Fertility Preservation: Egg Freezing Before the Window Closes

Three drug classes now exist: GLP-1 agonists (semaglutide), GLP-1/GIP combinations (tirzepatide, marketed as Mounjaro), and a GLP-1/GIP/glucagon combination about to be released. Injectable semaglutide starts at 0.25 mg subcutaneously, rising gradually to 2.4 mg; an oral form (Rybelsus) is also available but must be taken daily rather than weekly. Mounjaro, launched in the US two years earlier at roughly $1,000 a month, was released in India at about one-sixth of that cost (roughly Rs 15,000 to 20,000 a month) because of the scale of global obesity; with semaglutide's patent expiring in March and around eleven companies preparing to launch competing versions in India by April, prices are expected to fall further.

Ozempic is semaglutide. Untreated obesity itself carries heart, kidney, liver, joint and psychological risks that dwarf the drug's own side effects, which Dr. Pai compared to the rare risk of a plane crash or of liver failure from paracetamol, neither of which stops those products being used. He attributed the outsized scrutiny to how much public attention weight-loss drugs attract, not to an unusual risk profile compared with other common medications such as blood pressure drugs.

These drugs are not used during pregnancy. Dr. Pai's protocol is to bring the patient's weight down, stop the drug, wait about a month for it to wash out, then begin ovarian stimulation, retrieve eggs, freeze embryos, and transfer roughly a month later. He noted that around 50,000 unplanned pregnancies occurred among women on Ozempic in the US with no reported harm, and drew a parallel to metformin, once considered risky in pregnancy and now used throughout it.

Clomiphene 50 mg twice daily from day 2 to day 6, plus HMG 150 IU on days 7 and 9. HMG is avoided in PCOS patients because of hyperstimulation risk; PCOS is diagnosed by an antral follicle count above 15 with a necklace pattern on ultrasound and a high AMH, which Dr. Pai called their gold-standard test. He also recommends AMH testing for daughters to check ovarian reserve, with egg freezing considered before age 35 if a woman is not yet married.

Most commonly amenorrhoea or very scanty periods, occasionally heavy bleeding. Diagnosis relies on TB-PCR and D&C with histopathology, but because PCR can be falsely negative, Dr. Pai prefers laparoscopy for direct visual confirmation, alongside a chest X-ray, palpation of cervical and groin lymph nodes, family history, sputum AFB testing on three consecutive days where indicated, interferon-gamma release assays and a Mantoux test. Treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months in total, which must be completed fully to avoid multidrug-resistant TB; laparoscopy and hysteroscopy are repeated afterward before trying IUI, and IVF only if that fails.

The clearest reason is medical: eggs and sperm can be frozen before chemotherapy or radiotherapy for cancer to preserve fertility that treatment would otherwise destroy. The faster-growing reason is social, among women who are not yet married by their early thirties and want to protect against the decline in egg quality that accelerates after 35.

AMH testing before age 30 establishes baseline ovarian reserve, and egg freezing before age 35 is recommended for women who are not yet married, since both egg quality and genetic risk shift once that threshold passes.

Centres performing this work run 5 to 10 egg-freezing cases most months, though the practice remains concentrated among wealthier patients.

Baseline reproductive health measures, AMH testing, regular health checks, weight management and three-dose HPV vaccination for cervical cancer prevention, are framed as accessible interventions regardless of income.