Behind BMI Limits in Egg-Freezing Procedures
Photo-Illustration: The Cut; Photos: Getty
When Michelle went in for an egg-freezing consultation at a Sacramento, California, fertility clinic in February 2021, she was, in most ways, the typical egg-freezing patient. She was 36, a college-educated professional, and had spent much of her 20s and 30s focusing on her career and traveling to more than four dozen countries. Like the majority of women who seek out elective egg freezing, she was single and thought it would lighten the anxiety she felt while dating. “So that it’s not like, ‘Hi, okay, when do you wanna have a baby,’ you know?” she says.
Nine months later, after a five-month recovery from ankle surgery, Michelle was ready to start the process, which entails hormone injections to stimulate egg-follicle growth; regular monitoring; and a short, 15- to 30-minute egg retrieval, during which a needle guided by ultrasound is used to gently suction out the eggs from their follicle sacs. The procedure is done under anesthesia, and after a few hours’ rest, patients can go home (clinics recommend doing so while accompanied by a friend or family member, to be safe). In the interim, she also had her hormone levels measured and learned that her anti-Müllerian hormone (AMH) level was lower than average for her age, a possible sign that her ovarian reserve was depleted. She was anxious to get going.
After a few false starts — on the first two attempts at getting an appointment, communication and scheduling mishaps pushed her start date back by a month each time — the busy clinic finally slotted her in for March, and called her back to the clinic in January to update her vitals. But just as she was gearing up to begin, she hit an unexpected roadblock. A few lines into a long email from the nurse coordinator in which she instructed Michelle on which vitamins and supplements to take, discussed the timing of the cycle, and counseled her to abstain from unprotected sex during the course of treatment, lay an unexpected ask: “Dr. Lovely wants you to loose [sic] 9 more lbs before you can proceed with the treatment, we would like you under 262 lbs.”
Michelle pushed the nurse for more information. She felt healthy and strong: She works out three to five times a week, eats nutritious food, and is a longtime member of a competitive traveling roller-derby team. The nurse pointed her to a practice bulletin from the American College of Obstetricians and Gynecologists on the management of obesity during pregnancy, of which only the abstract is visible without a subscription. The nurse also cited the bed-weight capacity in the clinic’s operating rooms, which Michelle found dubious (standard hospital beds support between 350 and 450 pounds.)
Put bluntly, Michelle was told she was too fat to continue.
Egg freezing today is sold as an empowering option for everyone. Fertility clinics and egg-freezing “studios” hammer this message home through social-media advertising aimed at under-40 women, promotional vans offering free fertility tests to passersby on the street, and wine-and-cheese informational nights held at clinics and egg-freezing studios across the country. But when it comes to women in larger bodies, some clinics draw the line, turning away patients over a certain body mass index, or BMI. Although there is no national data kept on this phenomenon, an estimated 11.7 percent of American women are considered severely obese, with a body mass index of 40 or higher.
There is little, if any, research evidence on egg freezing and weight. The vast majority of studies examine BMI and in vitro fertilization, and results from these are mixed. Some have linked overweight and obesity with fewer eggs retrieved and lower rates of pregnancy and live births, while others find no impact of a high BMI on IVF outcomes. Dr. Nicole Noyes, a reproductive endocrinologist who has published extensively on egg freezing and helped establish the egg-freezing program at NYU Langone Fertility Center, notes that higher BMIs are linked to more health risks in general. For egg freezing in particular, she cites risks such as those related to anesthesia; increased difficulty in performing the egg-retrieval procedure because of technical issues (such as suboptimal visualization on the ultrasound machine due to fatty tissue, which increases the risk of inadvertently piercing adjacent pelvic structures and causing internal bleeding); and a still rare but greater likelihood of needing surgery such as laparoscopy in case of complications. These risks combine with the potential for lower egg quality in obese women, something Noyes suspects may be due to the influence of an abnormal hormonal environment surrounding the developing egg, although she admits there is no known explanation for this.
The messaging is “that this is the responsible thing to do, the thing that they should be doing to preserve their fertility,” says Nicola Salmon, a U.K.-based fertility coach who specializes in working with larger patients. Salmon, whose job includes assuring her clients that they are worthy of care, engaging with clinicians and presenting them with research and evidence on caring for larger bodies, and screening clinics to ensure they’ll provide sensitive and individualized care, is currently working with an egg-freezing patient in Texas. Salmon’s client, like Michelle, is ready to begin the egg-freezing process. But, by Salmon’s estimates, they’ve reached out to at least eight or nine fertility clinics in the Texas area about their BMI guidelines, and none will work with them, typically citing BMI cutoffs of 40 (her client’s BMI is 42). “This has been a real blow to their body confidence, to how they feel in their body,” Salmon says, “because they feel that this option — this thing that should be available to everybody — has been taken away from them.”
In general, complications from egg freezing for larger-bodied patients are rare: Noyes estimates she has done at least 20,000 egg retrievals in her 30-year career, and had fewer than ten bleeding-complication cases, none of which were in overweight or obese patients. In some cases, she has performed egg retrievals on larger-bodied women without anesthesia, either because the patient exceeded the anesthesiologist’s threshold for providing anesthesia or in order to avoid anesthesia risks. (She likens the procedure without anesthesia to having blood drawn; the puncture of the needle through the vaginal wall hurts, but most patients do well if they are prepared for that moment.) Ultimately, she says, medicine is about weighing risk versus benefits, and when risks creep up and the benefits are potentially lower, doctors ask themselves, Is the outcome worth it?
Dr. Lynn Westphal, chief medical officer at Kindbody, a national chain of fertility and women’s health–care clinics, suggests a simpler reason — many freestanding fertility clinics are only accredited to perform anesthesia on patients classified by the American Society of Anesthesiologists as having a risk score of I (“a normal healthy patient”) or II (“a patient with mild systemic disease”). People with BMIs between 30 and 40 are considered obese and fall into category II; those with BMIs over 40 are considered morbidly obese and have a risk score of III. This is why, Westphal explains, anesthesiologists at many clinics use 40 as the cutoff for who they can and can’t treat. Fertility clinics based in hospitals, which have different accreditation, have more leeway to treat a broader range of patients. “For example, they are able to intubate patients if there is any airway problem,” Westphal says, “which is something that should not be done in a procedure room.”
Michelle wasn’t told any of this. Instead, the nurse suggested “a change in diet” for weight loss, without knowing anything about what Michelle currently eats, a clear sign, Michelle says, “that this person has assumptions because of your size.”
The weight loss itself didn’t trouble her as much as the lack of context — or at least context she found plausible — for their request. “Nine pounds on a large body is not a lot. I could lose nine pounds overnight if I wanted to,” she says. “I wasn’t concerned about the amount of pounds; I was more concerned about the way they talked to me about it without any kind of explanation.” She eventually got so fed up with the nurse’s communications that she stopped responding. By then, she’d lost three months (most of December, January, and February) to their unhelpful back-and-forth. “Because this process had already taken so long, it was a big risk for me to completely let go of this group that I had already worked with, I’d already paid the consult for. I’d have to do all of that again,” she says.
This is what advocates for body-positive fertility care say is really at issue here: stigma. Jen McLellan, a childbirth educator who blogs at PlusSizeBirth.com, notes that many of the same risk factors doctors cite for high BMI are also present in women of advanced maternal age (35 and older), yet that patient population is targeted for fertility care all the time. Similarly, people with normal or low BMIs may be poor egg-freezing candidates for other reasons. Instead of using a single number as a cutoff, she advocates for evaluating patients on an individualized basis, especially in facilities that are equipped to handle patients with higher ASA scores. “To make these blanket statements, when we don’t have evidence to point to dramatic increased risks, to me points to a lot of weight bias,” says McLellan.
Furthermore, weight stigma, and the stress experienced by people of size during their encounters with the medical system and in the world more generally, can also create unhealthy physical reactions, such as higher stress and cortisol levels, which in turn affect hormones and inflammation. “Anyone who is in a bigger body that has been to their doctor, they will tell you how stressful that situation is,” Salmon says. “When you look at the research around weight stigma, a lot of health-care risks associated with being fat can be explained by this weight-stigma phenomenon.”
Candace, a freelance web developer in San Diego, had been hoping to do IVF in Mexico, where the procedure is less expensive than in the U.S. The clinics she called, though, all had BMI limits lower than her BMI of 44. (She recalls the cap being around 35.) She called local clinics in Southern California, and eventually went in for a consultation at one for a 20-minute appointment that cost $195. The doctor took one look at her, she says, and told her she was a poor candidate for IVF. Instead he recommended she get weight-loss surgery. When she suggested freezing eggs to buy her some time to lose weight before carrying a pregnancy, he said her eggs would probably be poor quality and doing it would be a waste of money. He spent the remainder of their consult talking nonstop about her weight. Candace had brought a notebook filled with questions she had written down that she opened up at the beginning of the consultation. Once she realized she wasn’t going to get any of the answers she hoped for, she closed it and resigned herself to enduring the rest of his lecture. Like Michelle, she left that appointment out her consultation fee and no closer to getting her eggs frozen.
“I’m receptive, because I am trying to lose weight,” says Candace. “It was just how it was presented … to go to a fertility appointment and spend so much time on my weight. Certain people, you can just see their bias. It was less about what he said; he was being professional. It was how he was saying it.”
The advice to come back after losing weight is particularly vexing for patients who feel the clock is ticking on their fertility. “Especially if you’re older, delaying treatment in order to lose weight is going to lower your chance of success because of the delay,” says Dr. Peter Klatsky, a reproductive endocrinologist at Spring Fertility, which has locations in California, New York City, and Vancouver. At Spring Fertility, patients with BMIs over 40 may need an additional anesthesia consultation, and at 45 or over, will require the approval of a physician review committee to ensure the patient’s safety during the procedure. This is because it becomes harder to protect and maintain a patient’s airway under anesthesia, and there may be “other medical risks like diabetes and cardiovascular disease that must be assessed before undergoing anesthesia,” adds Klatsky.
For Beth, a 35-year-old attorney in New York City who asked that her real name not be used, weight loss had been on the agenda since she was in her 20s. She had always had irregular periods, and a series of ob-gyns told her that losing weight could help regulate her cycle. When she reached her early 30s, it occurred to her that her irregular cycle could affect her ability to get pregnant, so in the fall of 2020 she arranged to see an ob-gyn at New York University who specializes in fertility. The doctor confirmed she had polycystic ovary syndrome (PCOS), which is linked to irregular periods and weight gain. The conversation got her thinking that “time’s a-ticking,” especially because one complication of PCOS is infertility. “We need to start taking a little bit of ownership here,” she told herself. But when she asked about egg freezing, “that’s when the BMI thing became an issue.” She doesn’t remember what the BMI limit was, but it was “far below” her BMI at the time (NYU Langone Fertility Center confirmed to the Cut that 42 is the cutoff, citing anesthesia guidelines). She called around to other clinics — an additional one in New York, one in Miami, one in Connecticut, and one in Utah, and was told the same thing. “The first time I heard it, I dismissed it, because, like, the lawyer-asshole in me didn’t really believe it. I was like, oh, it’s just what they said,” Beth recalls. “The second time I heard it, my heart definitely sank.”
Beth wishes someone had warned her earlier on that her weight might be a barrier to accessing care. “It’s kind of the fourth quarter here, or the end of the third. To find out that there’s this huge obstacle now — had I known this at 30, I could have made different changes or choices,” she says. “But to find out now that there’s a year’s worth of self-work that I have to do before I can even get to the plate to talk about egg quality, to even get to the plate to talk about fertility, I think that’s what frustrated me. I wasn’t depressed. I was mad.”
Now Beth is focusing on losing weight in a healthy, sustainable way. She has stopped eating as much takeout and is snacking less often, and has dropped about 50 pounds since August. But it hasn’t been an enjoyable process. “I eat a ton of vegetables and bad-tasting food,” she says. “I’m always a little bit hungry.” She is giving herself until the end of this year to lose more weight, and will revisit the egg-freezing process then.
The question of whether to lose weight is itself a tricky one. Salmon notes that if losing weight were easy, many larger patients would have already done so. Going on crash diets by, say, cutting out entire food groups, is also unhealthy and may lead to poor fertility outcomes, she adds.
After her discouraging experience with the Sacramento clinic, Michelle had a lucky break. Her sister, who is also of size, referred her to Dr. Geoffrey Sher, a fertility specialist in New York, with whom she’d undergone IVF (and who had never mentioned her weight during treatment). Michelle traveled to New York for the retrieval in March. At the recommendation of Sher, she chose to have the eggs fertilized with donor sperm, since frozen embryos are believed to survive the freezing and thawing process better than eggs. Although she is relieved to have two embryos frozen, when she looks back at her experience with the first clinic, “I’m like, Oh, yeah, that was wrong — like, everything about the way that they interacted with me” was wrong, she says. She worries that the bias and obstacles she encountered might discourage other larger patients altogether. What if they never get the memo that there might be better, more responsive care options out there?
“If I didn’t have my sister encouraging me … I think some people would just let it go,” says Michelle. “They would just let it go because they couldn’t lose the amount of weight that they were asked to, or they would let it go because they were like, I wasn’t anticipating being fat-shamed today, and I don’t want to deal with this.”