What every 18 year old should know about fertility preservation
And a Fertility Rules first opinion piece
Just like every other investor, fertility companies have to check the obvious boxes—market size and team and exit—before I’ll write a check. But after authoring two books on reproductive health, speaking to thousands of fertility patients and pregnant women, and now as a parent, I’ve added another filter. Would I recommend this service or technology to my (future) adult children? With fertility preservation and egg freezing in particular, I am stuck at “it depends” since the outcomes have yet to catch up to the marketing and profits. Here’s what I would tell them.
See above for the birth of egg freezing as a pillar of the women's “having it all” reproductive freedom movement. While it is often associated with women who put off children because they are in love with their careers, it’s actually a dearth of love, the growing divide between men and women fueled by differences in education, professional achievement, and politics, that caused egg freezing to go mainstream. Hormone testing, especially changes to AMH, can also motivate a retrieval even though AMH is not a good single indicator of fertility or ones ability to get pregnant naturally.
Eggs are finite, fragile, and adversely affected by age, and once the chromosomally normal supply runs out, there is no rebuilding it. There is no way to test the quality of a single egg either: the only data you have after a retrieval is a number, your bank. This lack of surety leads some women to freeze embryos so they know what they have. In a post-Roe and post-Alabama world, however, embryo freezing is far more fraught.
The ideal time to freeze eggs is in the 20s when women can least afford it. Due to the high costs, fertility benefits are prized by prospective employees. It also bears mentioning that for many fertility clinics, egg retrievals are the most lucrative procedures on offer. “Productivity bonuses” given to doctors for achieving retrieval targets make it more difficult for them to turn away poor prognosis patients; incentives are not always aligned.
Beyond finances, many women do not know that a single retrieval involves weeks of intense hormone shots and an invasive procedure; it is the first half of IVF. Most women do not use their frozen eggs either. For those that do, the news isn’t always positive. A retrospective study at NYU showed that of patients who tried to thaw and use their eggs over 15 years, only 39% welcomed a baby. This study isn’t perfect—it uses data from a single clinic and the average age of women included was 38.2 years old. However, it illustrates how much age at freeze matters and why informed consent and full disclosure during patient-provider conversations are so critical. Outside of the office, we have the data and tools to better counsel women. This egg freezing calculator (which is also a marketing tool albeit a useful one from Spring Fertility) estimates the probability of future children based on age and egg bank size.
If you read my sperm-focused piece in The Economist, you know that my sons will be gifted the option to freeze sperm when they graduate high school. The cost in time and money is minimal, and putting sperm on ice is, unlike eggs, a good insurance policy against aging, fertility decline, other exposures, and, as you will read later, the perils of external genitalia. No shots, and no procedures either. Sperm is much less fragile, and even if some loss occurs during freezing and unfreezing, there is almost always enough in a sample for fertility treatments.
Even though men make sperm into old age, more and more research shows the detrimental impacts of chemicals, climate change, and processed foods on its quality. For a future partner, younger sperm could reduce the number of expensive, invasive IVF cycles required to make a baby or make it possible to have a genetically related child if there is a more serious problem. Healthier younger sperm can also lead to better long-term health outcomes for moms and future children. The biggest downside is cost which, in the scheme of life, is not that much.
No one really tells parents to have these conversations with their kids (much less how), but it's never been more important in the complicated and uncertain world we now live in. My boys, who are now 2 and 4, both know that they came from eggs (we’ll get to sperm later), body parts, and where (and what) a uterus is. My goal is to normalize biology so they grow up understanding how everyone’s bodies work, along with their limits. For anyone counseling their daughters, egg freezing requires careful consideration for all of the reasons above and, as The Cut’s latest banger uncovers, regret can go both ways.
For the first time in Fertility Rules history, I’m featuring an op-ed written by a guest contributor. Khaled Kteily, the founder and CEO of Legacy, wrote the op-ed below, which includes a very unexpected reason to freeze sperm.
Have thoughts or want to pitch a piece or a perspective? Email me: hi@leslieschrock.com.
Op-Ed: Why I’ll freeze my son’s sperm at 18
By Khaled Kteily
When I was 18 years old, I started a “how to be a good dad” folder. It contained a collection of publications focused on raising children well, from language introduction to developing intrinsic motivation. My friends thought I was a little odd, but really, I was just planning for the future. Now that I’m in my mid-30s, my friends still think I’m odd, but for a different reason—because I believe the average 18-year-old should freeze their sperm.
I do not have kids yet, but I do have about 100 vials of healthy sperm stored safely in liquid nitrogen tanks at -196 Celcius. My journey to the world of sperm freezing began when I spilled scalding hot coffee on my lap, which resulted in second-degree burns and a trip to the emergency room. Shortly after that experience, I made a trip to a local fertility clinic to ensure I could have kids in the future. Since then, I’ve been fascinated to track how my sperm quality and fertility have evolved over the years, and am reassured to know that no matter what else happens, I’ll be able to have healthy children in the future.
If one of those future children happens to be a son, I’d encourage him to do the same when he hits adulthood. Knowing what I know now, I wish I had frozen my sperm when I was 18. That was the peak stuff! And while many men believe they can be Mick Jagger or Robert De Niro, fathering children in their sunset years, the reality is starkly different: the older you are, the worse your sperm. And older sperm is associated with much higher risks to your family, your children, and you.
There are studies demonstrating that using younger frozen sperm is just as effective—potentially more effective—than conceiving naturally. Studies found that the age of the father can adversely affect the health of the mother during pregnancy. And it can lead to a higher risk of adverse birth outcomes. Advanced paternal age is also associated with an increased risk of pediatric cancers like lymphoma as well as breast or prostate cancers as kids get older. Another study links paternal aging to an increased risk of congenital diseases like autism as well as psychiatric disorders like schizophrenia.
My future son might also think I’m odd, or that 18 is far too young. As a future dad, I’d tell him that it’s better to be safe than sorry. In a world where 1 in 6 couples are now infertile, and more couples than ever are using assisted reproductive techniques to conceive, he might be one of them no matter what he does. After all, sperm counts have plummeted 50% in the last 40 years, and are now declining about 26% each decade. And imagine the benefits of using sperm that’s 20 years younger, 20 years healthier, and with 20 fewer years of accumulated DNA damage and pesticide-infused Honey Nut Cheerios. After all, everyday chemicals like BPAs and phthalates are making us all sick and disrupting our fertility.
Freezing sperm is my day job at Legacy, the company I founded, so I see every day how quickly this world is evolving. It’s easy to forget that egg freezing was considered controversial and even unsafe just a decade ago. Today, it’s considered a reasonable option to optimize for a healthy pregnancy and healthy child in the future. And unlike egg freezing, with sperm there are no hormone injections, medications, or invasive procedures, and it is much lower cost. Freezing and unfreezing sperm is also less risky than eggs since they are biologically simpler. While eggs are typically frozen for 5-10 years, sperm can be frozen indefinitely with no loss in quality over time.
The future I imagine is that sperm freezing is a rite of passage, and parents buy a simple sperm freezing kits for their kids as soon as they come of age. Compared to cord blood storage when a child is born, which is rarely used and costs thousands of dollars, sperm freezing has a more guaranteed benefit to your child, their family, and your eventual grandchildren.
If I could go back in time to my 18-year-old self, I would keep the “how to be a good dad” folder and ignore the skeptical reactions. But I’d add research and resources on how to speak to kids about their future fertility and the optimal timing to freeze, since those years when it feels too early to think about it can make all the difference.
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