Gresham College Lectures

Freezing Eggs and Delaying Fertility: Law, Ethics and Society

April 14, 2022 Gresham College
Gresham College Lectures
Freezing Eggs and Delaying Fertility: Law, Ethics and Society
Show Notes Transcript

With the development of new vitrification techniques, egg freezing has become a viable option for women to protect and extend their fertility. Being able to control when to have children can help achieve life-goals. But there are downsides. 

This lecture explains the science of fertility and egg freezing, the impact of child-bearing and rearing on women’s educational and employment prospects, and outlines the law on freezing eggs. It will cover the complex issues around the law's regulation of this practice.


A lecture by Imogen Goold

The transcript and downloadable versions of the lecture are available from the Gresham College website:
https://www.gresham.ac.uk/lectures-and-events/fertility-law

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- So I want to start this lecture by letting the women who seek fertility treatment like egg freezing, speak for themselves. So one says children are wonderful, but they can also stress you financially, physically, and emotionally. I wanted to be in a rock solid marriage with a track record before I had kids. And I didn't want that process to be strained by some deadline that could really identify. I was starting to feel that my desire to have children was putting pressure on my current relationship, deciding to freeze my eggs helped me to separate the issues. Yes, I want to have children. Yes, I'm in a relationship, but my desire to have children shouldn't cloud whether we should be having children together, I don't want to have children until I feel emotionally and financially prepared. I really like this one, the biological clock, a worn metaphor, but spot on accurate because sometimes it ticks so loudly. It makes us stay up all night furiously Googling fertility options, who hasn't been there, I've been there. I have seen this pressure push people into lack luster marriages or fret their lovely, confident selves into fearful, frenzied heaps. So it's a ticking clock. And that I think is an idea that we see throughout the way the press and the media and social media presents women and their fertility journey. So we can immediately see why women might want to freeze their eggs. And that's what I'm going to talk to you about today. Women have a range of reasons why they'd freeze their eggs. They're medical, as well as people who might be transitioning and they might want to preserve their fertility, people who are facing cancer treatments and so on. Good examples of people who want to freeze their eggs, but I'm going to talk to you about what we call elective or social egg freezing. So people who are freezing their eggs, not because they have a medical condition and they need to preserve their fertility, but because they want to make sure that if they put motherhood off a bit later, that they don't lose the ability to have children. Now the law in this area isn't really particularly problematic. But what I want to talk to you about is some of the ethical questions and certainly the practice around it and why women do this. And within that, I will bring up a couple of policy questions. Should we fund it to facilitate more choice? We might touch on that, and I'm going to leave you with the trickiest question. So you can ask me about that at the end, but I'll get to that when I get to it. But mostly what I want to talk to you about is the complexities about it as a practice. And I really want to try to redress the frequent tendency and discussions of about this around the assumptions that people make about women's views and their decision making capacity. So I want to interrogate some of those assumptions and I want to do this by showing you why women choose to put off childbearing and the motivations they have and give you some evidence to show that actually, a lot of the time they've got really good reason is for doing this. So what I want to offer from this is a more nuanced and accurate picture of women's situation and the reasons why they do as they do. So what is egg freezing and how successful is it? And well, until the early 2000s, the technique for freezing eggs was a slow freezing technique. And the problem with that was it wasn't very effective at preserving eggs, over very large cells. They have a lot of liquid in them. And so they form crystals. And in the late nineties and early two thousands, a technique called vitrification. So flash freezing or fast freezing became available and it produced much better results. So vitrification enables mature over to be preserved once they're harvested. And it has very strong, relative to previous techniques is much, much better. So since then, that's why you can see when we look at these stats, I'm sorry to give you lots of stats. What you see really clearly is since that time, this big jump, particularly from 2010 through to 2019, a big jump in egg freezing cycle. So a tenfold increase in the last decade and of these, about a third were women under 35, a third were women aged 35 and over, and then decreasingly into women who aged 45 to 50 were freezing their eggs. So you still see women even really late into their fertility window are freezing their eggs. Of those, see a similar pattern that increasingly women are thawing their eggs and using them. So again, a tenfold increase is 2010. So clearly egg freezing is on the rise. And that's very clear from the media interest. We hear about it all the time, but what sorts of do we hear? Well, we have lots of articles in the media about, should I freeze my, classic article in women's magazines in particular, should I freeze, but you'll also see a lot of headlines talking about women are going to be disappointed. They need to get ready for anxiety. They need to get ready for disappointment, or it's an expensive lottery ticket that women hope it works, but it probably won't, or that women are using it as a life hack for ambitious women. And I think that's slightly pejorative tone sometimes in the media there. And in particular, you'll see sometimes these comments saying, egg freezing is indirectly encouraging women to have children at an advanced age, and that carries with an increased risks. So there's a lots of warning that this might go poorly. And that's the background against which I want to look at women's motivations and how women make their decisions, and this idea of false hope. So we see that a lot, this idea that it will give women not hope, but false hope. And later on in this lecture, I want to really unpack what it might mean and to have false hope when we're suggesting, when we see things suggesting that it's expensive and it won't really work. So before we can go any further, we want to look at how successful it can be. Now success rates are rising, but we don't have lots of data. And part of the reason for that is we don't have a lot of data about women who have thaw their eggs and frozen them and used them, it's a small data set. So it's important not to extrapolate too much from it. So the Royal College of Obstetrics and Gynecology says, that in a clinic that's proficient in vitrification, a frozen egg has about the same developmental potential as a fresh egg because what's happening is you're stopping age related decline in the egg. So they're saying that the clinical pregnancy rates reported in randomized series using warmed eggs in vitro are pretty much equivalent to IVF fresh treatment, so that it sounds like it should be pretty good, but they go on to explain really importantly, that actually a lot of this data is from egg donors and those eggs have been taken at the point where they have optimum fertility and they're younger. So we can't easily extrapolate from that, and simply say, it's the same because actually those donors are often a lot younger than the recipients of them. It also, we need to take account that some clinics are better at this than others. And so clinics will have better experience, longer experience. And so therefore success rates can't easily be extrapolated across. So we need to be really careful with what we think about the data that there is out there. The HFEA, the Human Fertilization Embryology Authority produce some on success rates as well. The best that it could, that success rate data isn't very granular, unfortunately. But what they did was they looked at data from 2010 to 2016 and they said the average success rate using thawed, frozen eggs was 18%. So what does that mean? Well, one thing it means is that most of the time it didn't work, but it also means that they're taking data and extrapolating across. So one of the key things that we're going to see however, is that the age of the egg is really crucial to your success in IVF. So having a success rate of 18% across the whole body of data doesn't actually tell you much, but it tells you something, that it isn't not going to work, but his success rates aren't high. So the key thing to understand about this is that the point at which an egg is frozen determines in large part, the chance of success. So the Human Fertilization Embryology Authority confirms this and they say when egg freezing takes place, it freezes the quality of the egg at that point in time of a woman life. This means that the age at which a woman freezes her eggs is really important. Our data show there's a pattern in success rates for women who use their frozen eggs in treatment, the success rate decreases with the increasing age of the woman when the eggs were frozen. And they say the highest success rates that they could discern were for women age 35 and younger when they froze their eggs. So that's partly informing the kinds of warnings that we see but even that isn't the full picture. We have some other data, there are clinics that produce their own data. So the London Egg Bank produces data. And it says, well for women below 38 years at time of freezing, they had about a 45 success rate in terms of using the eggs. Whereas after that age, it dropped to about 22%. Another way to think about the data we have about success rates. And there's lots of this on clinic sites is they'll say things like, well, you'll need this many eggs to produce this kind of chance of success. So the London Egg Bank says, well, if you're under 35 years of age, you'll need to freeze 15 eggs to have an 85% chance of producing one child. Now, again, that's still just a database on previous success rates and so on. And then they'll go on. They go on to say that if you're between 40 and 42 when you freeze your egg, you'll need 30 eggs to have a 50% chance of having a child. So none of this is a guarantee in any sense. So they're trying to give you a sense of this idea that as you age, your eggs age with you and the chances of successfully conceiving a pregnancy with them decreases. Now the thing to point out about that data as well is that they don't put there, but they do put it elsewhere is that it becomes progressively more difficult to produce eggs as you age as well. So the idea that you would simply freeze more, we'll come to that in a moment, but it isn't as simple as just, well, I'll just freeze lots and lots of eggs, because of course that becomes more difficult. The other dimension I want to explain to you before we go any further is the cost. Because one of the things I'm really concerned about is that women have the right kind of information so they can make an informed and well grounded choice. So when you freeze your eggs, it's expensive. It costs around £3000 for a cycle, just to have the eggs removed, but that comes with other costs. It comes with pre-screening, it comes with medication costs. And also there's the ongoing storage costs, which are up to £350 a year. So you are looking at three, £4000 per cycle of eggs to remove the eggs. And if you are looking to freeze 20 or 30 eggs, you might have to do two or three cycles at least, depending on your ability to produce them. And then you're going to have to pay out £350 a year to store them, so if you're storing for 10 years, that's itself three and a half thousand pounds. So it's not cheap. And I would say, if you are looking, if you're watching this lecture and you're thinking about freezing your eggs, pay really close attention when you look at clinic websites to get a really clear picture of what all of the costs will be and really plan it out, don't just look at, well, one cycle costs this much. There's lots of extra costs that are involved in this that you need to be aware of. One of the things these clinics do offer are what called freeze and share arrangements. And we'll look at those a bit more later, where you can get free cycles and some free storage. If you give away some of your and eggs to other women who need them, so you donate them to other people who need them. So that's the lay of the land in terms of cost and what it is. So how is it regulated? Well, I think the first place to start before we look at the law, which isn't terribly complicated, is to look at a bit of the background. And it's quite an interesting story I think the background, to how we came to where we generally, so not necessarily in this country, but in more general responses to egg freezing. So when the new technology of vitrification came out, there was pushback from some quarters. And the concern was of course, that it wasn't going to pay out, this worry that women would rely on it, but it wasn't yet sure that it was going to work very well. So in 2009, the American Society of Reproductive Medicine called for fertility clinics to refrain from offering egg freezing for social reasons. So medical reasons, fine, social reasons, not so much. Later on, a few years later, they released another statement in which they that well, even though vitrification wasn't experimental anymore, it was still something that really you should avoid using it for social uses. They said that there's good evidence that for fertilization and pregnancy rates are similar to IVF and with fresh Aytes, however, the data are limited. And what they suggested was it was important to really inform women about this. And at the time, sometime shortly afterwards, American academic John Robertson said, well look, it seemed like when they said these things, that they were hedging and that they were hedging because they were worried that women would essentially make choices that were ill informed or they rely on it when they shouldn't. But I would say, I mean, the ASRM was restent because it wasn't clearly safe. It wasn't clearly efficacious at that point. So they were being careful, but other people certainly thought at that time that they were being paternalistic, they were worried that it was going to give women this false hope and that in part of that, it would actually encourage women to delay childbearing. So they would put things off, rely on something that wouldn't then pay out for them. They didn't actually say we should ban it, but they really emphasized the need to carefully counsel women, and to give this clear message, to look at the risk very, very carefully now, by contrast in the United Kingdom, legally was simpler. And in terms of policy was also simpler. So since 2000, it's been legal in the United Kingdom to use frozen stored eggs for infertility treatment. And in fact, the HFEA lifted the ban that it previously existed, because they saw after their own independent report that they commissioned. They saw that even though the success rates were low, they were clearly improving. And there was hope to be had here as a technique. And so unlike the US, we saw a much more positive attitude or, well, it is risky, but will allow people to do it. It's a much more permissive response there, I think. And it's been permissive ever since. So, as it is now, the law does now allow you to use them, to store them. The particularly interesting thing that's happened recently, the one thing that was the really big problematic thing was that the storage limits for eggs stored in this way were very short. So what the HFEA had said was that previously, if you stored gametes and you didn't have a medical reason, after 10 years, they would have to be destroyed. And now, and I can point someone in the audience and say, well done, Sarah, because we can thank Sarah. There's been a campaign to change this. And now we are seeing the government has said that they will shift this and allow now social egg freezing to be expanded to up to 55 years. So we get the same storage limits. So we will have the same storage limits for socially frozen eggs as we were for medical eggs. So the problem before was had you frozen your eggs early, freeze them at 30, want to use them at 45, you would've actually been made to destroy them at the 10 year mark. So it was really problematic. And so that's a really important shift that's come about because of progress, educational trust and others campaigns to change the law. But that only happened in late 2021. So in that sense, that's one of the key regulatory issues to think about, the other key regulatory issue to be mindful of is what the HFEA does as well, is that licenses clinics and requires them to provide information about the risks and successes of rates of services, including egg freezing. So this is something that is required of them. The HFE supports and bolsters this with its own information on its website. And this is a good thing. There's certainly people who've done research into this who suggest that some websites, some clinics are not always entirely clear in their information or their information is somewhat misleading. I think that's a fair comment. I wouldn't want to point out particular clinics at all, but what I would say is that if you are looking at clinic data, you need to really drill down into it and look for as much information as you can get. And also look at general information and compare clinics and so on. All right, so that's the background. So let's look then at why would a woman want to freeze her eggs, to explore some of that. Well, there's a whole range of reasons why women want to do this, and I'll go through a couple in time. The key reason is, or the key fundamental driver for women is that their fertility declines as they age. So the exact point at which a woman will no longer be able to conceive varies enormously. Some women will be approaching infertility in the early forties. Some it's going to be their late forties. Some women have babies into their fifties, it's exceptionally rare, but most women will be approaching infertility by the time they're in their mid to late forties. I think widely believe that what happens is your fertility is absolutely fine and then it falls off a cliff edge. And as I understand, I don't think that's exactly right. You see a slow decline through your thirties, but it gets progressively worse. So it isn't the case that everything is 100% simple. And then all of a sudden you lose your fertility. It is a gradual decline. What we can see is that IVF can help some women conceive. But what we know is that it's the age of the egg that's affecting that success rate as well. So as a woman ages, and she's using IVF, if she's using her own eggs, her success rates decrease. And, by the time you're in your mid forties, if you need IVF, your chance of success are about 5%. However, if a woman uses a donor egg, and this includes frozen eggs, her chances of success say relatively stable, be it they begin to drop, but by the time you hit your late forties, early fifties, even with donor eggs, women will be having a very difficult time getting pregnant. So we do see these news stories of women having babies in their fifties and sixties, but they're very much the unusual case, that women simply become less able to carry pregnancies as well. What also happens as women age, happening in tandem with this is, and this is intertwined with it, is they begin to face high risks of miscarriage. And so this affects as well, their ability to carry pregnancy successfully to term. So it's absolutely the case that women are facing this cliched ticking clock. Although it doesn't always tick exactly I think as we might have been led to believe, so it seems obvious then that what women should do in the face of this is just have their children when they're younger and when they're more fertile. But of course, as I'm sure you will know, it's far less obvious than that. And I think you'll understand that at least some of the reasons why women might put off having children until later in life. And so it's not actually as simple as that for most women. So what I want to do now is unpack some of those reasons, the reasons that women say they have, but also the reasons that they need to be aware of that ought to be informing their choices. So one of the really important things to appreciate about women's choices about timing of reproduction is the impact that it has on their outcomes. And one thing we know is that the point at which women leave employment really affects their long term employment prospects and their career earnings, has a big financial impact on women. Now, partly this is because women step out of their career and they have a long hiatus, that can affect things. But one thing we know is that the point at which they step out will affect how they go back into the workplace. So women stay away from the workplace for a while. They come back into the workplace and there is lots of data that shows that employers have particular perspectives on that, that they're less inclined to think these women have skills. They worry about whether they could put the time in. They worry about them being absent. They have all sorts of concerns that are in the literature that they have about women going back into the workplace is one thing. Another thing is that if you step out of the workforce, you actually lose time in building your skills. So you'll necessarily be behind other people, and that's going to affect women's outcomes in terms of income and progression and promotion. There are also really key points that we stepping out of the workplace can be really problematic for women. So if you step out at a point where you're just getting to the level of promotion, you step out at that stage, that might be really problematic. Other people will surpass you, you'll have gaps on your CV when you come back in. So there's all these practical impacts that are had there. Another dimension of why women do this, so why do they not simply behave differently? Well, I think it's important to see that also when women step out of the workplace, stepping back in might be really difficult. And part of that comes from the idea that often what happens is women crystallize into being the carer. So women step out, they have to take a certain amount of time out to have the baby, to do the breastfeeding. Whatever, happens in the early stages. What we see still happens is they crystallize into being the carer, they remain in that carer role. Now this is improved as we have shifted and given men more generous leave entitlements, than we had previously, previously women were absolutely the one who had to take the leave. Now that's obviously changed now, but even though men can now take parental leave in the same way, the culture hasn't shifted enough, many men report that actually they still don't want to step out. Either their workplace doesn't accept it, or the culture makes them feel like it's the wrong decision to make. So it's still the case that is often women who step out and particularly if it's the case that across the board on average, women are earning less. Then that may also be just in many couples, the rational choice for them financially. What we also know, not looking just in this country, but more broadly, is in other countries where they don't have equal leave in the way that we do, then women have even more incentive to be the people who take time away because they're the ones who can access the leave, and that was certainly my experience. I was the one who had access to leave, so I took the leave. My husband didn't, he stayed in work. So the net result of all of this is that it is women rather than men who are taking more time out of the workplace when a child is born. And there are later that show that a year of delayed motherhood actually increases career earnings by up to 9%. So that's American data, but it probably applies here. It increases work experience by 6% and average wages over lifetime by 3%. So these are serious financial impacts when you add them up. And they're also stronger, the more women. So women in more professional and managerial occupations take even larger financial hits. So those with college degrees and professional managerial applications receive the greatest career returns if they delay, so the longer they put it off and they get to a particular level in their profession, the better it is for them financially. And so it has been said that in fact it can account for, there's one study that suggests that it could account for as much as 12% of the gender wage gap is the fact that women have to step out of the workplace at suboptimal points and step out for a particular period of time. And so this is one dimension and women are very much mindful of this. So this is a survey from BPAS in which they explain, well, the three most important factors women say they have when they're starting a family, are they want to be in the right relationship, but they want financial security and they want to own their own home, so far from not being live to the financial pressures on them, they very much are. Women also suffer if they step out of higher education at particular points. So it's well established that women's educational outcomes can be adversely affected by a decision by the time at which she decides to have children. And what we know is that postponement is correlated with greater participation, higher education, and higher rates of childlessness with the attainment of degree level qualifications. So they track with one another. Now, why are men not affected in the same way? Well, similar reasons to employment, childbearing affects the women's capacity to undertake education, her capacity to be in full-time education, go to class every day, do everything that's required is affected if she is the primary carer. And so they may not be able to stay in education. They step out, they don't come back into education. They have all sorts of complexities. There also childcare costs might make it difficult for women to come back into education. If they need to put their child into daycare. And yet they can't afford it because they're a full-time student. So they face all sorts of complexities, particularly if they don't have a partner at that point, that even more complicated for them. So it's not surprising that there is this relationship between timing of childbearing and educational outcomes. Women often say another reason why they might want to wait or have the capacity to wait is they're looking for the right partner. So some women feel pressure to find a partner. The classic thing you will see in the media is that women are kind of waiting for Mr. right. So this is one woman saying I was starting to feel that the desire to have children was putting pressure on my relationship and that was concerning her. Other women say they want to postpone because what they want is time to be emotionally ready. So this is one woman saying I experienced four miscarriages, after the birth of my first daughter when I was 43. And the loss was excruciating, especially as I did not have years ahead of me to try again, the upside, however, was having a child when I was ready psychologically and emotionally, and was in the right relationship and the time of life to do so. She's saying that she in hindsight, found that this was a benefit. So what see is you have this situation, that's getting women to have to juggle, establishing a career and having a family and finding the right person and feeling ready. And so they're under a great deal of pressure in that sense. So why then given all these really good reasons that women have for wanting to potentially push their fertility and have children slightly later and thereby want to access egg freezing services to back them up, why would anybody have any concerns about it? Well, this is the bit to unpack. There are a long list of reasons that have been raised in the various literature and in the media. So one of those that sometimes suggested, and this is where the debate about whether women should have children older at all, right? So it feeds into the egg freezing debate, but it's not the whole of the egg freezing debate, but you'll see it in general responses to women having children when they're older is the idea that it's better for women to have children when they're younger. Why would people think this? I mean, I would say women are the best judges of when they ought to have their own children, but what are people trying to say? Well, the arguments people make about this are that women will be earning more when they're older. So that's a good thing for them, but the problems are that of course, if they have their children earlier, they don't face the various risks that women who have them later have. And those risks are things like risk to their health. So being pregnant later in life, particularly in your forties has a range of risks. Health risks increase at that age, but also women report that they are very worried about community attitudes to being an older mother. So the shock or disgust that some report, the criticism, being referred to as a geriatric mother or being mistaken for a grandmother at the school gate, all of these sort of ideas, women are very much live to those and concerned about them. They also say they're worried about things like their energy levels and their capacity to cope and so on. So they do say all of these things. And so therefore people build on this to say, well, it would be better if they just had their children earlier, they should take the hits on their education or their employment, and just do it sooner. People also suggest that it's better for children to be born to younger mothers. There's a range of ways this is framed. And it comes up again in the debates, where people talk about women having babies in their fifties and sixties. I mean, the thing I want to say at the outset of this is we really don't see that criticism of men. It is very gendered. All you have to do is Google all of those articles about women having babies in their sixties, and that all really gendered. No one is criticizing Charlie Chaplin for having babies. In fact, if you look for that, well, the dominant thing that you see when men have children late is well done you, you're still very fertile, women get the absolute response to them. No one is worrying that the dad is going to look like a granddad at the gate, but they're very concerned about a woman who might not look right at the school gate, but what are some of the better options? Well people like Arthur Kaplan, he's an American academic. He says, look, it's not good public policy to produce children in a context where they might end up orphans. So he says, producing orphans is not good public policy. And what he means is that if you have your children later as a woman, you're more likely to die sooner. And so the child be left without a carer. And this objection, of course, rests on things like lack of parental support and emotional anguish at the early death of the mothers, this is very terrible for the child. Now that might be legitimate. You might see that there's a logic to that, but it isn't about women having children later. It's about people having children later. And yet it isn't framed that way. It's very much framed in terms of the woman is doing the wrong thing here. And I think the way to understand that is this presumption. Again, a woman is carer and the loss of the woman is more problematic. The presumption is, there will be a carer throughout the child's life, and it will be the woman. The man might be the as well, that's fantastic. And it feeds into these wider ideas of the man babysitting his own children. I saw a hashtag the other day twist where someone said, they're his kids too. It's like, but actually we see lots of assumptions about women are the dominant carer. And it feeds into all of these things. And it's feeding in here that the loss of a mother is particularly problematic, but when you break it down, actually, life expectancy for women is over 80 these days. So even if she postpones to 50, chances for her producing an orphan are not actually that high. So for one thing it's factually not really true is one thing. It's also not true that all younger women are going to outlive all old women. So you can't predict that this is going to happen. So it's not particularly good grounding there. And also there are many good things about women having their babies later. So they may be financially more secure. They may have more financial resources to take care of the child. There might be in a more stable employment positions. They're more able to take time out. There's all sorts of things that actually might be beneficial to the child. One thing people suggest is actually, well, the problem will be that actually, then the parent will be dying, right? So the child will be carer. So that seems kind of like a good arguments. Like, well, no, because the child will be in the position of looking after their elderly parent sooner. But when you actually break that one down as well, it isn't this problematic because one of the things that's good about it is you have a bigger age gap. So let's say you have your child when you are 50. And by the time the woman is 80, she needs care. At that point, this child is 30. That is a big gap, but the child is becoming a carer at a time when they're younger and more able and financially secure, their own children might be young, but they're quite capable. By contrast, if the woman had her children, when she's 20, by the time this woman is 80 child is 60. And what you actually have is a much more difficult potentially situation where you have one older person looking after another older person, there might be all sorts of complexities that not necessarily, but the presumption that it is bad to have this large gap is just not true, I think. And it needs careful scrutiny when you think about those kinds of arguments, we also know there's lots of studies that show that actually, there's not really any differences between parental stress physical capacity to paired across ages 30, 40, and 50, that you might think that you're more tired, but there's all sorts of stresses that happen at different points in your life. So it's not clear on the data that it's necessarily worse for children to have older parents, there's benefits and there's dis benefits. So it seems to me that most of the arguments there are really quite poor, despite that though there are still people. So Anora O'Neil is a good example where she says, you know, there's a difference between the misfortune of an early death of a young parent and actively setting up a situation in which the likelihood of death while the child is young is increased. That might be true. But I think that argument really doesn't hold sway until very late on. So maybe that will hold sway for a woman who is 65 having a child, but the sorts of situations we're mostly talking about are not remotely close to that. So we don't even need to have that argument, problematic though it is, because the point at which people are using frozen eggs are much like more like to be in their forties, mid to late forties, early forties. Another argument people raise about whether or not we shouldn't be, you know, really supporting women or at least promoting egg freezing and pushing having children later is the idea that actually women face physical risks, so I've mentioned a couple of them. It's important to notice that maternal mortality increases with age. So there's a roughly four fold increase in maternal mortality over the age of 40. So far more women will die in pregnancy and childbirth. They face high rates of ectopic pregnancies and preeclampsia, chronic hypertension. And that's true. Pregnancy does get riskier as you get older, but that's one of the key points where I think, well, that's for women to choose for themselves. That's really not anybody else's business. As long as women are alive to those risks, then they aught to their own autonomous decisions of about them. It is also the case that there are risks from egg collection, they're very low, but they exist and women need to be aware of them. But again, it's their decision, but there are risks of ovarian hyper stimulation, which sometimes requires hospital admission, incredibly rarely, but it does happen, does cause death as well. So that's another risk on the table and certainly they exist. But the key response that I think is information, as opposed to resistance to this as a practice, some people have suggested that egg freezing actually might have societal harms. So an example of this would be JJosephine Quintavalle. And she says, well actually, delaying motherhood if it became routine, she says the structure of family support in society would change. She says to, so to quote, to imagine that IVF can be an alternative to natural reproduction for healthy women is an absurdity. The chances of children having grandparents becomes ever more remote, this will undermine the whole structure of society. Well, I think for a lot of the reasons I've raised, that's probably not true. It isn't likely, not everybody wants to have their children later. We clearly see a whole range of ages at which women want to start their families. And the idea that it would causes widescale social collapses is not very convincing at all. One reason that I have explored in the past in a paper of mine a while ago with Julian Savulescu was the idea of whether or not they were social equality and justice concerns about egg freezing and particularly whether or not we would fund egg freezing on the NHS. And that question that's worth thinking about. And that's something that Matt Hancock raised a couple of years ago, this suggestion that perhaps the NHS would pay for egg freezing for social reasons. With that, the idea is that, well only certain people will be a able to pay for egg freezing, it's expensive. And so whether or not this means that it is something that we should be supporting people to have. And the idea is that if only wealthier people can do this, only wealthy women can put off their childbearing, then it will increase inequities that are already present in society. Now we might say, well look, that's just something that already happens, but you might think that actually, if this is a sufficiently severe problem, that that makes the case for it being funded or supported. But there, we would have to unpack that argument about whether this is an assessed, we've had that debate about IVF and obviously the NHS funds it. I don't intend to explore it in detail now, but it's certainly something that people raise as a potential issue. The second to last one I want to look at, and then I'm going to give quite a lot of time to decide false security. Is this idea that egg freezing will lead to an increase in the alienation of gametes. So this is an argument John Robertson made, and he talks about how well if women can freeze their eggs, one of the impacts of this, certainly in the US where he's writing is that they can give them away. They can donate them and they can sell them. And he says, essentially, they can use their gametes like private property. And what he suggests is at this point, is that it will mean that the bond between women and their gametes is somehow broken. They become producers and consumers of their body's reproductive inputs. And this creates commodification and distancing and seemingly harms to women. Now, whether that's true or not. And whether that's a problem, I'll come back to that when we talk about sales of eggs as well briefly. But one thing I think to think about that is doesn't seem to me to be an argument that's raised about men and their sperm. So again, we see this very gendered idea that women will be upset about this in a way that men will not. And when I look at egg freezing, I'll revisit this and talk about it there, but just bear in mind, can you imagine anybody saying that about men and their sperm, doesn't tend to be the case. So the big focus of people's concerns when they're, worrying about women freezing their eggs, is the idea that it will give them a false sense of security. Now, I think we can break that down into two elements. One is the idea that it will encourage women to be complacent about their declining fertility and the other dimension to it is it will encourage women to pay for an expensive but ineffective service. So there are two strands to it. They'll put it off because they'll be complacent and they'll pay for this service that won't work. And they operate together. So they're intertwined and effectively, it means they'll buy an insurers policy that's expensive and doesn't pay out, and then they will pay the price of that. And they will do. But the really key part of this is this idea that it will be a false sense of security. And I want to unpack that quite a bit. So we see lots of statements about this. This is Heidi and she's saying, look, it's often misleadingly portrayed as an insurance policy that we see this is a lot. I like the fact that she says, rather than an insurance policy, women are instead buying lottery tickets, is a different way to think about it. And if they buy a lot of tickets, they're able to bank a large number of good quality eggs. They might have a reasonable chance to success, but uncertainty is a fundamental feature of the system. So she's kind of pulling apart some parts of it, but she's right, it is very often referred to as an insurance policy. And I think that's a misnomer both in the way women think about it. And of course in the reality of what it can do. Now, the Royal College of Obstetrics and Gynecology has very similar concerns. They say what their concern is. And this is part of this sort of falseness is they say, yes, elective egg freezing provides women with an opportunity to take action to address the drop in their fertility. But at the moment, women who are doing this are already in their later thirties when success rates are limited. So that's a sort of bear that in mind. But what I want you to see about this whole notion of it being a false sense of security is the idea that what it means is that women won't get what they expect. They believe they're getting security. And in fact, this is a losery. And so this in effect implies that they are mistaken or they misunderstand things, or they don't have the capacity to understand the information. So when this is raised, of course, we know that women ought to freeze when they're younger, that doesn't necessarily mean that their beliefs are false or their sense of security is false however, but regardless, I'll show you what I think is probably the high point of this kind of false sense of security argument. And again, it comes from John Robinson. And so what he says is that women will have an optimism bias, and this is how he explains it. He says, because of this optimism bias of younger women, those in their twenties, he says, what they might do is they might risk their future infertility, seems quite distant to them. So they say to themselves, he says, I'll find a man, I'll settle down in the next few years. And so why undergo the intrusion of cost of egg freezing now only the most risk averse or those who have a yin for the latest technological fix and will be willing to take the hormones and pay out the cash for egg insurance that they may never need to cash in. So that's the first part of what he suggests is that actually the women who should be freezing, won't be doing it. And then he says, but as they reach their late thirties, their perspective may start to shift, he says, leading them to take a cold look at the facts, which may lead them to stock the egg freezer. So he's saying that women in their twenties, not thinking about it, it's not until they start to get nervous in their late thirties they start thinking about it. Now that is a bit true in terms of some of the data, but it's far from the whole picture, but his point is that it won't be until their late thirties when they're starting to have anxiety and so on, that they'll do anything about it. And then he says, well, the eggs they freeze may not give them the fertility they hope for because of the state their eggs are in now. So they will wrongly, leave it too late and then freeze eggs that won't give them the kind of insurance they were hoping to have. Now I think that there are two implicit assumptions about women's approach to egg freezing here. And one is that the vast majority of women who freeze will do so at a suboptimal time, that they'll get it wrong is number one, they'll leave it too late and they'll waste their money or have their ill-founded hopes dashed. They will essentially make a bad decision about when to freeze because they should have done it sooner. Now, I think actually we need to challenge the implicit premise here, because what it's suggesting is that women can't actually take on board the information and they can't navigate the risk benefit analysis they're going to confront. The second assumption here is that these women will have a false sense of security. So what he means is that they will miscalculate the risks and benefits, and they'll mistakenly rely too much because they don't really appreciate how low their chances are. And so what they'll do is they'll push back having children, thinking it'll be fine, and then they're mistaken and it won't be. And so that's I think how he's framing women. And that's what I really want to object to because I just simply don't think that that's entirely accurate, it's certain or accurate of many women. So let's look at what we do know about what women understand about their age related fertility decline. So actually there's lots of data that shows, this is a BPAS fertility survey. This is actually nine out of 10 women were aware that the risk of pregnancy increase with age and the majority of this was a factor of trying to have their child earlier. Many women were concerned they were running out of time, including a third of women, age 25 to 29. So actually quite lots of younger women realizing that their fertility was going to decline and BPAS themselves commented on their survey, far from sleep walking into infertility, women are aware their reproductive window closes and more than 60% feel that there's pressure on women now to have a baby before they're ready to do so. So they're well aware that this was happening. So the first thing I think we should understand is that it's not accurate to say that women have an optimism bias. In fact, most women I know would say they're crucially aware of this and why would they not be when there are constant media messages telling women the clock is ticking. They know they live with that clock inside them all the time, they're well aware, and I find it kind of, sorry, I get quite cross. I find it profoundly patronizing to tell women that they don't know this when I really think that they do and the data backs this up. So the next thing we might wonder is the extent to which women fully understand whether or not technology will help them. Now, what we do see is that as women age, their interest in the technology does increase. But what's really interesting is that there's survey data that shows that women of all ages will consider having their eggs frozen, it isn't just older women. So the fantastic Liminal Space who produced a really excellent exhibition a few years ago called Timeless, it's all women putting off fertility, putting off having children and egg freezing. They surveyed over a thousand women who came through and they said, 11% of women of all ages would consider having their eggs frozen. And among 18 to 24 year olds, 20% would. So actually the higher represented group was the younger women. They were very live to this. And so I think findings of this kind suggest at least that women are considering freezing their eggs relatively early on. They realize the benefits and they realize the need. Now, related to this, we could sort of flesh this out a bit more, certainly a lot to say here and I'm mindful of the time. So I don't want to spend too much time on this, but whether or not women realize that IVF generally will help them because egg freezing is quite a niche question to ask about. We have lots of data about IVF and what women think about it. And so another BPAS survey said that over a thousand women surveyed, only 9% felt that the availability of IVF made them less worried about running out of time. So far from thinking that IVF was going to be a panacea, less than 10% thought IVF would fix it for them. They were very live to the fact that it might help, but not that that it would necessarily help. In another, there are, however, to be fair, there are also surveys that show that some women are unrealistically confident. So it isn't a one way picture. And this is the other thing that's really important though, is there isn't a blank picture in either direction. It's not the case that all women have a false sense of security. It's not the case that all women have a really good understanding of the actual risk and benefit. It is a complex picture and women as a group have different views and different levels of knowledge, and certainly is true that there are some women and both of these studies here, both suggest that some women absolutely are over confident, but what should we do in the face of that? Does that mean that women can't make their own decisions? Does it mean they don't understand? Does it mean they have a false sense of security? Sometimes, maybe that's true, but these are all informational arguments, their informational problems. And so the way to respond to them is to think, well, actually what these women need is to be given appropriate information that they can understand and allow them to think about it and to weigh it and make their own decisions. And then bear the consequences of those, which is in fact, what we do for people in all sorts of other contexts, we treat them as autonomous citizens who are allowed to, and are capable of making their own decisions. Now, when we think about how women are doing that, the really key thing I think people should be bearing in mind is that women understand the pressures on them. And so when they are making these decisions about putting off when they bear children, they are doing so for what for them are good reasons. We may not share them. We may not make the same risk calculus as they might, but we shouldn't assume that they're doing it irrationally or unreasonably. What we should assume is that they are, almost all of the time, going to balance those risks and benefits because it's about something they care about, they care very much about it. But rather what we should do is just make sure that when they're doing that, they're making that calculus on the basis of accurate information. I think what's important also to add into this is the idea that when we add egg freezing into the mix, it doesn't really change the background against which women are choosing. All it does is add an extra option.'Cause what's really important is to remember all the things I said at the beginning is that what you are doing here is you're just adding an extra way to deal with the challenges and the risks that women already have to balance. So we're already balancing these things, putting off education, staying in their careers, when will they commit to a relationship? And so on, what's happening is you were giving them a small amount of extra ability to slightly shift that calculus. And some of them will then use that option to freeze and it won't make any difference. They go on to have children naturally. They don't use them. And in fact, so far, that's what's happened in a lot of egg freezing cases. And it doesn't matter. Some of them will then waste their money. Others will postpone for the same time as they would've done anyway. And they still don't need the eggs. Didn't need it, that was fine. Some will postpone longer and reliance and it'll work out and they'll use the eggs and will have done exactly what they hoped it would do. And some will postpone longer than they would've done because they're relying on these frozen eggs as an insurance policy. And it won't pay out, that of course is the complex picture here. But the only thing that's important there is they understand that that's the picture. So the key thing that we need to focus on is giving women the right kind of information. Now, another thing that I wanted to talk about before I finish, 'cause I'm mindful that I'm going to run out of time and can that's going to come and make me answer questions instead of continuing to tell you all my lovely things that I want to tell you is this question that this all leads to, that I often think about is whether or not egg freezing empowers women. Now, one of the arguments that it does, is it gives them a full sense of security. But the other interesting question that this raises is whether or not giving women this choice in giving women additional choices is a good or bad thing for them. So it might often seem that giving women, anybody having more choices has more power, more ability to do what they want. And a lot of the time that's true, but it might be slightly more complex in this context. And this is worth bearing in mind. Is it the case that there will be situations in which the opportunity to freeze might actually transform into an expectation to freeze or a pressure to freeze? Now, how would this work? Well, it would work if you are in a workplace context where other women around you are freezing and it becomes normalized, standardized practice, and everybody is pushing off the point at which they step out of the workplace to later, your choice architecture there is different then, instead of just choosing freely you are choosing against a background of everybody else is making a particular choice and potentially, you make a loss by not making the same choice. They get ahead of you in the workplace.'Cause they put off having their babies and you didn't, that might be a way in which women are disempowered by having an additional choice, that's quite possible. Or if they end up making choice they wouldn't have wanted to do because everybody else is doing it and they feel like they ought to do it, or if they don't do it, they're resisting doing it. So it shifts. So this is something that philosopher Simon Rippin talks about. He says that once you've got an extra choice on the table, when you don't take it previously, you just didn't do it because you couldn't, now you're actively not doing it, and how does that affect you? That might have negative effects on women. These things are certainly things that are worth thinking about, whether they are sufficiently strong to therefore undermine whether we should continue support egg freezing. I think they probably aren't. But I think it's to be aware of when we think about the way in which we frame egg freezing as a choice. So should the law do anything? I don't think there's a great deal that the law needs to do. I think that one of the big shifts that was needed has happened, storage limits have extended. And this is a really good thing. We already know that the HFEA has to require information provision. What I would say is that we do need to take very good care about the level of information provision. And I think it is quite hard for women to get really good, detailed information about egg freezing success rates, partly, and I say this as someone who has spent quite a lot of time trying to find this information. It is not easily accessible, even for someone like me who knows a lot about it. It's quite tough. I think to find lots of detailed information about your exact age and the risks, the chances of success, and certainly other women report to me that they don't find it easy. It's not impossible, but you have to work for it. So that could be improved. But in terms of the key problem with storage limitation, now that we know that that's resolved, that's a good thing. So where does this leave us? Well, it leaves me with the one question that I want to raise at the end to leave you thinking about, because at this point, egg freezing is allowed, it's working well. We need to make sure women know what the choices are, but the question is, do we take the next step? So the step that is taken in the US and the one that Robertson is concerned about, and do we move from simply allowing them to store them and donate them and to use them, to allowing them to sell them. Now, why would we wonder about that? Well, because elsewhere, you can do that. So this is from a US webpage where they tell you all about how much they pay 8,000, $10,000 a cycle. It seems like relatively big business. What's really interesting is their next page where they tell you, here's all I know you can't read it, but I'll tell you what they're saying. What they're saying is here's all the great reasons you might want to sell your eggs, help you pay for your education, travel, buy a car, save for a down payment or save for a rainy day, open your own business, right? It's a really big push to sell here. And particularly, travel is an amazing way to expand your horizons. And with your egg donation payment, you can afford to discover the world in style, from an epic cross country journey to a dream European vacation. What is really fascinating here is this push, this marketization in that we don't have here. Now, if you were taking my autonomy line, women can make their own choices and so on. It would seem that egg freezing, egg selling should be fine. I do think this is the one bit that we need to have pause. Women can at them and get compensation of up to £750 when they give their eggs and they can have freeze and share arrangements, but we haven't moved to this stage yet. And we frame it as a gift. I think this is thing that is our next thing to be thinking about. Do we want to go down this road and why would we not want to go down this road? I'm going to finish up here because I'm mindful that Claire's going to come and give me the hard word any second, which is what I wanted to say. And what I wanted to do with this talk is to say, look, it's very clear that the time at which women have their children has an identifiable impact on the educational and their employment outcomes and that they need to have the capacity to make that decision as freely as they can. And for some of them, egg freezing, if they fully understand the risks and benefits, will be a valuable additional way in which to balance those risks in the way that they want to do it, we should really take care that the option to freeze eggs isn't sold through as a panacea for the challenges they face. But at the same time, we have to respect women's capacity to make autonomous personal choices, where they're provided with accurate information and any assumptions that portray women as overly optimistic or as lacking understanding, I find really problematic, but what we really need to do is keep putting out good empirical research that tells women about the risks of it and the success rates. And so that needs to be our focus rather than fear mongering ring and telling women it won't pay out, instead, give them calm, balanced information that says, this is the risk, this is the chance of success. You make the choice that is best for you based on what you want in your life. And I'll leave you with some places you can get some extra information and do come and ask me any questions, thank you very much.(audience clapping)- Someone is asking, is there any data on women and men's feelings about any eggs left over after they have the number of children they want? How are people feeling about destroying eggs or having them used for further research?- Yes, so there is some data about that. So I think the assumption is that men really don't care about their gametes. They don't care about their sperm and that women really care. And actually, I looked at this quite extensively in a paper that I wrote, and it turns out it's not really as gendered as you would think, that women and men have pretty similar attitudes actually, a lot of them, not always, sometimes it's men care a little less, but mostly it's about the same and that both men and women report, when they sell their eggs, that they have altruistic motives and they have financial motives. So this idea that women are thinking their eggs as little babies going off into the world and that men are just not caring at all, actually a lot of men report that they really care. I mean, one of the reasons men give sperm is because they have children too, and they report saying, I want to help other people have children. So I think, yeah, absolutely. It's not really gendered at all. Some people care, some people don't care.- Should the FHEA's powers be extended to the commercial aspects of egg freezing as a means of mitigating the inequalities that arise with access to egg freezing.- Yeah, so that I think is the really tough question, is whether or not we think the inequalities are worth doing something about and I have to confess, I dunno, the answer to that one. I was asked it this morning as well. And I, and I kind of fudged it 'cause I think, well, you know, if you framed egg freezing in a similar space to IVF, people use IVF because they can't have children. Sometimes the reason they can't have children is 'cause they've put it off, of course, sometimes cause they have health, all sorts of reasons people get access to IVF and we absolutely understand it to be something that's really deeply important to people's lives to have children. And that's why we fund it. So when people say, well, infertility's not a disease, that's kind of missing the point, the point that it is a thing that makes their lives go very badly, that happens in the health context. And that's why the NHS funds it. So you could frame egg freezing in the same space as that to say well against a background of women having very, very good reasons for wanting to do this, that will affect the fertility, it can fall into that space, whether we would then go so far as to fund it in the way we do, I think is a hard question. And I have to convince uncertain at this point, how I feel about it. So I do want to point them out and embarrass them because there are people in the audience here, in fact, from Progress Educational Trust, who are the people who I think, in person say you did a brilliant job. And these are the people who fought to get the storage limits extended. And I think that's fantastic. Right, you can't ask me a tough question now Sandy.- No, no, thank you very much. I'm curious about the HFEA that here is an information source about whether you do think they're the people best place to provide this good information. And whether you think they're doing a decent enough job of it already, it occurs to me that providing information is actually quite remote from their core statutory legal purpose, which is licensing and inspecting fertility clinics in certain research centers. So are they the best people to be doing this? And if so, are they doing an alright job of it?- Yeah, so I don't think they're the best. They're the best in the sense they gather lots of data. But when I went and looked at the data where they said, we've put out some information about egg freezing, they information about increasing is really, as I said, not very granular. And it doesn't tell you enough, if you really wanted to know what are my chances of having a baby if I freeze at 35 and get pregnant at 40 their data doesn't tell you that. They say, we didn't really collect it in that way. And I think that's a really good point, the best source of info.'Cause I was looking around to think, where could people find it if they wanted it, the best source are kind of egg freezing banks, problem with them, of course, is they want to tell you that they're good at it because they're the one who are trying to sell it to you for thousands of pounds. I mean, what we really need is of course, independent researchers and there are some, so there's a pretty seminal paper from about 2016 of fertility and sterility. And that's got some pretty good data from the US. Then the problem is though the skill of the clinic is really relevant to egg freezing still as well. So you kind of, the best data would be honest data from each clinic. So I guess that's where the HFEA comes in. We could legislate say, you've got to really give out all this data, which they do and they don't. And I think the place I'd send people to look at this sort is Kylie Baldwin, which is why I put her there is that she's done some stuff on this that I think is really revealing. I'm kind of curious for you to tell me who you think would be the best, because I think everybody has got good sides and bad sides, really. You can tell me after.- I'm afraid I'm a bit ignorant about the background to this, but do you know why 55 years was decided on as the extension of the time and why it wasn't, I dunno, 30 years or 60 years.- I don't know why it was 55 years. I think someone here does know if I could put you on the spot Sarah. So Sarah might know. I mean, 55 years is a good long time. If you freeze if you freeze at 25, 55 is going to be long enough, but I dunno why 55 was chosen exactly. But previously it was 10, so yeah, anything was better than that really.- Okay. If there are no other questions from the in person audience, I think we draw it to a close there. Thank you all very much for attending. Thank you to our audience online and thank you to Professor Gould for a great lecture.(audience clapping)