The Bill(s)

Update

So I have been terrible about updating the blog, but I swear that being on the Pill makes my head fuzzy and drains my motivation in general.  (I'll explain shortly why I'm on the Pill.)

As it turned out, the 2009 RMA video was outdated and RMA has since entered the new age of vitrification, a huge relief to me!  This goes to show how new vitrification really is.

While I did check out NYU as a backup plan while I anxiously awaited an answer from RMA, I learned that NYU use vitrifications and/or the slow-freezing method depending on what’s called for upon examination of the retrieved eggs.   A nurse told me this, so no idea if this is accurate or not.

In any case, I’m moving forward with having my eggs vitrified at RMA.  My treatment cycle is to be on the Pill for 24 days, then go off of it for four days (to get my period), and then begin ~10 days of hormone injections to stimulate the follicles, and then egg retrieval/freezing.  

Not all women go on the Pill prior to their egg freezing cycle, but because my hormone levels were OK (FSH 8.36, Estradiol 31.2 based on the bloodwork done prior to my consultation; then FSH 7.1 right before I began the Pill), I guess they think that the Pill, which suppresses the ovary function for this month, can actually help the ovaries be more responsive to the hormone stimulation I am about to undergo next month.

I'm on Day 18 of the Pill.  I take my 24th Pill on July 18.  I go in for more bloodwork on July 22nd, and assuming my hormone levels are OK that day, I begin my injections that night.  Egg retrieval should be around the first few days of August, but actual date will depend on how my follicles respond to the hormones.  The progress will be monitored at least every other day during my hormone injection cycle to determine optimal retrieval date.

So all this means that I need to figure out how to actually pay for it since I have some big bills coming up soon.

How Much It Actually Costs

There are so many hidden costs in the egg freezing process.  They’re quick to toss around “$15K” as a number, but it really is closer to $20,000 depending on your treatment cycle.  NYU seems to charge even more (see their fees for services here), and the nurse told me that some of these fees are outdated, meaning that fees have gone up!

These are the initial costs I incurred to determine my eligibility for egg freezing:

• $300 blood tests for FSH, Estradiol (taken prior to consultation in order to evaluate and discuss results at consultation)
• $375 initial consultation fee 
• $200 pelvic ultrasound at time of initial consultation

>Initial Consultation Total: $875

This is the cost summary that RMA gave me once I decided to go ahead with egg freezing:

• $9,000 – Single Egg Retrieval and Freezing Cycle (includes cycle management fee; office visits, blood tests, and ultrasound during cycle; post-operative visit; freezing costs for one year) 
• $300 - Psychological Orientation 
• $750 - Anesthesia
• $4000 to $6000 - Hormone medication for stimulating follicle growth (variance is due to the fact that different women require different cocktails of meds; rule of thumb is that the more meds you need to stimulate the follicles, whether due to declining fertility or lack of hormone response, the higher the cost)

>Egg Freezing Costs: $14,050 to $16,050

The following future costs are not included, which I never expected to be included:

• egg freezing after the first year ($500/six months)
• egg fertilization and embryo transfer services (~$15K to $20K?)

Here’s the fine print:

• The services covered under the egg retrieval/freezing cycle (cost: $9,000) only begin from the start of your first injectable medication until Oocyte Retrieval.  Any services performed prior to the start of your medication is not covered.    This means that if you have any blood tests taken to measure your FSH and Estradiol levels prior to the cycle to determine how your hormones are doing, these are additional fees (for me, $300 each time).  If they check your bloods to see if it’s a good time to start your cycle and the levels are no good, then you have to skip that month and take the blood test again the following month.
• Before you can begin your cycle, they require a battery of blood tests to screen for infectious diseases such as HIV, Hepatitis, gonorrhea, etc.  Because many of these tests aren’t standard, your insurance won’t cover it unless there’s reason to believe you’ve really been exposed to unusual viruses.  This bloodwork cost me $637.
• Another pre-cycle requirement: they require a recent pap and culture results (I think within the last six months).  I was able to transfer these records gratis from my OB/GYN to RMA because they’re both within the Mt. Sinai network, but if that were not the case, I may have had to pay a fee for document transfer. 
• For my particular treatment cycle, I am on the Pill for 24 days prior to hormone stimulation.  So I will need to obtain two months of the Pill (since each pill pack only contains 21 doses).  My insurance will cover this, but if yours won’t (or if there are restrictions on how soon you can refill the second pack), you will go out of pocket.  For me, it’s a $10 copay for me for each pill pack. 
• I will be on antibiotics for a week after the egg retrieval—it is surgery, after all.  Again, insurance should cover it ($10 copay for me).

These are the unexpected expenses I will incur (those marked with * are anticipated costs to come):

• $300 – check for FSH/Estradiol levels before I began the Pill
• $300* – I expect that I will have to pay to check my FSH/Estradiol levels on July 22 before I begin my hormone injections [UPDATE July 22, 2011 - I had bloods/ultrasound this morning to see if I would begin my cycle today, and they did not charge me for any of the tests they ran today, so I guess this is not a charge that is incurred unless the plan is to push the cycle by one month]
• $637 – infectious diseases pre-screening
• $20 – two pill packs (co-pay for insurance)
• $10* – copay for antibiotics

 >Unexpected Costs Total: $1267

So here's my Grand Total:

• Initial Consultation Total: $875
• Egg Retrieval/Freezing Total: $14,000 (my meds seem to be coming in <$4000, fingers crossed)
• Unexpected/Hidden Costs: $1267

>GRAND TOTAL: $16,142

Gulp. 

And this is on the lower end of my estimates because I'd slotted in a $5K estimate for the hormones.

But I have a plan to pay for all this which may be either very stupid or pretty strategic.  Or both.  More on that tomorrow.

To Vitrify or Not To Vitrify-- That Is the Question...

I watched this video earlier this week, and I’m still reeling from it.  It was released in 2009 by RMA, the reproductive clinic I'm working with, and it describes the egg freezing process.  What horrified me is that the video says that my clinic uses the “slow freezing method”.  All this time, I thought they used vitrification, which is the latest egg freezing technique much ballyhooed as the new breakthrough in successful oocyte cryopreservation.

One of the reasons I’m inspired to do undergo oocyte cryopreservation now is because of the advances made in egg freezing techniques, namely vitrification.  I felt cheated and outraged that my clinic might have misled me about the technique they use.  So many articles they’re associated with tout the benefits of vitrification.  Even their website touts vitrification as a superior technique, which I think is extremely misleading if they do not utilize it themselves!  In a recent NPR story regarding egg freezing, one of the doctors are my fertility clinic, Dr. Alan Copperman, discusses the promise of vitrification (see under "Technological Innovations").

I’m positive that I asked the question about the use of vitrification in my consultation and that I got an affirmative answer.  This video is over two years old, and vitrification is a relatively new freezing method, so I'm hoping the video is outdated.  I’ve sent an e-mail to my IVF coordinator to confirm. 

By way of comparison, NYU Fertility Center uses both vitrification and slow freezing because there isn’t enough evidence that one is more proven than the other (this is based on a published interview with Dr. Jamie Grifo that I can't find anymore).  I did call NYU for a second opinion back when I was first exploring the procedure-- but they never called back.  Some other fertility clinics, such as the Pacific Fertility Center in the Bay Area, use vitrification only.  Cornell does not support egg freezing at all.

But even if they don't use vitrification, I feel "pregnant" with working with RMA in part because I am so far along (I've done all the necessary tests, training, etc., and I can begin my treatment cycle any day now), plus the fact that NYU, the only other clinic I'd work with in the NYC area, has never called me back.  Plus their procedure seems so much more expensive.  I left them a call on Friday anyway.

In light of the fact that I might need to go slow-freeze, I dug deeper into the process, and that only confused me further.  I thought vitrification is clinically proven to be superior, but there isn't enough evidence to prove it one way or the other because the technique is so new.  Is this a medical fad?  Even if vitrification is a superior method, fewer embryologists are trained in it, and I’m apprehensive that it introduces a greater risk of human error. 

All of this hit me very hard that egg freezing is an experimental (says the American Society for Reproductive Medicine), and no one can really provide me with the right answers.  There just isn’t enough evidence to claim one technique over the other, or that either works effectively at all.  And I felt again the difficulty in feeling like I'm navigating this experimental process myself, and that there aren't too many choices in doctors and clinics because very few have a real track record in this space.  

And then I started to get cold feet.

Freezing Process

Here is some info I’ve gleaned about the freezing process (I am not a medical expert and there may be errors in the information below; I’ve used various articles and websites for the information):

There are three steps to the egg freezing process:

1.  Hormone treatments to help the patient produce more eggs
2.  Retrieval of the eggs
3.  Freezing and storing of the eggs

The first two steps are not considered experimental; the same procedures are used for IVF.  The third step is what's deemed experimental by the ASRM.

The egg is the largest cell in the human body, and it contains a lot of water.  Long-term preservation of eggs has been elusive because the formation of ice crystals in the freezing process can destroy the cell.   These days, water is drawn out of the cells and replaced with cryoprotectants (basically “antifreeze”), and then they are frozen (either through vitrification, which is flash-freezing, or using the slow freezing method).  When the eggs are eventually thawed, the cell wall is too hard to allow sperm to penetrate the old fashioned way, so sperm is injected directly into the egg using the intracytoplasmic sperm injection method (called ISCI, also not considered experimental).  

Slow freezing is the method long used for oocyte cryopreservation, and it is the same technique used for embryo freezing.  This technology developed in Europe due to the banning of embryo freezing in Italy in 2004 (since embryos are considered to be human life in Catholicism), and freezing gametes (eggs and sperm) is more acceptable.  Since similar techniques are used for embryo freezing and egg freezing, embryologists and labs are very familiar with the process.

These are the oocyte cryopreservation success rates cited by RMA NY (which I presume are based on slow freezing, especially since the data is a few years old): 

• Over 86% of eggs survived the freezing and thawing process. This is significant achievement as the egg is the largest cell in the body made up mainly of water, which makes it particularly sensitive to damage from freezing.
• Over 90% of thawed eggs achieved fertilization with use of the technique intracytoplasmic sperm injection (ICSI). ICSI is a technique that takes a single sperm and injects it directly into an egg. Due to some hardening of the outer shell of the egg after the thawing process, ICSI is recommended in these cases.
• 92% of fertilized eggs (now embryos) survived to day three, which is when a transfer could take place.

My doctor told me that the hope would be that we get at least 10 to 12 eggs from my cycle.  I've heard of some women getting only a handful of eggs, others yielding 20 or more.  Not every egg harvested is mature and appropriate for freezing.

So the way I interpret this, if 10 mature eggs are harvested in my cycle (which I think is optimistic), then:

• At 86% freeze/thaw rate, 8.6 eggs would survive freezing and thawing.  Let’s round down to eight eggs since you can’t do anything with 0.6 of an egg
• Then 90% fertilization rate = seven fertilized eggs (7.2 rounded down)
• And then another 92% of those, or six eggs (6.4 rounded down), will survive to day 3 embryos
• The implantation rate for embryos from fresh or frozen eggs seem about the same (some say frozen eggs do slightly better, some say slightly worse), and they range from 40% to 46%.  If we apply an average of 43% to the six embryos, that’s about two or three potential implantations* (based on 2.58 rounded up and down)

Vitrification is a newer freezing technique that developed out of Asia.  Higher concentrations of cryoprotectants are added to the eggs, and they are “flash frozen”, and the egg results in what looks like a frozen glass ball.  Early studies seem to indicate that this method results in a higher “rate of return” on frozen eggs, perhaps as high as 90% to 95% survive the freezing/thawing process (as compared to 86% cited by RMA).  Applying these rates to 10 eggs as above,

• If we apply 92.5% freeze/thaw rate, 9.2 eggs would survive.  Let’s round this number down to nine eggs.
• Then 90% fertilization rate = eight fertilized eggs (8.1 rounded down) 
• And then let’s assume the same 92% rate survive to day 3 embryos using ISCI = seven embryos (7.36 rounded down) 
• If we apply 43% implantation rate, then we end up with three potential implantations* 

*In both scenarios, it is important to keep in mind that successful implantation does not necessarily lead to full-term pregnancy and delivery…  

 

Clearly this is very crude arithmetic that oversimplifies a complex procedure with many variables, but this gives you a sense of how vitrification might help eke out slightly better numbers, especially if precious few good eggs are retrieved.

Before I have total buyer’s remorse, I have to remember that I was comfortable with the stats provided to me by my clinic, and I decided to pursue this for myself based on those numbers.  I'm just crossing all my fingers and toes that I have a very productive cycle...

Why

I thought about egg freezing at least three years ago.  I was 29 or 30, very idealistic about having a great, loving family some day, and very realistic about the fact that the basic ingredients required for starting a family were not currently present in my life: husband, career environment conducive to working mothers, and financial means.

Back in 2007, my "finger in the air" assessment of the message from the reproductive community was that doctors were bullish on women having children late into their 30s and early 40s with the help of reproductive treatments.  Egg freezing existed as a possibility, but it seemed less necessary in this confident environment in which fertility doctors were demi-gods, giving the precious gift of newborn babies to older women who had pushed the limits of time.  I always liked the idea of freezing my eggs as a concept (postpone having children until factors aligned themselves in my life for optimal family-making), but I was suspicious that egg freezing was a fad that preyed on the insecurity of unattached women.  I wasn't sure if the science was really there anyway.  The idea that doctors could successfully freeze the largest cell in the body for a significant period of time, then successfully unfreeze it, fertilize it, and transfer the embryo into my uterus seemed like a quixotic promise.  My frozen steaks developed freezer burn within two weeks; how could they successfully freeze my eggs for 10+ years?

I thought about it regularly since, wondering if I should sell some of my investments to undergo the procedure.  My career was going well, but I was in a very demanding, competitive industry, and I did not feel like I could have a child any time soon.  Add to that the fact that there were no bona fide suitors on my horizon.  While I was always OK with the idea of having a kid on my own, my income at the time did not support that dream.  I had always thought that I could be lucky enough to have my mom as caregiver, but her situation at the time would not allow it.

I thought of other schemes-- having a baby daddy (gay or straight) or a mutual marriage of convenience.  After reading Lori Gottlieb's eye-opening article, "Marry Him!" in the Atlantic Monthly, I even considered-- very briefly-- the idea of marrying with divorce as an expected outcome.  Fortunately (or unfortunately), I could not think of the right prospects for either of these scenarios.  And none of these outcomes felt right to me anyway -- I realized that I didn't just want children, I wanted a real, cohesive, loving family, and it didn't feel right to me to ever go into a situation contemplating an eventual divorce.  Divorce happens, yes.  But it should not be the expectation.

I never subscribed to the conventional notion of marrying, settling down, and having kids with someone "good enough" just because it was time.  While I dated steadily and had relationships throughout my 20s, I was also very interested in my career as well as other interests.  In my late 20s, I realized a bit too late that I was supposed to be focused on finding Mr. Right for the last few years in the ever-narrowing pool of men.  And then suddenly, like a game of musical chairs, the music stopped, and everyone seemed paired up. 

But I was also convinced that I had not yet found my life partner.  I wanted to be inspired and challenged by my husband-- you know, actually be deeply in love with the guy.  I wanted to build a life with this person, find someone who would be there with me through thick and thin, someone to grow old with when the kids left the nest.  I didn’t feel like it was my time yet because I had not found the right guy yet.  I liked my life, I didn't feel alone, and I was completely OK with the idea of meeting my guy later in life, perhaps a guy on his second marriage or the bachelor who finally wanted to settle down at 50.  But I felt caught in a cruel joke because while I was OK postponing the husband decision until the time was right, I have always dreamt of being a mother, and conventional wisdom dictated that I meet someone in what felt like a very narrow band of child-bearing years, even if he was not the right guy for me.

A few things finally tipped things for me.  Earlier, I was willing to postpone certain reproductive decisions until I reached the Critical Age (by my arbitrary definition)-- and now, here I was at 33.  As I examined my situation, I accepted that there was a good chance I was not going to meet my guy in the very near term future, and even if I did, the likelihood that I would have a kid before 36 and a second kid by 38 seemed highly unlikely.  Secondly, my financial situation had not changed dramatically, and there was no way I was going to have a kid by myself any time soon.  Thirdly, I began hearing more and more stories about women who couldn't get pregnant even though they were relatively young-- and they weren't much older than me.  And lastly, I’d been keeping tabs on the technology surrounding oocyte cryopreservation, and there seemed to be more consistent success with a new freezing technique called vitrification.  I had money invested in the stock market that I did not wanted to part with in my early 30s, but by 33, I almost felt (not quite) that cashing some of it out to invest in myself and my future ability to have children might be a worthwhile pursuit. 

Coupled with this, I decided to make a few changes in my life.  I applied for a new job in a different industry, targeting a company that is well known for being a relatively friendly environment for working mothers.  They offer generous maternity leave, some flexibility in working from home, and great benefits.  Somehow I actually got the job, and suddenly with greater income and earning potential, I felt that the universe was telling me to do it.  I made this career change in part to have the option of being a single mother at some point in the future should I need it as a fallback, so there was no excuse not to take additional steps to help secure that dream.

So within weeks of starting my new job, I made an appointment at one of the two reputable clinics in New York City currently offering oocyte cryopreservation, and was on my way.