An Overview of Fertility Preservation Options
Fertility preservation was initially developed for young patients undergoing gonad toxic therapies. However, in recent years increasing delays in child bearing to later reproductive years have created demand for elective fertility preservation.
Two very distinct patient populations with radically different needs utilize fertility preservation. Here we outline currently available options for both, medically indicated and donor eggs elective fertility preservation in Newport Beach center. Our expert physicians at Eden fertility clinic in Newport Beach CA, uses advanced assisted reproductive technologies.
Fertility preservation for women
Fertility-sparing treatments can be offered to women in a variety of clinical situations, either “elective,” when fertility preservation is usually pursued for elective reasons or “non-elective,” when fertility preserving treatments are used to avoid damage to the ovaries from what is called “iatrogenic” (i.e., medically-induced) causes.
Embryo cryopreservation / Embryo Freezing
(banking) is the most established fertility preservation technique is. It has been successfully utilized for decades, – with many hundreds of thousands births resulting. It requires that a woman of reproductive age undergo in vitro fertilization (IVF), which includes ovarian stimulation with fertility drugs and subsequent egg retrieval. Retrieved oocytes are then fertilized by sperm from either spouse or semen donor.
The process of fertilizing a women’s egg with a mans sperm and creating an embryo and then flash freezing the embryo and storing it until the couple is ready to create a family. Unlike egg freezing, embryo freezing requires the women to have a partner to fertilize her egg or to choose the sperm donor prior to freezing.
Embryo banking is, therefore, only an option if a woman is willing to commit to a given sperm provider. Many single women considering elective fertility preservation are, therefore, not interested in embryo banking. It, however, is an excellent method of elective fertility preservation for couples in stable relationships.
Since ovarian stimulation requires approximately two weeks, some newly diagnosed cancer patients may not have the option of undergoing an IVF cycle before fertility treatment has to be initiated. Even if enough time for such a cycle is available, a single cycle may not yield enough embryos for cryopreservation (freezing).
Studies have documented that only approximately 8 embryos are typically cryopreserved per treatment cycle in cancer patients, which may not be enough to achieve a later pregnancy. Therefore, additional IVF attempts or additional fertility preservation techniques, like ovarian tissue freezing (see below), may be required to reach an adequate level of reasonable certainty that enough fertility potential has been preserved.
How many embryos should be cryopreserved
How many embryos should be cryopreserved will vary between patients, and will depend on the age of the patient, her ovarian reserve and, ultimately which certainty of pregnancy the woman wants to have once she decides to attempt conception later in life. In most women, we recommend cryopreservation of at least 10 embryos at young ages, and more embryos in women in their late 30’s and early 40’s.
Oocyte (egg) cryopreservation – Egg Freezing
Oocyte (egg) cryopreservation (egg banking ) is, in comparison to embryo banking, a relatively newer technique of fertility preservation. Like embryo banking, this technique requires that a woman undergo ovarian stimulation (of approximately two weeks) and egg retrieval. Retrieved mature eggs are, however, not fertilized with sperm, as in embryo banking, but immediately cryopreserved.
There are many reasons why a woman may want to delay starting a family. Regardless of the reasons, freezing your eggs will enable you to stop your “biological clock” until you are ready to become pregnant. In this process eggs are retrieved from your ovaries, frozen and stored for your future use. To complete an egg freezing cycle you must undergo controlled ovarian stimulation, and egg retrieval.
Though a much more recently developed technique of fertility preservation, oocyte banking in young cancer patients is no longer considered experimental because, even though we do not know yet enough about long-term outcomes, we know enough about the alternative in these patients (which is losing ovarian function and, therefore, future fertility potential), from either chemo and/or radiotherapy to know that the risk-benefit ratio of the procedure favors oocyte cryopreservation, however small the chanced of pregnancy later may be.
That is, however, not the case when oocyte banking is performed for elective reasons. Here, the process is still considered experimental because outcomes are not, yet, well enough defined to offer patients for an obviously elective procedure guidance and reliable advice. Unfortunately, this fact is not always well communicated to patients.
It, however, is a reason why elective fertility preservation is usually not a covered benefit in insurance plans, though some large tech companies including Apple and Facebook offer coverage in their medical plans.
Since oocytes are very large cells, it is still technically challenging to cryopreserve and thaw them efficiently compared to embryos, which consist of much smaller individual cells. Vitrification is the most effective technique to freeze eggs. Several thousand children have been born from thawed oocytes so far worldwide. Though still considered experimental, elective reasons for egg banking, at least in the U.S., have become the by far most frequent utilization. Find more info on egg freezing in Newport Beach & Fullerton..
How many oocytes should be frozen to preserve fertility
How many oocytes should be frozen to preserve fertility will also vary with female age, ovarian reserve, and the number of desired children. Whether for medical or elective reasons, we recommend cryopreservation of at least 20 oocytes for young women and even more in women in their late 30’s. Like with embryo banking, egg banking, therefore, in most women will require more than just one egg retrieval in order to generate a reasonable likelihood of pregnancy later in life.
Ovarian tissue cryopreservation is also still considered an experimental technique. It can be coupled with in vitro maturation (IVM) (see below for detail) of oocytes at time of tissue collection.
In this method of fertility preservation part of an ovary or a whole ovary is surgically removed. The ovary is then dissected in the IVF laboratory, where its outer layer (the cortex) is peeled off. It contains all the primordial follicles, which are the most primitive and immature stage of follicles (also called resting follicles).
This is the follicle stage at which follicles are when a female is born. From birth on until menopause women loose follicles. Most of this loss occurs because these resting follicles are after menarche steadily “recruited” on a 3-5 months-long journey of follicle and egg maturation until, in every month, only one of these follicles reaches ultimate maturity and releases a mature egg during ovulation.
Current medical knowledge does not yet allow for IVM of primordial follicles. We at the present time can in the laboratory only mature later maturation stages of follicles to full maturity of eggs. It, however, is reasonable to assume that the knowledge to culture primordial follicles to maturity will be feasible in the coming years. Once that is achieved, thousands of primordial follicles will be available for IVM after ovarian tissue preservation, changing the whole concept of IVF.
Until IVM of primordial follicles will become available, ovarian tissue preservation can, however, lead to pregnancies in a very different way: Little strips of their ovarian cortex can be surgically re-implanted into women where the ovary used to be, once the patient is cleared for pregnancy. These implants in most cases become functional ovarian tissue, which again produces hormones and follicles, retrievable in an IVF procedure.
Over a hundred births have so far been achieved worldwide with this approach. This technique, therefore, potentially offers a woman multiple attempts of achieving pregnancy if successful transplantation is accomplished.
Ovarian tissue cryopreservation can be done prior to or, sometimes, even after gonad toxic therapy. It can also be performed in still pre-pubertal girls. The method’s shortcomings include the need for laparoscopic surgery and the potential, and mostly hypothetical risk of transplanting cancer cells with the re-implanted ovarian cortex graft, when tissue is transplanted into cancer survivors.
In vitro maturation (IVM)
In vitro maturation (IVM) of oocytes is a relatively new technique in IVF, in which immature eggs are matured in the laboratory. It allows retrieval of immature oocytes without prior ovarian stimulation. Oocytes can then be matured in the laboratory and subsequently either fertilized with sperm and/or cryopreserved. IVM is often performed in women with low ovarian reserve to maximize available egg and embryo numbers.
Especially in women with polycystic ovaries (PCOS), this technique can avoid the need for ovarian stimulation with fertility drugs. In women who quickly have to enter gonad toxic medical treatment and, therefore, do not have time for an IVF cycle with ovarian stimulation, this technique sometimes is performed prior to initiation of therapy. We also noted above, that IVM is often done in combination with ovarian tissue cryopreservation.
Medical ovarian suppression with GnRH-agonists in conjunction with chemotherapy has been reported to help preserve FOR in young women with high starting ovarian reserve. However, outcomes are highly variable, depending on patients age, ovarian reserve and gonad toxicity of the selected treatments regimen. Other treatments have also been reported successful in reducing damage to ovaries from either chemo- and/or radiotherapy. No definite treatment to accomplish this goal has so far, however, been established.
Fertility-sparing surgical and medical treatments for women with gynecological cancers These treatment options are disease specific, and are performed by gynecologic oncologists, usually before radiotherapy is administered.
Ovarian transposition prior to pelvic irradiation is performed laparoscopically, moving the ovaries surgically out of the pelvis prior to radiation therapy to the pelvis. This can help preserve both fertility and ovarian endocrine function.
Radical trachelectomy (removal of only the cervix and not the whole uterus) for early stage cervical cancer can be utilized to preserve the uterus and ovaries and allow future fertility in cases of cervical cancer. When surgical margins of the removed surgical specimen are clear of cancer, the procedure is curative. While the risk of preterm delivery is increased in subsequent pregnancies, most women are able to carry to term.
Ovarian cystectomy or unilateral oophorectomy, along with lymph node biopsy, can be utilized to spare the contralateral ovary and uterus in cases of borderline ovarian malignancy and early stage ovarian cancer, confined to one ovary. Recurrences are rare in properly staged patients with no residual disease.
Hormone therapy for early stage endometrial cancer can be successful with systemic or local high dose progestin treatment. Pregnancy should be established shortly after regression of the malignancy. After completion of pregnancy, a hysterectomy with comprehensive staging is typically performed.
Fertility preservation in men
Sperm Freezing –
The process where a man’s sperm is frozen until he is ready to have a baby. Sometimes patients choose to freeze their sperm or eggs prior to undergoing chemotherapy. This will allow the patients to preserve the utility of their reproductive organs.
Sperm cryopreservation is the most established technique, utilized for decades in post pubertal males prior to gonad toxic therapies. In recent years sperm cryopreservation has, however, also been utilized in other situations, including prior to military deployment and prior to elective sterilization via vasectomy.
Semen cryopreservation can be done rapidly; it is relatively inexpensive and widely available in most areas. Multiple vials of washed sperm are cryopreserved for later use. In men with no sperm in the ejaculate, sperm can often be extracted from the testicle or from the urine in cases of retrograde ejaculation.
Shielding of the testes is an established technique in patients undergoing radiation therapy and should be utilized whenever feasible.
Fertility preservation in pre-pubertal children
Ovarian and testicular tissue cryopreservation techniques are considered experimental but are, due to the high probability of primary disease survival at such young age, frequently utilized. Since research is progressing rapidly in both young females and males, these options should be discussed with the family prior to initiation of gonad toxic therapies. Thawed tissue can be later utilized for either autologous transplantation or for potential in vitro maturation of gametes.
Important general considerations for fertility preservation
Fertility preservation techniques require a very detailed informed consent process. The patient’s and, where applicable, the family’s desires for later disposition of cryopreserved gametes and/or tissues have to be carefully documented during this process. Specifically, the disposition of cryopreserved cells and/or tissues in cases of incapacity, death, and divorce should be addressed.
Ethical practice of medicine requires that patients be clearly informed about what treatment options are considered established and which are still considered experimental. Informed consents have to reflect the status of each proposed treatment.
Further required are realistic assessments of later successful reproduction for each proposed treatment and/or fertility preservation method, assessment of likely required number of treatments and expected costs.
Direct communication between treating oncologist/oncologic surgeon and/or other medical specialists and the expected provider of fertility preserving treatments are essential, and will ensure that patients receive the best possible coordinated care in consideration of both treatment perspectives.