Public broadcaster NHK aired a current affairs program on fertility in 2012 that caused a stir nationwide. Titled “The Impact of Aging Eggs,” the program warned viewers that women in their 30s and 40s were flirting with disappointment by delaying any attempt to conceive until they are older.
The problem, however, is that many women in modern times simply aren’t ready to have children in their 20s and early 30s, ages that fertility experts usually say is the best time for a woman to conceive. Many women in this age group are still in the early stages of their career, while a significant proportion are also likely to be looking to wait a while before settling down into married life.
To get around this conundrum, some doctors in Japan have recently begun to offer oocyte cryopreservation, a procedure in which a woman’s eggs are frozen cryogenically. The procedure was historically only offered in Japan to women suffering from severe health problems.
By freezing healthy human eggs that have been harvested from an individual who is still relatively young, a woman can postpone trying to have her first child for a few years and then try to conceive through in vitro fertilization when she is older.
While some women welcome the newfound freedom such a procedure provides, medical experts are divided on the issue and some have warned that it only encourages women to delay giving birth.
Minako Saito was a successful businesswoman who used to work in the financial sector. Saito, who wishes to use a pseudonym in order to protect her privacy, lost her job when she was 36 and the sudden change of circumstances gave her a new perspective.
“I didn’t have a boyfriend or a job and I didn’t have any money,” Saito says. “All of a sudden, I realized I had nothing left — except a lot of time to think. It dawned on me that I might end up being alone for the rest of my life, and realized that I wanted to have children.”
Saito’s parents had seen the NHK program on aging eggs and suggested she give it a go. She consented and, in the spring of 2013, Saito froze four of her eggs at an organization called Repro Self Bank, which has since changed its name to Princess Bank. She was 37 years old.
After undergoing counseling and taking a course of hormone pills to create healthy eggs, four eggs were harvested from her ovaries. The procedure cost about ¥800,000.
“My parents and I felt a lot more assured after the procedure,” Saito says. “It’s basically insurance. I didn’t want to close the door on the possibility of being able to have children in the future.”
Lack of legislation
A woman has about 2 million eggs when she is born. Unlike sperm, which are generated continuously over the course of a man’s lifetime, women’s eggs decrease with age. Fertility experts believe women have about 200,000 to 300,000 eggs when they hit puberty, and just 25,000 or so when they are 35 years old.
Women who wish to have their eggs frozen typically take hormone pills to ensure multiple healthy eggs are created. Ovulation-inducing drugs are then used to establish a manageable timetable before they are harvested and frozen in liquid nitrogen at minus 196 degrees Celsius.
Until recently, the Japan Society of Obstetrics and Gynecology specified that only cancer sufferers and people facing serious health problems that could affect their reproductive organs were allowed to undergo oocyte cryopreservation.
A national law on reproductive technology has yet to be approved by the Diet. In theory, therefore, the procedure is not illegal if a woman has no health issues. However, fertility clinics usually follow the guidelines issued by the society or risk expulsion.
Nevertheless, the Japan Society for Reproductive Medicine, another influential organization in the industry, issued a set of guidelines in November 2013 that permitted healthy women to undergo oocyte cryopreservation. Under the guidelines, the organization does not recommend women aged 40 or older to undergo the procedure. Moreover, women should also use any harvested eggs before their 45th birthday.
At Princess Bank, about 140 women have had their eggs frozen. One hundred and ten of these women have no illness.
But Noriko Kagawa, the 38-year-old head of Princess Bank, expresses mixed emotions over whether to recommend the procedure to healthy women.
Kagawa used to work at as an embryologist at Kato Ladies Clinic, a famous fertility center in Tokyo, where she says she was dismayed to find the average age of women seeking treatment was 39 years old.
“It was our job to help women conceive through science but you can’t help eggs that are aging,” Kagawa says. “Most of these women didn’t even know they were too old to undergo such procedures.”
It’s best to freeze a woman’s eggs while she is still young, Kagawa says, and still the patient should still think about trying to conceive as soon as she can.
“I know I am contradicting myself when I say I don’t recommend this (procedure),” she says. “It’s sort of like a good-luck charm. … By going through this procedure, a woman becomes aware that she needs to find a partner and conceive as soon as possible.”
Older women typically face more problems trying to conceive, and simply having an egg that has been frozen is ultimately no guarantee of success.
The procedure also carries a few risks. Kagawa says 1 in 100,000 women experience complications during the extraction of eggs with a needle. The hormone treatment may also damage a woman’s ovaries.
“The procedure isn’t for everybody,” says Kagawa, who froze her own eggs several times between the ages of 31 and 34. “However, I don’t see why those who have been informed of all the details shouldn’t try if they still wish to continue.”
Medical experts such as Yasunori Yoshimura, a professor emeritus of obstetrics and gynecology at Keio University School of Medicine, express reservations about adopting such an approach.
“More women will conceive when they are older, which isn’t good for them,” Yoshimura says, adding that the risk of complications for older women and their babies is much higher.
Yoshimura was head of the Japan Society for Reproductive Medicine when it issued a guideline on oocyte cryopreservation irrespective of marital status.
Some members of the society had expressed concern that issuing the guideline might suggest it was, in fact, advising women to undergo such a procedure. In the end, however, they agreed that it was better to draft a guideline than do nothing at all.
The society’s Ethics Committee issued a statement at the time of making the guideline public, clearly stating it did not recommend women to choose oocyte cryopreservation. Media reports, however, stressed that the society had “approved” oocyte cryopreservation for healthy, single women as well.
Yoshimura notes the guideline was not meant to encourage women to go through the procedure.
“However, we decided that the benefits (of drafting a guideline on oocyte cryopreservation) outweighed the risks,” Yoshimura says.
“Those who are interested will hopefully learn about the risks involved,” he says. “The guidelines will also prevent clinics from doing these procedures under the radar.”
Toshio Hara, head of Hara Medical Clinic in Tokyo’s Shibuya Ward, froze eggs for single women who weren’t suffering from any health issues between 2010 and 2012.
“I wanted to help women choose when to give birth so that they don’t have to interrupt their careers,” Hara says. “I wanted to make sure they weren’t forced to give up the notion of conceiving and giving birth.”
The procedure on average costs at least ¥1 million. Contracts to keep the eggs at the clinic were renewed annually until a woman turned 45.
Hara says he explained the benefits and risks of oocyte cryopreservation to the female patients.
The recovery rate of eggs that have been frozen depends on a woman’s age, according to data compiled by the clinic. Eggs of women who are 31 or younger have a 95 percent rate of recovery, whereas those of women who are 41 or older have a 50 percent rate of recovery.
One hundred and sixty-seven women — the majority of which were in their late-30s to early-40s — expressed an interest in oocyte cryopreservation at the clinic over the two years but only 32 went through with the procedure. They were all single at the time, and not one of them ended up finding a partner with whom they could use their eggs.
In August 2012, the clinic stopped accepting new clients for oocyte cryopreservation.
“The women who came to my clinic were in their late-30s, single and had no immediate plans to get married,” Hara says. “The clinic had turned into a refuge of sorts. It wasn’t what I had imagined in the beginning at all.”
And that’s not the only problem. Hara is more recently encountering women with frozen eggs who refuse to allow him to dispose of them when they turn 45 — effectively reneging on their contractual promise.
Hara says he set the limit at 45 because the possibility of conceiving after that age is virtually zero. What’s more, the health risks for both mother and child increase considerably after a woman turns 45.
Some women have taken their eggs to another egg bank.
“I think a woman should be able to choose whether to freeze her eggs or not,” Hara says.
“At the same time, however, she must understand that she can’t have it all,” he says. “There are certain rules she needs to follow.”
Sex education is key
Oocyte cryopreservation has recently been stirring controversy in both the United States and Japan.
Last autumn, Facebook and Apple in the United States made headlines for offering benefits to female employees to undergo oocyte cryopreservation.
In Japan, meanwhile, the city of Urayasu in Chiba Prefecture announced in February that it would spend a total of ¥90 million over three years on a joint research project with Juntendo University’s Urayasu Hospital to promote research on technologies to freeze and store eggs. This is the first time a local government has agreed to effectively subsidize oocyte cryopreservation.
The move has been criticized by some experts, who argue that public funding suggests the procedure already has the government’s seal of approval.
But Hideki Shintaku, head of the city of Urayasu’s Health and Welfare Division, says the fund is only a small part of Mayor Hideki Matsuzaki’s grand plan to tackle the declining birthrate.
Matasuzaki has created a fund worth ¥3 billion to, among other things, provide subsidies for men and women undergoing fertility treatment; increase the number of kodomoen, a combination of daycare and kindergarten; and establish a special allowance for high school and university students who have a 3.8 or higher grade point average and come from financially strained homes.
“There is a gap between when people want to have children and when they can have children,” Shintaku says. “Many women are right in the middle of building their careers when they are most fertile but we want to give them more options.”
Shintaku says that it is important for the city to be involved in order to help educate young people on how difficult it is to conceive once they grow older. Like the rest of Japan, many Urayasu residents are going through difficult fertility treatments because they are too old to conceive naturally.
The city of Urayasu considers this to be a long-term test to see whether or not oocyte cryopreservation can really contribute to curbing the declining birthrate.
“By providing government funding, we can keep an eye on the project and also offer support to residents,” Shintaku says. “Who knows? Oocyte cryopreservation could be a common procedure in 10 years time.”
Juntendo University is expected to begin holding seminars this summer for women aged between 20 and 34 who are interested in the procedure. These seminars will provide extensive information on reproductive issues. Women who decide to proceed must have their application approved by the university’s Ethic’s Committee. The procedures are likely to begin in about six months time.
Iwaho Kikuchi, who heads the project team at Juntendo University, says he has been tasked with finding physical evidence to support the benefits of oocyte cryopreservation.
Kikuchi says he must tread carefully, however, because the Japan Society of Obstetrics and Gynecology is poised to announce that it doesn’t recommend oocyte cryopreservation for healthy women.
“There is no evidence on the benefits of oocyte cryopreservation yet,” Kikuchi says, “but rules should be made based on evidence.”
Most medical experts agree that a major review of the country’s sex education program, which focuses on contraception and sexually transmitted diseases, needs to take place.
Young people are not taught about the best time for women to conceive, nor do they learn about the difficulties of having children when they are older.
Kikuchi says the oocyte cryopreservation research shouldn’t necessarily focus on the benefits and risks of the procedure itself. Instead, it should look at a broader picture that also covers fertility treatment, infertility prevention and education.
“It’s about changing awareness,” Kikuchi says. “I think oocyte cryopreservation gives us an opportunity to teach the younger generation about how difficult it can be to conceive later in life. If they learn this now, their life plan could be very different.”
During the process of having her eggs frozen, Saito met her current husband through a match-making event. To her own surprise, she got married and became pregnant naturally with her first child within a few months.
Now, at 39, she is eight months pregnant with her second child. She still hasn’t used any of the eggs that have been frozen, but is keeping them in case she wishes to have a third child.
“I am so glad I did this and I have no regrets, even though I might end up not using any of them,” Saito says. “A woman should be able to do this if she wants. The decision, and the responsibility for that decision, should be left up to her.”
http://www.japantimes.co.jp/life/2015/06/27/lifestyle/fertility-experts-divided-benefits-freezing-eggs-cryogenically/#.VZJvpPVOP3h
