“You will live your normal life.”
A blonde woman in a white coat smiled from the screen, melodically prolonging the first vowel of normal. I was thirty-eight, single, Skyping in April, picturing a summer I might spend sipping vino blanco. It was 2018, and I was hoping to go on vacation in Bilbao. I was also hoping to extend the period in which I might someday, somehow biologically reproduce.
Though the men I tended to sleep with were unsympathetic with this second goal, my toothsome, if pricey, fertility specialist was not. During our follow-up appointment in 2017 to my initial round of oocyte vitrification at his St. Louis clinic, he pulled up the webpage for IVI, an assisted reproduction medical group in Spain. “This place is the best,” he grinned as he swiveled his laptop, its lid plastered with 1990s band stickers. “At least if you’re not in the states.”
That first egg-freezing escapade a few weeks prior had led to meager results. “You can always try again,” the nurses had assured me when only four were procured (on Thanksgiving Day, no less). No, I shook my head, the twilight sedation fading, “I cannot.” I didn’t have the money, and my insurance wasn’t covering it. With no proven history of infertility, I had already battled with my provider to invest its standard $10,000 toward the procedure. “But I haven’t ever tried to get pregnant,” was my refrain, duly proud of my decades dodging unplanned progeny. “God only knows how fertile I am!” My private university boasted of its generous health care benefits, yet endorsed a fertility assistance policy that punished anyone who had never tried (and failed) to get knocked up “naturally” with a heterosexual man.
As far as lack of access to equitable (let alone affordable) assisted reproductive services, I had significant company. In the United States, “40 percent of American women of reproductive age have limited or no access to nearby fertility treatments,” according to the New York Times. One in eight couples including a woman over thirty has trouble conceiving, and the number of individuals, across sexual orientations, interested in non-traditional routes to biological parenthood is on the rise. With the average cost of in vitro fertilization (IVF) around $12,000 or $30,000 for one cycle and cryopreservation around $10,000 or $20,000 in the United States—per round!—few but the wealthy can usually justify the expense. I was also far from alone in finding myself unpartnered in my late thirties. As noted in a 2019 study in the Journal of Marriage and Family, among college-educated singles, women currently outnumber men, and these same women (at least in the hetero sphere) are more inclined than men to want a partner with the same or greater education. This same study concluded that unmarried women of both low and high socioeconomic status face “serious shortages of potential marital partners.” Skepticism toward marriage itself aside, given how precipitously a woman’s age can inversely affect male interest, it’s no wonder I had at least a dozen fetching female friends fretting about difficulty of finding a mate before their clocks timed out.
Even if it didn’t feel so at the time, I had it much better than the majority of wombed citizens who wish to have children. I had a solid position as a senior lecturer at an elite institution, a first-rate medical center a mile away from home, a small amount of savings, minimal debt. And even if my Catholic parents were not emotionally supportive, my younger sisters were, as were a bevy of friends (and even exes) who extolled my efforts to ice my ovums as intrinsically feminist. That reproductive autonomy is a feminist issue seems to go without saying. But, as is so often the case, a feminist issue is also an economic one, and economic issues are less likely to foster estro-solidarity. Roe or no, the affluent are much more likely to have access to safe abortions. On the flip side, the affluent are frequently marketed ever state-of-the-art ways to pass on their genetic material; the poor and working class are often treated like their material is cursed to begin with. As someone with a fair amount of cultural capital, I was bombarded with the “it’s never too late” mantra common among the former group, while keenly aware of the financial limits of “doing it on my own.” Having children is expensive. So, too, for a significant percentage of women, is the act of getting pregnant, or taking steps to do so later.
For many women, especially those unpartnered, the question of whether to vitrify one’s eggs before they crack is more accurately a question of whether to risk going into debt before one has even entered the henhouse. While the numbers are improving—in part due to the aftermath of the Great Resignation—as of 2020 nearly 20 percent of major U.S. employers provide funding for freezing. For smaller companies with over five hundred employees, it hovers around ten percent. Note that “funding” and “coverage” do not necessarily mean paying for all expenses involved—expenses that, due to the amoral clusterfuck that is our health care system, are almost impossible to estimate ahead of time.
During my first stint injecting my lower abs with a cocktail of refrigerated hormones—together known as “ovarian stim”, for “stimulation,” at the cost of some $5,000—my daily life was radically altered: blood was drawn early every morning, followed by vaginal ultrasounds; exercise, caffeine, and alcohol were verboten. The less life’s pleasures could be enjoyed, it seemed, the more eggs I would harvest. Sacrifice was virtue—even before official motherhood.
Communicating with Dr. Maria Martínez Cañavate on Skype the next spring, I wondered if my Basque country exploits would need to be just as immoderately temperate. “Normal life,” she told me. At the time, it never felt wilder.
Egg-freezing in the twenty-first century may seem de rigueur for a blown-out breed of lady professional; Sex and the City broached the topic as early as 1999, after Miranda, thirty-three, is diagnosed with a “lazy ovary.” But in fact, the American Society for Reproductive Medicine removed the “experimental” label only ten years ago, once rapid freezing became reproducible, paving the way for women with no (proven) history of infertility to pursue “elective” vitrification. Between 2010 and 2016, the rate of American women freezing their eggs rose 880 percent. At the time I decided to freeze, I knew only one other woman who had—a friend who did so at thirty-seven when she was working for a New York health care advertising agency in 2015. “I felt like I was on a conveyor belt at a factory farm,” she shared when I asked about her experience. “NYU’s med center was a well-oiled machine.” But still single two years after the procedure, she didn’t regret her decision.
So why, after a similarly impersonal, often demoralizing experience freezing my eggs, would I want to go through it again? Numbers. Studies have found that for a woman who freezes five eggs at age thirty-five or younger, the chance of live birth is only 15 percent; I netted but four eggs at age thirty-eight. If I could get closer to ten, my chances would—optimistically—increase to closer to 60 percent—odds decent enough, I wagered. If you freeze fifteen or more, the odds get even sweeter, at 85 percent. But given my plummeting levels of AMH—the hormone which determines ovarian activity—even a baker’s dozen wasn’t in the cards; with all the money in the world, I’d still have to go through the process four or five times, simply untenable for someone with a full-time job (or lacking a needle fetish).
While options abroad abound for less costly cryo, Spain remains the most popular European country for international fertility treatments—largely due to the quality and affordability of procedures that in other developed countries, like France, Germany, or the UK, are either illegal (especially for single or lesbian women) or, in the case of the United States, prohibitively expensive (in many cases even for those who, like me, enjoy subsidized health insurance). Conducting more than one hundred fifty thousand procedures per year, Spain ranks first in Europe and fourth in the world for reproduction technologies. Nearly 10 percent of births in the country result from assisted fertility measures, be this in-vitro fertilization or the artificial insemination of eggs (unlike most states in the United States, surrogacy there is still illegal). Doctors are economically “more close to the people,” explained Dr. Martinez, via Zoom interview last summer. “Even though I work in a private clinic, I have clients across sociological classes. The prices of materials of the lab is exactly the same here and in United States; the price for the patient is higher there because of doctors and clinics.”
Enlisted to join me across the Atlantic in preserving my genetic booty was my close friend Eva (a pseudonym). A novelist and teacher I had known for over a decade, she had just moved back to the States after a breakup with yet another man who (lo and behold) did not know if he “was ready” to be a father. One year my junior and now reliant on Medicaid, Eva hesitated over the cost of the trip, not to mention the stress of seeking medical treatment in a town that neither of us knew. At the same time, both of us had our summers mostly off. I had a friend from Bilbao—Alicia (also a pseudonym)—who would gladly help us navigate. Perhaps most crucially, Eva could put the entire thing on her credit card. “If you wait till you have savings, you might not get many eggs,” I reasoned at a hummus bar in Chicago, where I’d taken the train to visit her before the holidays. Eva knew that my first attempt with freezing was rotten with disappointment. She also read and spoke Spanish fluently. By the time I boarded the River Runner south to head home, we agreed to sync up our cycles late spring.
What is “having it all”—and why has it so stubbornly endured as the American woman’s approximation of personal success (or failure)? In short, it is to emulate what (arguably very few) men have enjoyed for decades: the fulfillment of an individual passion or talent through well-compensated work along with the (arguably) narcissistic thrill of reproducing yourself without ceding your entire identity to the thrall of charming clones. So long as high-achieving women aspire to the same opportunities as high-achieving men, “it all” will remain a fraught proposition. So long as the nuclear family remains, in concept if not in reality, the ideal U.S. household unit, professional women will need to outsource caregiving so long as they lack competent, stay-at-home co-parents. As has been widely written about, quite often this caregiving is outsourced to foreign women whose labor is cheaper. The recent rise in international cryopreservation is perhaps an extension of this pattern: when the costs of assisted fertility become unaffordable in your own country, outsource the service to a cheaper one, especially if that country, as is the case of Spain, is known as becoming a global leader in scientific innovation.
In 2019, Instituto Valenciano de Infertilidad (IVI)— the first Spanish clinic specializing exclusively in assisted reproduction—merged with Reproductive Medicine Associates of New Jersey to become the largest assisted reproduction group in the world, with branches across Europe and the United States. They share a logo featuring three cerulean sans-serif letters hugged by a parenthesis that mimics a baby bump, but the similarities end there. As of October, 2022, IVI’s Spanish website lists the price of fertility preservation, or egg freezing, at starting at €2,630 (excluding pharmaceuticals, typically around a thousand); on the American RMA webpages, prices are, tellingly, nowhere to be found. Instead, we are given a list of accepted insurance companies, along with a list of “Questions to Ask Your Insurance Provider,” aside a photo of a bubbly brunette holding a rhinestone iPhone (one can only surmise what her agent could be telling her).
On the website for Ginemed, the Spanish medical group for which Dr. Martinez currently works in Madrid, empowered woman rhetoric is front and center. Scrolling down the site, a photo of a hip, bespectacled woman is captioned “Unidad de Maternidad y Edad Avanzada,” or “the union of maternity and advanced age.” Toward the top, three pics advertise pages for their respective categories: “Mamá sola” features a slender woman with an infant’s crown against her cheekbone; “Mamá y papa” depicts a heterosexual couple beaming down at a swaddled newborn; and “Mamá y mama” presents two women in sweaters walking down a quiet boardwalk. Moderately diverse as the poignant trio may be, each family is comprised of fit Caucasians in polished casual clothing. Drop the babies (tenderly!), and you have a Crate & Barrel ad.
While a handful of U.S. fertility clinics feature couples of color on their websites, none that I have found feature single black women. Instead, the black women presented on these sites tend to be the nurses—or doctors—administering advice or treatment to white families. As important, and accurate, as it is to reflect the black female leaders in reproductive endocrinology, the pattern is also a bit disquieting given the history, and enduring reality, of black women playing caregiver to middle-class and wealthy white families. As Caille Millner put it in a 2021 essay about her experience in a support group for black women facing fertility issues: “The issue at hand was our race-based pattern of wealth accumulation, but the result was that these women were being denied the chance to reproduce. It was another ugly chapter in a long history of oppressive control over women’s fertility in general and Black women’s fertility in particular.”
Outside IVI’s clinic in Leioa, a tony suburb of Bilbao, the left entrance is framed with a photo of sun-kissed chicas, their mouths spread as though laughing at a joke; the right entrance is bordered by a photo of a thirty-something mujer in a pastel sweater, beaming down at a sleeping baby. The first entrance is for young women looking to donate their eggs; the second for presumably older women seeking to freeze or conceive via in vitro. In 2018, I identified more with the ethos of the first group and felt flattered when a friendly woman outside the building asked me to bum a lighter. But I undoubtedly belonged to the second group: over thirty-five and serious about spawning.
At the time, I assumed the millennials heading toward the left entrance were motivated by a hefty chunk of euros. Not so. Whereas egg donation in the U.S. nets between $5,000 and $10,000, it was, and remains, illegal in Spain to donate one’s eggs for payment; women are, at least in theory, motivated by goodwill, compensated between €800 and €1,000 because, as an IVI webpage describes, “the process can be invasive.” And yet, according to its website, IVI has one of the largest egg banks in the world, suggesting that at least some level of intergenerational female solidarity is at play. “In Spain, there is a strong belief in the value of altruism, of helping other people,” Dr. Ferrando, current director of IVI Bilbao, stressed to me in a recent video chat. “We also have the highest rate globally of organ donation. A lot of the women who donate their eggs will ask to be contacted if their eggs are used. Because of the law, it’s illegal to do this. But if the women were only interested in money, they wouldn’t ask.”
Solidarity aside, the process of artificially stimulating ovaries to produce as many viable eggs as possible, then suck these eggs out before it’s too late, is far from predictable from woman to woman. For Eva and me, generic birth control may have aligned our menstrual cycles, but that’s all it could guarantee in terms of shared outcomes. While we both had a pesky, empty egg follicle in one of our ovaries before we arrived in Spain, by our first appointments at IVI, Eva’s had disappeared, while mine lingered like a loitering jellyfish. Whereas it was unclear whether I would be able to proceed at all, my friend, only a year younger, was blessed with what seemed a chica’s fertility. Compared to her veritable Frigidaire of follicles, from which it was predicted they could pull some fifteen-to-twenty eggs, I might as well have been lugging around a mildewy Coleman. Four days later, after Eva had already started “stim,” my follicle had dissolved and my estrogen levels were just high enough to move forward. When I wasn’t shooting up hormones, I spent my afternoons wandering Getxo’s beaches, consuming gelato, and, when it wasn’t raining, sunbathing topless while exploiting the free Wi-Fi to work on my online summer course.
In the States, I had expected to be on the drugs for at least ten days, then was called a week later, while in line at TJ Maxx, with the news that “[my] ovaries are ready!” even though the yield was half the initial estimate. In Spain, the protocol was deliberately adjusted to “stim” much more slowly, so that overzealous empty follicles would not crowd out legitimate eggs. That I had never been informed that a particularly large, empty follicle was also present in the States, lowering my final count, came as no surprise; after all, I was not meeting with my doctor the entire week of ovarian stim. The revolving round of nurses spreading my legs and taking my blood barely explained a thing, and the ultrasound screen was placed behind me, so that I had no idea what was going on.
At IVI, I witnessed my follicular progress on the ultrasound screen on the daily, after which I was given the lowdown, in detail, by Dr. Martinez, whose English was prone to endearing idiosyncrasies. As she narrated how my eggs “would grow up,” I imagined them crossing important milestones like learning to drive or breaking someone’s heart. After twelve days tracking their coming-of-age, she indicated that we would need additional time for the eggs to mature. Meanwhile, my mother’s surprise sixtieth birthday party was a few days after my scheduled return. Was it worth it to extend my stay to maximize the chances of greater retrieval? With the goal of ten eggs in mind, I wrestled with the amount extra it would cost, and whether my mom would care if her eldest, who planned the party, wasn’t there to host it.
On hold with AirFrance in IVI’s soft-lit waiting room, I hummed along with a Madonna refrain emanating above the Nespresso station. “If I could melt your heart . . . we’d never be apart.” The travel insurance I’d purchased was, apparently, useless, since my medical complications were not the result of an accident abroad. “Give yourself to me . . . you hold the key.” I ended up booking a flight on a budget airline, departing four hours after my surgery. “You’ve done this before and it will be okay,” Dr. Martinez assured. “You’re not going to miss your mother’s day.”
Who “deserves” to become a parent? And who deserves to have that opportunity in their later years? Rhetorically fraught as the verb deserve so often is, these questions continue to pose thorny political—and philosophical—implications. Given the number of U.S. women forced to exit the workforce during the pandemic, forfeiting ever more economic solvency, the inability for many to afford or pursue cryopreservation opens up even more questions in terms of who has the right to conceive and where they will choose to conceive in the future. At the same time, fertility tourism could eventually mean that countries like Spain prioritize serving foreign women like me over their own citizens. Would a single-payer health care system in the United States change this in the future? Should any such system privilege assisted fertility as much as family planning? Should the chance to postpone childbearing be a priority at all—especially when families in developed countries already ransack an alarming percentage of the planet’s dwindling resources?
Of course, framing these quandaries as “yes” or “no” is itself reductive. So long as humans have been around, the desire to reproduce has run deep, and is unlikely to disappear, even among the staunchest environmentalists. So long as we honor women’s desires as valid, we cannot dismiss the desire to become a mother as automatically indulgent, especially when these days it is precisely the most indulged who can afford to procreate. In Spain, at least, the pandemic seems to have hastened a class-wide awakening. “All the clinics in Spain blew up once lockdown restrictions were over,” Dr. Martinez explained to me. “People were thinking about their lives [during the pandemic]—it was a kick for many women.”
My own “kick” occurred much earlier, when, in 2017, I lost my gay best friend of twenty years, a man with whom I’d half-seriously planned to make a baby if we were childless at thirty-eight. When I lost him, I also lost the possibility of creating a child with someone I loved. That my surgery in 2018 added five eggs to my cryo-nest existentially buoyed me; I returned to the United States fuzzy on painkillers and high on renewed options for the future. I made my mother’s birthday party. And I did not break the bank.
Why is the cost in Spain so much lower, despite comparable—or, in my case, superior— facilities and care? For one, the lower rates of remuneration for all labor involved. Reproductive endocrinologists like Dr. Martinez and Dr. Ferrando make about half the salary of their U.S. counterparts (who net an average of $270,000 a year). The cost of pharmaceuticals—even designer hormones of the same brand I was prescribed in the United States—are partially subsidized by the Spanish government, such that the total price was about a fifth for identical products. At the same time, the average salary for a professional thirty-year-old Spanish woman hovers right under $30,000, with at least a quarter of that devoted to taxes. A justifiable expenditure for a middle-class American woman making about twice that (as I did in 2018) may not be for the average middle-class woman in many European countries. “There are people in Spain who cannot even afford to get this,” Dr. Martinez acknowledged, pointing out that public insurance does not cover fertility treatments at private clinics.
Private Spanish clinics have recently taken efforts to finance the process for women who would otherwise balk at the sticker price. Instituto iGin, a clinic in Bilbao, advertises transparency about total costs, offering three to thirty-month payment plans for the procedure plus storage. The total for five years? Under €2,500. For two? Under €1,700. Drugs are an additional eight hundred to a thousand, bringing the grand total to €2,500 to €3,500—about half what I spent on pharmaceuticals alone in the states, and about a sixth the total typical price. “I am thinking about freezing next year,” my Spanish friend Alicia, thirty-seven, shared with me recently when I told her about this essay. Making around €23,000 a year as an international marketing assistant, she would have to hand over a tenth of her salary, which isn’t a viable option. “Even if I can save enough money, the financing will really help.”
A survey published by IVI this year found that 78 percent of Spanish women were delaying motherhood due to socioeconomic conditions—and these were women within income brackets higher than my friend. Like many women stifled during pandemic layoffs and lockdowns, Alicia faces harsher challenges than I did at her age, compounded by the gnawing feeling that the curtains are closing on her window of fertility. Like I did at her age, she feels tremendous pressure to act soon or foreclose on the possibility of experiencing both an exciting career and parenthood. Our recent conversation gave me pause—about not only my own reproductive choices but my rationale in making them. What “right” had I—or anyone—to become a mom in a world where so many lack the luxury of choice? Had my desire to reproduce capitulated to the same meritocratic myths as everything else: work hard, plan ahead, and accept your reward? Could I disentangle my desires from what I “deserved?”
Perhaps rather than trying to “have it all,” we should aim to “revel in more” of what we already have—whether that be personal freedom, professional fulfillment, or erotic satisfaction. While rallying for more options in term of starting, forestalling, and preventing biological parenthood, we also should focus on building extended kinship networks in which we can support one another, especially if we lack a romantic partner. And not just for women at the top of the economic pyramid, but all women—including those who were not deemed biological “women” at birth. In any future worth having, “sharing it all” might be a much more realistic, and surely less solipsistic, vision.
And what has come of my adventures in cryopreservation some four years later? I am forty-three and have, to the extent it is possible, made peace with the fact that my nine frozen eggs, in two different countries, will never be fertilized—at least not on behalf of my own motherhood. There are times I wish I could auction them off to the greatest bidder, presenting an (admittedly dated) flattering headshot, (admittedly dated) standardized test scores, and (evergreen) list of salient accomplishments (your child could also be queen of obstacle courses!). But the reality is that these eggs will probably chill for years, and I will pay to keep them this way. I keep them in case my sisters—or nieces—might ever want to use them, so that my labor and money were not for naught. I also keep them in the extremely unlikely (and tragic) event that I lose my current partner before old age.
As for Eva? We are still very close, though parts of that trip certainly tested our friendship. Now forty-two, she is in her second trimester of pregnancy, having conceived last summer—with her 2018 eggs—via in vitro with a man she met mid-lockdown. While I envied her in 2018, I am happy for her today in a way that is, sadly, all too rare: the joy that comes not from getting the thing you want yourself, but from seeing someone else get it, and knowing that in some small but meaningful way, you helped make it possible.
If that’s not a legacy, I don’t know what is.