The newest frontier in reproductive medicine and how it’s impacting the Orthodox world
Like most young religious women, Miri Abrams (not her real name) assumed she would get married at a young age and immediately start building her family. But, as is the case for far too many women these days, the years passed, and the New York native was still searching for her bashert. It was when she hit her mid-thirties, still single, that a friend of hers sat her down for a talk.
“Have you considered fertility preservation?” she asked. “Because you should do it. Now.”
Miri had heard of the egg freezing procedure, or oocyte cryopreservation, in which a woman’s eggs are extracted and preserved for use at a later date. Many of her single friends were speaking about this option, which, thanks to medical advances in recent years, has transformed from a procedure with a spotty efficacy record to one with a very high success rate. Still, it was one thing to speak about it; deciding to do it was another matter altogether.
“The biggest hurdle was emotional,” relates Miri. “Agreeing to undergo a fertility preservation procedure meant admitting that I’m an older single, and that by the time I get married, there’s a good chance that I’ll have trouble getting pregnant naturally.”
The other hurdle involved coming to terms with the practical aspects of the procedure, and this, too, was formidable. “This is a medical procedure,” she points out. “It’s not like going for a pedicure; it’s invasive and involves discomfort.” And then, of course, there was the price, which runs into the many thousands of dollars and is not covered by insurance.
Still, at the end of the day, Miri decided that the benefits far outweighed the costs. “I told myself, hopefully I’ll get married soon and become pregnant naturally, and I will have wasted my money. That would be the best-case scenario. But I would never want to look back later and regret that I didn’t take this step to preserve my ability to have children when I was still young enough to do so.”
Some people may claim that freezing my eggs [reveals] a lack of emunah. But I believe the opposite. The fact that Hashem gave me this option means that He wants me to use it.
A Growing Trend
Recent years have seen fertility preservation go mainstream. It started in 2012, when the American Society for Reproductive Medicine announced that egg freezing technology had improved dramatically and that it was no longer considered experimental. Soon after, in 2014, Apple and Facebook moved the procedure into the national discourse by announcing that they would offer egg freezing as a perk for female employees. Today, some cryopreservation clinics throw “egg-freezing parties” to woo women through their doors and convince them to undergo the procedure in order to extend their childbearing years.
The draw for a woman to freeze her eggs is easy to understand from an emotional perspective and also has strong medical backing. Yet critics contend that the industry is engaging in biological fear-mongering and promising unrealistic hope in an effort to convince customers to part with quite hefty sums of money (in an average clinic, about $10,000 for the actual procedure, plus another $3,000 to $5,000 for the hormones and drugs, and then an annual storage fee of $500 to $1,000). Questions are also raised about the ethics involved in giving a woman the illusion that, with her eggs safely stored, she has all the time in the world to pursue her career, play the singles scene and enjoy a carefree life and whenever she feels like finally settling into motherhood, her eggs will be patiently waiting to do their job.
What are the facts and myths regarding egg freezing? And what are the implications for the Orthodox community, particularly the growing population of older singles?
A Numbers Game
First, the medical background. The premise behind fertility preservation is the unrelenting fact that a woman’s reproductive ability decreases dramatically with age. This can be hard to swallow in a society that glorifies youth, and in an era when people are increasingly pushing off adulthood responsibilities for many years. While forty may be the new thirty, a woman’s biological clock stubbornly knows its age.
It actually starts ticking from the time she is born. A female baby is born with 1 to 2 million potential eggs—all the eggs she will ever have. By the time she hits puberty, this number is down to about 1 million; by twenty-five, it’s at 300,000. And starting from age thirty-five, the rate of follicle loss increases rapidly. In addition, and even more significantly, the quality of her eggs decreases dramatically, meaning that the egg has less of a chance of becoming fertilized, and even if it does, there is a higher risk of genetic or other disorders. The decrease in egg quality is the main factor accounting for the drastic reduction in fertility as a woman ages.
The numbers can be disheartening, and downright frightening. At age thirty, roughly 70 to 75 percent of a woman’s eggs are normal quality; by age forty, the numbers reverse—70 to 75 percent are abnormal, and her chances of becoming pregnant naturally in any given month is only about 5 percent (as opposed to a thirty-year-old’s 25 percent chance.) However, here’s the good news: a forty-year-old woman’s ability to actually carry a pregnancy is not much different than it was a decade or two ago (assuming she’s in the same general state of health). Hence the medical theory that if a woman’s better quality, thirty-year-old eggs could be put aside for use in her forties, fertility problems could hopefully be avoided later.
A Boon for Singles
The field of fertility preservation was originally developed to benefit cancer patients. Since cancer treatment can permanently harm reproductive tissue, researchers devised a technique for extracting and preserving the healthy tissue prior to treatment. The National Institutes of Health (NIH) lists several populations that can benefit from fertility preservation procedures, including cancer patients, women exposed to toxic chemicals in the workplace, women who have a genetic disease which affects future fertility and women who, whether due to personal choice or other circumstances, delay having children.
Dr. Joshua U. Klein, chief clinical officer and reproductive endocrinologist, Extend Fertility
It’s this last group—by far the largest percentage of people undergoing the procedure annually—that has given fertility preservation somewhat of a negative overtone. However, this is undeserved, says Joshua U. Klein, MD, chief clinical officer and reproductive endocrinologist at the Manhattan-based Extend Fertility, the only practice in the US dedicated exclusively to egg freezing.
“There’s a narrative in the media that women who freeze their eggs are selfishly focused on their careers. But really, the vast majority of them are single women who haven’t found partners yet and feel the clock ticking. Preserving their fertility takes away the panic in the dating scene,” says Dr. Klein.
Indeed, a brief survey of online personal accounts of egg freezing all reveal this same theme of growing older without having found a partner. If this panic is being felt even in the secular world, it is many times more acute in the frum dating scene, where the ability to have a family is so strongly valued that older single men will often reject women whom they fear do not have the same childbearing potential as their younger counterparts.
According to Rabbi Elchanan Lewis, rabbinic counselor at PUAH, an international fertility organization which specializes in the field of fertility and halachah, the prospect of having their childbearing years pass by without having found a marriage partner has led some women to make choices that are highly problematic from a halachic standpoint.
Rabbi Menachem Burstein, founder and dean of PUAH, meeting with a couple. Courtesy of PUAH
“For many years, the only real option that was available for single women who wanted to have children was to be inseminated by donor sperm and become a single mother. This is something that halachic authorities prohibit,” says Rabbi Lewis.
The other available option was to freeze actual embryos, again using donor sperm, which was just as halachically problematic. For this reason, when the option of oocyte cryopreservation became viable about ten years ago, with the development of the vitrification process for egg freezing, PUAH was at the forefront of promoting this procedure as a halachically permissible way for single women to preserve their fertility.
What is the vitrification process? For decades, the only method in use was by a slow-freezing process. However, due to the high water content in eggs, ice crystals would form during this freezing process, compromising the quality of the eggs when defrosted. About twelve years ago, researchers began experimenting with a flash-freezing technique called vitrification. Being able to immediately lower the temperature to extremely low freezing levels prevented ice crystals from forming. Vitrification quickly became the freezing method of choice and, as mentioned above, in 2012, in the US egg freezing was reclassified and no longer considered experimental. (Israel’s Ministry of Health approved the procedure in 2011.) Suddenly, egg freezing became a real medical option for women looking to preserve or extend their fertility.
“About ten years ago, we heard about this new method at a fertility conference here in Israel, and we were impressed with the data,” recalls Rabbi Lewis. As is their policy for any new fertility advancement, they immediately turned to the gedolei haposekim in Eretz Yisrael; Rabbi Mordechai Eliyahu zt”l, and, ybl”c Rabbi Shlomo Amar, Rabbi Asher Weiss and other rabbanim from across the Orthodox spectrum were all supportive of the procedure.
“Their main concern was that it might cause women to choose to push off marriage, which is what’s happening in secular society,” says Rabbi Lewis. The rabbis stressed that the option must be presented in the right way—as a means to help older single women who have not yet found their bashert preserve their ability to become mothers in the future.
The biggest hurdle was emotional… Agreeing to undergo a fertility preservation procedure meant admitting that I’m an older single, and that by the time I get married, there’s a good chance that I’ll have trouble getting pregnant naturally.
Halachically, Rabbi Lewis explains, there are two issues that must be dealt with before PUAH will do the procedure: First, the woman must understand that the eggs are only to be used when she is married—even if she turns forty-five and is still single, she may not use them. And second, the procedure must be done under halachic supervision. This supervision (which PUAH provides, free of charge, for any fertility procedure involving the transfer of genetic material) ensures that the eggs are properly labeled, sealed and certified as belonging to the correct owner. This is vital to prevent serious halachic problems that may arise in the case of human error in the labs.
With these two conditions in place, Rabbi Lewis says, the process itself does not have any halachic problems attached to it, and he is not aware of any major rabbinic authority who prohibits it.
Rabbi Dr. Aaron E. Glatt, assistant rabbi of the Young Israel of Woodmere and chair of medicine at South Nassau Communities Hospital (SNCH), lectures widely on reproductive technology and halachah. Courtesy of South Nassau Communities Hospital
“This is done in all Orthodox circles—Chareidi, Chassidic, Modern Orthodox. The only difference of opinion among the posekim of the various communities is how publicly the matter should be discussed. It doesn’t matter what kind of head covering she’ll wear when she gets married—a thirty-five-year-old single has the same needs.” This is also the opinion of Rabbi Dr. Aaron Glatt, assistant rabbi of the Young Israel of Woodmere and chair of medicine at South Nassau Communities Hospital on Long Island, New York, who lectures widely on reproductive technology and halachah. Rabbi Dr. Glatt urges unmarried women who will follow the above guidelines to begin the process of making a conscious decision regarding undertaking this procedure when they reach their thirtieth or thirty-first birthday.
“There is no chiyuv for a woman to freeze her eggs,” he explains, “since we pasken that a woman, unlike a man, is not obligated in the mitzvah of peru urevu [the Biblical injunction to ‘be fruitful and multiply’].”
Moreover, he explains, that since egg freezing is a medical procedure that is somewhat painful, burdensome and expensive, the procedure, although halachically permissible, is not obligatory. Yet, he says, while there is no chiyuv, it is a great opportunity for a single woman, from a practical standpoint, to increase the likelihood of having a baby when iy”H she does find her bashert and marry.
Rabbi Glatt states that there are some hashkafic concerns with general advocacy of egg preservation: halachah would not, for example, sanction egg freezing in order to delay childbearing when married, or to put off marriage so a woman could pursue her career. Of course, if a woman has a medical reason for delaying childbearing, this would not pose a halachic problem, and is, says Rabbi Glatt, “a wonderful way to have children later in life when the medical contraindication for having a child is no longer present.”
But Does it Work?
So egg freezing is medically solid and halachically sound. But the real question is, does it work? And, its corollary—is it worth the money?
Because the technology is so new, there haven’t yet been significant numbers of women attempting to use their frozen eggs to get pregnant. However, preliminary statistics are encouraging.
“We are able to say that the egg freezing method is successful,” says Dr. Tal Imbar, director of fertility preservation services at Hadassah Hospital. “In terms of the eggs retaining their quality after being frozen, results have shown a 90 to 95 percent success rate. We already have eggs frozen for ten years, and, theoretically, they can remain frozen forever.”
Studies comparing success of IVF treatment using donor eggs have shown that there was no significant difference whether the donated egg was fresh or frozen. And documented success rates of women using their frozen eggs that culminated in a live birth are, on average, about 4 to 14 percent per egg, which, while it sounds low, is actually an encouragingly high number when taking into account that no one freezes just one egg. Most freeze ten to fifteen.
The midtown Manhattan office of Extend Fertility, a practice dedicated exclusively to oocyte cryopreservation. Courtesy of Extend Fertility
But across the board, the strongest factor affecting success rates is the age of the woman when she freezes her eggs; thus, the urgency. Doctors agree that there is a very specific window in oocyte cryopreservation. Virtually no one recommends electively undergoing the procedure before age thirty; the likelihood of having a baby naturally is too high to warrant the cost and risk of a medical procedure. Between thirty and thirty-four is the optimal window for freezing, when egg quality is still at its peak. Between thirty-five to thirty-nine, egg quality goes down, but for women who haven’t frozen their eggs earlier, this is still a viable time to do so. After age forty, egg quality lowers to the point that it generally no longer pays to freeze. (To compare, a thirty-four-year-old who freezes the recommended ten to fifteen eggs has a 60 to 70 percent chance of having a healthy baby; a forty-year-old freezing that same amount has only a 30 to 40 percent chance.)
The majority of Dr. Klein’s patients are in their thirties, with an average age of thirty-six. He is a strong advocate of the procedure; yet, he says, it is not for everyone. And that’s the real answer to the questions above. The procedure, when all is said and done, is an insurance policy, with no guarantees of success. Every woman needs to make her own informed decision, and her own cost-benefit analysis. Dr. Klein always presents the hard statistics to his patients at the initial consultation.
“Women who are forty-two or forty-four will come to me, asking to freeze their eggs. It’s a tough conversation. On the one hand, she sees this as her last hope—how can I take that away from her? On the other hand, ethically, can I let her spend thousands of dollars on something that has a low chance of success? The best I can do is to give her my informed opinion.”
For many, the cost is a barrier. Dr. Klein would not necessarily recommend that a woman do this if she will have to go into serious debt over it. However, in an effort to level the playing field, he has worked hard to make the service as affordable as possible—his practice charges only $5,500, about half of the country-wide average fee.
Rabbi Lewis relates that PUAH has been working to reduce the cost of the procedure in Israel as well. “We’re in the process of working to get this partially covered by the major health funds,” he says. In the meantime, due to an arrangement with Hadassah Hospital, a reduced fee is offered to women referred by PUAH—6,000 NIS instead of 14,000 NIS (about $1,700 instead of $3,800). And yes, says Rabbi Lewis, some American women come to Israel to have the procedure done at a fraction of the US cost.
Raising Awareness
Ultimately, childbearing, like matchmaking, is in the hands of Hashem. Yet our generation’s remarkable advances in fertility technology are undoubtedly a gift from Heaven and are here to benefit us. Rabbi Gideon Weitzman, director of PUAH, says egg freezing is a real gift for Orthodox single women, for whom marriage and children are a priority. “We get calls on this question every single week, if not every single day,” he says.1
While not every single woman in her thirties may choose to freeze her eggs, those active in helping our community with fertility issues feel strongly that every woman deserves to know about the option.
While Miri says that going through the procedure itself was not easy and involved several weeks of discomfort, from the twelve days of hormone injections prior to the extraction to the recovery period afterwards (while recovery varies, she says that it took her about a week to get back to herself), she is very happy she did it, and encourages her single friends to do so as well.
“Before I did this, I didn’t realize how common it was. Afterwards, I found out that there’s a whole underground of frum single women freezing their eggs. But people don’t feel comfortable talking about it, and because of that, a lot of women don’t know about the option.”
For that reason, she was very eager to share her experience with others and feels strongly about spreading awareness in the community.
“Some people may claim that freezing my eggs [reveals] a lack of emunah. But I believe the opposite. The fact that Hashem gave me this option means that He wants me to use it. By doing this, I’m showing Him I believe that one day I’ll get married. Look, this is what I’m doing to ensure I have a family. Now You do Your part.”
Notes
1. ABC News Network. James, Susan Donaldson. https://abcnews.go.com/Health/rabbis-urge-single-orthodox-women-freeze-eggs-age/story?id=17185321 (retrieved June 15, 2018).
Gila Arnold is a widely published author and journalist whose articles have appeared in numerous international magazines. She is also freelance copywriter, specializing in creating marketing materials for nonprofit organizations.