The article analysis should be written for the topic " ethical dilemma " based on the below PDF and must include the below 3 sections in APA format. DEFINITION: a brief definition of the key term foll

Keywords Social freezing, delay of motherhood, women´s fertility, autonomy, assisted reproduc- tion Introduction Occasionally, and for various reasons, many women wish to postpone motherhood.

The most common procedure used to achieve this is to freeze their eggs or part of their ovarian tissue while young. These are then thawed at a later stage when they wish to become mothers and used in a reproductive process, generally in vitro fertilization (IVF). When ovarian tissue is used, it is thawed and implanted in the woman’s ovary so that its functions are activated, thus opening the door to procreation, either naturally or using assisted reproduction procedures.

There are essentially two reasons for delaying childbearing: medical and social.

Medical reasons are when the woman, due to cancer or another disease, requires treatment that may affect her fertility. In this situation, her eggs or part of the ovarian tissue can be frozen before undergoing treatment, to be used at a later date when the therapy has finished and the woman has recovered her health.

When eggs or ovarian tissue are not frozen for medical causes, the process is called “social freezing.” In this case, there are two fundamental reasons why a Vol. 35:3 Fall 2019 162 woman might choose to undergo this procedure: the first is that she has not found a partner who she considers suitable for a matter as important as creating a family, and the second is for professional reasons. In the latter case, the woman considers that becoming pregnant at a young age—usually before age 35—could harm her professional career, prompting her to freeze her eggs for use at a later date. The biological reasons that underlie social freezing are that women’s fertility declines with age, 1, 2 especially due to a decrease in ovarian function, 3,4 owing to a reduction in the number of eggs, since, in humans, around 85% of potentially useful eggs are lost before birth. From then on, their number diminishes from around 100,000 useful eggs at age 20 to 25 years to only 1,000 at menopause. 5,6 Therefore, if women delay having children for any reason, their likelihood of becoming pregnant falls. This justifies obtaining eggs at around age 30 —or earlier if possible—to freeze and then use from age 35 years (and especially from age 40), if at that time they wish to become mothers. Thus, the longer they delay freezing their eggs, the less of a chance they will have of having a child. 7 In this regard, evidence has shown that when the eggs are frozen at age 37 years, the probability of a live birth is 51.6%, but when the woman is younger than age 34, this probability may be greater than 74%. According to this study, most women who have frozen their eggs at age 34 have a 70% chance of having a child. 8 History Social freezing broke in the media when, in October 2016, two Silicon Valley business giants, Apple and Facebook, announced their intention to provide their female employees with the opportunity to freeze their eggs to delay motherhood, according to them, in order to attract and promote female talent. 9,10,11,12 To that effect, Apple released a statement saying that they had introduced the policy because “we care deeply about our employees and their families.” For this reason, “we continue to expand our benefits for women, with a new extended maternity leave policy, along with cryopreservation (egg freezing) and egg storage as part of our extensive support for infertility treatments.” They continued, “We want to empower women at Apple to do the best work of their lives as they care for loved ones and raise their families.” 13 Not everyone agrees with this measure, though. Indeed, a group of German politicians from the Christian Democratic Party has publicly stated that Facebook and Apple’s policy promoting social freezing is “an indecent proposal.” 14 Similarly, some feminists, such as Daisy Sands of the Fawcett Society, are not completely convinced of the measure, saying that “there’s a danger that with this sort of policy companies give a signal—or even promote the idea—that a woman needs to postpone having children in order to succeed in the workplace.” Sands continues, “In reality, probably a very small amount of women will take up the offer, but it again puts the onus on women rather than men to think about when to have children and how this will impact on their career.” Sands adds that this policy could mean that other important structural changes are not introduced. 15 Ethics _ Medicine Aznar & Cuenca / Social Freezing 163 A large group of scientists also advise against this procedure, according to Josephine Johnston and Miriam Zoll of the Hastings Centre for Bioethics in New York, in an article in New Republic. 16 Nevertheless, Apple and Facebook are not the only establishments to promote social freezing. The United States (US) army also offer it, thereby seeking to compensate for the challenges imposed by military life when trying to have a family, extending their program to freezing the sperm of their military men. 17 The initiative is an attempt to make a military career more attractive to those who want to have a family and also to offer guarantees of having children to those who are wounded on the battlefield. As in any other company, retaining talent has become a priority in the US army because many women who are at the ideal age to have a family abandon their careers when they complete 10 years of military service.

“For women who are midgrade officers and enlisted personnel, this benefit will demonstrate that we understand the demands upon them and want to help them balance commitments to force and family. We want to retain them,” claims North American Defence Secretary, Ash Carter. 17 Oocyte Cryopreservation A key aspect for evaluating social freezing is to understand as much as possible about all matters concerning the cryopreservation of oocytes (or eggs) because these are what are used. Consequently, the outcomes of social freezing depend largely on the particular characteristics of the cryopreserved oocytes.

History The first child conceived using frozen eggs was born in 1999, 18 and in the United Kingdom, frozen eggs have been used for the treatment of infertility since 2000. 19 The first pregnancy reported after egg freezing in a cancer patient was in 2007. 20 Only three children have been born to date after fertility preservation for oncological reasons, 21,22,23 and very few articles make reference to the birth of children from egg banks for reasons of advanced age. 22,24 At the end of 2012, the American Society for Reproductive Medicine (ARSM) and the Society for Assisted Reproductive Technology (SART) announced that oocyte cryopreservation would no longer be considered simply an experimental technique, 25 thus paving the way for its clinical use; however, in 2013, both societies expressed their doubts about the use of frozen eggs, due to scant data on the safety, efficacy, cost effectiveness, and emotional risks for healthy women. 25 In 2014, the American College of Obstetricians and Gynecologists endorsed the recommendations of the ARSM and SART. Despite these calls for caution in its use, social freezing has significantly increased, 26,27 and indeed has practically tripled in the last 5 years. 28 This may be linked to a number of complex and interrelated reasons for delaying motherhood, including personal, professional, financial, and psychological factors.

29 In Spain, in 2014, 816 women attending 65 different clinics froze their eggs for future use, almost triple the number who did so in 2009, which was 284 women from 34 clinics. 30 Vol. 35:3 Fall 2 1 164 According to their own data, the Valencian Institute of Infertility (IVI) reported that, as of December 2014, 5,842 children had been born in their clinics using vitrified eggs. Most of the women who froze their eggs were aged between 37 and 39 years, while 18.9% were aged between 31 and 35 years and 16.2% were aged 40 or older. Technique Egg cryopreservation is a process that involves ovarian hormone stimulation, transvaginal retrieval, and subsequent freezing and storage of the eggs. The most widely used technique at present is vitrification, which uses cryoprotective agents and ultrarapid freezing in order to solidify the cells as quickly as possible to avoid the formation of ice crystals. This technique increases the survival of the cryopreserved eggs and improves pregnancy rates.

Survival of Frozen Eggs The ASRM and the SART estimate egg survival following vitrification and warming to be around 90% to 97%, with a fertilization rate of between 71% and 79% and implantation rate of 17% to 41%. 25 With respect to the length of time that eggs can be kept frozen, according to the Human Fertilization and Embryology Act, in 1990 it was claimed that eggs could be stored for more than 10 years and embryos for 5. 31 More recently, though, this time could be extended up to 55 years. 32 Efficacy of the Technique and Birth Rate The efficacy of the technique is measured by the live birth rate. This rate was initially 21.6% per embryo transfer using vitrified eggs, 33 but has been increasing over time such that, in 2014, Grifo and Noyes reported a birth rate of 57% per embryo transfer. 34 In 2017, Massarotti reviewed and summarized various studies that evaluated the live birth rate using vitrified eggs, finding values of 22.6%, 35 25.5% , 30 38.6%, 36 and 36.4%. 37 This variation largely depends on the age at which the eggs were obtained. In a recent meta-analysis of ten studies, the birth rate was 31.3% in women aged up to 25 years old, falling to 13.4% among women over age 40 years. 38 In another multicentre study, the decrease in the number of births per year was 7%; when natural eggs were used, the decrease was 8%. 39 Adverse Effects of the Vitrification Process The largest review conducted to date found that the use of vitrified eggs had no adverse medical effects for the mothers nor objective perinatal problems for the children born, although according to its authors, further studies with a large sample size are required to confirm these conclusions. 40 Reasons to Justify Social Freezing: Benefits for Women There are four main benefits for women who use social freezing:

a) To facilitate female participation in the field of employment. Many women think that delaying pregnancy could benefit their career pro - gression in many different aspects, so some consider the possibility of postpon - E | _ M ~ } | ~ Aznar & Cuenca / Social Freezing 165 ing having children. For this reason, they use social freezing. 41 b) Possibility of waiting to find the right partner. Some women wish to find the right partner to have children with, so they may feel pressured when they get older and have not done so. In this res\ pect, the possibility of egg freezing means that when they meet that partner, they can use IVF to have children with them. 29,42,43 c) To wait to be emotionally, psychologically or financially ready to be a mother. The possibility of freezing eggs and using IVF allows women and their part - ners to have children at a time of their choosing. d) To be able to have children with a different partner. If a woman wants to have the option of having children with a partner ot\ her than the one she currently lives with, social freezing could be the answ\ er. e) Using social freezing could also reduce the risk of having aneuploid foe\ tuses due to age. 44,45 Possible Negative Side Effects For the Mother Women who decide to use cryopreserved eggs should be objectively informed of the possible complications of a late pregnancy, such as hypertension, preeclampsia, gestational diabetes, placental insufficiency, decreased intrauterine growth of the foetus, and caesarean delivery, all of which are higher for older compared to younger women. 25,46 Even maternal mortality increases around four-fold when the pregnancy occurs after age 40. 47 Perhaps the greatest risk associated with social freezing, however, is ovarian hyperstimulation syndrome, secondary to the process used to obtain the eggs. This may be moderate with fatigue, nausea, headache or abdominal pain, painful breasts, and irritability, although these adverse effects can be easily controlled. 48 Nonetheless, 0.1% to 2% of women who undergo an ovarian stimulation cycle can experience severe ovarian hyperstimulation syndrome, which can trigger blood clotting problems, severe abdominal pain, dehydration, and vomiting; on most occasions it requires hospital admission, and, rarely, can even cause death. 49 Risks for the Child Medical risks can also increase for the child born using social freezing. In addition to prematurity and low birth weight, there is evidence of a moderate increase in the risk of congenital abnormalities, and some experts suggests that there may be a small increase in the risk of cancer and cardiac abnormalities owing to the use of IVF. 50 Financial Aspects In the United Kingdom, the process of obtaining eggs, then freezing, warming, and implanting them, can cost around £15,000. 51 In Australia and the United States, the cost of freezing eggs varies between $10,000 and $15,000. According to Apple and Google, the total cost of egg freezing is around $20,000. 3,52 Vol. 35:3 Fall 2019 166 Furthermore, according to the calculations of the US Department of State, the estimated cost of social freezing for the armed forces is about 150 million dollars over five years. “As many families know all too well, these treatments are very expensive and often require multiple attempts,” explained Matthew Allen, spokesman for the Department of Defence to the New York Times, so “providing this benefit across the board would result in a significant cost for the department.” 17 Social Assessment One reason to justify social freezing is to present it as a social advance, one further step towards women’s equality with men in professional aspirations. We believe, however, that this statement raises many questions.

In accordance with this, Geraldine Gallacher, head of a company specializing in advising women returning to work after having a baby (particularly in law offices and banks), says that it is “a high-tech solution to a human problem. It’s trying to change nature rather than the organisation.” Gallacher says that companies go to great lengths to keep their female staff happy—such as providing breakfast and even beds at work—but that this is “a step too far.” 53 The one thing that companies could do to make a returning mother’s life easier is give them more autonomy over their hours, she argues.

Private insurance coverage for employees who use social freezing may cause them to feel pressured to freeze their eggs, often stressing the benefits that social freezing may have for them, while ignoring the risks involved in this practice. 41,54,55,56 Several Swedish studies show that Swedish women aged between 30 and 35 years have a positive attitude to egg cryopreservation for non-medical reasons. 57,58,59 All these findings seem to suggest that the practice of egg cryopreservation for non- medical reasons is gaining social acceptance. 45 In relation to social freezing, another aspect of interest is to determine the opinion of assisted reproduction professionals on this issue. This was assessed in a recent article, which surveyed 201 professionals in four public hospitals in Spain between May 2013 and March 2014. 60 The survey found that 41.8% of gynaecologists think that social freezing should be offered to all young women, compared to 62.7% for other specialists. Among nurses, 48.9% would offer social freezing to all women.

Remarkably, only 4.9% of participants are opposed to this practice.

In terms of the maximum recommended age for social freezing, most gynaecologists establish it at 35 to 38 years, while other specialists and nursing staff would offer it up to age 40. However, they could be giving false hope to women who use social freezing by assuring them that they can achieve their goal of having a child when they are older. 51 In this respect, the British Fertility Society (BFS) and the Royal College of Obstetricians and Gynaecologists (RCOG) have issued a joint statement saying that, while they approve this practice for medical reasons, they do not do so “as a way to delay childbearing as a lifestyle choice.” 61 BFS chairman and RCOG spokesman, Adam Balen, also says that encouraging social freezing is going too far because the technique does not guarantee a baby and also introduces objective risks for the woman, for the ovarian stimulation and necessary IVF that she will have to undergo are not risk-free. 61 In the same article in The Telegraph, Professor Winston, Ethics _ Medicine Aznar & Cuenca / Social Freezing 167 a pioneer in assisted reproduction techniques, is very critical of social freezing and believes that it is being “grossly oversold.” Ethical Assessment Aside from the aforementioned biomedical and social problems, social freezing unquestionably presents ethical concerns. In our opinion, the main one is that, although not explicit, it implicitly objectifies the woman by prompting her to make a decision that is disguised a good for her when, as reported, this practice entails objective negative medical consequences for the user and also for her child. According to Martinelli et al., “Social egg freezing is a paradigmatic demonstration of how the medicalization of women’s bodies can be used to mask social and cultural anxieties a b o u t a g i n g [...] .” 62 However, we believe there is another ethical difficulty, derived from the fact that it is hard to guarantee the autonomy of women to make such a decision if they are not provided with adequate information on the risks and benefits entailed in social freezing, something that is not always easily verifiable, as previously mentioned.

Another ethical problem that social freezing may pose is the possible social inequality between groups of women who work in economically powerful companies, which can bear the costs of social freezing for their employees and those who work in companies that cannot do so. Another question therefore arises: to avoid social injustice, should social freezing be supported with public funds? We believe the answer should be that, given the myriad of objective medical problems that exist— some of vital importance—and that have to be treated with these funds, would it not be creating a problem of distributive justice? Finally, it should also be pointed out that social freezing implies that fertile women, capable of conceiving and carrying a child naturally, renounce this, substituting natural conception for IVF. This not only reduces the possibilities of eventually becoming pregnant but also, as mentioned, increases the health risks for mother and child. It must be carefully considered whether the advantage of using young eggs compensates for the risks derived from the processes required in social freezing, described in this paper. Conclusions The cryopreservation of oocytes used in cases of healthy women in which it is not sought to overcome an infertility but as a means of postponing a pregnancy for social reasons, entails serious ethical difficulties derived, fundamentally, from the risks that the procedure entails for the health of the mother, resulting from ovarian hyperstimulation, gestation at an older age, and the lower probability that it will eventually occur, and for the child’s health, related to the risk of medical problems that assisted fertilization techniques—which a mother resorts to in order to achieve a pregnancy—present about their gestation and future development. The need for adequate information to the candidates about the risks involved in the procedure and the chances of success is essential for them to exercise free consent.

To try to facilitate these techniques to all women on equal terms to avoid discrimination would involve devoting important public resources to a non-medical problem, taking them away from other more urgent care needs.

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Justo Aznar, MD, PhD, with Extraordinary Prize from the University of Navarra (Spain) is Head of the Department of Clinical Biopathology and Coordinator of the Biochemical Research Unit, at La Fe University Hospital in Valencia, from 1974 until his retirement in July 2006. From 2005 to 2016 he was a Corresponding Member of the Pontifical Academy for Life. He is currently Director of the Life Sciences Institute of the Catholic University of Valencia. He is a member of the Royal Academy of Medicine of the Valencian Community and corresponding of the Royal National Academy of Medicine. He currently resides in Valencia, Spain.

Julio Tudela Cuenca , Pharm, PhD, is Professor at the Catholic University of Valencia and Director of the Master in Bioethics of the Catholic University of Valencia. He is Member of the Life Sciences Institute of the Catholic University of Valencia. He is Member of the Research Ethics Committee of the Catholic University of Valencia and the Research Ethics Committee with Medicines of the Valencian Oncology Institute Foundation (Spain). He currently resides in Valencia, Spain.

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