The commercialization of egg freezing for fertility preservation spawned a market in information and education as much as in clinical services. The work of constructing a market in egg freezing began in 2002 just as famed entrepreneur Christy Jones entered Harvard Business School after establishing two successful companies in the software industry. Jones went back to graduate school with the express intent to research and network in order to conceptualize and concretize an egg freezing business plan. Using her own money to fund a start-up, Jones launched the business in June 2004 shortly after she graduated with a contest-winning plan. Jones recognized an untapped market: real social issues could be transformed into an unmet need for a technology with the potential (but at the time undemonstrated) viability to preserve female fertility.
In this article I use “egg freezing” to refer to the clinical practice of oocyte retrieval and cryopreservation for what have been called “nonmedical,” “social,” “elective,” or “planned” purposes. It excludes persons who seek to preserve their fertility before undergoing either 1) cancer treatments that compromise gametes, or 2) gender-affirming medical or surgical therapies that can lead to infertility. Neither of these groups have the numbers to inspire market-building capable of expanding to profitable levels. Jones recognized a “multibillion-dollar opportunity” primarily from one market segment: an “explosion in the number of single, childless women aged 30–40—5-million-plus in the US,” and “the economic reality that unmarried women in their 30s tend to be top wage earners and price insensitive with respect to preserving motherhood options” (Hart and Sensiper Reference Hart and Sensiper2004, 10). In order to realize this market, a medical/technical solution had to be created alongside scientific research and the development of clinical protocols and procedures for storage. According to Jones's plan, “[her business] is building the trusted brand for fertility preservation solutions by investing in direct-to-consumer marketing activities to promote fertility awareness, educate women and attract clients” (14). “Educational seminars,” one of the “marketing and education” programmatic strategies mentioned in Jones's business plan, is the subject of this article.
Jones's 2004 business plan was based on the prospect of securing exclusive use rights and FDA approval for the use of “cryoprotectant media,” a product used in earlier processes of slow-freezing eggs (Spar and Hull Reference Spar and Hull2019, 1). The company's failure to achieve this objective was rendered moot when vitrification, a more effective method of egg freezing, became available for use in standard, private fertility clinics. Without the offer of an attractive technical innovation, Jones's business could not compete and had to scale down to essentially a marketing and referral service. As reported in a Harvard Business School case report describing the company's history, “In spring 2015, Jones sold [the company] . . . in order to forward integrate into the medical practice with a national chain of egg freezing focused clinics” (2).
A decade and a half after Jones first proposed the “educational seminar,” in-person informational events have become an industry trend. Dubbed “parties” by the now defunct Eggbanxx, an influential broker/financier temporarily on the New York City scene when the market began to take off, these events are regularly offered by traditional fertility clinics and new start-up entities promoting egg freezing. Given the transparent objective of recruiting paying clients, these events must inevitably combine persuasion with education. Between 2017 and early 2020, I conducted participant-observation at three such information sessions held by different clinics in a large city located in the eastern US. My focus on information events began as part of a broader exploratory study reviewed and approved by the Institutional Review Board at the University at Albany on the scope, recruitment, administrative processes, communications, and user experiences related to egg freezing. All events were free and open to the public to attend with registration. In two cases, I secured permission to attend as a researcher in advance and disclosed this purpose when mingling with other attendees. In a third case, due to lack of time for advance notice, I attended unobtrusively without mingling with others. Sandra González-Santos provides a rare reference in the literature to “recruiting events” in a book on the assisted reproduction industry in Mexico, noting that “the structure of the event, its visual arrangement, the images presented, the speakers’ attire, and the content of the talks all followed a well-planned, orchestrated, and performed marketing scheme to recruit patients” (González-Santos Reference González-Santos2020, 204). Interestingly, the author highlights how attendees wield greater power in relation to physicians in these encounters than they would in an individual clinical consultation. Irrespective of their credentials and expert status, physicians must appeal to their audience and inform cum sell in the context of a highly competitive market (206). Yet the relative power of event attendees is easily counteracted by information that reinforces social vulnerability (the risk of childlessness), keeping them at the mercy of market mechanisms that individualize responsibility for and resolution to social problems. Through a comparison of their content and form, I present an analysis of their art of persuasion through information, and the production of affect and sociality. Focusing on the content of information relayed or withheld, I examine the extent to which these events adhered to guidelines suggested by the American Society for Reproductive Medicine (ASRM) on securing informed consent. Further, I describe how the form of these events—through comparison with classic forms of event organizing designed for and by women such as those embodied in Our Bodies, Ourselves (OBOS) and Tupperware—produces a complex blend of affect and sociality that likely affects how information is received. Ultimately, I argue that egg freezing informational events employ subtle techniques of persuasion that cultivate anxiety, while linking egg freezing to desirable traits or lifestyles through social enactment.
The Market in Egg Freezing Takes Off
The market for egg freezing began to take off in 2012 once the American Society for Reproductive Medicine (ASRM), the premier US professional association for providers and source of ethical guidelines in fertility care, lifted the experimental label on the technique used to freeze eggs. This occurred despite the ASRM's explicit directive not to market the technique for age-related fertility decline. The market itself got a significant boost in May 2014 through the launching of Eggbanxx, the aforementioned start-up, and announcements made by Facebook and Apple in October of that year that they would offer egg freezing benefits to their employees. These developments were accompanied by a spike in news media portrayals (Campo-Engelstein et al. Reference Campo-Engelstein, Rohia Aziz, Jennifer Raffaele and Parker2018). News media described the Eggbanxx signature, in-person event as a “cocktail party” held in “swanky” hotels accompanied by photo-shooting journalists (Henig 2014; Richards Reference Richards2014; Paquette Reference Paquette2015; Rabinowitz Reference Rabinowitz2015). Founded by Gina Bartasi, Eggbanxx, like Jones's company, itself was not a clinic. It linked potential clients with clinics and offered clients financing options. The Eggbanxx party, first held in Manhattan but replicated in other cities, began with a happy hour followed by a panel presentation with physicians from participating clinics. Attendees left with gift bags including a Cadbury cream egg and a coupon for $1,000 off the price of egg freezing (Duberman Reference Duberman2014; Henig 2014; Finnerty Reference Finnerty2015). The company disappeared quietly in 2016 through rebranding (Mack Reference Mack2016), but not without leaving a discursive, societal impact through strategic communication slogans like “Smart Women Freeze,” “Lean in. But freeze first,” and “Let's Chill.” Although the ASRM Ethics Committee in 2018 eventually acknowledged the growing egg freezing market to avert age-related fertility-decline by reinforcing the importance of obtaining valid informed consent, the authority had from its first articulation on the practice in 2004 sent mixed messages.
Informed Consent: To Protect Patients and New Treatments for Industry Use
Although securing informed consent is, of course, necessary in any clinical situation, it is even more critical in the US's competitive, for-profit, and relatively unregulated market for assisted reproductive technology. Within this context it is not uncommon for fertility clinics to offer new treatments that do not have an established evidence base demonstrating safety and effectiveness. In an opinion on “Moving Innovation to Practice,” the ASRM recognized:
Early adoption can be confusing for patients, who may not understand that a treatment they have read about lacks a basis in evidence and may, in fact, do them more harm than good. Inadequate data about appropriate inclusion and exclusion criteria can lead to misuse; incomplete understanding of risks and safety consideration can lead to harm. A promising innovation can then fall out of favor. (Ethics Committee 2015, 40)
Here, the professional authority articulates a need to protect the future marketability of new treatments just as much as its patients. Clearly, where regulatory bodies do not have the authority to closely monitor and curtail experimental techniques in the private clinical realm, the implementation of full informed-consent procedure is touted by professionals as having a dual purpose: both protecting patients as well as the (future) markets on which their profitability depends.
Although the ASRM consistently discouraged egg freezing for the purpose of averting age-related fertility decline until 2018, it is also clear that it facilitated early adoption. In October 2004, just as Jones was launching the first egg freezing company, the Practice Committee of the ASRM recognized oocyte cryopreservation as experimental, potentially efficacious for treating the future fertility issues of cancer patients, but that it should not be “marketed or offered as a means to defer reproductive aging” (Practice Committee 2004, 997). In 2007, the Practice Committees of both the ASRM and the Society for Assisted Reproductive Technology (SART) reiterated that opinion, noting additionally that “[o]ocyte cryopreservation is not an established medical treatment” (Practice Committees 2007, 1495). Nonetheless, the 2007 statement listed thirteen specific pieces of information that ought to be included to ensure full informed consent when used for what they termed “elective” purposes. The statement does important preemptive work toward building/protecting the market by providing the literal guide by which physicians could sell cryopreservation, which presumes at the same time as it ensures that individual autonomy should prevail in the question of access to experimental treatments.
In 2012 the Practice Committees of ASRM and SART released a “guideline,” which lifted the experimental label on egg freezing and recommended the technique for a number of “medical indications,” most prominent among them the case of patients seeking to circumvent the gonadotoxic impact of cancer treatments. However, the statement cautioned, “there are not yet sufficient data to recommend [egg freezing] for the sole purpose of circumventing reproductive aging in healthy women” (Practice Committees 2013, 42). It further stated, “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing. In particular, there is concern regarding the success rates in women in the late reproductive years who may be the most interested in this application” (41). In spite of this cautionary tone, the impact of the guideline was to unleash unfettered commercialization of egg freezing, as already described. Rather than pressuring its member physicians to protect patients by not marketing egg freezing, the ASRM reacted to these developments by releasing a fact sheet in 2014 on its patient-education website titled, “Can I freeze my eggs to use later if I'm not sick?” The document provided the information a patient would need to ensure valid consent. Thus, although the ASRM until 2018 had officially and consistently discouraged egg freezing for age-related fertility decline in word, its facilitation of informed-consent procedures appears vested in ensuring that the “promising innovation” would not “fall out of favor.”
In late 2018 the ASRM Ethics Committee reversed its nearly fifteen-year position of discouraging egg freezing for women who want to avoid age-related fertility loss, a practice formerly classified as elective. The opinion critiques terminology that draws a hard line between medical and social uses of egg freezing. The statement renames the practice planned oocyte cryopreservation (OC), explicitly rejecting the term elective “as trivializing and insufficiently respectful of the fact that the treatment is being undertaken to avert infertility that, if it arises, will in fact be a medical condition” (Ethics Committee 2018, 1023). It underlines the practice's now ethically permissible status and recognizes the increasing numbers of women seeking it and physicians providing it. Outlining ethical arguments both in favor and against planned OC, the statement largely refutes the latter, offering up informed-consent procedure as a solution that can protect “women's legitimate interests in reproductive autonomy” (1022) as well as diminish most concerns. However, the statement does recognize the issue of potential commercial exploitation. Specifically, it states:
The Ethics Committee is concerned about coercion and the line between education of young women and inappropriately aggressive marketing to them. Messaging in the media or through in-person gatherings may have the benefit of educating women about the decline in future reproductive potential while they are still good candidates for unassisted reproduction or planned OC; but it may also generate disproportionate fear or encourage action that is not in the women's best interest. (1025–26)
It is precisely the line identified by the ASRM Ethics Committee between education and “aggressive marketing” that I seek to scrutinize in my analysis of the form and content of three in-person meetings. Explicitly rejecting the Eggbanxx model (though not in name), the Committee singles out the practice of outsourcing in-person marketing as particularly unacceptable—“this Committee disapproves of arrangements in which medical practices hire firms to hold marketing sessions for women and then pay those firms for each woman who becomes a patient” (1026). The medical practice is deemed by the ASRM as the most appropriate entity to provide education without the influence of third-party marketers or brokers. The commercial interest itself is not challenged on ethical grounds. Although the ASRM Ethics Committee does make a point of barring members of the Committee from developing opinions who have specific conflicts of interest based on “disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients” (1027), the professional authority's mandate to protect industry interests is not controversial. In fact, one contributor to the 2018 ASRM Ethics Committee opinion that deemed “planned OC” ethically permissible, Lynn Westphal, previously served on Jones's management team in 2004 and today serves as Chief Medical Officer for another egg freezing start-up. This demonstrates that persons vested in building a market for egg freezing were not excluded from ethical deliberations.
Medical practices utilize the in-person sessions as a primary mode of recruiting new patients for a highly profitable service. Intrinsically, therefore, there is a potential conflict of interest between provider and patient unacknowledged by the ASRM. In order to recruit patients, the possibility of neglecting to inform or even misinforming can be unacceptably high even without hiring third-party brokers or marketers. Although the US public is generally aware that medical information may inevitably come mixed with persuasion, in-person gatherings employ subtle (rather than aggressive) affective elements among their techniques of persuasion, which may motivate new patients to overlook critical components of consent, whether stated or absent in the communication. Such persuasive affect can remain all the more hidden given that selling occurs under the pretense of education.
Event Descriptions
What follows are observations of in-person meetings in a large city in the eastern US. I follow these descriptions with an assessment of the information provided in relation to what the ASRM deems essential for ensuring valid consent. Finally, I present an analysis of these findings contextualized against the background of classic forms of event-organizing designed for and by women, such as feminist health-consciousness-raising and feminized direct sales. I argue that the body of information presented at egg freezing informational events along with the form of engagement simultaneously raises anxieties while fulfilling social needs that promise as they enact desirable traits or lifestyles.
Event A—Hosted by a Standalone Egg Freezing Clinic
I attended Event A in July of 2017 not too long after the host clinic's launch as a start-up focused solely on egg freezing, rather than offering a full palette of IVF services. The event took place on the fourteenth floor of a building in the heart of the city in a bright, trendy, rented space with sleek minimalist furniture. On a table as you entered there were fancy hors d'oeuvres and bottles of water, but no alcohol or music. The main host, a woman in charge of outreach and education at the clinic, was casually dressed. The atmosphere, as I experienced it and confirmed later in informal conversation with her, was intended to contrast with the more glamorous style of egg freezing “party” associated with Eggbanxx. The idea was to convey that the clinic takes your education and reproduction seriously, and they want to build trust. Although the host said they normally see twenty-five to thirty people attend the monthly event, she expected only fifteen because it was summer. Twenty-one people attended. The host opened the event with an ice-breaker quiz followed by a slide presentation by one of the company's male reproductive endocrinologists. After the slide presentation, the host took over with explanations on the procedure including details on starting the cycle and hormone injections, as well as pricing. This was followed by Q & A.
The ice-breaker quiz included six multiple-choice questions like, “how many eggs is a woman born with, on average?” (The answer: one to two million), or “approximately what percentage of a woman's egg supply remains by the time she's 35?” (The answer: 6%). The host used the last question to prompt a brief discussion.
According to In the Know: Fertility IQ, a survey of fertility knowledge among 25–35-year-old women, 94% of women surveyed said they were “confident in the fertility counsel provided to them by their OBGYN.” What percentage of these women report ever discussing with their OBGYN age as a factor in getting pregnant? (a. 94% b. 72% c. 45% and d. 22%)
After revealing the answer (22%), the host asked the women in the audience if they had discussed these issues with their OB/GYNs. One very vocal woman in the front disclosed she had just undergone egg freezing at another clinic and paid $14,000. She angrily said that she alone had to bring it up because her OB/GYN had not. Two others raised their hands saying they also had to initiate a discussion on age-related fertility decline with their OB/GYNs, and a fourth woman said that the issue came up “mutually.”
Then, the doctor proceeded with a presentation of seven slides. The first slide, titled “Egg quantity and quality with age,” depicted a dramatic decline in healthy eggs with age using an image of a gumball machine filled with mostly blue gum balls (standing in for healthy eggs) and then, after aging, just a few, mostly green gumballs (or unhealthy eggs). Slides four and five also visually depicted the problem of age-related fertility decline using bar graphs. Thus, three of seven slides cultivated a sense of urgency around being proactive before it is too late. Two further slides discussed clinical testing one undergoes to kick-start the process (a blood test and an ultrasound) used to determine ovarian reserve. The audience was encouraged to be curious about where one stands and to ask themselves how many eggs they might have. The sixth slide, titled “Can I take home a live baby in the future?” presented a set of predicted probabilities based on age and number of eggs frozen. The final slide lauded the freezing technology, vitrification, in a way that reassured the audience of the scientific legitimacy and state of the art techniques used by the clinic.
During the Q & A, the doctor and host fielded questions. One person asked whether IVF was necessary to have a child using the eggs retrieved, revealing that, even among a presumably well-educated audience, some critical information was neither stated up front, nor absorbed. Clinic representatives tried to clarify much confusion around their pricing model, in particular the offer of a “12 egg or 4 cycle” guarantee (more on this later). There was also confusion on how to access and use the eggs later since the clinic did not at the time provide IVF. The main host explained that the clinic planned to open a “sister” clinic in the near future that could provide those services without jeopardizing the separate, stand-alone clinical focus on egg freezing. She underlined the importance of maintaining a separate space for healthy, presumably not (yet) infertile egg freezers, and described messy situations she had heard of in standard fertility clinics where nurses simply crossed out inapplicable sections in general IVF consent forms.
Some of the affective elements deployed in this event were to stoke a sense of injustice: OB/GYNs do not consistently advise their patients about age-related fertility decline, and the specific needs of healthy egg freezers are neglected in traditional IVF clinics. By focusing overwhelmingly on precipitous fertility decline with age without presenting options available to address that issue other than egg freezing, the event also stoked anxiety. Lastly, even if accompanied by confusion, the event invited attendees to play the numbers game. How many children do I want? How many eggs would I need? How many eggs might I have? There was an invitation to speculate on probabilities and imagined futures with one or more genetically related children.
Event B—Hosted by an Experienced and Established Clinic
Unlike Event A, this event, which I attended in May 2018, underlined the host company's role in innovating vitrification and its many years of experience. Billed as for women only, this event took place on one of two floors owned by the clinic in a large room with framed newspaper articles featuring the clinic's founder and director on the walls. The main host was a male marketing manager, who apologized for having to replace a female billing specialist unable to attend. A female doctor in a white coat arrived to present the slides. Only nine people attended this event. The event had an overabundance of trays of cut fruit, cheese and crackers, salami, olives and fig jam, and many bottles of wine, mostly rosés. The arriving attendees were offered wine several times before the event began, but most declined. The music playing in the background as people assembled included songs like “Girls Just Want to Have Fun,” by Cindy Lauper, “Let it Go” (from the Disney blockbuster film Frozen), and Beyoncé's, “All the Single Ladies.” There were goody bags lined up on a table filled with information, including anthropologist Marcia Inhorn's opinion piece from Cnn.com titled, “Women, Consider Freezing Your Eggs” and excerpts from Sara Richards's self-help book, Motherhood Rescheduled: The New Frontier of Egg-freezing and the Women Who Tried It.
The event began with the marketing manager making a pitch. If we requested a consultation for egg freezing, we could lock in an offer of $1,000 off the first cycle; a free initial consultation; a free ultrasound; and free storage for six months. He also mentioned a “split cycle offer,” for those who qualify, in which you donate half your eggs in order to pay for your egg freezing cycle. Then, the doctor went through the slides, followed by the marketing manager, who took over to provide pricing information, and the event ended with Q & A. In comparison to Event A, this session emphasized not only the advanced technique of vitrification but the clinic director's role in pioneering it (the subject of four out of fourteen slides). During mingling at the end of the event, one attendee in conversation with me misunderstood that the clinic was the only one using vitrification, which was implied by the content. Three slides depicted age-related fertility decline in the typical fashion of a line chart. For example, a downward-leaning fertility line overlapped an upward-reaching line marking increased rates of miscarriage with age. Finally, three slides got into the weeds of process with details on tests needed at the onset of a cycle, hormone injections, office visits, and anesthesia during retrieval. One slide titled “What you need to know” did not provide any crucial information needed to secure valid informed consent. Rather, it stated, “Freezing young, healthy eggs can eliminate the pressure of family planning while you focus on your career and personal life.” This marketing pitch appeared next to an ideal-lifestyle image of a reclined young blond woman who can presumably relax in knowing that she can “balance it all” in her pursuit of career and family. More persuasive than informative, the image presents an unobtainable fantasy. Further, results from qualitative studies demonstrate that most egg freezers are not actually motivated to undergo the procedure because they desire to focus on their careers or education (Carroll and Kroløkke Reference Carroll and Kroløkke2018; Inhorn et al. Reference Inhorn, Birenbaum-Carmeli, Westphal, Joseph Doyle, Dror Meirow, Daniel Seidman and Patrizio2018; Baldwin et al. Reference Baldwin, Lorraine Culley and Mitchell2019). According to Kyle Baldwin and colleagues, “few women were motivated by a desire to enhance their career.” Rather, the authors found that “women's use of egg freezing was shaped by fears of running out of time to form a conventional family, difficulties in finding a partner and concerns about ‘panic partnering,’ together with a desire to avoid future regrets and blame” (Baldwin et al. Reference Baldwin, Lorraine Culley and Mitchell2019, 166).
My overall impression of this event was that its party-like atmosphere felt noticeably contrived in comparison to the more sophisticated messaging of Event A. The event sought to engender a relaxed affect that was less about becoming an engaged learner and participant in one's own fertility care than about entrusting experts to care for you. The atmosphere appeared cultivated to obscure aspects of the procedure itself that reflect cold medical practice, as it is normally imagined, with scary injections and surgery. We were instructed to drink wine, relax, and let the experts take over so that we can focus on other aspects of our lives.
Event C—Hosted by a Clinic Run by and for Women
I attended this event in January 2020, hosted by a start-up clinic touted as run by and for women. News media accompanying its launch highlighted the millions of dollars in venture capital raised by the executives. Although the clinic hosting Event C focused foremost on egg freezing, news media also highlighted the company's goal to expand into a “one-stop-shop” for all women's health needs.
Accessible directly through a ground-level entrance, the approach to the event was immediately different from the other events, which were held on higher floors of tall, generic office buildings. In spite of construction scaffolding that wrapped around the block, I could not miss the bright yellow neon sign announcing the clinic and the entrance thickly wreathed with yellow flowers. Flanked with large windows, I could immediately view two floors before I entered the open white space dotted with clusters of wall art mainly in yellow and black. One prominent display of word art in lower-case cursive stated, “own your future.” There was a platter of cheese, crackers, and Prosecco situated behind a seating area with two sofas, a coffee table, and added rows of chairs. The food and drink became quickly difficult to access as the space filled up and people were directed to the upper floor to watch over a balcony. Popular music was quietly playing in the background; I noticed that all the singers were female. There was a mauve vase on the coffee table with a matching plush throw on one of the sofas. Prominently displayed books on the coffee table included The Art of Feminism: Images that Shape the Fight for Equality, with three raised fists on a pink cover; Period Power: Harness Your Hormones and Get Your Cycle Working for You; and Vogue Essentials. This event was led by a female doctor not in a white coat, but rather in a sweater dress and boots, made up, with freshly styled hair. She stood behind the coffee table and addressed the audience without slides, speaking for a half hour, and then leading a Q & A session for about an hour.
The doctor began by saying how good it was to see all these women (there appeared to be four men in the audience) and introduced herself. With franchises opening in other major cities across the country, the doctor described the clinic's plan to build a national network of women's health practices focused on “ending the fragmentation that currently exists in women's health care.” She also described the clinical network as “a place where women can get better informed.” The doctor named a broad range of gynecological and fertility services the company offered under one roof, such as well women's visits, provision of birth control, STD-screening, treatment of yeast infections, egg freezing, IVF, intrauterine insemination, and donor egg and sperm. Yet, after listing this broad range of services, the majority of the doctor's comments focused on content similar to that provided in the other two events: the lack of education on fertility decline with age in women, the need to take preventive action before infertility problems arise, the limited supply and dramatic decline in egg count and quality in women with age, the process of determining ovarian reserve through a “fertility assessment,” and the process of egg freezing. As with Event A, the content focused on the injustice of a lack of education. The doctor critiqued gynecology for providing a standard response to patients with questions about their fertility, which is to suggest that they not worry unless they want kids and have tried to conceive for a year without success. Similar to Event A, this session also focused on engendering anxiety and curiosity about one's ovarian reserve through a battery of questions. Stressing that all women will reach zero eggs eventually, the doctor suggested everyone should be asking themselves where they are on this downward trajectory. The test “functions so well as a marketing tool” according to sociologist Lucy van de Wiel, “because both below- and above-average outcomes can become an indication for treatment—whether to salvage declining fertility or maintain optimal fertility” (van de Wiel Reference van de Wiel2020, 224). This session was distinct from the previous two in that its content appeared focused on marketing the fertility assessment just as much as, if not more than, egg freezing. Regardless of one's desire and intent with regard to reproduction, the assessment is priced at $200 for session attendees. Much in the style of 23andMe, it was marketed as a way of knowing yourself through data.
Unlike Events A and B, this session's overall messaging targeted younger women through its provision of birth control, acknowledgment that women in the audience may not be ready to contemplate having children and may not even need assisted reproduction for a first child, while emphasizing they should consider their age when ready to have a second or third child.
Assessment of Information Presented
Through a close reading of the current ASRM Ethics Committee opinion on planned oocyte cryopreservation (Ethics Committee 2018), I identified five main areas of information that ought to be relayed to patients in order to ensure valid informed consent. Highlighting more specific details from each session, where provided, I assess below how well each event fulfilled this ethical obligation.
Did they identify all options for forming a family?
The 2018 ASRM Ethics Committee statement compels “physicians and those advising women about planned OC” to “identify all the options for forming a family: early unassisted reproduction, assisted reproduction with their own oocytes, embryo donation, adoption, or living childfree” (Ethics Committee 2018, 1026). Neither Event A nor B relayed this information. At Event C the doctor did acknowledge that some might not want children or want to adopt. However, the clinic's strategic marketing to younger women may have necessitated a broadening of options so as to remain relevant to women in their mid-twenties. By providing well women's visits, birth control, and meeting other reproductive health needs apart from fertility (abortion noticeably absent), the clinic seeks to build brand loyalty so that younger women who utilize their services might come back later for egg freezing or IVF. Thus, strategic marketing rather than ensuring informed consent may have motivated mentioning a variety of options for forming a family and acknowledging that a woman may not (yet) be ready to think about having a baby in the future. Furthermore, claiming that twenty percent of women under the age of thirty-five have uncharacteristically low ovarian reserve for their age, the doctor asserted the need to undergo the assessment even if one was not ready to consider reproduction.
Did they identify unknowns or knowns, where appropriate?
The 2018 ASRM Ethics Committee statement on planned oocyte cryopreservation emphasizes that advice “be clear about the novelty of the technology and the unknowns.” Specifically, it raises the concern that “studies have not yet established whether there is a ‘shelf life’ for cryopreserved oocytes” (1024) and that “most studies of OC have involved young women, with the oocytes cryopreserved for shorter periods of time” (1026). During the Q & A for Event A, a participant asked if there was an optimal time period when one should use the eggs to improve success rates; the host responded that once frozen they were good forever. In response to a question about how long one can keep eggs frozen, the doctor at Event B responded anecdotally that the longest case was thirty years, which, she said, was probably longer than anyone would want. At Event C the doctor stated up front in the presentation that frozen eggs “don't have an expiration” and are “good for eternity.” Yet, given the lack of any long-term studies, these statements have no evidence base. In each case presenters were less than candid about the unknown “shelf life” of frozen eggs, suggesting they would be good “forever.”
The 2018 ASRM statement on planned OC acknowledges an association between late childbearing and medical risk: “Studies indicate that the risks of maternal and neonatal harms increase with the increasing age of the woman carrying the pregnancy (51). This again, is important information that needs to be conveyed to women considering cryopreserving their oocytes (52)” (1025). None of the three events identified this information. The doctor at Event A acknowledged (social) issues with pregnancy at advanced maternal age. Yet he emphasized that the age of the uterus or woman has no impact on pregnancy success rates so long as the eggs were young. He stated that even postmenopausal women can get pregnant with younger eggs. The doctor at Event B gave the same response to a question on whether there was a cap on age at which one could do IVF. In the Q & A of Event C, when asked if the age of your body when ready to carry a pregnancy impacts viability or success of the pregnancy, the doctor similarly answered that the uterus as a muscle had the capability of pregnancy at any age but did acknowledge an ASRM recommended age limit of 55 years. Although less deceptive than the responses given at Events A and B, the doctor similarly emphasized the possibility of pregnancy for an older woman so long as she is healthy. At all three events the doctors overemphasized the possibility of pregnancy at advanced maternal age without specific reference to known risks of maternal and neonatal harms.
Did they acknowledge the potential to experience regret and suggest or provide consultation with a mental health professional?
The 2018 ASRM statement acknowledges a potential to experience regret, citing a study of 201 women of whom nearly half (49%) experienced some regret about their decision to freeze their eggs. The statement suggests that patients seek consultation with a mental health professional before the procedure in order to “explore their expectations, motivations, and any concerns surrounding the procedure” (1026). None of the events acknowledged the possibility of regret. To the extent that regret was insinuated, it was in the suggestion that by not freezing their eggs attendees may experience future regret. The marketing director at Event B mentioned in-house psychologists involved in clinical psychological screening evaluations for egg donors and surrogates who offer private counseling and could make referrals. The doctor at Event C mentioned they had therapists specialized in dealing with IVF journeys and recurrent miscarriages available as an add-on service.
Did they disclose clinic-specific experience and results with egg freezing?
The ASRM ethical guideline from 2018 states in no uncertain terms that clinics marketing egg freezing must “disclose their own clinic-specific statistics, or lack thereof, for successful freeze-thaw and for live birth” (1022). All three events neglected this obligation.
At Event A, a slide titled “Can I take home a live baby in the future?” might have provided an opportunity to disclose clinic-specific statistics or lack thereof. The slide presented a set of probabilities in four line graphs, each presenting predictions for different age ranges. The doctor spoke very fast when going over this slide, focusing on the youngest age cohort. With twelve to sixteen eggs saved, he stated, a woman between ages thirty to thirty-four would have a seventy to eighty percent chance of bringing home a baby in the future. The clinic used these probabilities as a basis for coming up with a financing model that guaranteed the patient a minimum retrieval of twelve eggs or up to four cycles of egg freezing (whichever came first) for $4,990 so long as their anti-müllerian hormone (AMH) level was found to be normal (1.0 or greater). There were many questions and much confusion about this offer, which the host and doctor sought to explain. During post-event mingling, one attendee with whom I conversed appraised the clinic positively, noting that she really liked their “twelve-egg guarantee.” She may have mistaken the offer as a guarantee of retrieving twelve eggs. Further, the host provided a general answer to a specific question from the audience about their clinic's success rates, stating that success depends on individual results including the number of eggs yielded and the age at which they were frozen. Similarly, the doctor generalized that no clinic could provide that information since the vast majority of their egg freezing clients have not gone back to use them.
At Event B the doctor skipped over one slide depicting a timeline from egg freezing to live birth in seven years until an audience member asked her to go back to it. Speeding through the information, the doctor first pointed to information on the slide stating that a woman starts out by needing, on average, three egg freezing cycles and noted that the slide was old and that it was actually only one to two cycles in her experience. Then, the doctor continued, they freeze their eggs on average for five years, after which they undergo three IVF cycles on average to get pregnant (again noting it was just one cycle in her experience), followed by nine months of pregnancy for a total of seven years to live birth. The doctor interpreted the infographic for the audience, stating that the point of the slide was to show that newer clinics would not have this information because they do not have the “results.” However, it was unclear how this slide provided clinic-specific information on its own results. The information implied one will eventually get to live birth (it is just a matter of time). It did not specifically state the number of cycles attempted with thawed vitrified oocytes overall and rates of pregnancy or live birth from those oocytes. In another slide, a highlight put on “6,000+ eggs unfrozen for transfers” did not state whether those eggs all survived the thaw, nor whether they led to pregnancy or live birth.
In Event C, the doctor, like the host of Event A, deflected a question about rates of miscarriage specific to the clinic by stating that the success of IVF will depend on the age of the egg. By analogizing the search for a clinic with buying a plain white t-shirt—you get the same quality regardless of whether you pay designer prices—she implored the audience to not get caught up in comparison shopping under the assumption that other clinics would yield better results. Shifting the responsibility for results squarely to the patient and their willingness to take action before it is too late, success is defined within these events as variable depending on the age at which one freezes their eggs. As with Event A, the doctor generalized the response further by claiming that all clinics use the same advanced vitrification and genetic-testing technologies and that to judge them on the basis of success rates is “a thing of the past.” None of the clinics offered clinic-specific results up front. Only in response to questions from the audience would they highlight their competitive experience or pricing, but none of them disclosed clinic-specific statistics, deemed by the ASRM Ethics Committee as necessary to ensure valid informed consent.
Did they provide information on the egg freezing process, including potential and uncertain risks along with limited safety and outcome data?
All events devoted substantial time to describing the process, but none mentioned the possibility of uncertain risks in spite of the ASRM's directive to disclose “unknown long-term health effects for offspring” and the possibility that “harms that are not fully understood” may emerge (1022). Side effects mentioned were nausea, bloating, and pain at the site of the ovary (Event A), tenderness and bloating (Event B), and bloating and fatigue, but not in ways that would be noticeable to others (Event C). In response to a specific question on potential complications, only the doctor at Event B acknowledged the possibility of “extreme bloating” and “overstimulation.”
Affect and Sociality of Egg-freezing Events
That these events were deficient in relaying critical information for valid informed consent is relevant. Strategic omission of information or the presentation of misleading information is troubling, even if partly corrected through ongoing communication in later consultations with medical providers or through the detailed information relayed in informed-consent forms. The importance of timing of information provided on known and unknown risks, for example, was evaluated by egg donors as critical to their autonomy. Egg donors, who undergo an identical procedure as egg freezers, felt that being told about immediate side-effects shortly before getting injections or surgery prevented them from making a different decision about undergoing the procedure (Tober et al. Reference Tober, Garibaldi, Blair and Baltzell2020, 8). As a gateway to the egg freezing process, informational events play a critical role in initiating informed-consent procedure. However, the issue is not just about what is relayed but how. Harnessing particular affective responses via egg freezing events may influence the way one engages the informed-consent process. Although retrospective and long-term studies of egg freezing experiences are severely lacking, at least one study documented “nonnegligible” decision regret, with sixteen percent of survey participants experiencing moderate to severe regret and nearly half some regret (Greenwood et al. Reference Greenwood, Pasch, Hastie, Cedars and Huddleston2018). This raises the question of whether event participants are more likely to overlook missing critical components of information or to skim over some components based on their own compelling affective responses.
In order to understand the more nuanced and complex forms of affect that circulate at these gatherings, I draw on classic forms of event organizing designed for and by women such as entrepreneurship and self-help consciousness-raising as embodied in Tupperware and the classic book, OBOS. Although making profit is inherently a part of the Tupperware party and the antithesis to grassroots feminist health-consciousness-raising (Ruzek and Becker Reference Ruzek and Becker1999), the strategic production of egg freezing events draws on a potent combination of the sociality inherent to both. Egg-freezing events are characterized by the consumption of information as well as affect in an inherently social situation that provides social recognition to attendees.
Eggbanxx in 2014 brought “party” into the nomenclature of egg freezing events, beginning an initial association with the classic Tupperware party of the direct sales past. Even when the titles of the these events have shifted away from “party” to “101” as the classic introductory college course number, the events I attended, especially Events B and C, strove to achieve a party-like, relaxed atmosphere through music, wine, Prosecco, hors d'oeuvres, happy-hour scheduling, and physical aesthetics, such as an interior design that resembled a living room with a coffee table and sofas, complete with a “host” not in a white coat. Egg-freezing events blend work and fun, a critical element to the classic Tupperware party, to take the edge off cold, clinical encounters and the rigors of a procedure that involves daily injections, frequent bloodwork, ultrasound monitoring, and surgical retrieval. I observed women coming to these events alone, sometimes in small groups, and less often with partners. Although not capitalizing on women's preexisting social relationships quite in the same way as classic direct sales did, the gathering itself becomes the point of social departure that demonstrates that one is not in this alone. One leaves with free material and discounts but no reciprocal social obligation. Nicole Woolsey Biggart, author of Charismatic Capitalism, argues that direct sales fulfill social needs that more rational forms of a capitalist market cannot by drawing on social interaction, caring, and the emotional labor on which these depend (Biggart Reference Biggart1989). Christy Jones recognized the potential for big business and demand, but her own embodied experience with the procedure gave her another insight. “[O]nce I realized what you have to go through emotionally and physically to freeze your eggs, I realized this is a major societal shift. It became clear that only very motivated women were going to go through with it” (cited in Spar and Hull Reference Spar and Hull2019, 1). Direct sales facilitate not only exchange of physical products, but also provide social recognition to the consumer (Bardowski Reference Bardowski2012; Mullaney and Shope Reference Mullaney and Shope2012; D'Antonio Reference D'Antonio2019). In the case of egg freezing, the function of empathetic social recognition may be just as invaluable, a way to motivate women by championing their desire for maternity, giving them permission to engage in a futuristic enterprise, and stoking their imagination of family. If Tupperware parties once recognized women's efforts in the domestic sphere, egg freezing events recognize their achievements in the professional sphere: “You are all educated women—rock stars living in [major US city] but don't know about our fertility,” the doctor at Event C stated and then went on to righteously critique that women, through no fault of their own, must unjustly bear the price of a lack of information and education on female fertility decline. The statement makes a strategic shift from “you” to “our” mid-sentence. Just as with the iconic trope, “Our Bodies, Ourselves,” the host seeks to motivate “women” collectively to take control of “our” fertility. Similarly, Event A advocated for special recognition of egg freezing clients, who ought to be served in their own dedicated clinical space rather than ignored by traditional fertility clinics focusing on the needs of the infertile. Both conservative (feminized) and liberal (feminist) ideals lie at the core of direct sales and egg freezing marketing. They both are oriented toward a domestic sphere (from the inside out or the outside in), promise a kind of enactment of work–life balance, embrace the tradtitional biological family ideal, and respect and recognize working women.
Apart from fun and (social) recognition, physical aesthetics are a critical element of feminized modes of consumption. Jan Thomas and Mary Zimmerman document the corporatization of women's health since the early 1980s and related selective appropriation and dilution of the organizing principles of feminist health care. As hospitals sought to increase revenue by attracting women as self-paying clients, they built attractive and comfortable feminized spaces that offered a range of profitable services. “Pavilion rooms were decorated in soft décor such as mauve and gray. Fluffy robes or bed jackets, stylish hospital gowns, and other ‘feminine touches’ were introduced to make the environment more women friendly” (Thomas and Zimmerman Reference Thomas and Zimmerman2007, 367). Egg-freezing events follow the overall trend in the corporatization of women's health, in which “women have moved from subjects of care to become objects of treatment and revenue production” (361). All three events sought to create a “woman-centered,” relaxed atmosphere distanced from clinial physical environments. A young, feminized aesthetic was most pronounced at Event C, which, like one model of hospital women's health centers, seeks to become a “one-stop shop” through the provision of additional fee-based retail and nutrition and mental health counseling services (370–72). Coupons or free trials of women's group therapy and guidance, immune-boosting superfoods, pregnancy supplements, as well as perspirology workouts were among the offers made through their email communications.
Other aspects of the egg freezing events mimic somewhat more authentically the legendary 1970s women's health movements in the US as embodied in OBOS. A major impetus for the women who first assembled to research and write the iconic book was a critique of “condescending, paternalistic, judgmental, noninformative,” predominantly male doctors at the time (cited in Morgan Reference Morgen2002, 4). Events A and C employed this sense of injustice, suggesting that OB/GYNs paternalistically withhold critical information that prevents women from “seizing the means of reproduction” (Murphy Reference Murphy2012). The movement's appeals to demystify medical knowledge are appropriated by these events in a way that cashes in on the classic liberal impression of knowledge as power. Kathy Davis describes women's health activism associated with OBOS as a critical epistemology that reclaims the epistemic agency of those who seek knowledge about their bodies for the purpose of taking practical action to empower themselves and for the sake of a broader feminist collective agenda (Davis Reference Davis2007). Egg freezing event participants are encouraged to engage medical knowledge in this way, but not too critically. Instead, they are invited to know their own bodies in a prescribed way (through a fertility assessment). They should become curious and ask questions about their personal risk of infertility and probability of reproducing, and then they should take action. That is, they are to engage as agents in a speculative (and embodied) form of reproduction through calculation and cycling. For example, at Event C the doctor devoted considerable time to discussing various scenarios on how to calculate the number of eggs a woman would need and the number of cycles one might undergo based on her age, the number of children she wants, and a presumptive ten (eggs) to one (baby) ratio. Similar to speculative financial investing, speculative reproduction should be engaged in with optimism and without reliance on a return. To a question at Event A about success rates, the host answered that many women who freeze their eggs assume they are only using it as a back-up, do not actually use them, and sometimes conceive naturally later. The doctor at Event C, which aggressively marketed to younger women, took this one step further by making strong and repeated pleas to those who might imagine having a good chance of conceiving a first child naturally to consider their need for assistance later on when ready for a second or third child.
Imaginaries of family in the future are critically important elements of speculative reproduction. This is not maternal role-play in a game of house but a new feminist wellness protocol (add a fertility assessment to the annual pap smear) enacted in the present as it orients to the future. Participants are encouraged to actively imagine the number of genetically related children they want ideally as they consume information that equates their fertility with “loss and decline,” a point made by van de Wiel, who distinguishes this type of fertility education from a more liberatory and critical form of fertility literacy:
[R]ather than a general fertility education focused only on women's declining conception rates, what we need is a fertility literacy for analyzing the rhetorical framing of fertility facts, situating one's experiences within sociocultural and political-economic systems, and positioning oneself in relation to structures of power, whether organized by nation-states or by global markets. (van de Wiel Reference van de Wiel2020, 234)
I agree and suggest that egg freezing events invoke futurism in a way that “tends to displace discontinuities, contradictions, exclusions and violence, in favor of a celebratory, monumental future time” (Marez Reference Marez2016, 9). Futurism, as encouraged in egg freezing events, can smooth over reproductive disruptions in the present by bringing one back to the imagined linear path of “straight time” (Edelman Reference Edelman2004; Inhorn Reference Inhorn2008; Muñoz Reference Muñoz2019). By weaving together aspects of direct sales marketing with legacy elements of women's health activism, egg freezing events produce and perform sophisticated affect that raises anxiety just as it promotes relaxed complacency, that informs just as it obscures, and that forecloses some imaginaries while profiting from others. A feminist response would hold these events accountable not only to their obligation of fulfilling valid informed consent, but also to reclaiming sociality and futurity in ways that open alternatives to prescribed social orders.
Acknowledgments
I would like to acknowledge the contributions to the development and improvement of this article of Lisa Campo-Engelstein, Ellen Foley, Jade Sasser, and Emily Merchant as well as the anonymous reviewers.
Rajani Bhatia is Associate Professor in the Department of Women's, Gender, and Sexuality Studies at the University at Albany, State University of New York. The author of Gender before Birth: Sex Selection in a Transnational Context (University of Washington Press, 2018), her research interests lie in developing new approaches to feminist theorizations of reproduction and feminist science and technology studies. Topically, she has focused on issues that lie at the intersection of reproductive technologies, health, bioethics, and biomedicine.
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