Not everyone will, but they are likely to. They are more likely than not to succeed.
Whereas when we freeze eggs for women, you know, in the later stages of reproductive life, that's not true. Many of them will fail.
And so that doesn't mean they shouldn't do it if it's meaningful to them.
The reason we freeze eggs — like, why would we ever freeze eggs?
We freeze eggs to be able to have a baby with our own DNA.
We can use a donor egg from someone else whenever and be very successful if it's a good egg.
So we freeze eggs to have the opportunity to have a baby with our own genetic material, from our own family line — because that's important to us.
And I wouldn't deprive that woman in her forties the chance to do it because that's meaningful to her at that point, but she needs to understand that it might not work.
Dr. Raelia Lew (continued):
Whereas if I have the exact same woman on paper, the same parameters, and she's 28 — she may never need to use these eggs.
That's quite possible that she won't. She's got lots of fertile years ahead of her where she could get pregnant naturally or by other methods.
But those eggs as a resource for her are gonna be fantastic.
Very much — very likely to make a baby successfully if they're used, either for her or if she chose to, for example, donate them to somebody else.
As a biological entity, those eggs are great eggs for the majority of women at that age who freeze electively because they don't have any pathology. They're not identified to be infertile necessarily.
So their chances of making a baby with their eggs are terrific.
Jordi Morrison:
A question that we get asked a lot is: how long does the process take?
So someone's done their tests. They've had an appointment with you or one of our fertility specialists. They understand what's gonna happen next.
How long does it take to freeze your eggs?
Dr. Raelia Lew:
So one cycle takes roughly two weeks, and I would say put away three weeks of your time.
Because it's not just about collecting the eggs on the day of egg collection.
There's a runway to that — where from when you start taking medications to get ready to when you're recovered from your egg collection, your downtime is over.
I would say three weeks.
Dr. Raelia Lew (continued):
Not much.
Jordi Morrison:
And you can work through most of that too?
Dr. Raelia Lew:
Yeah. So what I would also point out is that most of that three weeks is actually a couple of minutes a day giving yourself an injection at home or taking a tablet — usually a combo of the two.
Then there'll be a couple of times where you need to come in for an appointment, and that's for us to check how you're going.
So you have an ultrasound. Usually, the way that we try to accommodate that in our practice at Women's Health Melbourne is: you come in early in the morning, our nurses start bright and early, and you have your scan and you go.
And we gather that information. Sometimes, occasionally, you might have a blood test as well — not usually during egg freezing, but sometimes depending on the person.
Dr. Raelia Lew (continued):
And then that information is recorded for me.
And usually around lunchtime, I check the results for all of my patients.
And so I have a look and I see, okay, everyone's had their scans — who's doing an egg freeze cycle or an IVF cycle or an ovulation induction cycle today?
What's the best next step for them?
And I personally consider every result, and I make a treatment plan for each patient, which then my team communicates to the patients to make sure they know what to do.
Sometimes it's terrific — everything's good, you're ready for your egg collection, this is when it's gonna be.
Sometimes it's not quite ready — let's see you again in a couple of days.
So it's very different for different people.
And then once a decision has been made as to when an egg collection will be, that day — the day of the egg collection — will be communicated, usually at least with two days' notice.
And then the egg collection itself is a day you need completely off work.
And I recommend that the next day should be taken off as well.
And through, you know, more than a decade of experience doing this, I can tell you that patients who take the next day off recover better.
Dr. Raelia Lew (continued):
In terms of the week after the egg collection, you're not gonna feel terrific.
You're not gonna feel 100%. You're gonna be a little bit tender for a couple of days,
and then you're gonna feel a bit bloated for a couple of days.
And then your period will come, and you're gonna feel emotional for a couple of days.
So that's probably the heaviest week — after the egg collection and the aftermath of the egg collection.
Jordi Morrison:
That's a really interesting perspective because I think we all consider the lead-up and the injections and the procedure.
But in fact, it's the recovery that takes its toll.
Dr. Raelia Lew:
I would say from a coping perspective, that would be my take on it.
Like the lead-up — especially, you know, we're all a little bit frightened of the unknown.
And for most women who freeze their eggs, while we might've done things like Botox or medical treatments for various ailments we might suffer — most women who freeze their eggs are young and healthy, and they've never actually had serious medical problems.
So — and obviously, there's an exception to every rule with kind of upcoming cancer treatment — we freeze eggs for people who have endometriosis.
So definitely there are patients who freeze eggs who've gone through a lot.
But most people who freeze eggs electively for the future are very healthy, and so this is the most medical thing that's ever happened to them — that they've ever been involved in.
Dr. Raelia Lew (continued):
They're not used to giving themselves medications, let alone injections.
They're not used to, you know, having a very strict time frame where things have to happen by the clock.
So there's pressure and there's fear of the unknown.
But actually, when you get your head around it, I think relatively speaking, that bit is the easier part.
Jordi Morrison:
I wanted to ask about the potential side effects of the medications and the procedure.
And I think you've spoken a bit about the following week — when we're gonna be a bit sore, bloated, and grumpy.
What other side effects are there?
Dr. Raelia Lew:
So the procedure itself is actually not an operation per se.
It is more akin to an interventional radiology procedure.
It's an ultrasound with a needle.
And what happens is — when you're asleep — transvaginally...
Jordi Morrison:
There's no cutting?
Dr. Raelia Lew:
No. There's no injury.
There's no cutting. There's no scalpel. There's no suture. There's none of that.
There's an ultrasound in the vagina.
I use the ultrasound probe to immobilize the ovary and to position the ovary so that it is accessible without any structures being in between the vaginal wall and the ovary.
So we want bowel out of the way.
We don't want any other structures like fallopian tubes in the way. We don't want the bladder in the way.
So we move things out of the way.
And that's why doing an ultrasound beforehand to check out the anatomy is important — because if someone's got issues, then we want to know about it.
Sometimes issues can be overcome in theatre. So just because you've got anatomical concerns on scan doesn't mean you can't have an egg collection.
And there are also other ways we can try and do an egg collection, like through the tummy — transabdominally — or laparoscopically.
But the vast majority — 99%+ — of egg collections are done transvaginally.
Dr. Raelia Lew (continued):
We introduce a little needle through the roof of the vagina into the ovary itself, and we aspirate the follicles, which is the structure that an egg comes from.
The follicles we can see on the ultrasound screen — the egg we cannot.
The egg is microscopic.
If I put an egg in a petri dish in front of you and you looked at it with the naked eye, you would not see the egg.
So it is tiny, and I can't see the egg during the egg collection either.
What I see is the follicle, and I drain the fluid.
And then the fluid goes to a scientist, and they use a microscope to locate the eggs from the fluid.
So it's an imperfect science. It's an art.
Not every follicle is gonna give us an egg.
Not every follicle has an egg to give.
We can't tell on an ultrasound if the follicle still has an egg that you made when you were an infant as a fetus — or if that egg within the follicle died ten years ago.
We can't tell.
So we make the assumption that each follicle might — best case scenario — give us an egg, but then not every follicle will.
And the number of follicles we count on a scan before an egg collection gives us a rough indication of the absolute best case scenario from an egg collection.
It's very normal that not every follicle delivers an egg, and it's very normal that of the eggs we find, they're not all terrific.
So we freeze eggs if they look good. And if they don't look good, we don't freeze them.
And so when we talk about statistics and live birth rates from frozen eggs, we're talking about eggs that make it to the freezer — not eggs that we found as the denominator.
Jordi Morrison:
And you mentioned about how most women going through this are quite young, and this will be, like, the most medical thing that's ever happened to them. I like that.
Are there any long-term health risks with freezing your eggs?
Dr. Raelia Lew:
We don't think so.
We don't think there are from IVF either — not based on the data we have.
And it's been very rigorously looked at, which is very reassuring.
Jordi Morrison:
I think something that everyone considering freezing their eggs thinks about is success rates.
What are the success rates with freezing your eggs and then the thawing?
Dr. Raelia Lew:
Yeah. The success rates from freezing eggs are terrific.
As you told us at the start of the episode — they are.
It's a great technology. It's one of the great revolutions of reproductive medicine.
They're as good as IVF.
The caveat is: not every egg survives to have a chance.
We lose 10%, and we must allow for that.
We must make sure that when we freeze eggs, we freeze enough eggs so that we know we can lose some — because we will.
But of those eggs that survive, we will get the same pregnancy rates as we do for the same-age woman having IVF.
Obviously, if you bring me perfect sperm, I'm gonna get better pregnancy rates from the same batch of eggs.
50% of the equation comes from the other 50% of the DNA that contributes to an embryo, so that's important.
Dr. Raelia Lew (continued):
And when I talk to my patients about coming back to use their vitrified oocytes — I talk to, especially if they're with a partner who can enact diet and lifestyle change — it takes 70 days for guys to make sperm.
They are making sperm. They don't make it all at the beginning like we do with our eggs.
So we can actually put them on a health kick before we take the eggs out of the freezer — that is within our power — and that will improve outcomes as well.
So thinking holistically and outside the square of just being egg-centric is important.
But, you know, eggs do really well.
And so I would say, on average, one in five eggs makes an embryo.
And on average — depending on the age of the person — somewhere between one in two and one in ten embryos makes a baby, ranging from an age of 30 when you froze your eggs to an age of 40.
Jordi Morrison:
And how many eggs do you recommend a woman freezes?
Dr. Raelia Lew:
A lot.
You'll always find that my patients at their first consultation about egg freezing will be told — because I say this to absolutely everybody — even if you've got a great egg count, you may need more than one cycle to hit the goals that we set for ourselves.
Because while it's predictable that someone with a higher egg count will do better and may not need as many treatments, it's not a guarantee.
We don't know how you're gonna perform until we do a cycle.
We don't know how you're gonna respond to medications.
And we also don't know what your eggs look like until we get them under a microscope and assess them.
You could have a high number of terrible eggs, or you could have a small number of fabulous eggs.
The number and the quality are not directly proportional.
And so a lot of the assessments we do pretreatment are about number, not about quality.
Dr. Raelia Lew (continued):
The biggest predictive factor we have to let us know about quality is age, but you can have younger women who have bad eggs, and you can have older women who have better eggs than expected.
So there's gonna be biological variation within that general rule.
Jordi Morrison:
And how long can our eggs stay frozen?
Dr. Raelia Lew:
Again, that is a question that has many facets.
One way of answering it is a legal answer, because in Victoria, we have laws that stipulate that when eggs are frozen, they have to be checked every five years.
So you can freeze them for five years, and then you've got to do paperwork.
And after ten years, you've got to do paperwork again.
Now, if you lived in the United Kingdom and had the same biology and went to an equivalent laboratory, your eggs could be frozen for fifty years.
So that’s a legal answer, and it’s different place to place, and it is completely arbitrary.
If, from a biological perspective, we freeze eggs well and they’re under stable conditions, there’s no real limit to how long they could be frozen.
The world record that I’m aware of that was published is twenty-three years in the freezer from an egg being frozen to making a baby — and that was even using the older technology.
Jordi Morrison:
Wow.
Dr. Raelia Lew:
Yeah.
So in terms of that — and embryos — you know, embryos can be frozen for a long time.
It’s not about how long they can be frozen biologically. It’s about the legal perspective.
Jordi Morrison:
Just to finish off — what happens when we want to use our frozen eggs?
Dr. Raelia Lew:
You come and see your doctor and, you know, have a runway.
And some people don’t have so much of a runway because they’ve been trying naturally and it hasn’t worked.
Or — they potentially have already been on their runway, I guess, in that scenario —
where they’ve been optimizing diet, they’ve been optimizing lifestyle, they’ve been looking into things, having investigations.
But that is the first part of the preparation process.
We get everything ready to be as good as it can be.
And then when we make our attempts, we strategize.
As I mentioned earlier in the episode about batching, we decide on how many eggs we’re going to warm.
Are we going to warm everything we’ve got? Are we going to mitigate risk by warming a fraction?
How big will that fraction be?
You know, what is our risk appetite for not having an embryo versus having to refreeze a limited resource of excess embryos?
Sometimes there’s a cost implication that’s important because each time we warm a batch, it’s technically an IVF cycle from a lab perspective.
These are things to consider. So part of what we talk about is strategy.
Jordi Morrison:
And family planning in terms of size as well.
Dr. Raelia Lew:
Yeah, that’s right.
And when — with your question about how many eggs to freeze — obviously I didn’t give you a numerical answer because it’s different for different women at different ages.
But I answer that question more like: What percentage probability do I accept of having one, two, or three children with those frozen eggs?
Then I calculate that for the patient, and we work out what their special number is going to be to achieve that percentage risk — or chance.
Think about risk and chance — it’s the same thing.
You know, our risk of not getting what we want is the same as our chance of getting what we want.
What I try to aim for — for somebody who wants two babies — is to try and get a 90% probability of that occurring with the resource we create.
You’re never going to get a 100%, because there are factors you can’t control.
But if nine out of ten of my patients get what they want, for me, that’s where I should be aiming.
Jordi Morrison:
Wonderful. Thank you, Raelia.
I will say that we’ve done a few episodes on egg freezing before — not for a long time, but we have.
And there are some great blogs on the Women’s Health Melbourne website as well, so we’ll link to those in the show notes.
And my best advice to everyone is to make an appointment and to learn about your situation.
To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram at @knockeduppodcast, and join Raelia at @drraelialew, and email us your questions to podcast@womenshealthmelbourne.com.au.