Women’s reproductive choice and (elective) egg freezing: is an extension of the storage limit missing a bigger issue?

Abstract

Egg freezing can allow women to preserve their eggs to avoid age-related infertility. The UK's recent extension of elective egg freezing storage has been welcomed as a way of enhancing the reproductive choices of young women who wish to delay having children. In this paper, I explore the issue of enhancing women’s reproductive choices, questioning whether there is a more significant aspect overlooked in egg freezing. While increasing storage limits expands reproductive choices for some women, focus on this extension alone, I argue, misses a fundamental issue with egg preservation that often remains ignored; the importance of effective information on egg freezing and the effect this has on women’s reproductive choices. Ultimately, I highlight the crucial role of balanced information in enhancing women’s choices regarding egg freezing and argue that focusing on extending and increasing provision may obscure this real opportunity to empower women and their authentic reproductive choices.

KEYWORDS:

• Elective egg freezing
• oocytes storage limit
• social egg freezing
• extend fertility
• reproductive autonomy
• empowerment

Introduction

Elective egg freezing (EEF) allows young women¹ to freeze their oocytes in an attempt to avoid age-related infertility and to be able to have children at a time that is right for them, later in their lives. Unlike egg freezing as a result of a medical condition that may curtail fertility (for instance, a cancer diagnosis that may involve fertility limiting treatment) this kind of EEF is done in an attempt to increase the time window in which young women can successfully conceive. Until recently the law in the UK set the storage period for embryos and gametes stored for fertility treatment at a maximum of 10 years (Department of Health & Social Care 2021) and allowed an extension of this limit to a maximum of 55 years in cases where people already were or were likely to suffer from premature infertility. However, a new law has been effective since 1 July 2022 (Human Fertilisation and Embryology Authority (HFEA). Egg freezing. HFEA. Available from: https://www.hfea.gov.uk/treatments/fertility-preservation/egg-freezing/#:∼:text=If%20you%20previously%20consented%20%20to,have%20to%20be%20renewed%20at[Accessed%2012%20April%202023. [Accessed 12 April 2023]) according to which the time limit on storage of frozen eggs, sperm and embryos is now raised from 10 years to a renewable 10-year limit and up to a maximum of 55 years for everyone, regardless of medical need. The government announced this change in September 2021 a few months after it had launched a public consultation to seek views about changing the statutory storage limits. Seventy-four per cent of respondents to this public consultation wished to see an increase in storage limits (Department of Health & Social Care 2021).

Egg-freezing success rates are optimal at young ages (Alteri et al. 2019, Department of Health & Social Care 2021), thus, it is reasonable to think that women in their twenties will mostly benefit from storing oocytes, as well as, from an extension of the storage period. Essentially, such an extension can be seen as a way to preserve additional reproductive choices for longer and, subsequently, to enhance these women’s reproductive autonomy. The extension in the storage time on frozen eggs was met with great enthusiasm as a way to enhance reproductive choices of young women who wish to delay having children (Meierhans 2021, SMC 2021). The proposed extension and finally the extension itself received significant media coverage and support from experts, celebrities, professional bodies and politicians. Similarly, significant support was shown to the relevant campaign #ExtendTheLimit² which had been launched a few months before the introduction of the public consultation (HL Deb 2019, Hill 2019, Gamble 2020, Jellings 2020, Lamb 2020, Money-Coutts 2020, Meierhans 2021, SMC 2021).

In this paper, I argue that while this extension and the availability of EEF are welcomed and may well extend the choices of some women, egg freezing cannot by itself, deliver the enhancement of young women’s reproductive choice it promises neither can the extended storage limit improve its ability to do so. I suggest that we are missing something much more significant when it comes to this practice of egg freezing. I argue that without significant changes to the way that information is given about this process, egg freezing cannot accurately be portrayed as enhancing women’s autonomy and may even be more accurately described as enhancing the promotion of medicine and medical procedures rather than the choices of women.

While this paper focuses on the example of the extension of the storage period for EEF in the UK, as this method of EEF continues to gain popularity among women of reproductive age in countries where EEF is available (e.g. the UK, Canada, Australia) (Fitzgerald et al. 2018, p. vi, Gurtin 2019, Smith 2019, Varlas et al. 2021) the arguments I put forward will be important in this wider context. Given the increasing provision of EEF internationally this technique could significantly enhance the reproductive choices of a huge number of women globally. However, I argue that if we really are wedded to this notion of enhancing young women’s reproductive choices then we cannot simply stop at an extension of storage but must also undertake work to ensure that the type of information given and the way that is given facilitates deliberate choices. Ultimately, I suggest that the extension of storage should be encountered as an opportunity to refocus on the key issues related to informing young women about EEF. In this paper, I focus on those issues related to first-line information that women encounter before they actively seek specialist consultation (how women get to learn about EEF with an extended storage limit) and I argue that ignoring these issues misses an opportunity to ensure that it really is women’s choice that is promoted by this procedure.

Extension of the storage period for EEF: a change within an ethically controversial context

In order to put this issue into context it is important to understand the background to this kind of ‘social’ egg freezing. Egg freezing has been used since the 80s for women under treatment for cancer, whose fertility was compromised by the treatment undertaken (Waldby 2015 cited Kondapalli et al. 2010). While this kind of ‘medical’ egg freezing was already established, it was not until between 2012 and 2013, when the introduction of the technique of vitrification significantly improved the efficacy of egg freezing (Rybak and Lieman 2009, p. 1509, Barritt et al. 2007), that the practice of ‘social’ or ‘elective’ egg freezing was finally recognized as sufficiently advanced to be introduced into clinical practice (Waldby cited ESHRE Task Force on Ethics and Law et al. 2012 & American Society for Reproductive Medicine 2013). The technique of vitrification (flash-freezing) involves the use of cryoprotectants and rapid freezing which prevent the creation of ice crystals that are damaging to the eggs (Petropanagos et al. 2015, p. 666). As a result of this advancement, the use of vitrification increased rapidly in the years that followed (Greenwood et al. 2018, p. 1097). However, its use for ‘social’ egg freezing remained a controversial topic.

The ongoing ethical debate on EEF has involved arguments in support of the method, but many commentators have raised several concerns about it. Enhancement of reproductive autonomy and promotion of equality have been major arguments underpinning the use of EEF (Savulescu and Goold 2008, Justo Aznar and Pharm 2019, pp. 164–165, Anderson et al. 2020). Regarding equality, it has been argued that by offering women the option of EEF, we also offer women the chance to ‘enjoy the same choices’ to have children when they want, as men already do. Arguments around reproductive autonomy and egg freezing, which is the focus of this paper, suggest that it enables women’s empowerment in terms of enhancing the control these women have on ‘their reproductive destiny’ (Rybak and Lieman 2009, p. 1509) allowing them to ‘proactively maximize their chances of passing their own genes on to a child, regardless of their age’ (Rybak and Lieman 2009, p. 1509). In short, it is argued that this method allows women to procreate when they want and with whom they want, something which is in accordance with mainstream and well-known definitions for reproductive autonomy.

On the other hand, there have been objections to EEF related to worries about an adverse impact on women’s reproductive autonomy and equality. For instance, concerns have been raised about potential ‘ … commercial exploitation, pressure on women to use egg freezing, and the overall impact of egg freezing on sex inequality and professional norms’ (Harwood 2015, p. 59). For instance, several scholars share the view that egg freezing as a means to deal with the impact of age-related infertility constitutes an inadequate ‘technological solution to social problems’ (Harwood 2009, p. 46) and that ‘social structures’ causing difficulties to women ‘to combine childbearing and employment’ are the ones to judged (Harwood 2009, p. 46) and change, instead of trying to make women ‘better adapt to … those conditions privately’ (Goold and Savulescu 2009, p. 50). Commentators have also expressed worries about the likelihood of ‘ … unnecessary medical interventions and the exploitation of reproductive anxiety’ (Anderson et al. 2020, p. e116) given that many women are expected not to make use of the frozen eggs, as well as, about ‘idealisation about the right time to have a baby’ (Anderson et al. 2020, p. e116) and ‘false sense of security’ (Anderson et al. 2020, p. e116) in egg storage given that although ‘egg freezing does not guarantee a baby in the future’ there are women who still choose this method out of hope (Waldby 2015, p. 478) or in fear of decision regret (Harwood 2015, p. 65, Greenwood et al. 2018, Baldwin et al. 2019).

Currently, although there are more positive attitudes towards social egg freezing, both on the part of professional bodies and consumers (Anderson et al. 2020, p. e117, Wennberg 2020, p. 96), the procedure remains morally controversial given the absence of consensus regarding scientific aspects of the procedure, such as ‘the suitable age for elective egg freezing’ (Wennberg 2020, p. 96), the optimal number of eggs ‘to predict chances of success’ (Alteri et al. 2019, p. 648), as well as, the safety of the procedure (Alteri et al. 2019, p. 648), and age limits (Anderson et al. 2020, p. e117–e118, Wennberg 2020, p. 97).

Although further analysis of all these concerns and ethical issues is beyond the scope of this paper, they have been acknowledged at this point to highlight the fact that the decision to extend the storage limit was made within an already ethically controversial context. As I argue below, although the extension is a reasonable change, it is also likely to bring along further challenges to young women’s decision-making which can feed into this problematic context unless significant changes are made in the way that women and particularly, young women are made aware of the option of EEF with extended storage limit.

What is good about the change?

The increased technological advancement leading to higher success rates for childbearing with the use of egg storage and the improved safety of the invasive procedure prior to egg freezing (Anderson et al. 2020) can definitely provide a safety net for some women who might want to preserve the ability to conceive later in life. This method is particularly effective and beneficial for younger women and especially for women in their twenties, but the previous 10-year limit did not support a major purpose of this procedure which is to provide women with the potential to overcome the impact of age-related infertility (Nuffield Council on Bioethics 2020, p. 1, Department of Health & Social Care 2021). With the 10-year storage limit it is unavoidable that for some women, and mostly for those who freeze eggs at younger ages, the storage time will be up before they decide to use their eggs. Effectively, the 10-year limit favours those who freeze their eggs at an older age and are more likely to use these eggs sooner than women of younger age. As a result, it is not conducive to the maximum efficiency of the procedure because women who freeze their eggs after the age of 35 and closer to their 40s are less likely to achieve childbearing with the use of their own frozen eggs. Therefore, an extension of the storage limit is a reasonable choice as from an ethical point of view, it meets the needs of young women and maximizes benefit for them as well as, in terms of clinical applicability, it maximizes the method’s efficiency. In short, an extension of the storage limit should be welcomed as a way to preserve women’s reproductive choices for longer.

However, although the extension of the storage period seems like the right thing to do for all these reasons, I argue that we should be careful about linking this extension with an enhancement of reproductive choice. In the following sections, I explain in detail, the reasons why I am concerned that young women’s autonomous decision-making may be undermined instead of enhanced in the context of the new extended limit; these reasons are

1. the way the extension of storage limit has been reported may not be conducive to providing balanced information about EEF and may even serve to promote rather than present this option.

2. the similarities between the positive attitudes towards the extended storage limit as a way to enhance young women’s reproductive autonomy and how in the past the use of prenatal screening was promoted and spread allegedly as a way to empower women’s autonomous choices. The aim of this comparison is to show how the promotion of technological advancements and legal changes aiming to enhance women’s reproductive autonomy can also entail risks to this and what we can learn from past experiences in order to minimize the occurrence of such risks in current and similar situations.

Extension of storage limit: how a means to empower reproductive choice can become a risk to young women’s autonomous decision-making

A wave of positive attitudes toward the change

I argue that the risk to young women’s autonomous decision-making was already evident during the period the public consultation and the accompanying #ExtendTheLimit campaign which lobbied for the extension were taking place. This risk is related to the positivity with which both the method of EEF, and the extension of storage limit are met. During the campaign to extend the limit of storage and after the success of the campaign we have seen an overwhelmingly positive response in the way that this extension was reported.

The consensus view among obstetricians and gynecologists was that ‘UK law on storage limit for egg freezing [was] too restrictive’ (Anderson et al. 2020, RCOG 2020). This view has been supported by advocates of this change, and it has been widely circulated and shared in the media.³ A commonly shared headline has been the one of ‘Leading doctors back egg freezing extension’.⁴ Newspapers’ titles such as this can be the first stage of raising awareness and informing young women about EEF (Jackson 2018). Effectively, the primary source of information on EEF for young women (the print and online media) sends a positive message about the change, sealed by the scientific prestige of the medical world. That overall positivity adds to the existing positive attitudes towards the method itself and, I argue, may unbalance the information provided to women. While the sort of aggressive campaigns seen overseas,⁵ advertising EEF and explicitly targeting unaware young women, have not been seen so far in the UK, information that women are provided in the media is overwhelmingly positive about EEF, cultivating the idea of insurance, peace of mind and choice empowerment (Hvidman et al. 2015, p. 12).⁶

In this way, it is likely that young women will be positively predisposed to EEF already before they learn and understand why the method might be relevant to them or useful in the future. Even the petition⁷ which was part of the relevant campaign #ExtendTheLimit, although unintentionally, could positively influence for the use of EEF. Τhe title of the petition ‘Help others to be mothers’ accompanied by a photo of a smiling young woman in a patient gown, presumably at some stage of the egg-freezing process, selectively gives an optimistic message about the chances of childbearing after EEF. By contrast, the photo does not at all remind of the opposite, not so pleasant experiences of taking hormones and getting through the oocyte retrieval procedure (Baldwin and Culley 2018, p. 188) or getting through multiple unsuccessful embryo transfers since the percentage of embryo transfers that result in a live birth, particularly with the use of previously frozen eggs, is relatively low (HFEA 2020, 2021, NHS 2021a).

The physical discomfort (Nuffield Council on Bioethics 2020) and the psychological impact that the experience of EEF can have on some women are not negligible. Regarding the physical discomfort, this can vary with most women having mild symptoms such as mild abdominal pain, headaches, hot flushes, nausea and bloating (Suthersan et al. 2011, p. 125, NHS 2021b). However, these symptoms can get worse for those who will develop Ovarian Hyperstimulation Syndrome (OHSS). OHSS causes ovarian swelling and pain as a result to an exaggerated response to injectable hormone medication that women take to stimulate the development of eggs in the ovaries (Mayo Clinic 2021). OHSS is described as ‘a potentially serious complication’ (RCOG 2016) in the relevant patient information leaflet which is available online by the Royal College of Obstetricians and Gynaecologists. Although the chances of a woman developing severe OHSS are low, with ‘2-8% of patients needing medical intervention’ (Manchester University, NHS Foundation Trust 2017, p. 1), mild OHSS can affect ‘as many as 33 in 100 women (33%)’ (RCOG 2016). A risk of 33% is not insignificant but more importantly, ‘the risk is higher in women who are under 30 years old’ (RCOG 2016). In addition to the physical discomfort, there is significant evidence about the psychological impact of EEF on women. For instance, in a qualitative study in 2018 by Baldwin and Culley ‘[m]any women reported finding the process of freezing their eggs physically uncomfortable and emotionally difficult, particularly the experience of undergoing the procedure without a partner’ (Baldwin and Culley 2018, p. 188). Several studies have shown that the experience of egg freezing is ‘anxiety-producing’ (Suthersan et al. 2011, p. 125, Baldwin and Culley 2018, p. 188) as the hormone injections affect mood and cause feelings of general anxiety (Baldwin 2019, p. 101). Women ‘may also mourn not being able to pursue motherhood in a way considered as normal’ (Baldwin 2019, p. 90, Nuffield Council on Bioethics 2020, p. 3) and ‘can feel isolated and stigmatized if they do not have a partner’ (Baldwin and Culley 2018, Nuffield Council on Bioethics 2020, p. 3). Yet, considering that one cycle cannot guarantee an adequate number of oocytes to have good chances of ‘achieving a live birth using cryopreserved oocytes’ (Alteri et al. 2019, 648), some women will need to get through ‘multiple cycles of controlled ovarian stimulation’ (Alteri et al. 2019, 648), which amount to multiple experiences of unpleasant physical and emotional distress.

Contrary to the unpleasant experiences of EEF, which are not hidden but neither are highlighted, the media has been endorsing one-sided information about the positive image of the method and the extended limit. Effectively, as described above, the widely shared positive mindset towards the extension encourages young women to see, first and foremost, one side of the coin which is the positive image of an extension on the storage limit, reinforcing the stable positive profile of EEF. In this context, there is a real risk for young women’s decision-making to be driven by one-sided information. Also, young women’s autonomous decision-making can be further undermined since often, they lack other vital information to make a sufficiently informed choice. Notwithstanding repeated calls for more and better information, better knowledge and comprehension among women about age-related infertility and the method of EEF (Harper et al. 2017, Alteri et al. 2019, Wennberg 2020), significant evidence from numerous international studies repeatedly demonstrates a lack of adequate information and a low level of understanding and knowledge among women (including women who have actively sought to freeze their eggs) about the process of EEF and age-related infertility (Baldwin and Culley 2018, p. 186, Platts et al. 2021). Regarding women of a younger age, there is evidence showing that many are either unaware or not well informed (Mertes and Pennings 2011, Harper et al. 2017, Wennberg 2020) about the decrease in fertility and particularly, the decrease in oocytes’ quality with increasing age.

It is true that women have the chance to obtain adequate information through discussion with a medical professional or counsellor. However, the way that the first source of information can influence young women’s decision-making about EEF may be difficult to change. As Manson and O’Neill have pointed out ‘informing is inferentially fertile’ (2007, p. 46). The provision of information is not simply a transfer of ‘a discrete item from one agent to another’ (Manson and O'Neill 2007, p. 46) as people can make a range of inferences when involved in informational transactions. Manson and O’Neil note that the inferences an agent is likely to make based on ‘gaining knowledge of any particular proposition depends both upon what the proposition is and upon the agent’s other beliefs’ (2007, p. 46). However, ‘informational transactions are sometimes distorted by people’s poor inferential competences’ (Manson and O'Neill 2007, p. 47). Essentially, recipients of any kind of information tend to jump to conclusions which, however, may be incorrect. Thus, when a woman receives some information about EEF and the extended storage limit ‘she may consciously or unconsciously go on to make a range of inferences’ (Kater-Kuipers et al. 2020, p. 674) about the method. Consequently, when she visits an IVF clinic for consultation about egg freezing, she may have already decided (van den Berg et al. 2008, Kater-Kuipers et al. 2020, p. 674) about using the method and when she consents, she may consent to something in agreement to her inferences which are driven by information gathered from the media but may be different than that which is described to her by the medical professional or counsellor (Kater-Kuipers et al. 2020, p. 674). In such cases, although professionals may provide sufficient information to a woman, her choice can still be controlled to an extent by the inferences she makes about EEF which are drawn from limited and one-sided information. Thus, this kind of information is likely to remain influential and deprive a woman of at least some degree of the other necessary element for maximally autonomous choices which is voluntariness.

Overall, considering how information that does not fully serve the purpose of empowerment can easily become the subject to raise awareness among young women about the option of EEF, I argue that it is at least early to celebrate a victory of women’s empowerment in reproductive choice simply by extending the storage limit. Without any intention to devalue the contribution of this change in empowering women’s reproductive choice, I see that there is no strong link between empowering women and extending the storage limit, unless first we are clear about what women need to know. Promoting the extension of the storage limit in the name of women’s choice empowerment instead of focusing our efforts on the promotion of voluntary and adequately informed choices is morally wanting.

In the following subsection, I exemplify this issue by considering the impact that a similar situation had on women's reproductive autonomy in the past. Accordingly, I note the similarities between the current context of the extension of the storage limit for EEF and the context of the introduction of prenatal screening in clinical practice. The experience with prenatal screening and testing (PST) technologies is a good example to see and understand the weak link between making changes and introducing innovative reproductive technologies in the name of reproductive autonomy and the actual empowerment of women's choice when the aim for such an empowerment is not top priority neither is this reflected in the way women are receiving information about the new options to them.

The pitfalls in using the moral argument of empowerment of women’s reproductive choice to support an extension of storage limit for EEF: similarities with the example of prenatal screening

I have argued that rather than empowering women, the current provision of EEF is in risk of undermining women’s autonomy due to the unbalanced and incomplete information that women receive about this procedure. However, despite this often-weak link between women’s reproductive autonomy and EEF this procedure is invariably promoted as a clear way to enhance women’s choices. This is a familiar story if we look at the way that other enhancements in reproductive technology have been promoted and introduced to women (Watkins 2012, van de Wiel et al. 2020, Nakou 2021).⁸ However, there have been instances where the ways of informing women about a new reproductive option or offering such an option to them, were criticized for curtailing instead of enhancing women’s reproductive autonomy (Lippman 1991, Tymstra 1991, Seavilleklein 2009, Nakou 2021).

An example of this is the morally controversial beginning of the widespread use of prenatal screening. Although it is widely recognized that the main purpose of offering prenatal screening is to promote ‘meaningful reproductive choices’ (Williams et al. 2002 p. 743, De Jong et al. 2011, p. 657 Stapleton 2017, pp. 203–204, Ravitsky 2017, p. S34) and in this way, prenatal screening can indeed be an invaluable means to empower women and their reproductive choices, there is strong historical evidence to support a claim that rather than being driven by a desire to enhance women’s reproductive choices, the development and introduction of prenatal screening was driven by enthusiasm for new medical innovation and other motivating factors (e.g. eugenics, financial profit, satisfaction scientific curiosity, etc.) (Williams 1964, p. 563, Kerr and Shakespeare 2002, pp. 63–67, Cowan 2008, pp. 74–78, Löwy 2014, p. 293, Nakou 2021). Notwithstanding the fact that the empowerment of women’s reproductive choice is listed among the reasons justifying the wide and routine offer of prenatal screening, according to historical evidence it seems that this ‘idea has never played the starring role’ (Nakou 2021, p. 80). Instead, it has been argued that this idea was rather fitted within a system that primarily aimed to ‘achieve a number of wholly different goals other than women’s choice and empowerment’ (Nakou 2021, p. 73). As a result of this, women’s reproductive choices cannot be adequately protected and enhanced within such a system as is also proven by continuous concerns and issues around the quality of women’s choice when it comes to prenatal screening options.

Prenatal screening, especially in the form of routine, has been criticized as something that does not do a great job in enhancing women’s autonomy. Particularly, it has been argued that prenatal screening and the very offer of it have an imperative nature (Tymstra 1989, Bennett 2001, Suter 2002, van Den Berg et al. 2005, Schmitz et al. 2009, Seavilleklein 2009, Ravitsky 2017). Such criticism is supported by evidence showing that the introduction and wide use of prenatal screening was followed by problems with patients’ autonomous decision-making and the process of informed consent (Smith et al. 1994, Press and Browner 1997, Jaques et al. 2005, Constantine et al. 2014). For instance, there has been evidence that women often lacked the vital understanding to make informed decisions (Bernhardt et al. 1998, Green et al. 2004, van Den Berg et al. 2005); research evidence shows that there have been women who could not understand the reasons for testing and did not make deliberate choices (Press and Browner 1997, pp. 980 & 984).

Overall, it is argued that this kind of routine screening can undermine women’s choices by putting pressure on them to accept screening as it encapsulates the message that this is the right thing to do. I do not mean to say that the same will happen with EEF. However, I argue that we must be vigilant in order to avoid a similar scenario when it comes to EEF and particularly, I consider the example of prenatal screening as a lesson learnt that is worth revisiting; my point is that any new reproductive technology such EEF or any legal change aiming to facilitate the use of such technology and ultimately, to empower reproductive choice, are less likely to achieve this aim unless there is a comprehensive plan of how to make this technology available to consumers and what information should be provided to them in order to limit the defects is autonomous decision-making and empower reproductive choice. In short, information and education should come first, before any promotion or offer of such products is attempted. Through identifying the similarities between how PST was promoted in the past and how the extension of the storage period for EEF and the method itself are met, I intend to illustrate the importance of prioritizing such planning.

Apparently, there are many technical and clinical differences as well as different purposes for using PST and EEF and at first sight the parallel between the two technologies and the change of storage limit might seem odd. However, simultaneously there are significant similarities which are mostly related to the issue I am concerned with in this paper, which is the aspect of provision of adequate information. Both PST and EEF as well as the increase in storage limit share a common aim which is to empower women’s reproductive choice; their promotion and introduction heavily rely on this aim. Also, although each technology and the increase in storage limit have been introduced to increase uptake and benefit different groups of women, those over 35 for PST and those under 30 for EEF, they also have a common meeting point which is targeting specific groups of women. Additionally, although PST and EEF can be chosen for several different reasons, it is undeniable that both are preventative in nature. PST can be opted to prevent the birth of a disabled offspring whereas EEF can be opted to prevent the impact of age-related infertility. Yet, EEF can also be a means to prevent fetal anomalies since the younger a woman who freezes her eggs is, the lower the chances of conceiving a fetus that will suffer from maternal age-associated congenital anomalies or conditions, such as Down’s syndrome. Certainly, the motivations, profiles and aims of women who choose to use each technology differ, however in both cases, there are similarities in relation to the internal decision-making process that women get through in order to make their choice. For instance, as I have presented above, in both cases there has been research evidence demonstrating that there are women whose decision is driven to an extent by a feeling of decision regret.

In short, in both cases the aim is to empower the reproductive choice of specific groups of women whose decision-making is driven by similar motivations by providing access to technologies which are preventative in nature. Apparently, when it comes to the component of choice an important element to achieve enhancement of reproductive choice is adequate information. However, in both cases there has been evidence that to achieve maximal autonomous decision-making is a challenging task. Since the introduction and expansion of PST technologies there has been evidence about women’s limited understanding and lack of information to make decision about prenatal screening (Smith et al. 1994, Press and Browner 1997, Jaques et al. 2005, Constantine et al. 2014). Similarly, in EEF there is an ongoing issue with women’s understanding and knowledge about aspects of the method and age-related infertility (Harper et al. 2017, p. 19, RCOG 2019, p. 60, Wennberg 2020, p. 95).

Hence, given that the problems in women’s decision-making when it comes to PST have been significantly examined and identified and knowing that the way PST was introduced and promoted to women has played a role in initiating these problems, a comparison between the beginning of the widespread use of PST and the beginning of EEF with an extended storage limit is worthwhile to be considered. I argue that this comparison can be useful in highlighting those pitfalls in the experience with PST which can be prevented in the case of EEF with an extended storage limit.

The similarities between how prenatal screening was promoted in the past and how the extension of the storage period for EEF and the method itself are met currently are striking. One similarity can be found considering the significant evidence that, as in the case of EEF and the extension of the storage period, leading medics, politicians and other well-respected professionals have been backing the extension,⁹ it was medical professionals, the related medical industry and other interested parties that lobbied to use prenatal screening into clinical practice (Nakou 2021, pp. 79–80). Further, as with EEF, in the case of prenatal screening it was widely argued that prenatal screening was motivated by women’s demands, and further justified in terms of choice empowerment (Cowan 1993, Harbers 2005, p. 241). However, the evidence to back this up was unconvincing. While there was evidence that women with a family history of hereditary disease or those who already had an affected child were interested in testing for these conditions (Seavilleklein 2009, Löwy 2014, p. 293), when the clinical use of prenatal diagnosis for fetal aneuploidies began ‘only a few pregnant women were aware of the fact that their age put them at greater risk of such anomalies’ (Löwy 2014, p. 293) and thus, evidence for widespread support from women for comprehensive routine screening was not evident. Respectively, in the case of EEF and the extension, a similar demand, in the form of an opinion circulated in the media and promoted by the relevant campaign, comes from a specific group of women; these are mostly women who have been through the process of EEF and are already aware of details about the method as well as about age-related infertility.¹⁰

One may argue that contrary to the case of prenatal screening, in the case of extending the storage limit there has been a real involvement of the public and women could have their say. A public consultation took place, with 84% of the respondents being supportive of change to the storage limit of 10 years and 74% of them wishing to see the limit increase. However, the responses received were only 1222 (Department of Health & Social Care 2021); we do not know how many of the respondents were women in their twenties and considering that in 2019 the number of women in their twenties in England was about 4 million (Park 2020), we cannot claim that these responses really represent young women.

I recognize that the public consultation, the campaign, the supporters and advocates of the change and the government’s response show a genuine interest, however, this interest is expressed in a parental-paternal way; we think of young women’s interest, we make plans to meet their needs but without really giving them a voice and listening to them. I appreciate the effort of the law to consider and uphold scientific developments which can be favourable to women’s empowerment and reproductive autonomy. However, in the case of EEF with an extension of the storage limit one can only be certain about the uncertainty regarding the extent to which this change will empower young women and particularly those in their early twenties. Most women at such a young age cannot afford egg freezing. In addition, they are mostly uninterested and not likely to use the eggs in the future (Mertes and Pennings 2011, Pennings 2013, p. 523, Harper et al. 2017, European Society of Human Reproduction and Embryology 2018, HFEA 2020, Wennberg 2020).

On the other hand, young women are still the target group of women to inform. Young women are best candidates for the method and will benefit the most from the extension of the storage limit. To maximize the benefit for them and consequently, to maximize the method’s efficiency, women should be choosing EEF at a younger age and to make this choice it is essential to be informed about the availability of the method and why they are best candidates for using it. Here, it is interesting to look at another similarity to the example of prenatal screening. In the case of prenatal screening, the best candidates for the use of the method have been women over 35 years old (Nakou 2021, p. 76). For the efficient use of prenatal screening, these women have been the group of focus to be made aware of and offered the method. Also, gradual suggestions were being made and eventually materialized for the method to be offered to all pregnant women (Nakou 2021, p. 74). I do not claim that sooner or later a widespread and routine offer of EEF to young women or women in general will happen however, the fact that such suggestions are not uncommon particularly among gynecologists (Cobo and García-Velasco 2016, Jones et al. 2018) should not be underestimated as such suggestions can be considered indicative of a likely possibility.

Yet, I argue that the possibility of a routine offer of EEF to young women is a cause for concern particularly because the experience of routinely offering prenatal screening is characterized by continuous concerns around the quality of women’s choice. The process of decision-making when it comes to routine prenatal screening is still problematic despite well-meant efforts to overcome issues (Schmitz et al. 2009, De Jong et al. 2014, Dondorp et al. 2015, Vanstone et al. 2018). The similarities between the early promotion of prenatal screening and how the extension of the storage period for EEF and the method itself are met currently, at the very least, foreshadow a risk to the quality of women’s reproductive choice about EEF too. Essentially, the example of prenatal screening works as a simulation of future difficulties in improving the quality of women’s consent in the context of EEF which however, we still have time to prevent. Ultimately, to avoid repeating mistakes of the past, there is a strong necessity to be clear about what women need to be aware of sooner rather than later.

Setting priorities

As I present above, the extension of the storage limit was decided within an already ethically controversial context where the role of EEF as a method capable of benefiting a number of women has been downplayed. Among others, EEF has been portrayed as a ‘technological solution to social problems’ (Harwood 2009, p. 46) which gives ‘false sense of security’ (Anderson et al. 2020, p. e116) to women who will choose it. Simultaneously, it has been argued that it allows space for commercial exploitation, pressure on women by employers to delay childbearing in favour of their careers or pressure on women to use their eggs in favour of profit on the part of the fertility industry or in the name of pronatalism. An in-depth analysis of these arguments is beyond the scope of this paper however, there is one aspect to which I would like to draw attention; that the respective criticism seemingly applies to the method of EEF but in fact, it relates to the context within which EEF becomes available to women. In this paper, I have also argued that the first line of information regarding EEF, and the extension of storage limit mostly sends a positive message about the use of the method which is likely to influence uniformed young women’s choice unjustifiably. This is something that can also feed into the wider problematic context.

With all this in mind, I should first clarify that I do accept that social circumstances can impact women’s reproductive choices leading them to have to face the consequences of delaying procreation and I agree that such a disadvantaging context for women should change in order to give to women the opportunity to make deliberate choices ‘rather than having to fit into a model designed without them in mind’ (Goold and Savulescu 2009, p. 50). However, to change social circumstances, attitudes and rationales moulding this disadvantaging context is a lengthy process whereas in contrast, EEF rapidly becomes more popular among women and the increased storage limit can encourage more women and particularly younger women to use the method.

Accordingly, I argue that our first concern should be to respond to the immediate challenges of the current and evolving situation within the given context and encounter the extension of storage as an opportunity to refocus on the key issues related to informing young women about EEF. The provision of adequate information aiming to improve young women’s understanding and knowledge not only on EEF but more holistically, on their reproductive options and abilities, can function as a line of defense and counterbalance the impact that first-line and one-sided information can have on young women’s decision-making but also, promote more deliberate choices within the overall disadvantaging context.

‘What now for egg freezing?’

After the UK government’s announcement about the increase of the time limit on storage of frozen eggs, a shared question among involved parties and stakeholders is ‘What now for egg freezing?’ (Mahmoud 2021). The importance of implementing an appropriate plan for informing women about the use of EEF has been acknowledged by professionals in this field and many scholars. However, when it comes to informing women about EEF, things are complex. Designing and implementing an appropriate plan of information is not an easy task as there is a very fine balance between under-informing and over-informing young women or any woman about the method of EEF.

Commentators on this matter have highlighted the necessity for a comprehensive way of providing information that includes both the limitations and inherent risks of egg freezing, as well as that ‘the method should not be portrayed as a unique or optimal solution’ (Lemoine and Ravitsky 2015, p. 45). Also, professionals in the field make calls for the provision of better information ‘about the potential difficulties of the process of EEF’ including the fact that EEF cannot guarantee an offspring in the future (Sherratt 2018). For instance, Dr Jane Stewart, chair of the British Fertility Society, instigates women to undertake thorough research before investing money into cryopreserving their eggs. She has also raised another issue regarding women’s understanding and knowledge on the impact of age-related infertility; in her own words Dr Stewart encourages women not to ‘be scared by the fertility statistics – many women conceive in their late 30s and 40s if they don’t have a separate fertility problem, but it can take longer – and for some may not happen. Understanding that helps to make other decisions’ (Bearne 2019).

Involved parties and professionals who supported and pursued the extension of the storage limit have also been concerned with the issue of informing young women about EEF after the extension of the storage limit. It has been highlighted that awareness is a big challenge (Slater 2020). Joanne Anton, the head of policy at the HFEA, has emphasized that given the increasing number of younger people freezing their eggs, there is a ‘need for a robust framework in place to preserve fertility, while accounting for capacity, patient communication, and consent’ (Mahmoud 2021).

These suggestions mirror a particular factor which in the case of the extension of storage limit further complicates the provision of information and raises the question of where to draw the line when providing information related to EEF. This is the fact that unlike other medical procedures where the patient expects an immediate result or one to occur in a short time, in the case of EEF the patient makes a decision about a medical procedure which, if the final result is still desirable or needed in the future, it may be completed then. The main issue with this is that in the case of the extension of the storage limit, this future can be too far away from young women’s present.

In essence, EEF is part of a medical procedure; it is not an entirely independent procedure so that information about it will be enough to secure maximally autonomous choices. This method concerns one stage of consecutive, possible stages which, depending on when they occur and in what combination (for instance, whether a woman will have a child with a partner, or with a donor) they also attach to different relevant information. In short, a woman’s choice to freeze her eggs is linked to more and potentially more difficult decisions in the future (Salecl 2010, Waldby 2015, p. 478). Accordingly, the actual question that is raised is how far we should go with providing information to young women who are far away from understanding the circumstances of being over 40 for example and deciding to use frozen eggs to have a child.

The range of information that could answer this question is vast. But commentators on this matter do not clarify how far we should go when informing women about risks and limitations, which information is essential, and which passes to the level of over-information. Considering the calls on the part of professionals for a better framework of information and taking as a starting point their suggestions on what kind of information should be provided to women about EEF I suggest that there is a number of questions that should be at the forefront and stakeholders need to dwell on in order to create a robust framework.

A puzzle: how far we should go with providing information to young women

Approaches such as the Fertility Education Initiative (FEI) (British Fertility Society 2024) emphasize improving fertility and age-related infertility awareness and suggest pro-fertility activities (Hvidman et al. 2015, Lemoine and Ravitsky 2015, Martinelli et al. 2015, Harper et al. 2017, Alteri et al. 2019, Wennberg 2020). However, such approaches are not enough to secure balanced information unless we first discern the stage at which information should be provided; for example, would it be right to start systematically informing teenagers about the option of EEF? Also, another issue of consideration is the fact that ‘while freezing eggs from younger women may be optimal biologically speaking, younger women are much less likely to ever need their eggs to conceive and instead have a greater chance of having a child naturally’ (Pennings 2013, European Society of Human Reproduction and Embryology 2018, Anon 2021). Regarding this issue, it is interesting to observe that although the information that egg freezing is more successful under 35 is provided in FEI resources, the fact that many who freeze eggs under 25 do not use them is not highlighted (British Fertility Society 2022). However, it is questionable if this information should be given to teenagers or if it falls into the realm of information overload. Another questionable point is related to how we balance pro-fertility and EEF awareness with the equally important less stereotypical image of life without children and how this, although it is not fulfilling for every woman, can still be fulfilling for some. However, further to this, the question raised is whether such information amounts to over-information.

In this difficult context of decision-making about EEF for young women, in terms of what information to be chosen to inform young women around the option of EEF and how and given the difficulty to justify the provision of this information on the grounds of reproductive choice empowerment, one justified way, at least for now, seems to be the option of educative programmes such as the FEI in the UK which I mentioned in the previous section. FEI aims to provide accurate information about fertility and reproductive health to teenagers and young adults, including information about reproductive technology options such as EEF (British Fertility Society 2022, 2024). Another relevant development is the Fertility Assessment and Counselling Clinic (FAC). FAC was initiated in 2011 in Copenhagen, and it is a more personalized approach with the aim to protect fertility by offering ‘individual assessment and guidance to women and men with no known reproductive problems’ Hvidman et al. 2015, pp. 9–10). According to a study in 2016, the FAC ‘concept seems usable and offers a tool for fertility experts to guide women on how to fulfill their reproductive life-plan’ (Birch Petersen et al. 2017, p. 313). This has been confirmed again by a more recent 6-year follow-up qualitative study looking into ‘women’s perceptions and experience of fertility assessment and counselling after attending FAC’ (Koert et al. 2020, p. 1). Interestingly, in the wider implications of the findings the researchers found that the women who participated in the study ‘wished for more information and guidance’ (Koert et al. 2020, p. 1) after attending FAC and suggest that an expansion of this intervention may be needed (Koert et al. 2020).

Without getting into further details about these approaches, as that is beyond the scope of this paper, it is important to note that the operation of these programs shows both the limited information and the need for more information on the part of young women and young people in general about fundamental issues regarding fertility and infertility which precede information on EEF.

Overall, there is no justified reason to demonize the method of EEF or deny an extension of the storage limit, however it is necessary to clarify that EEF is just another option to preserve reproductive ability and an extension of the storage limit will increase the duration of this option’s availability but cannot alone empower the choice of this option. The required empowerment emerges from knowledge about all aspects of this option and understanding of the underlying information related to it. But adequate, rounded-out knowledge and understanding emerge after gradual steps and not by leaps. There is no point in promoting information about a new programming language to someone before clarifying that she/he has got some programming foundation. Thus, given the complexities of decision-making about EEF and the risk to young women’s reproductive autonomy within the context of the extension of the storage limit, I argue that it is timely and prudent to invest in and promote educative approaches and moves coupled with further research on young women’s attitudes, including intentions, knowledge and understanding. Such an approach can shed light on young women’s real needs and preferences and inform the next steps in building a robust framework of informing them about the option of EEF and its capabilities which can really work toward the aim of reproductive choice empowerment.

Conclusion

In conclusion, in this paper, I have argued that while an extension of the storage limit for EEF will be a good thing for some women, much more work needs to be done before we can say that EEF and the extended storage limit enhance the autonomy of women. In fact, there is a great deal of evidence that EEF as it is currently offered may actually undermine women’s autonomy as a result of unbalanced and limited information which means that there is a serious danger that women do not have sufficient information to consent to this procedure. I argue that to take this aim of upholding women’s autonomy seriously, to ensure that EEF really does enhance women’s choices rather than curtailing them, a great deal of work needs to be done in order to define clearly what constitutes adequate information about the option of EEF. I do not claim that I can provide an ‘all-encompassing’ answer on what information is good enough, however, I argue that the acknowledgement of the difficulty of answering this proves that it is oversimplified to declare that EEF with extended storage limit empowers young women’s reproductive choice and highlights the necessity to focus the discussions on dealing with the complexities involved in the decision-making when it comes to EEF. Everything considered, much remains to be done, however I suggest that a good starting point is to counterbalance the first-line information that young women may come across in media with the promotion of educative approaches which focus on the provision of balanced information.

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Notes on contributors

Panagiota Nakou

Panagiota Nakou is PhD candidate in Bioethics and Medical Jurisprudence, Centre for Social Ethics and Policy, Department of Law, University of Manchester. Teaching Associate at the Department of Law, the Faculty of Biology, Medicine and Health and the University College of Interdisciplinary Learning of the University of Manchester.

Notes

1 I use the word ‘women’ here to represent the group of individuals who may be seen as candidates for elective egg freezing, who might be interested in using this method or who might be affected by any change in the storage of frozen eggs. However, it is very important to recognize that there will be individuals who do not identify as women who can use elective egg freezing and are similarly affected by the issues raised in this paper. The arguments put forward in this paper concern these individuals too.

2 The #ExtendTheLimit campaign was launched in 2019 by the fertility and genomics charity Progress Educational Trust (PET). PET's #ExtendTheLimit campaign to change the storage limit for social egg-freezing launches. https://www.change.org/p/matt-hancock-mp-secretary-of-state-department-of-health-and-social-care-help-others-to-be-mothers-extendthelimit-on-social-egg-freezing-822ca948-2571-4c63-9581-084f47e01abc?utm_source=share_petition&utm_medium=custom_url&recruited_by_id=f29218a0-653e-11ea-85e9-ebe23b358af1 [Accessed 25 March 2023].

3 A few titles of newspapers and articles which constitute representative examples of the wide media coverage and support this view has received: Jellings (2020), McDermott (2019), Devlin (2019) and Nargund (2019).

4 Examples of such headlines: Anon (2020a, 2020b) and McManus (2020).

5 See, for instance, the example of fertility clinics throwing ‘egg freezing parties with champagne and canapes as described in the following article: La Ferla (2018)and Morris (2015).

6 See for instance the pun in the name of the website ‘eggsurance’ which provides information about EEF (https://www.eggsurance.com/ [Accessed 12 October 2022]) and Anon (2012).

7 PET's #ExtendTheLimit campaign to change the storage limit for social egg freezing launches. https://www.change.org/p/matt-hancock-mp-secretary-of-state-department-of-health-and-social-care-help-others-to-be-mothers-extendthelimit-on-social-egg-freezing-822ca948-2571-4c63-9581-084f47e01abc?utm_source=share_petition&utm_medium=custom_url&recruited_by_id=f29218a0-653e-11ea-85e9-ebe23b358af1 [Accessed 13 November 2022].

8 We have encountered such frameworks again in the past (e.g. prenatal screening, ART-IVF & contraception), when medical professionals and advocates of a change at the time put forward the well-known argument about reproductive choice empowerment as a forefront of the moral justification for the change.

9 See notes 3 and 4.

10 A few examples of women who have been through the process of EEF and how their opinion circulated in the media: BBC News (2019), Moss (2019) and Slater (2020).