Single Chinese Women Are Demanding the Right to Freeze Their Eggs. What Do We Actually Know About Egg Freezing — and What Should We Know?

We talked to women who have frozen their eggs, to agencies that broker assisted reproduction abroad, and to several doctors who do the procedure — and came away with some thoughts and questions.

On February 6, Zhan Yingying walked into a post office in Guangzhou carrying a thick stack of letters. She meant to mail them to every delegate of the Jilin Provincial People's Congress.

"When I learned that unmarried women in China are not allowed to use assisted reproductive technology, I felt disappointed and hurt. I felt I was being discriminated against for not being married, that the chance to freeze my eggs was being taken from me, and that this is really unfair," Zhan wrote in the letter.

Zhan Yingying is 29. She studied medicine as an undergraduate, psychology in graduate school, and is now preparing to switch fields again, to law. In January this year she went alone to a hospital in Guangzhou to ask whether she could freeze her eggs. She knew she would be refused, but went anyway: "I wanted him to tell me to my face that I couldn't, and to tell me why."

Until then, egg freezing had not been part of her plans. She knew little about it — partly because she was young, partly because she had never thought about marriage or children.

As she got older and the friends around her married and had babies, a thought surfaced one day: I don't want a child now, but when I'm 40, will it still be possible? That question is where almost every woman who looks into egg freezing begins.

"The World's Only Cure for Regret"

Many Chinese women, like Zhan, had no idea at first that the option existed, or that the law forbids it.

In 2015 the actress Xu Jinglei revealed that she had frozen nine eggs in the United States two years earlier. She was 41 at the time, and she called it "the world's only cure for regret."

The remark set off a public argument, and women began turning up at hospitals to ask about the technique, the procedure, and the price. In issue No. 8 of Health in 2015, Li Rong, deputy director of the reproductive center at Peking University Third Hospital, said the number of women coming in to ask about egg freezing was indeed rising, most of them over 35. The technique had matured, she added, but it had been practiced in China for less than ten years and had never been promoted widely.

The surge of interest prompted CCTV to make a six-minute segment restating the rules: "The Ministry of Health stipulates that single women may not undergo assisted reproductive procedures. Some hospitals allow single women to freeze their eggs, but to use those eggs they must produce three documents: an ID card, a marriage certificate, and a birth permit."

That one statement about egg freezing drew a storm of comment — which is a measure of how much demand, and how much confusion, there is among Chinese women.

In 2016, a Chinese woman named Manman also went to the United States to freeze her eggs. The BBC filmed the whole process. Manman is not single; she is married. But she said her job at this stage left her unable to give a child her full attention, so she decided to freeze her eggs first and keep the choice open.

"A lot of women are caught in this dilemma by the pressure to have children. Staying child-free takes too much courage, and once you've had one you're expected to have a second," Manman said.

The Single Women Going Abroad to Freeze Their Eggs

In April 2017 a travel package called the "U.S. Egg-Freezing Tour" appeared on Trip.com Group's app and website, and drew attention of its own. A Trip.com Group staff member told The Paper that China has 700 million women, and that as the number of older single women in big cities grows, egg freezing has real market potential.

Chinese law being what it is, more and more women are following Xu Jinglei and Manman abroad. The most common destination is the United States.

The United States opened egg freezing to general clinical use in 2012. Citing data from the Society for Assisted Reproductive Technology, The New York Times reported last year that of California's 51 fertility clinics, 33 offered tailored services for Chinese clients: Chinese-language paperwork, Chinese-language websites, Mandarin-speaking staff. Kevin Doody, then the society's president, said the number of egg-freezing cycles in the United States rose from 568 in 2009 to 6,165 in 2014.

Plenty of people have noticed the demand. Himalaya Medical Service Center is one of them. It is less than a year old and has offices in Shanghai and Washington, D.C. Its website says it "arranges treatment in the United States for patients, and offers a full range of services to clients in China with fertility needs who want to give birth in the U.S."

"Take infertility — the Chinese market may have 10 million people. IVF is available here, but it comes nowhere near meeting demand. As far as I know, plenty of single women are aware that egg-freezing technology in the United States is very advanced," Dr. Xu Jingwen, who founded Himalaya Medical Service Center, told QDaily.

The number is in fact larger than Xu Jingwen thinks. A China Population Association survey released in 2015 by the China Reproductive Health Network put the share of people in China with fertility problems at 12.5%, or 40 million. That is why agencies like Himalaya Medical Service Center have multiplied in first- and second-tier cities in recent years.

Besides the technology, the United States has relatively loose rules on human assisted reproduction, which is why women from many countries go there. Different states set different rules, and quite a few allow single women to freeze their eggs and give birth.

There, egg freezing is neither unfamiliar nor hard to talk about, and some companies even offer it as a benefit to their female employees.

In October 2014, Apple and Facebook announced new benefits, among them coverage for egg freezing and fertility treatment for female employees. Facebook's internal materials show it worked with Progyny, a well-known American fertility network, on a package of incentives — an employee who freezes her eggs through the program can receive up to US$20,000.

"The original idea behind egg freezing was mostly to serve cancer patients, to preserve their fertility. In recent years the demand has come more from social trends," said Dr. Shen Mengxun of Aiqun Obstetrics and Gynecology in Taipei, pointing to the rising share of people who marry late or not at all.

Dr. Li Risheng, an attending physician at the Assisted Reproductive Medicine Center of Taipei's Mackay Memorial Hospital, also told QDaily that the number of women freezing their eggs rises every year. Last year about 400 women did so at Mackay, the largest group of them over 38.

Taiwanese law, it is worth noting, does allow single women to freeze their eggs. But to thaw them later and go through assisted reproduction, a woman must still produce a marriage certificate.

Even that single provision has been enough to bring inquiries from women in mainland China.

Dr. Shen said that at Aiqun alone, close to ten single women from the mainland froze their eggs last year.

Why Can't Single Women Freeze Their Eggs Legally?

Egg freezing — oocyte cryopreservation — is one procedure within human assisted reproductive technology.

In 2001 the Ministry of Health under China's State Council issued the Administrative Measures for Human Assisted Reproductive Technology, which state: "Only women with malignant tumors, before radiotherapy or chemotherapy, and women with infertility who cannot undergo in vitro fertilization in time, may have their eggs retrieved and frozen." And: "It is prohibited to perform human assisted reproductive technology on couples and single women who do not meet the requirements of national population and family-planning laws and regulations."

The ministry's ban on egg freezing for single women is explicit.

Yet on September 27, 2002, the Standing Committee of the Ninth Jilin Provincial People's Congress passed, at its 32nd session, the Jilin Provincial Population and Family Planning Regulations, which state: "A woman of legal marriageable age who has decided not to marry and has no children may bear one child by lawful medical assisted-reproductive means." Jilin is the only province in China whose statutes let a single woman freeze her eggs legally.

"This is a regulation from their provincial people's congress, and it sits at the same level as the prohibition handed down by the Ministry of Health. Which means that whether a local hospital in Jilin performs the procedure or refuses to, neither breaks the law. It hands hospitals a gray area," Zhan Yingying said, explaining why she wrote to Jilin's delegates. The provision, she said, showed her both the contradiction between central and local rules and a way the law might be changed.

After Jilin passed the regulations, a few unmarried women teachers reportedly had their eggs frozen. The rules are still on the books, but no one has done it since, and hospitals generally refuse single women.

Some delegates raised the question of single women's egg-freezing rights at last year's Two Sessions. In February this year the National Health and Family Planning Commission replied that neither the Population and Family Planning Law, the Law on the Protection of Women's Rights and Interests, nor the marriage law denies single women the right to bear children — but that "writing specific provisions on single women's reproductive rights into the Population and Family Planning Law would require further study and deliberation."

Xu Jinglei's 2015 announcement drew experts and academics into the argument.

Liu Ping, deputy director of the reproductive medicine center at Peking University Third Hospital, told Health News at the time: "For a single woman, freezing eggs is a safeguard that extends her window and increases her chances of having a child. Given the needs of certain groups, and as long as it accords with public morals and harms no one and nothing in society, I personally think society should respect the individual's choice." If the family-planning principle had to be upheld, he added, controls could be applied later, once a woman enters the childbearing stage.

Zhai Xiaomei, dean of the School of Humanities and Social Sciences at Peking Union Medical College Hospital, took the opposite view: "The rules bar assisted reproductive technology for single women. From an ethical standpoint, that is mainly out of concern for protecting the child."

In March 2016, Zhu Min, then a deputy managing director of the IMF, said publicly that China would gradually become an aging society, with the elderly making up 12% to 13% of the total population. Against that background, letting single women freeze their eggs would push women's childbearing age back further and make the aging worse.

Some scholars argue as well that egg freezing delays childbearing, so the pregnancies that follow run into the problems of advanced maternal age — and that the rules around surrogacy are still unfinished. People may have a right to reproduce, but the act of reproducing raises a chain of ethical and legal questions.

The charge that it upsets traditional ethics is the one single women hear most often when they argue for the right to freeze their eggs.

"I think the state's system is built to protect the monogamous nuclear family. And there is a deeper problem, which is distrust — distrust that a single woman has the responsibility and the strength to raise a child and grow alongside that child," Zhan Yingying said. "Marriage may be one vessel for raising children. It doesn't have to be the only one."

Set the Law Aside for a Moment: What Do You Need to Know About Egg Freezing?

At the end of 2016, Cheng Xin (a pseudonym), a 34-year-old Taiwanese woman, was about to be posted to Europe. First she decided to freeze her eggs. Sixteen were retrieved. They sit in storage at Tri-Service General Hospital in Taipei and have been frozen for more than a year now.

"I think it would be pretty good to have my own child without being tied to anyone else emotionally or legally, and to raise that child my own way," Cheng Xin told QDaily.

She broke up with her boyfriend in 2014 and has not found anyone since. Two years on, she began to think she might never marry. But she did not want to lose the chance of a child just because she was unmarried. She was also aware of the biology: ovarian function declines with age.

Her mother had an ovarian condition, Cheng Xin said, which made her pay closer attention. One day she went in for a checkup and raised the subject of egg freezing with her doctor.

Once she remembered that Europe was coming, she decided quickly. "I'm the sort of person who doesn't let herself regret things later," she said.

It was a rushed decision. Looking back, Cheng Xin admits she had not thought it all the way through — but, she added, by the time the first stimulation shot went into her belly it was like getting braces: once the teeth are out, there is no point regretting it.

"The whole procedure turned out to be a bigger thing than I expected, and a more serious one," Cheng Xin said.

For women like her, the decision leads through several stages: ovarian stimulation, retrieval, freezing, and — possibly — thawing.

1. Egg quality falls with age

Fertility is tied to age mainly through the eggs. Doctors still disagree over whether a woman's lifetime supply of eggs is a fixed number, but they broadly agree that egg function declines with age and that the supply shrinks.

"In each cycle a woman ovulates only one egg, but somewhere between 100 and 1,000 eggs compete along the way. Think of fertilization, where many sperm compete and only one fertilizes the egg. When a woman ovulates, a single mature egg is released, and the eggs that lost the competition die at the same time," Dr. Li Risheng of Mackay Memorial Hospital explained.

Dr. Shen Mengxun of Aiqun added: "Statistically, 38 is the threshold. From a fertility standpoint, why do we say older mothers risk having a child with birth defects? Because the rate of chromosomal abnormality at 35 is not the same as at 38."

It varies from woman to woman, Dr. Shen stressed, and the key variable is her AMH level.

AMH is anti-Müllerian hormone, secreted by the granulosa cells of the ovaries, and it serves as a measure of ovarian reserve. Every woman who freezes her eggs is assessed for it first. It determines not only how many eggs she is likely to get and how good they are, but how much time and money the process will take.

"If AMH is between 2 and 8, egg freezing works quite well. Below 0.02 the cost goes up and the treatment cycle gets longer," Dr. Li said. AMH also bears on the pregnancy rate after thawing, and on how many eggs it is prudent to retrieve.

2. How many eggs are enough?

"We think 10 to 15 is best. Some women get only 2 in a cycle, others get 20," Dr. Li advised.

Dr. Shen described a real case: a 37-year-old single woman came to Aiqun to freeze her eggs, her AMH level was in good shape, and a single retrieval produced 20 eggs. A woman with a very low AMH level who gets only 2 in a session has to repeat the stimulation and retrieval several times, and each round is billed separately. At Aiqun, one round of egg freezing costs roughly 20,000 to 30,000 yuan.

Cheng Xin says she was lucky: her first cycle yielded 16.

3. What are the risks of retrieval?

Retrieval has to be preceded by stimulation, delivered by injection into the abdomen, and that part alone can take about ten days.

"The stimulation shots rescue the eggs that would have died competing during the cycle," Dr. Li explained. Some people think the shots drag out the next cycle's eggs and therefore age the ovaries. That is a myth.

Cheng Xin remembers the injections. They genuinely hurt, she said, and afterward she retained water and felt bloated.

"Honestly, stimulation shots can't be free of side effects. The common ones are bloating, abdominal pain, or mood swings," Dr. Shen said, adding that they pass, and clear up completely after the next period.

During the stimulation phase a woman must return to the hospital for ultrasound scans to see how many eggs are developing.

Once stimulation has gone smoothly, retrieval can begin. Dr. Li said the risks at that stage are the ordinary risks of surgery: a reaction to the anesthetic, bleeding, infection.

Retrieval means passing a needle through the vaginal wall to draw out the eggs. It requires general anesthesia, and the operation takes about 30 minutes or less.

4. Are children born from frozen eggs any different?

Egg freezing is not an old technology, and the methods have changed more than once. In 1986, Australian scientists reported the first successful in vitro fertilization using frozen eggs.

The technique then was very different from today's. It was "slow freezing," borrowed from embryo freezing. But eggs hold a lot of water, ice crystals form easily during freezing and damage the cell, and very few eggs survived thawing. That is why early egg freezing worked poorly, and why the field moved slowly.

What changed the course of it was vitrification, the method now in general use. "Before freezing, the egg is treated with a cryoprotectant, then dropped quickly into liquid nitrogen at -196°C, where it goes dormant," Dr. Shen said.

Because vitrification sharply reduces ice-crystal formation and keeps the egg intact, on average more than 80% of thawed eggs survive and more than 80% fertilize successfully — safer and more effective than what came before.

Even so, women keep asking one question: is a frozen egg worse than a fresh one?

Today's technique does not damage the egg, Dr. Shen said. What it might affect at most is function — the fertilization rate, for instance. "In principle a fresh egg and a frozen egg are no different. Freezing an egg does not produce a child with birth defects. The genes are fixed, we don't alter them, and there's no reason to worry that freezing causes chromosomal abnormalities. What matters is whether the thawed egg fertilizes properly. Once it becomes an embryo, everything after that is normal."

That does not mean a successful thaw guarantees fertilization and pregnancy. From surviving the thaw to fertilizing, then to pregnancy and live birth, the odds are not 100% at any step; they fall as you go.

In August 2017, Taiwan's Department of Health published its analysis of assisted-reproduction results on the island. The pregnancy rate for assisted reproduction — not egg freezing alone — rose from 37.2% in 1998 to 44% in 2015; the live birth rate rose from 27% to 32.5% over the same period.

5. How many years do I have to thaw them?

Cheng Xin is about to pay another year's storage fee, and has started turning over a different question: she may never use these eggs at all.

Under Taiwanese law, to thaw them and undergo assisted reproduction she would have to submit a marriage certificate. The eggs she froze are the eggs of a 34-year-old; her body, she knows, is getting less suited to pregnancy every year.

She does not doubt the technology, she says. If anything the experience convinced her that Taiwan is well ahead on it. What she noticed was the distance between the technology and the law, and that has left her feeling both contradictory and regretful. "The way the law is now, it only protects the right of married people to have children," Cheng Xin said.

Countries set different rules. Japan announced in 2013 that healthy single women could apply to store their eggs, though it advises against it for women over 40. Britain, like the United States, permits single women to freeze eggs.

Those laws track the local culture and the medical arrangements that go with it. Egg freezing is, after all, about reproduction, and it pulls in egg donation, sperm donation, assisted reproduction and surrogacy behind it.

If she means never to marry, Cheng Xin says, there may have been no need to freeze the eggs at all, because she may never get to thaw them — not unless she considers going to the United States to give birth.

"Statistically, only about 30% of single women worldwide who freeze their eggs ever thaw them. Egg freezing now is a bit like buying insurance: freezing gives you one more safeguard, but you may never use it," Dr. Li said.

Dr. Shen added: "Technically you can keep them frozen as long as you like. If a 35-year-old comes in to freeze her eggs, I'd advise her not to put off thawing them until after 38 or 40 — the mother's own condition during pregnancy matters too, and there can be complications from a high-risk pregnancy."

Zhan Yingying understands the risks and the procedure well. She wrote her own account of being turned away at the Guangzhou hospital into the letter to the Jilin Provincial People's Congress. One delegate, she told QDaily, wrote back personally and warmly, and said he would put forward a proposal on it before long.

"I have at least five more years to push this and finish it in China. I can't be sure those five years will produce results, or that more people will step forward or do anything. But I'm still hopeful, and I want to put a bit more of myself into it," Zhan Yingying said.

Cover image from BOSS Magazine and Roman Kraft on Unsplash