Dr. Daniel B. Shapiro is the medical director of Reproductive Biology Associates (RBA) in Atlanta. He is renowned for his work with GnRH antagonists in IVF treatment. With the advances made in egg freezing by RBA’s lab, under Dr. Peter Nagy, Dr. Shapiro led the effort to establish a working clinical model for RBA’s egg bank. Since the opening of the frozen egg bank for egg donation in 2007, Dr. Shapiro has acted as its clinical manager.
Eggsurance Interviews: Dr. Daniel Shapiro
Q. How long has your RBA offered egg freezing?
A. In 1997, we had the first babies born from egg freezing in the U.S. using the slow freeze method. At that time, slow freezing was extremely inefficient. RBA has been doing egg vitrification since 2006.
Vitrification was first reported in 2000 with a human egg, but it was not replicated until 2004. Then in 2005 there were about 6 or 7 babies born in Japan and Italy. In 2006, RBA ran an extremely successful pilot study in which 17 of the original 20 recipients had live births. After that, we started to bank donor eggs. We do almost no fresh egg donations now – they are almost all frozen.
Q. What do you think is the optimal age for women to freeze their eggs? Why?
A. The best time to bank your eggs is the earliest you can do it as an adult. Fertility rates do not really decline measurably in an IVF lab until the early 30’s. So, I would say that the sweet spot is in the late twenties or early thirties. Very few people have diminished ovarian reserve in their late twenties or early thirties and they will get their age-related statistic, which will be close to a 50% live birth rate, even 60% for the highest performers, per embryo transfer.
Once you get past age 33, 34, even up to 35, there is still about a 50% baby rate from frozen eggs. However, once you get past 35 it follows the pattern in regular IVF: from ages 36, 37, 38 you should expect a 30-40% live birth rate, from ages 38, 39, 40 it is approximately a 25-30% live birth rate, and from age 40, 41, 42 the live birth rate significantly declines to about 15-20%. Above 43, the genetic abnormality rate is extremely high at 90-99%. I would not recommend freezing eggs after age 41.
Q. Many women are confused by the variety of hyper stimulation protocols, can you clarify the primary differences between protocols?
A. Someone who wants to egg freeze with a high, favorable AMH will be on a Ganirelix-based protocol using FSH only. This has been the core protocol for our donor program, which gives us the ability to give an agonist trigger instead of hCG to avoid hyper stimulation. We have not had a single case of hyper stimulation with our donors since 2009 when we started using agonist triggers. However, in the event of over stimulation, we don’t have to cancel the cycle, but can finish it off with Lupron.
The alternative to that is someone who we suspect to be a low responder (with a low AHM) and wants to harvest as many eggs as possible. In this case, we use a high dose flare protocol. Sometimes we use combination protocols with hMG in them as well.
Once you get past 35 it follows the pattern in regular IVF: from ages 36, 37, 38 you should expect a 30-40% live birth rate, from ages 38, 39, 40 it is approximately a 25-30% live birth rate, and from age 40, 41, 42 the live birth rate significantly declines to about 15-20%.
Q. RBA is an egg banking pioneer, how do you think egg banking will impact the future of assisted reproductive medicine?
A. Egg banking for fertility preservation and egg donation basically allows levels of efficiency to come to IVF that we have not yet seen. It also allows us to accommodate all spectra of feelings about frozen embryos and what to do with them. Because, of course, if you can freeze eggs then you don’t have to use every egg that you collect. You can elect to inseminate a limited number, see what happens and if that doesn’t work you can always dip back into the supply of frozen eggs.
The obvious impact of egg freezing is for cancer patients in their late teens, twenties to early thirties who are facing long chemotherapy treatments, which could interfere with or end their fertility all together. So long as it is safe to delay the cancer treatment, we can, in about 2 weeks time, orchestrate an egg collection and egg freeze. The other group is professional women who either have not met Mr. Right yet or don’t plan to meet Mr. Right, and don’t want to be a mom yet. These women are interested in preserving their remaining fertility before they lose their remaining eggs.
Egg banking is already changing egg donation, which right now is completely dominated by donor agencies in certain regions of the country, particularly in the North East and California. The agents, unfortunately, have no interest or requirement to take care of the health of the donors. All they are doing is making a match. Right now the responsibility for the care of the donor falls upon the clinics. If you have a series of egg banks established within the US that are taking responsibility up front to care for, identify, and treat young women who wish to be egg donors then the agents disappear and with them some of the problems with the donor system go away. This has the effect of lowering the cost of egg donation, reducing the time to make a match, creating a more convenient system (no synchronization of cycles), and increasing levels of safety too because (though it is not currently required) it allows quarantine of the eggs until follow up testing comes back negative.
Q. What is the one thing you would like to tell women about egg freezing that they might not know or have considered?
A. We are in the middle of a significant social change. Parents who grew up in the traditional 1940 &1950s America expected that their children would do the same thing as they did and provide grandchildren in their late twenties and early thirties. Now this cross over generation is getting to the point where they are saying: “my daughter is 33- she is not interested in getting married and there are no grand babies.” Your parents are your allies – they are deeply invested in the egg freezing process. Because you are an autonomous adult, they don’t want to bring the topic up and step on your toes. However, this is a conversation that your parents will welcome.