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Dr. Jones: We have so many choices in our lives now, but some things we don't have choices about and that's when is it time to have a baby and when is it too late? But there are some choices.

Today in the studio we're with Dr. Joe Letourneau, who is a reproductive endocrinologist at the Utah Center for Reproductive Medicine and director of our oncofertility program and also for fertility preservation.

Well, you've planned everything in your life just right and you kind of didn't have kids because you were looking to find the right person to have kids with or you were looking at your job, and now you're older and you find out that you don't have many eggs left. What are your choices then?

Dr. Letourneau: This is the circumstance in which having frozen eggs can be quite helpful. At that point, it would be possible to consider thawing some or all of those eggs to try to create embryos and use them for fertility treatment.

In the last 10 or 15 years, we have developed a new type of technology called vitrification. And with this process we use a safe sugar type of solution to dehydrate the egg as we freeze it. This takes the water out of it and prevents the ice crystal injury. When we then use the egg in the future, we warm it back up and we allow it to refill with water, and it's a very healthy egg. So the survival rate of eggs currently is very high. It's in the 80% to 90% range. Whereas in our own field with our best technology 20 years ago, it was probably only 1% or 2% survival rate.

Dr. Jones: That's been the biggest change in IVF. So if a woman then decides she wants to use her eggs, some of them are thawed, and then sperm are added and then the embryo grows in the labs. So they go through an IVF process once they're finally ready to make a baby?

Dr. Letourneau: That's correct. After five or six days of growth, we would put the embryo into the uterus the same way it would sort of roll out of the fallopian tube, but we actually place it through a natural opening in the cervix.

Dr. Jones: So if a woman is lucky and maybe she has 20 eggs, they'll go into the freezer. She might have more than one chance at IVF, maybe more than one chance at having more than one kid perhaps?

Dr. Letourneau: Absolutely.

Dr. Jones: And how successful is it? And that probably is a function of how many eggs you get and how old the patient is, but what's the ballpark?

Dr. Letourneau: You've intuited there that age and the number of eggs has a big impact. So one egg for any woman could make a baby. But it really comes down to a probability. So one egg in one's early 40s has a much lower chance of one egg in one's early 20s. And as such, it helps to have many eggs. So likely getting as many eggs as we can safely achieve is probably the best method to preserve fertility. But probably each egg has somewhere between a 5% to 10% chance of making a single baby.

Dr. Jones: So what happens for now a woman's 42 or 43 and she's tried a couple of times with her own eggs and IVF hasn't worked? What are her next options?

Dr. Letourneau: It's important to think of the frozen eggs as one method of helping one conceive, and it's not 100% success rate as we spoke about earlier. Not every egg makes a baby, but coupled with the idea that some people their circumstances in life may change where they're ready to try to conceive their first baby at 38 or 39, they may be able to do that.

It may be that the frozen eggs are most helpful for the second baby or some other aspect of their family building. So some people may conceive on their own, some people may require some fertility treatment, and some people may even consider fertility treatment to have that first baby if they've been trying to conceive at 42 using their eggs at that time for new IVF and then saving the eggs from age 34 for, you know, their second baby. So it's a pretty dynamic process, but in general, having the frozen eggs does involve sometimes revisiting kind of the IVF process in order to use the frozen eggs.

Dr. Jones: And then the option if for some reason none of those things are working, we have donor eggs from young women that can be an option for people who find that appealing or they're willing to think about that choice.

Dr. Letourneau: Absolutely. We've been using donor eggs for 30 years or so in our field, and it's a very normal thing to do and it's an excellent way to build a family. A common concern that patients have about the relatedness, you know, I won't be related and my partner will or I won't pass on my genes. The reality is that most of us humans have most of our genes that are exactly the same, just about and so there is certainly a uniqueness to us. Part of that comes in our genetic code and then part of it comes in the way we use our genetic code.

And what we've found in research in big studies of human populations and in other mammals is that the maternal environment during pregnancy impacts the way the baby and then even their babies and their grandchildren after that use their DNA. And so there is a big impact on genetics. There's a big biological relationship that's created between the mom who carries the pregnancy from the donated egg, and I think it's a really excellent way to build a family if that should be needed.

Dr. Jones: Well, I think that knowing that you have options, whether you can exercise those options or not, for women who are trying to think about making a family someday is important for us as providers and for women who have the questions it's good that we actually have those options here. Thank you for talking to us about it, Dr. Letourneau, and thanks for joining us on The Scope.

Dr. Jones: So you're 34 and the clock is ticking and you haven't met Mr. or Mrs. Right yet and you want a baby someday but not now. What are your options to protect your eggs because you can hear them getting older in your body?

So women around the world have been told they can have it all, and although I may not get agree with that completely, there is a time when you make babies and there's a time when you build your career. But, in fact, the making babies and chief career building tends to overlap, and sometimes we put something off and what gets put off, as we're learning about the increasing age of women having their first child in this country, is the baby making. But your eggs are getting older and what are you going to do to save them?

In the studio today with us is Dr. Joe Letourneau, who is a fertility preservation specialist and reproductive endocrinologist at the Utah Center for Reproductive Medicine. Thanks for joining us, Joe.

Dr. Letourneau: Thank you for having me.

Dr. Jones: So a 34-year-old is really looking for her next big job and she hasn't found the honey yet, but she wants to have kids someday. She's got your name. She knows you're the fertility preservation guy. What are you going to tell her?

Dr. Letourneau: That's a very common presentation that we see in our clinic now, and it's becoming more common. We've certainly become more sensitive over the years to the idea that women are building their families later. There is an intersection with, you know, family timing and ovarian and an egg physiology that that can be important. And the way it can manifest is that, you know, achieving a pregnancy becomes incrementally slightly more, you know, difficult with time.

One thing that I like to tell patients is that there's not really a fertility cliff. I think there must be many websites on the internet to suggest there is a fertility cliff where you're fertile one day and then not the next, and it's really a gradual change with time. But for some people if they anticipate many years elapsing before they plan to build their family, it may make sense to consider freezing their eggs. Essentially freezing them in time with a higher reproductive potential that they may have at their current age and that they may have in the future.

Dr. Jones: So is there a time when you're too old to save your eggs?

Dr. Letourneau: Age is quite predictive of a quality for women in one way in particular and that's having a normal number of chromosomes. The way that I like to frame this for patients is to, one, give them an understanding of how many eggs there are in the body at a given time and, two, what percentage of those eggs are normal.

So at birth, average women are born with about 1 million eggs, and by puberty there are around 300,000. It turns out that the egg comes in a unit with something called the follicle, and the follicle is what provides support to the eggs so that it can become fertilized. It also helps to regulate the menstrual cycle and provides estrogen. So the absence of follicles is what defines menopause, which is typically around age 50 or 51. So there is a decline from the start of puberty in the early teens until age 50 of about 300,000 eggs down to the end of the egg supply.

Interestingly, in this time, only 400 or 500 eggs will be ovulated or released from the ovary because, as humans, we release one egg per month because it's difficult to raise a human baby. So most eggs in the ovary are actually not released. Most of them are sort of selected for or against in a way that we don't understand well and many of them die off.

Each month, the egg that is released has a certain probability of being normal or being abnormal. And the normality of it I'm really talking about the chromosome number. If the chromosomes that come out are abnormal, the embryo that may be created will be missing some of the instructions for it to grow.

Most typically that manifests in the absence of a pregnancy. Occasionally it manifests in an early miscarriage, and more rarely it manifests as chromosomal abnormalities that the baby may have at birth. But really most commonly these chromosomal abnormalities make it hard to become pregnant. These go up with time raising pretty steadily, but rather rapidly in the late 30s and early 40s, and that's really what drives age-related fertility concerns. So freezing eggs earlier results in more normal eggs.

Dr. Jones: So ladies, as you're thinking about planning your life, understanding that women plan and God laughs. But if you're thinking about planning your life, there are some options about freezing your eggs, but you should know what's available and decide what's right for you. And thanks for joining us on The Scope.

Dr. Jones: What do you call a human egg five days after fertilization that's in the freezer? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: This week in the news was a report of a live birth, of a baby resulting from an embryo, a zygote, preimplantation embryo that has maybe from 8 to 100 cells that was frozen 24 years ago. Reportedly, this is the longest time between freezing and live birth, at least that we know of, at least in the U.S. In reality, this record is going to be broken regularly as the technology which allowed us to freeze early preimplantation embryos became regularly used over 20 years ago. So more and more babies from embryos in long-term storage will be used. We'll be hearing about babies 30 years, 40 years, 50 years from conception and on and on.

Now, for just a little moment, let's step aside into comparative reproductive biology and talk about bears. Bears in winter. Bears and some 100 other animals do something called embryonic diapause. Cool name, huh? Well, I think it's cool. This is a natural process wherein a bear egg gets fertilized by a wandering bear sperm and progresses a few days and then stops growing, pauses through mechanisms we don't understand very well, for months. It just hangs out in the fallopian tube until a bear goes into hibernation, and then the preimplantation embryo implants and grows while a bear is hibernating. The goal is to postpone the birth until the appropriate environmental or metabolic conditions for the animal, in this case, the bear. The bear cubs aren't born until near spring when there will be an abundance of food. These pre-embryos in suspended animation are not frozen. They're in the mother but not growing until later.

By the way, to the best of our knowledge, humans can't really do embryonic diapause in the mother's body, but we can put our embryos in the freezer, probably indefinitely. In the in vitro fertilization world, usually a number of eggs are produced either by the biological mother or by an egg donor and then fertilized. In the U.S., we're trying to decrease the rate of risky twin, triplet, and quad births by putting back only one or two pre-embryos. In the U.S., we offer the chance to freeze the rest of preimplantation embryos, which for the sake of easier, we're just going to call embryos, but they only have about 8 to 100 cells.

Now, these aren't frozen in an ice cube tray in a regular fridge, but are very carefully frozen so as to not make ice crystals in the embryos and kept in liquid nitrogen. There are probably millions of cryo preserved embryos in the world with regulations about what can be done with them differing from country to country. For instance, currently, embryos cannot be frozen in Italy. In the U.S., there aren't really any rules and regulations except that IVF embryo labs must be certified. Being able to freeze unused embryos from an IVF cycle allows couples to have another chance of becoming pregnant or have another baby, or have a lot more babies if they want. But what happens if they don't want, couples who have the family size they want, who get divorced, or who get too old?

In the U.S., we offer couples three options. They can donate the embryos for research. They can thaw the embryos without transferring them to a uterus and the embryos will die, or they can be donated to an embryo bank that allows for embryo adoption. The case of the baby recently born from an embryo created 24 years ago arose from a couple that received the embryo from an anonymous donation to an embryo bank that specializes in embryo donation, the National Embryo Donation Center. This child born to an infertile couple who desperately wanted children is possibly the best outcome for unwanted embryos.

There are issues, however. The genetic parents are anonymous, so it'll be hard for the new parents and baby to know their genetic heritage. Of course, with more and more people choosing to search out their ancestry with genetic testing, children and adults from donor sperm, donor eggs, and donor embryos are finding genetically linked persons and figuring it out on their own. In Great Britain and Australia, there are laws which prohibit anonymous donation of eggs, sperms, and embryos, and the genetic parents must be on file for the child to know about when they turn 18.

In the U.S., advanced reproductive technology is less regulated than in Europe, so the origins of the frozen embryos, the so-called snow babies, can be anonymous. But between the donation of extra embryos from the couple 24 years ago and the so-called adoption of the embryos a year ago, when the embryos were in the bank, who owned them? Who was responsible for them? What was their legal status? Should they even have a legal status? If there are egg banks and sperm banks, what do we think about commercial enterprises that create embryos, you pick the color, ethnic background, whatever, of the genetic egg and sperm donors, and they will make embryos for you for sale? There's a little bit, actually a lot, of the yuck factor going on there for me.

In the end, it's probably a good thing that couples who have excess frozen embryos don't have to destroy them if they don't want to. And it's a good thing that they don't have to use them if they already have the family that they want and want no more children. That means there's a place for an embryo adoption center. It also means that couples who cannot make their own embryos for some reason but want to experience pregnancy and having a baby from birth can do so, but we're still left with some sticky issues like who's responsible for the embryos for quarter of a century, or half a century, or a century who have no legal parents, and what right does the grown person have to know who they are? So in this season of snow and miracle babies, thanks for joining us and the snow babies on The Scope.

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