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The Business of Making a Baby

Lindsey J. Smith | March 26, 2018 | Story News and Features National

This story was originally published in the April issue of San Francisco

After spending her 20s
as an aid worker in Africa and India, Helena moved to the Bay Area in 2012, when she was 31. She wanted to apply her public health background to the startup world, so she worked for one health-tech company and then another. She quickly adjusted to life in the city and formed a group of single female friends whose ambitions closely matched her own. To Helena, these young women epitomized the freedom and boundless potential of Silicon Valley: They had worked hard, mapped out paths to promotions, and risen in their fields. They lived as mistresses of their own destinies.

But as their early 30s melted into their mid-30s, a question loomed like storm clouds on the horizon: How and when would any of them have children? Helena (who asked that her last name not be used) and her friends began discussing the option of egg freezing. A consensus soon formed: It was insurance for your future. It let you take your time and find the perfect partner. It would buy you more years to advance in your job before taking maternity leave.

Egg freezing became national news in 2014 when Apple and Facebook announced that they would begin covering the procedure—technically termed oocyte cryopreservation—for employees. Soon other tech companies, including Google, Uber, Netflix, eBay, and Intel, joined the fray. Before Helena knew it, seemingly all of her girlfriends were doing it: taking hormone injections to stimulate their ovaries, then undergoing in-patient “retrievals” to gather up all of their mature eggs, and finally having those eggs frozen in liquid nitrogen for however long they wished to wait before attempting a pregnancy. “I’m embarrassed to say that it was a little bit of like, ‘Oh, this is just a thing I need to do, I guess,’” Helena says.

Spurred by her friends’ experiences, as well as that of an acquaintance in her 40s who had been struggling with infertility, last year Helena decided to take the plunge. By that point, she was 35 and still single. But there was one hitch: The small health-tech startup she works for doesn’t provide egg-freezing benefits to its employees, nor does her health insurance cover the procedure. According to a 2016 report from FertilityIQ, a company that publishes fertility-industry data, the average cost for one cycle of egg freezing in San Francisco, including five years of cryostorage, is $15,600. Half of the women who undergo egg freezing need more than one cycle to obtain a good number of viable eggs, meaning average out-of-pocket costs can reach $30,000 or $40,000—way more than Helena could comfortably afford.

Then she learned about Future Family, a new San Francisco startup. After a yearlong private beta, the company launched last June, offering fertility testing for women (and later men) and financing for egg freezing and in vitro fertilization (IVF). Although most fertility clinics offer some form of financing, such plans are often partial, covering only the medical procedure and not the $2,000-to-$6,000-per-month course of hormone medications that precedes it. Future Family’s fertility plans, which run from $250 to $275 per month for IVF and from $150 to $175 per month for egg freezing, typically for five to seven years, cover all expenses—including initial screenings, medications, retrieval, genetic testing, and cryostorage—and require no down payment. (Future Family also offers “shared investment” financing plans that split the monthly cost between two people.) For Helena, the financing ended up being crucial. She got fewer eggs than expected in her first round of retrieval, so her doctor recommended she undergo a second round. “I would have hated to not be able to afford a second round after having gone through one,” she says.

Young, independent, and financially stable if not flush with thousands to burn, Helena is Future Family’s ideal client. The company, according to cofounder and CEO Claire Tomkins, aims to give people better information about and access to fertility services. And for Tomkins, a cheerful, driven woman, this mission is personal. Over the course of three years, she spent well over $100,000 on six rounds of IVF before getting pregnant with her now three-year-old daughter. At the time, she was the director of product and partner marketing at solar power company SolarCity (acquired in 2016 by Tesla), and she and her husband had the means to pay out of pocket. Nevertheless, she understood that for most women, the expense was a pain point at best and prohibitive at worst.

Her instinct is backed up by data: FertilityIQ found that more than 70 percent of people who undergo IVF earn at least $100,000 per year, while only 4 percent of IVF patients have incomes under $49,000. Tomkins began to wonder how to make fertility treatments more accessible to more women, and found the solution by thinking about the similarities between fertility treatments and residential solar. Both are expensive, complicated, and relatively nascent technologies. Both target consumers who have a higher-than-average level of trust in science and technology. And both cater to people who have the wherewithal to make a hefty financial investment and the faith that it will pay dividends in the long run. Tomkins bet that a financing structure like the one that worked for solar panels could bring egg freezing and IVF to the masses. “We’re very, very focused on access,” she says. “We really think about this as [a service for] the 99 percent.”

This egalitarian vision is bolstered by Tomkins’s belief that we’re on the edge of a fertility crisis. For reasons that are unclear, sperm counts among men in North America, Europe, Australia, and New Zealand dropped by nearly 60 percent between 1973 and 2011 and show no sign of leveling off, according to a study published last year in the journal Human Reproduction Update. While birth rates rose for women in their 30s and 40s, they declined for women under 30, and the Centers for Disease Control and Prevention reports that the general fertility rate in the United States hit a record low in 2016. What’s more, a tougher job market and longer life spans may be leading millennial women to hold off on having babies. These changes mean that more women and couples are likely to need a little help from science to conceive as they age.

But if women don’t start thinking about their fertility until their late 30s or into their 40s, they may have so few genetically healthy eggs left that they’re beyond the help of so-called assisted reproductive technology. Tomkins, unsurprisingly, believes women need to start planning at a much younger age. “It should not be the case that fertility is this black box that you don’t get to find out anything about until you start having kids and then you have a problem,” she says.

To help women peek inside that box earlier, Tomkins is offering Future Family’s Fertility Age Test. The test arrives in customers’ mailboxes inside a folder printed with a picture of a woman standing on a beach, watching waves break. Where the water meets the horizon hover the words “Plan Your Future.” The sense this gives you is of a confident and calm woman about to embark on an adventure. The language on Future Family’s website is even more seductive: “For all women who want a future family,” it promises, “insight into your current and future fertility.”

But under the surface of that perfectly blue ocean lurk pressing questions about the fertility industry. Some experts worry that the sense of empowerment that companies like Future Family strive to create is misleading, characterized by inadequate research, cherry-picked data about the risks and success rates of egg freezing and IVF, and a lack of clarity surrounding the usefulness of fertility testing. Marcy Darnovsky, executive director of the nonprofit Center for Genetics and Society in Berkeley, is skeptical about the paucity of research in certain areas of the fertility industry, like egg retrieval. “I think, in general, we want people to have access to information about their own health,” she says. “But if the results [of fertility testing] are really not very meaningful and there’s this big, aggressive marketing going on, then I think we’re in a different territory. It’s not providing information so people can make decisions. It risks being something different: cultivating panic, so people will buy what you’re selling.”

The United States
didn’t get its first IVF clinic until 1979, one year after Louise Joy Brown, the first baby conceived with the technology, was born in an English hospital. The decade that followed would see the first successful pregnancy from a donor egg as well as the first live birth from a previously frozen embryo. Egg freezing was developed in this context primarily as a last resort for cancer patients at risk of losing their fertility due to chemotherapy.

One of the nation’s first egg-freezing programs for cancer patients was established at Stanford University by a young doctor named Lynn Westphal in the 1990s. Today, Westphal maintains a clinical practice in fertility care and teaches at Stanford’s medical school, and last year she joined Future Family as an adviser. On a broiling October day, we meet at a cafĂ© on campus and she explains how the industry has changed. “Initially, the success rates were really, really poor,” she says. There were just a few pregnancies in the early years of the technology, but then two things changed: First, a new snap-freezing technique led to a better survival rate for thawed eggs. Second, a procedure that injects sperm directly into eggs, developed for men with low sperm counts, was applied to egg freezing and increased the number of eggs that got fertilized. As egg freezing became more successful, it began to draw the interest of women who wanted to freeze their eggs for nonmedical, or so-called social, reasons. Nevertheless, it was considered an experimental procedure by the American Society for Reproductive Medicine until 2012, when the organization removed egg freezing’s “experimental” label, albeit only for cancer patients.

Though the industry has grown exponentially since then—with an estimated 76,000 women projected to freeze their eggs this year, according to the fertility clinic EggBanxx—Westphal still sees significant barriers to access for patients. Future Family caught her attention because it addresses some of those barriers. Over the course of her career, Westphal has watched cancer patients struggle to scrape together extra money to cover the cost of egg freezing. The comprehensive financing that Future Family offers opens that door to many women. But the company also addresses another daunting barrier Westphal sees. “Some women feel a little isolated when they’re going through [treatment],” she says. “They’re not telling people at work, and they’re trying to adjust their schedule or sneak out for an appointment because they just don’t want to talk about it. And then sometimes they don’t really want to talk to family or friends, either.”

To abate this isolation, all Future Family clients are assigned a “nurse concierge” to follow them throughout their treatment. These registered nurses do everything from walking patients through test results to listening and consoling if an implanted embryo fails to survive. Another Future Family client, a single CPA in her 40s whom I’ll call Joyce, went through three rounds of egg freezing. She’d been worried about self-injecting the hormones and was prepared to hire a nurse from her fertility clinic for at-home help. Instead she found out about Future Family, which set her up with a nurse concierge named Nicole. They clicked, and Joyce soon found that Nicole’s empathy was just as important as her nuts-and-bolts advice about injections and medication timing.

“You could have a great friend who is compassionate and caring and loves you, but they don’t really know the process,” Joyce says. “Or you could have somebody who is very medically knowledgeable but may not have a human touch. Having all of those in one person was super helpful.”

Helena, too, credits her nurse concierge, Angela, with easing her path through the emotionally rocky procedure. When Helena first started working with Future Family, Angela asked how many kids she wanted. “And I was a little bit like, ‘Whoa, whoa, whoa! I don’t even know if I want to have kids!’” Helena says with a laugh. She wanted to freeze her eggs as “good insurance” for the future, but she hadn’t given much thought to what came after. “It was a little crazy to think that I had been ready to freeze my eggs but hadn’t really thought about if I wanted to [have kids],” she says.

Eve Blossom, Future Family’s cofounder and COO, says that the company’s mission is to normalize such planning. “The most important thing we want people to do is learn about what their options are,” she says one afternoon at Future Family’s Union Square office. “That’s empowering the women, men, and couples, and for us it’s very important for people to feel empowered about their fertility.” For many clients, Blossom says, planning and empowerment begin with fertility testing.

Future Family’s test for women, the Fertility Age Test, is a blood draw that evaluates the levels of three hormones: AMH, FSH, and E2. Women are born with a finite number of eggs in their ovaries and deplete their stockpile every time they menstruate. AMH, FSH, and E2 readings give a rough sense of how many eggs are left. The science behind the Fertility Age Test isn’t new, but the way to access it is. Typically, to get this test, a woman has to see her gynecologist or general practitioner, and possibly also a specialist. Future Family makes it available with the click of a button—and for the price of $149. Customers are mailed a lab slip and instructions in that beach-scene box; then they have their blood drawn at a lab and, several days later, are walked through their results by a nurse concierge. “We see that people are really hungry for information,” Tomkins says, pointing to data from Google about the high volume of searches for fertility testing. “We’re stepping into that [demand] and figuring out how to actually get them better information.”

However, Dr. Marcelle Cedars, director of UCSF’s Center for Reproductive Health, cautions women against reading too much into fertility tests like the one Future Family offers. “All these tests tell us is the quantity of eggs, not the quality,” she explains. There’s no test for egg quality—that is, the genetic normality of an egg. The best predictor is simply a woman’s age. “There’s a very gradual increase in genetic abnormality throughout the 30s, and then from 38 to 42 the rise in abnormality is steep,” Cedars says. “So at 42, even if tests look normal, all might not be normal.” Although testing all three hormones has been the industry standard, Cedars discourages testing FSH and E2, as their levels fluctuate too much from month to month. Knowing approximately how many eggs a woman has left by testing her AMH can help her make decisions, especially as she ages and genetics begins to work against her. But Cedars notes that the tests were developed “in the context of treatment”—that is, they’re meant to help doctors understand how a woman’s ovaries will respond to hormonal stimulation, or how many eggs she’ll produce in an egg-freezing or IVF cycle. What’s more, a 2017 study in the Journal of the American Medical Association found that in a population of fertile women, AMH is not a reliable marker of the likelihood that they will be able to conceive naturally.

After the study dropped, Future Family put out a statement from Westphal saying that “we fully agree and support the study’s findings” and noting that all fertility tests, the company’s included, are imperfect. “Like any testing, it’s partial information, it’s just a starting point,” Blossom says. “You’re not going to have 100 percent information to make decisions. But it’s better than not having any information.” Tomkins concurs that imperfect information is better than no information. “What we really feel strongly about is, if we can reach women in their 20s—and that’s what the Fertility Age Test is designed for—then we can start educating women and reaching them and start engaging them in planning,” she says.

UCSF’s Cedars agrees that testing can be a good way to get patients thinking proactively about fertility. “If it brings women in to get a more detailed history, and you can have that more nuanced conversation…then I think it’s great,” she says. But Cedars contests the idea that every woman should be tested, and the earlier the better. “Do we have enough data now to say that yes, everyone should get this?” she asks. “I would wager that we don’t.”

I have known
that having children can be difficult for as long as I’ve known how I came into this world. I grew up hearing about how my parents had longed for a child and struggled to conceive me. As a kid, I’d traced over scars on my mom’s stomach from her numerous surgeries for endometriosis—a painful disorder that can impair fertility. My dad, a needle-phobe, told me about screwing up the courage to give my mom hormone shots of Pergonal. On walks around our home in rural Sonoma County they’d sometimes take me to the special spot that they’d dedicated to the memory of the baby they lost before I was born. When I was doing research for this piece, my mom told me, half jokingly, that we don’t have the wraparound porch she and my dad had dreamed of because they spent that money having me instead.

So in my late 20s when my boyfriend—who’d previously been uncomfortable discussing weighty, future-oriented topics—told me he wanted to have his own children someday, I felt that I owed it to both of us to see if I’d ever be able to. I called my gynecologist’s office and told the receptionist that I was interested in fertility testing. She asked how long I’d been trying to get pregnant. Oh, no, I explained, I’m not trying to get pregnant, there’s just a history of infertility in my family and I’m being proactive, gathering some information. She laughed and told me that they don’t do testing until women have been unsuccessfully trying to get pregnant for a year.

I decided to try my luck with a different doctor and scheduled a new-patient visit with another gynecologist. This time, I sprang my request on her in the exam room—and I lied. My partner and I are about to start trying to have a baby, I said, and I’d like to test my AMH and FSH. The doctor shook her head and told me I was young and healthy and needn’t worry. Her prescription: Try for a year and then come back if you’re not pregnant. Instead I did nothing, defeated and frustrated. At a physical more than a year later, I decided to try one more time. I cornered my doctor and said I wanted these tests and wouldn’t take no for an answer. I know they’re not a guarantee of future fertility, I pleaded. But I have to know where I stand. She reluctantly authorized them.

Several days after I had my blood drawn, my results arrived by automatic email. FSH: 6.0 mlU/ml. AMH: 5.39 ng/ml. I attempted to decipher these figures and their accompanying ranges. I googled around but wasn’t sure what blogs or fertility clinic marketing materials to trust. Finally, I got an email from my doctor: The results were normal, with no sign of a diminished ovarian reserve, meaning I had no fewer eggs in my ovaries than would be expected for my age.

It was only a few days later that I happened to receive an email pitch from Tomkins promoting Future Family’s June launch. The Fertility Age Test immediately caught my eye. It seemed simple yet groundbreaking to offer these tests on demand and couple them with informed counseling. Had the company existed several years before, rather than scheme, lie, and visit three doctors, I could have simply paid $149, ordered a test, had a blood draw, and a week later hopped on the phone with a nurse who would have explained my results to me in plain, reassuring language. While that would have been more expensive—Future Family does not work with insurers, whereas my insurance-covered tests cost me only $30—it would have saved me a lot of frustration.

And had my test results come back with any red flags, it would have given me a number of years to decide what, if anything, I would do. A healthy woman in her 20s has a 20 to 25 percent chance of getting pregnant in any one month; by 40, that likelihood drops to 5 percent. Because of age’s effect on fertility, two years can mean the difference between freezing a high number of healthy eggs and not, between having biological children and not.

When my tests came back without any trouble signs, I was relieved. I’m safe, I thought. I have time. Shortly thereafter, though, during my first conversation with Tomkins, I inferred that, actually, I shouldn’t rest so easy. These tests show you where you are at the moment, she explained, but can’t tell you how quickly your fertility is changing. That’s why it’s so important, even with a normal result, to retest every year, if not every six months, she said. You might even consider your positive test as a signal to go ahead and take the final plunge. “You get back your great result and you’re like, ‘OK, maybe I’m going to freeze my eggs right now,’” she said. “‘Because everything looks good, I could probably freeze them very successfully and in some sense be protected.’”

When I asked
Darnovsky of the Center for Genetics and Society about this logic, she was skeptical. “They’re trying to pull in women in their 20s who have no reason to think that they have any fertility issues,” she said, “and they offer [testing] as a loss leader to get, it seems to me, people hooked on this idea that, ‘Oh yeah, I better freeze my eggs, I better do this to be a modern woman and have insurance for the future.’”

Over the next few weeks, I couldn’t shake that conversation with Tomkins from my mind. I’ve always felt reassured by data and information, and everything she’d said made sense. Of course one test in isolation doesn’t tell you everything you need to know. Of course freezing your eggs when you’re young, healthy, and fertile is more effective than freezing them when you’re in your 40s and working against the clock. Still, an uneasy feeling dogged me, and I found myself returning to Future Family’s website.

Where was the information about the rates of live births from frozen eggs? (They vary wildly based on the number of eggs frozen and the patient’s age at freezing, but they’re often lower than one might think. At 35 or younger, women who freeze 5 to 15 eggs have an 18 to 90 percent chance of a live birth, while women who freeze the same number at age 36 or older have a 7 to 40 percent chance of ending up with a baby.) Where was the information about the risks of egg freezing or IVF, including ovarian hyper-stimulation syndrome? (That’s a potentially serious side effect of the hormone medications that causes the ovaries to swell painfully, affecting up to 10 percent of women undergoing IVF and up to 15 percent of egg donors.) What about the fact that the American Society for Reproductive Medicine removed the “experimental” designation from egg freezing only for cancer patients? (The group notes that there is not yet enough data to recommend egg freezing for the purpose of “circumventing reproductive aging.”)

Instead of actual science, the website is heavy on empowering, aspirational messages: “Preserve your fertility and live freely.” “The best time to freeze your eggs is right now.” “Egg freezing is like insurance for modern women. Protect your fertility so you have all the options you deserve.” How easy it had been to not notice what was omitted, I thought. I’d come to Future Family awed by the doors it was opening, the control it was giving women over their own health. What I’d missed amid all the positive, inspiring messaging was the simple fact that I was being sold the idea of control over my fertility, not the reality.

In interviews, Tomkins and Blossom repeatedly emphasize that one of the company’s main priorities is providing good information about fertility to women and men. So I ask Blossom about the lack of information about risks and success rates on the Future Family site. “Those things are very particular to each individual, you know, about the risks,” she equivocates. “Each clinic has different success rates, so we can’t say the success rates. I mean, we could talk about, like, in general, but then it’s very generalized.” Reporting success rates could give women false hope, she adds; better to simply direct them to the best clinics in their region, since those clinics all operate per industry standards and report their results. She later followed up with two recent studies that concluded that there is no link between hormone medications and ovarian cancer, although one study called for further long-term research to evaluate the effects of the drugs.

Where Blossom sees not wanting to give women false hope, others see deception. “It’s really disturbing that they don’t acknowledge that some women have much more serious effects from egg retrieval,” Darnovsky says. “What I see on the website, it doesn’t seem like it’s adequately transparent to me.” In this regard, Future Family is not unique; lack of forthrightness about risks and other factors, including the rates of pregnancy from frozen eggs, is common throughout the fertility industry, according to Chris Barbey, a researcher at Harvard University. Barbey has studied the techniques that fertility clinics use to market social egg freezing and found that clinics routinely minimize the risks and low success rates of the technology in their messaging. (It’s important to note that Future Family finances fertility treatments and connects patients to testing, but is not a clinic.)

“The point of advertising is to create demand where there wouldn’t be otherwise,” Barbey says. “That’s not necessarily exploitative, and it’s not necessarily circumventing women’s rational capacities. But it definitely is supposed to be an influence on the decision-making.” This is particularly true with egg freezing, Darnovsky notes. If a woman is seeking IVF, she has already exhausted other viable methods and is turning to the service out of sheer necessity. But to successfully market egg freezing to women who are at their reproductive peaks, it’s necessary to create that need. And an easy way to do that is to instill in women a sense of vulnerability that will be eased only by acting urgently, by freezing eggs now, by protecting their future before their future is decided.

I feel that creeping doubt in what’s left unsaid. While trawling Future Family’s website, I couldn’t deny the pull of messages promising that egg freezing would bring me “peace of mind” and help “protect the downside.” I’m 30, and the thought of being able to jealously guard my freedom for another 5 or 10 years and still someday be able to hold a baby who has my rounded nose and the delicate spray of freckles that dusts my boyfriend’s eyelids is damn intoxicating. It would be all too easy to find a way to squeeze an extra $150 to $175 out of my meager budget each month without thinking about whether or not that investment will ever lead to children. “Insurance for modern women” sounds a lot more attractive than “an expensive hedge for anxiety-prone millennials.”

All of this—the messaging, what’s left unsaid, the cost—points to something women are sometimes loath to think about when it comes to their fertility. This is a profit-driven business. A 2016 analysis valued the global fertility services market at nearly $17 billion and projected that it would double by 2023. Women (and to a lesser extent men) are sources of untold riches. Egg freezing is a potential gold mine, Darnovsky argues, because fertile women represent a heretofore untapped customer base. “That’s really tempting for an industry,” she says. “As people who are considering availing ourselves of those services, we need to understand it that way, even though I think there still is a discomfort about talking about babies and business in the same breath. But we have to really recognize that the fertility industry has financial incentives. It’s always going to be looking for new profit centers. That’s just part of this picture.”

Tomkins doesn’t shy away from the reality that her company is both helping women and making money off them. “There was a big mission at [SolarCity] to bring clean energy to America, to lots of homes, and I think it really was an inspiring mission,” she says. “But in order to scale the company, there also had to be a business model that worked. That’s how you help more people—you build something that can be big.”

She acknowledges that not everyone can afford even the cheapest financing that Future Family currently offers; she knows she’s not yet reaching the 99 percent. But she hopes that by scaling the platform, she can get opening costs down to $39 a month for egg freezing. “We can’t help everyone on day one, but the goal is to get there over time.”

Here's the thing:
I believe Tomkins. As a woman who lived through multiple expensive and emotionally grueling IVF failures, she clearly wants to save other women from that pain. Of course, if she could go back in time and convince 25-year-old Claire to freeze her eggs—and provide an affordable way for her to do so—she would. Her desire to give other women information and options she didn’t have, to protect them in ways she couldn’t protect herself, is genuine and palpable. The fact that this desire is also leading her to tackle a problem in a booming and profitable sector doesn’t negate her good intentions. If, as Tomkins hopes, Future Family becomes the leading platform for women at every stage in their “fertility journey,” then countless more women will know more about their fertility and have access to care than currently do—an undeniably positive outcome. However, women who might not need fertility treatments will also be sold them, a more questionable outcome.

For Helena, whose eggs are now deep in a UCSF liquid nitrogen tank, Future Family has been a net positive. She is still single. Maybe she’ll unthaw her eggs someday; maybe she won’t. “It’s a little bit of a just-in-case scenario,” she says, perfectly at peace with her decision. If she never needs them, at least Future Family got her thinking about what comes next, she says.

You could say that Future Family has done the same for me. A few months ago, I had a free consultation over the phone with one of the company’s nurse concierges, a peppy and reassuring woman named Nicole. She went over my previous test results and told me the same thing my doctor had: All looked normal. She then asked me if I had considered “other fertility options,” meaning egg freezing. I had thought long and hard about that question, had tried to squint into the future and imagine whether I’d be filled with deep, unrelenting regret if I passed up the chance to freeze my eggs and then wasn’t able to have a child. It was the ultimate FOMO. But in that moment on the phone with Nicole, the answer was clear: No, I told her honestly, I was not considering other options.

She reassured me that that was just fine, but encouraged me to get tested again in a year—and to consider egg freezing if I haven’t had children by age 35. Then she said something true but disturbing: “You’re never going to be as fertile as you are now.” We ended the call, and I went back to Future Family’s egg freezing page. “Experience smart, modern fertility care,” it beckoned. “Women who make the decision to freeze their eggs report a feeling of freedom and peace of mind.”

I closed my browser and let the anxious tightening in my chest subside. Then I went to talk to my boyfriend about something neither of us felt ready to face: When, exactly, do we want kids?

Update, 3/27/18: In response to this story, Future Family updated the egg-freezing page of its website to include information about the risks and success rates of the procedure, with links to more information.

Originally published in the April issue of San Francisco

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