These are the first photos inside the lab at America’s only clinic dedicated exclusively to egg freezing.
Extend Fertility, a ’boutique’ clinic in New York City’s Midtown, is focused solely on removing and storing a woman’s eggs – as opposed to also treating infertility and offering in-vitro fertilization (IVF).
It was designed to offer a less clinical atmosphere to 20- and 30-somethings who do not need to discuss the medical issue of fertility, but rather want to prepare a back-up to ensure they can have children down the line.
The entire pre-op space – with its rounded walls, pastel colors, and a view of Carnegie Hall out the window – has more of a spa feel than a medical center. Staff are chatty, the seats are plush, and the lights are warm.
Through a small square window in the operating room, you can catch a glimpse of the one off-limits space: Extend’s state-of-the-art lab.
This week, the lab upgraded its services to become the first place on the East Coast using the latest freezing method, Cryotec. With that move, they make a staggering claim that they can ensure almost 100 percent survival rate of at least 12 eggs per patient.
Experts have hailed the clinic as groundbreaking.
And now, Daily Mail Online can offer a rare look inside that process, beyond the multiple sets of doors that seal the lab’s specific air flow and temperature to protect hundreds of patients’ eggs before they are sent to a natural-disaster-proof facility just outside Boston, Massachusetts.
Extend Fertility is America’s first egg-freezing-only clinic, as in it doesn’t also offer IVF or fertility treatment. This week, the clinic launched new state-of-the-art lab designed by rising star embryologist Dr Leslie Ramirez (pictured)
The lab the first place on the East Coast using the latest freezing method, Cryotec. With that move, they make a staggering claim that they can ensure 100 percent survival rate of at least 12 eggs per patient. Pictured: eggs in -195C liquid nitrogen
With these images, Daily Mail Online can offer a rare look inside Extend’s ‘groundbreaking’ process, beyond the multiple sets of doors that seal the lab’s specific air flow and temperature to protect hundreds of patients’ eggs. Pictured: inside the lab
WHAT DOES EGG-FREEZING INVOLVE FOR PATIENTS?
1. CONSULTATION
The patient discusses their desire to freeze their eggs with a fertility specialist.
The patient can decide whether to go straight ahead or wait weeks, months, or longer to proceed.
2. HORMONE INJECTION
Women inject high levels of hormones for a week in order to ovulate as many eggs as possible.
These cost an extra $4,000 for all patients – whether at Extend or elsewhere.
This hormone is called AMH (Anti-Mullerian Hormone), which is secreted in the ovarian follicles.
AMH levels are a marker of one’s fertility: women with a high level are likely to produce more eggs.
The patient’s doctor will perform a blood test to check their AMH levels and determine the exact concentration of AMH they need.
At Extend, the patient is then guided through how to mix the formula at home and self-administer the hormones, injecting them into the belly.
3. EXTRACTION
After about 10 days, the patient comes in for their retrieval.
At Extend, they are first taken to a pre-op room. They are then moved to the operation room and given anesthetic.
The surgeon retrieves the eggs through the vaginal wall.
The patient is then taken to the post-operation area. Extend Fertility says it is their policy to make sure they have a friend or relative waiting there for when they come out to take them home.
4. NEXT RETRIEVAL OR FREEZING
The patient will be immediately told how many eggs were retrieved.
Within a couple of days, they will learn how many of those eggs were ‘mature’ – i.e. how many can be frozen.
In every clinic aside from Extend, patients with fewer than 12 eggs will then have an option: to settle with that or to pay for another cycle.
At Extend, that patient will automatically be enrolled for another round included in the price.
Those with 12 or more will then set up payment for storage. Extend sends all patients’ eggs to a natural-disaster-proof storage center in Massachusetts for an extra cost of $450 a year.
The lab is the brain-child of Dr Leslie Ramirez, a young star in the field of fertility and embryology.
Originally from Queretaro, Mexico, she has trained with the industry’s leading figures – Dr Carlos Simón in Spain and Japan’s Dr Masashige Kuwayama, who invented the most effective egg-freezing method to date: Cryotec.
She was then headhunted by Dr Joshua Klein – formerly of the egg-freezing clinic at NYU’s fertility center – to develop a lab that did away with the other elements, and brought the world’s top freezing methods to the US.
Dr Ramirez is supported in the lab by Alexis Adler, Extend Fertility’s senior embryologist, who has more than 20 years’ embryology experience with Weill Cornell and at NYU Fertility Center.
NEW FREEZING METHOD
HISTORY OF EGG-FREEZING
Egg-freezing first began in 1986.
One of the early problems with the process was that, unlike sperm which freeze and thaw easily, eggs contain lots of water.
It means that, if the process isn’t done correctly, ice crystals could form, destroying or damaging the eggs.
That was the key issue with the first method, known as the ‘slow-freeze’, which was used almost everywhere until around 2009.
It involved gradually reducing the egg’s temperature to -196C over the course of hours.
Initially, it was thought this slow process was necessary to delicately allow the egg to adjust its temperature. Scientists now believe the more time, the more likely crystals will form.
In the past eight years, there has been a surge in clinics employing a flash-freezing method called vitrification that appears to overcome that challenge.
Vitrification is so named because during the process the eggs transition to a vitreous, or ‘glass-like,’ state.
A combination of cryoprotectants and faster cooling (compared to the slow freezing method) reduce the opportunity for damaging intercellular ice crystals to form during the process.
Studies have found eggs frozen via vitrification have, on average, a 91 percent chance of surviving the freeze-and-thaw process.
THE LATEST
The Cryotec method, invented by Dr Kuwayama, is the latest version of vitrification, bringing the egg to -196C in minutes. Every egg frozen and thawed with Cryotec has survived thus far.
At Extend, they have honed the technique even further, controling the air quality, air flow, and temperature of the entire lab as well.
Dr Ramirez is one of the only people in America qualified to perform Cryotec. Anyone else that wants to use it must train with her.
It is likely that Cryotec will one day become the standard method across the country.
FROM START TO FINISH WITH DR RAMIREZ
Retrieving and cleaning
On the day of retrieval, the doctor will retrieve the patient’s eggs via a tube inserted through the vaginal wall.
They put that in a test tube, which is placed in a gap in the wall leading to the lab.
Once the surgeon shuts the window on their side, Dr Ramirez opens the window on her side (to keep the external air from flowing in and tampering the atmosphere).
She retrieves the tube, carefully empties it into a labeled petri dish, and looks for the eggs, then starts the cleaning process. The eggs will then sit in an incubator for a few hours.
Checking for mature eggs
That day, the patient will be told how many eggs were retrieved.
Meanwhile, Dr Ramirez will be examining the eggs with a microscope to check whether they have extruded the cytoplasm.
Through a small square window in the operating room, you can catch a glimpse of Dr Ramirez in her state-of-the-art lab
The surgeon puts the retrieved eggs in a test tube in this window in the wall. Dr Ramirez then opens the window from her side
Finding the eggs: She carefully empties it into a labeled petri dish, and looks for the eggs, then starts the cleaning process
Among other products, Dr Ramirez sourced a new kind of incubator – a $16,000 contraption by BenchTopInc (pictured) – which keeps the eggs at 36.8C. It consists of six spaces, as opposed to the large incubator tanks normally used to hold many
Once inside, the incubators have a peep-hole to look through to check the eggs’ progress without changing the temperature
Dr Ramirez examines the eggs with a microscope to check whether they have extruded the cytoplasm. To a layman’s eyes, that broadly means a small dot in the egg has been pushed outside of the main circle. When that happens, it is mature
To a layman’s eyes, that broadly means a small dot in the egg has been pushed outside of the main circle. When that happens, it is mature.
Once they have the batch to freeze, Dr Ramirez starts the freezing process.
Freezing: the Cryotec method
The eggs have to sit in a petri dish at room temperature for at least one hour before freezing so they don’t degrade.
Then, over the course of 15 minutes, they will be placed into two different solutions to shrink them.
Meanwhile, Dr Ramirez prepares a small blue open-topped box of -195C liquid nitrogen.
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Once full shrinkage of the eggs is achieved, she retrieves the eggs from the solution by picking them up with a minuscule pointy-ended stick called a Cryotec.
The Cryotec is then swiftly inserted into a large cylindrical blue-and-silver stick called a cane, which is in turn placed in the liquid nitrogen and covered.
Each patient’s cane is sealed and labeled with their medical information, and placed inside a grenade-shaped tank. These tanks can hold up to 300 patient canes for six months before going to the storage unit in Massachusetts.
‘TREATING 21st CENTURY WOMEN’
The ability to conceive begins dropping around 35 and more rapidly as the 40s near.
Women have fewer eggs left, and these older remaining ones aren’t as healthy, meaning even if the woman can get pregnant she’s more likely to miscarry.
However, current lifestyles do not fit that timeline.
Today, about one in five U.S. women now have their first child after age 35, according to the Centers for Disease Control and Prevention.
This is the tank of liquid nitrogen (in gray), sat next to the space where Dr Ramirez shrinks the eggs in two solutions
The eggs have to sit in a petri dish at room temperature for at least one hour before freezing so they don’t degrade. Then, over the course of 15 minutes, they will be placed into two different solutions (pictured in tubes beforehand) to shrink them
Once full shrinkage of the eggs is achieved, she retrieves the eggs from the solution by picking them up with a minuscule pointy-ended stick called a Cryotec (pictured)
While the eggs are in their solution, Dr Ramirez prepares -196C liquid nitrogen to put in a blue open-topped box (pictured)
The Cryotec method, invented by Japan’s Dr Masashige Kuwayama, is the latest version of vitrification, bringing the egg to -196C in minutes in liquid nitrogen (pictured). Every egg frozen and thawed with Cryotec has survived thus far
Earlier methods, known as the ‘slow-freeze’, cooled the eggs over hours, meaning ice crystals could form, destroying or damaging the eggs
This shot captures Dr Ramirez with the box of liquid nitrogen, the room-temperature incubator, and the eggs in solution
Here, Dr Ramirez is pictured putting the Cryotec into the -196C liquid nitrogen solution
The Cryotec is then inserted into a large cylindrical blue-and-silver stick called a cane (pictured) in the liquid nitrogen
Each patient’s cane is sealed and labeled with their medical information, and placed inside the tank (pictured). The tanks can hold up to 300 patient canes for six months before going to the storage unit in Massachusetts
INTERIOR DESIGN: CREATING A LAB WITH THE SMALLEST MARGIN FOR ERROR
CONTROLLING THE AIR
The lab has an air-isolating system designed to keep the number of air particles per cubic foot below 1,000.
Typically, an office building has between 500,000 and a million particles per cubic foot of air.
CUTTING SPACE
The space is designed so that all surfaces and areas that the eggs could be kept in are 36.8C – body temperature.
The room is small, with each incubator, work surface, microscope, or tank positioned in close proximity, meaning the eggs do not have to travel far.
EQUIPMENT
Among other products, Dr Ramirez sourced a new kind of incubator – a $16,000 contraption by BenchTopInc – which further controls the temperature and space.
It consists of six small pockets, which fit one petri dish each, as opposed to the large incubator tanks normally used to hold many. Once inside, they have a peep-hole, which the team can look through to check the progress without changing the temperature.
The shift has led to a surge in women looking to freeze their eggs.
But while the option has been around for 30 years, studies show it is still something of a taboo culturally.
A recent survey of more than 1,000 US women aged between 25 and 35 found most of them had never discussed age and fertility with their gynecologist.
Seventy-eight percent of them had never discussed age as a factor in becoming pregnant, and 96 percent had never discussed treatment options to maximize their chances of fertility.
LUMPED IN WITH THE REST
Dr Klein, who trained at Harvard then Brigham Women’s Hospitals, heaps praise on the capabilities of his previous place of work (Reproductive Medicine Associates of New York in Brooklyn).
However, without naming it, he says his time there introduced him to an under-served client base.
‘I was involved from the conception,’ he says (chuckling, ‘I’m sorry, there too many fertility jokes’).
‘I worked for many years at a large university. One of the thing was that I had an increasing number of women wanting to talk about fertility preservation.
‘Even though the place I worked was excellent, the egg freezer patients weren’t served as well as I felt they should be.’
Fertility clinics, he explained, are usually designed for couples.
Usually, they are coming to the table with the recognition that there is some medical problem. First they need a diagnosis, second they need a way to fix it.
‘The egg freezing patient doesn’t have a problem per say, except being a woman in the 21st century,’ Dr Klein explains.
‘They want to do something pro-actively; they want to make chances that make sense to them in their lives. But they were not well served by the environment.
‘Many of them felt like the ugly step sister of the fertility problems. From a fitting in stand point, it wasn’t a very comfortable environment.’
PRICING
The idea of freezing eggs for a later pregnancy is hardly light on the pocket.
Retrieving eggs is an outpatient procedure that can cost $10,000 to $15,000 per cycle.
Patients also have to pay $4,000 for hormone injections to get them ovulating as many eggs as possible.
After that, clinics charge a storage fee of around $500 a year.
Women who wind up using their eggs will pay thousands more to undergo in vitro fertilization.
‘By far the most common reason women don’t follow through or follow up is that it’s such an expensive proposition,’ Dr Klein said.
‘For these other clinics, they have so many services, and that has to be offset by their pricing structure – offering IVF, IUI, male fertility, female fertility, genetic testing… that creates certain level of pricing.
‘When you remove one line out of the equation you can change that – and even improve quality, but at a different price point. The lowest, to be exact.’
Extend caused a flurry of headlines last year after announcing its plan to offer a $4,490 ‘all-inclusive’ service.
To be clear: the price does not include everything listed in this section. Extend’s patients are still required to buy the $4,000 hormones, since the clinic doesn’t have a license to prescribe them, and the storage is extra.
Still, Dr Klein insists, you can’t argue with the fact that it’s half the market rate – and includes up to four cycles.
‘One of the things that we changed about the delivery of care is that we don’t want women to come in for ‘you get what you get’,’ Dr Klein said.
‘The pricing includes the idea that one cycle might not be enough.
The entire pre-op space – with its rounded walls, pastel colors, and a view of Carnegie Hall out the window of the consultation room (pictured) – has more of a spa feel than a medical center. Staff are chatty, the seats are plush, and the lights are warm
In the exam room, patients are given an ultrasound and blood tests to start the process and check their hormone levels
On the day of the procedure, they will start in the pre-op room (pictured), which is a floor above the consultation room that they have been visiting with their fertility advisor for the past days, weeks or months – depending on the time frame they pick
Procedure room: On the day, they will lie in this chair, be given anesthetic, and have their eggs retrieved via a tube in their vaginal wall. Scroll down for a first-person account of her experience getting her eggs retrieved at Extend Fertility
Finally, the surgeon will put the eggs in a test tube and place them in this window to Dr Ramirez’s lab
‘We decided each patient should be able to have at least 12 eggs frozen, so she doesn’t walk away from the whole thing empty handed.
‘That gives a woman in her 20s about an 80 percent chance. For a woman in her 30s it’s about 50-70 percent.’
CAN PATIENTS BE CERTAIN THEY WILL HAVE KIDS?
‘That’s the million dollar question,’ Dr Klein admits.
Cryotec touts 100 percent survival – though Dr Klein cautions that he never likes to say ‘100 percent’ about anything.
Nonetheless, that simply refers to the survival of the egg through the thawing process.
Whether that egg becomes a baby is another matter.
The degree that women can be confident depends on two factors: first, the age at which these eggs are frozen; second, how many eggs are frozen.
Any individual egg – thawed or frozen – has a possibility of becoming a pregnancy.
But 20-year-old eggs have a higher probability of making it than 40-year-old eggs.
As a result, 20-something can bank fewer eggs and still be confident.
‘I WENT SHOPPING WITH MY FRIEND AFTER’: ONE WOMAN EXPLAINS WHY SHE PICKED EXTEND
Ayelet Raymond, an actress and children’s entertainer from Israel, is single in her late 20s.
With no medical or fertility issues, she could have kids today no problem.
But like most of her friends in New York City, that’s not on the agenda any time soon.
‘I love children and I work with children. I know I want to have kids, but I don’t want them now,’ Ayelet told Daily Mail Online.
‘When I heard about egg freezing I said to myself, it’s an amazing opportunity.
‘To have children is the most valuable thing. If you get older and you cannot… Well, I don’t want that.’
Despite coming from an orthodox religious family (‘they don’t understand it; my brother thought it was weird’), Ayelet felt set in her mind, and started pursuing the process about 18 months ago at a one of New York’s large established clinics.
Ayelet’s was the classic case Dr Klein described seeing time and again.
Her rolling list of complaints echoes everything you see if you take a gander on a few egg-freezing forums.
‘I just didn’t get the right attention. I was in this huge place, had to pay a lot of money, but everything was so random. No one explained anything to me, there were so many people running around… I didn’t feel confident in it at all.’
Looking back, she can remember the moment that drove her to quit the process halfway through.
‘I was sitting in the room with eight girls about to get our hormone injections. But none of us knew what it was or how to use it. Every girl had to have a different levels of hormones, so we couldn’t talk or help each other.’
Around November, a friend gleefully announced she had gotten her eggs frozen at America’s first egg-freezing-only clinic, Extend Fertility, which opened in August 2016.
As Dr Klein insisted, the entire premise of the place is to give a more personal feel to the Ayelets of today: making women feel comfortable, like they are in a living room with people they come to know like friends.
Case in point: Ayelet loved it.
‘I had already gone through it already so I could see a difference, the way everything was. It was like a spa. Everybody was there for me, I knew what was going on around me.
‘I was able to review all the people on the website, I could see all their pictures and names.’
She was introduced to a fertility advisor, who then became her contact for the next few weeks.
They taught her about the hormones she would be injecting (AMH) to boost her ovulation, and how to administer it – something Ayelet claims directly contrasted with her experience at the larger fertility clinic.
‘It was great. I could call late at night if I have a question, like how to mix the hormones or anything. And I did, I called when I needed to.
‘They give me the opportunity to understand what everything was – I didn’t know I had no clue. They were smart enough to teach me so I could feel confident about what I was doing.
‘The last place didn’t explain to me what AMH is.’
AMH (Anti-Mullerian Hormone) is secreted in the ovarian follicles. Its levels are a marker of one’s fertility: women with a high level are likely to produce more eggs.
The patient’s doctor will perform a blood test to check their AMH levels and determine the exact concentration of AMH they need.
‘They educated me [at Extend Fertility]. My friend had her eggs out somewhere else and she still doesn’t know what AMH is. They told her she didn’t produce enough eggs but didn’t explain why.’
Her description of the day itself is the lightest part of her entire recollection.
‘It’s like 10 minutes anesthesia. It’s more easy than going to the dentist, you don’t feel anything,’ she says.
‘I went shopping with my friend after. It’s really light, relaxed and fresh,’ she added, as if it were some kind of beauty salon treatment.
‘That was it, now I can move on with other things in my life. I don’t think I need to think about having kids yet.
‘When I actually think about it, it’s emotional, you get something so valuable. I’m preserving my future. I can have children naturally, it’s a back-up.
‘To me I look at it as something I achieved in my life, like any other achievement… like graduating university.’