In this article, we discuss the concept of fertility preservation and look specifically at how it can be used for women who intend to delay childbearing for social or medical reasons. 

Overview

Fertility preservation is the process of saving and protecting reproductive tissue so that an individual can use it to have a child in the future. It can be used for both males and females and it is becoming increasingly more widespread. In the UK, there are only a select few circumstances that permit fertility preservation through the NHS; otherwise, women must seek private care. 

This technology can be life-changing for those who face either social or medical barriers to reproduction during their reproductive years which cause them to delay childbearing, either voluntarily or involuntarily.  

Why would a woman feel inclined to engage in fertility preservation? 

A woman’s fertility is biologically limited to her fertility window. Women are biologically fertile from menarche (the onset of their menstrual cycles, usually in early teen years) until menopause (the ending of their menstrual cycle, usually around age fifty). The likelihood of successful conception and pregnancy decreases with age from around the mid-thirties onwards, and those nearing menopause often struggle to conceive.

Some women do not feel inclined to have children, which is an equally valid life choice. However, some women do intend to start a family but delay childbearing due to circumstantial barriers. These factors include: 

Social circumstances

Women may choose to delay childbearing due to social circumstances. A woman may not feel that her current living situation or lifestyle is appropriate for having a child, and wants to make changes before starting a family. Perhaps she intends to focus on her career shortly, and on building financial stability, which may be more difficult whilst simultaneously raising a child. She may not feel that she has adequate social support from the welfare policies or her family. Alternatively, she may feel satisfied with her current lifestyle but wants to delay childbearing until she finds a partner who she wants to start a family with.⁵ 

Medical conditions or treatment

Certain medical conditions can affect a woman’s fertility. Examples of this include endometriosis, or uterine fibroids, which can affect the health of the female reproductive system. Opting to preserve fertility before any potential or further damage occurs may therefore be a consideration, and even a recommendation, in some medical circumstances. 

Certain treatments for medical conditions can also cause infertility, such as chemotherapy for cancer treatment. Taking the precautionary measure of fertility preservation is likely to increase the chances of starting a family later in life, in the case that the treatment renders the woman infertile. 

Profession

Some women have jobs that entail physical risk, such as being in the Armed Forces. Injury may cause a detriment to fertility.¹

Transgender procedures

Some transgender individuals may wish to preserve their fertility if they intend to undergo gender reconstructive surgery or hormone treatment, which can affect fertility as it alters the physiology of the body. If they wish to delay childbearing until after the transition, fertility preservation may be an option.⁴

What methods of fertility preservation are available for women? 

Oocyte cryopreservation (Egg freezing) 

The process of egg freezing entails collecting eggs from a woman’s reproductive system and then freezing them in tanks of liquid nitrogen. At a later date, the eggs are thawed and can be used in fertility treatment to impregnate the woman. 

To prepare for this, women take hormonal drugs to stimulate the production of eggs by the ovaries. Sometimes women undergo more than one round of hormonal treatment to increase the yield of eggs upon retrieval.  The woman is then sedated and the eggs are collected. The process usually takes around two to three weeks, and it is essentially the first half of an in vitro fertilization (IVF) cycle. The second half of the cycle involves injecting the eggs with sperm and implanting this embryo into the woman. However, with oocyte cryopreservation, the eggs are immediately stored in liquid nitrogen instead of being fertilised. 

When the woman wants to use her eggs at a later date, the eggs are thawed. Usually, some eggs survive, but occasionally no eggs survive the thawing process. These surviving eggs are injected with sperm, and the formed embryo/s are implanted into the woman’s womb, completing the IVF cycle. The woman usually undergoes some hormonal treatment prior to implantation to prepare the womb for pregnancy. The intention is that a normal pregnancy and birth will follow.^1,2,3

Ovarian tissue freezing

For young girls who have not started ovulating (releasing eggs), or for women who are unable to freeze their eggs for other reasons, ovarian tissue freezing can be used. This involves a laparoscopic (keyhole) surgery whereby part of an ovary is removed, under general anesthetic. Similarly to oocyte cryopreservation, the tissue is frozen until desired future use. It is then reimplanted into the woman’s body and should function as it had previously. The woman can then either undergo IVF or attempt a natural pregnancy.^1,2

Embryo freezing

If a woman is in a relationship before undergoing fertility affecting medical treatment or wishes to delay childbearing for another reason, she and her male partner can freeze embryos.

Like the oocyte cryopreservation process, the eggs are harvested from the woman but are then combined with her partner’s sperm to produce embryos. These embryos are frozen until the desired time, at which they are thawed and implanted and hopefully produce a successful pregnancy. 

Not all embryos will be suitable for freezing, only the ones deemed high quality will be frozen. The storage period for frozen embryos is usually ten years, but this can vary depending on circumstances. Thawed embryos typically have a better survival rate than thawed eggs, though not all do survive. Thawed embryos have a success rate similar to fresh embryos.^1,2

Difficulties around fertility preservation 

Fertility preservation appears to be an ideal option in the case of women delaying childbearing for social and medical reasons. It offers reproductive freedom whereby previously women were biologically constrained. However, it does pose some difficulties and disadvantages to consider. 

• Cost 

In the UK, elective fertility preservation (fertility preservation unrelated to medical issues) is not provided by the NHS. This means that women would have to pay for the process itself, as well as the storage of the frozen tissues for the duration of their storage. The following IVF treatment would also have to be personally financed. This can be extremely expensive, which makes it inaccessible for many women. 

• There is no guarantee that fertility preservation will be successful

Despite technology rapidly improving, all current methods of fertility preservation hold no guarantee that there will be success. 

With oocyte cryopreservation, some women may have low ovarian reserves, and so there are either very few, or none at all, viable eggs to harvest. Having fewer eggs to freeze greatly reduces the chances of at least some eggs surviving the thawing process later down the line. 

Additionally, the frozen tissues may not survive the thawing process. The implantation of tissues may also be unsuccessful; they can be rejected from the body, or an embryo can no longer be viable.¹

• The process can be very psychologically, physically, and emotionally grueling

Undergoing fertility preservation often entails lots of hormonal treatment to prepare the womb and the eggs, both for the extraction of tissues and for later implantation. This can cause physical changes and emotional instability. It requires a commitment to the process and it can be very uncomfortable.

 In the context of medical egg freezing, this distress would be an addition to the existing stress of managing illness and its treatment. Some people, see this as worthwhile for the potential of a desired future outcome, but for others, the stress and toll of the process is too much to cope with. 

Additionally, because there is no success guarantee, it can be heartbreaking if the process fails later down the line. 

• Ethical dilemmas 

The process of fertility preservation is the subject of many ethical dilemmas. This means that there are many difficult and complex decisions to be made beforehand, most of which then require being formalized and finalized by signed contracts. 

From a social and religious perspective, the use of assisted reproductive technologies can be highly contested. A woman undergoing the procedure should be fully aware of what the process entails and provide informed consent. Attitudes and perspectives on how we should treat human eggs and embryos can also be difficult to navigate. Some believe that all embryos should have a right to life, while others are comfortable with potential incarnation. The process in the UK is regulated by existing biomedical ethics laws. However, these may not always align with the individual beliefs of the woman and her family. 

Furthermore, fertility preservation spans into the future, which poses preemptive issues to address and consider. For example, the time constraints on frozen embryo storage are usually around ten years. If the woman does not want to start a family before, or upon, reaching this point, is she comfortable with embryo discardation? Also, if the donors are no longer in a relationship in the future, what do they want to do with the frozen embryos? Another consideration is how, and if, the embryo may be used if one partner was to pass away before embryo retrieval.  

These are just a few considerations to think about before engaging in fertility preservation. All fertility preservation processes are extremely nuanced and have lots of ethical and situational issues to form decisions around. 

Summary 

Fertility preservation provides an incredible opportunity for women to delay childbearing, either due to social or medical reasons. It can provide hope, optimism, and a form of potential security. 

However, it must be remembered that there is currently no guarantee on the success of fertility preservation, and it can be an emotionally, physically, and financially draining process. 

Nevertheless, with continued technological development, it holds the potential for improving reliability, and therefore greater reproductive freedom for women.