By Tiffany Sinclair, MD
My saggy ovaries – that is what I’ve been calling them since I found out that I have “diminished ovarian reserve,” a term used to describe decreased reproductive potential based on the number of available ovarian follicles. Like many female surgical trainees, I prioritized my education and training over getting married or starting a family. I naively thought that I could get through medical school and residency and then start thinking about those things. During medical school, I still felt so young and not emotionally ready. During general surgery residency, the thought of having and raising a child while working 80 hours per week seemed impossible. But after seeing the steady stream of adorable baby pictures on social media from my friends and colleagues, my own biological clock started ticking and I thought that I should reconsider my baby-making plans. With a significantly reduced clinical load during my 2 years of dedicated research, I finally had time to ponder my fertility goals. Still early in my training and in a new relationship, I was not quite ready for pregnancy. I had heard about ovarian cryopreservation or “egg freezing” in medical school, but did not personally know anyone who pursued it. After over a year of thinking about it, I finally made an appointment with an OB/Gyn specializing in Reproductive Endocrinology and Infertility (REI).
At the tender age of 31, I thought I still had plenty of time to have children. “Geriatric pregnancy” does not begin until age 35, after all. At my REI consultation, the physician gave me an overview of fertility preservation therapy, which includes both egg and embryo cryopreservation, and recommended that I have my baseline anti-Müllerian (AMH) hormone levels checked. AMH is a hormone produced by the granulosa cells in ovarian follicles, and it regulates follicle recruitment. It has been correlated with the number of early antral follicles, as well as the clinical degree of follicle pool depletion. Levels of AMH are stable across the menstrual cycle and are used clinically as a marker to estimate ovarian reserve. AMH levels peak at approximately 24 years of age, then gradually decline to zero at menopause. A typical AMH level for a fertile woman is 1.0–4.0 ng/mL, whereas a level under 1.0 ng/mL is considered low and indicative of diminished ovarian reserve. At 31 years old, I was expected to have a normal AMH level and ovarian reserve.
I vividly remember when my physician called to tell me my lab results. I was walking in one of the outside courtyards on the way to resident teaching when she called. She told me my AMH level was “low.” Low enough that if I wanted to have children in 5 years, I would likely not be able to conceive naturally. She said that if I was contemplating having biological children in the future, then I should seriously consider freezing my eggs now. I cried – and I was surprised that I cried! Until that moment, I wasn’t even sure I wanted children, but the instant disappointment that I felt when she told me about my diminished ovarian reserve was enough to convince me that I needed to do this. For reference, my AMH level was 0.46 ng/mL, while the average level for a healthy 31 year-old woman is 3.59, and the 5th percentile is 0.6 ng/mL.
The egg freezing process is intense. For several weeks before the procedure, I had to inject myself subcutaneously (sometimes multiple times per day) with cycle-stimulating hormones. There were A LOT of doctor’s appointments. The week leading up to the “harvest,” I had to go in for an ultrasound every other day to monitor the maturation of my follicles and determine when the procedure would actually take place (it can vary by a few days based on an individual’s rate of follicle maturation). This required a time commitment and flexibility that I could only manage because of my modifiable research schedule. It was also EXPENSIVE. As someone with $300K+ of loan debt, I do not have much money to spare. The entire process ended up costing me over $10,000 out of pocket – $6,000 for clinical care and the procedure and another $4,000 for medications. This is pretty typical as the average cost of egg retrieval is $10-15,000 for most women. My insurance only covered some of the lab work and ultrasounds. Even for those with excellent fertility benefits, insurance companies will rarely cover prophylactic ovarian cryopreservation (i.e. when pursued by someone not actively trying to conceive), except for a few oncologic situations. I actually bought several of the drugs from Europe to save myself a few thousand dollars – not kidding. I was also very fortunate to be able to moonlight during my research time to make some extra money and offset my growing credit card debt. Finally, the procedure itself was painful, but tolerably so.
I was reminded of this whole ordeal after recently receiving my bill for ongoing egg maintenance – $520 per year to keep my frozen eggs frozen. Today, I have five healthy eggs sitting in a freezer in California. (One of my ovaries was really saggy and didn’t produce any eggs – a weighty disappointment for this overachiever). Despite the time and cost, I have absolutely no regrets. As I near the end of my fellowship training, “baby fever” is hitting me harder than ever. I still have to consider how pregnancy could impact my career prospects as a junior attending, but I feel a sense of relief when I think about my little frozen eggs. Egg freezing has given me the option to have children on my own terms, in my own time. It has allowed me to feel empowered, instead of defeated, by my withering, saggy ovaries.
Tiffany Sinclair, MD is currently completing her fellowship in Endocrine Surgery at the Cleveland Clinic. She obtained her medical degree from the University of Pennsylvania and completed her general surgery residency at Stanford Health Care in 2020. She hopes to pursue a career in academic surgery. Her research interests include pancreatic neuroendocrine tumors, hereditary endocrinopathies, and fertility among women surgeons. She is committed to diversity, equity, and inclusion in medicine and improving surgical culture. You can find her on Twitter and IG: @thefancysurgeon.
Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.