Fertility preservation is an emerging area of reproductive medicine that empowers women to make well informed decisions regarding their reproductive options. In 2013 The American Society for Reproductive Medicine (ASRM) published practice guidelines that removed the experimental label from oocyte cryopreservation. To date, there have been over 6,000 live births achieved from oocyte cryopreservation without an increase in pregnancy complications or congenital anomalies (Cobo et. al. Fertility and Sterility 2014 & 2016)).
The application of fertility preservation technology ranges from women who face cancer or who have underlying medical diseases that require chemotherapy to women who choose to delay childbearing for personal choice. Regardless of indication, the technology applied to all situations is similar and the options include embryo cryopreservation with partner or donor sperm or oocyte vitrification.
Many cancer treatments cause loss of reproductive function. Over 100,000 individuals less than 45 are diagnosed with cancer annually in the United States. Furthermore, 1 in 250 adults is a survivor of cancer. As survival rates increase and women are able to think about life after cancer, fertility preservation is becoming increasingly more important. Studies have indicated that after mortality, fertility ranks as the most important concern for cancer survivors.
Newer protocols are constantly being developed for ovarian stimulation in cancer patients. The different types of cancers may have different risks associated with ovarian stimulation. For example, women who have estrogen receptor positive breast cancer undergo ovarian stimulation with both gonadotropin and aromatase inhibitors to prevent estrogen levels from increasing dramatically during stimulation. Some studies indicate that cancer patients stimulate differently than their age-matched infertility patients. They require larger doses and greater ratios of urinary gonadotropins (contain LH and FSH components) compared to recombinant gonadotropin (FSH component only). To expedite treatment, “random start” protocols are being advocated in which patients start gonadotropin medications at the first visit regardless of where they are in the cycle. Studies have shown that follicular recruitment is not limited to the follicular phase, luteal phase stimulation start protocols have been shown to be highly effective and oocytes can be retrieved within 10-14 days of the initial physician consultation. Lastly, to optimize yield, multiple IVF stimulations are being performed in the interval prior to chemotherapy initiating. Given the incredible importance of the success of these IVF cycles a center with extensive experience is necessary.
ASRM published additional practice guidelines in 2013, guidelines unique to fertility preservation for patients undergoing gonadotoxic therapies. They identified key components to a successful fertility preservation program including rapid access, multi-disciplinary approach and excellent embryology lab. At Fertility Centers of Illinois, we have committed to seeing ALL cancer patients within 24 hours of the request. For fertility preservation patients with cancer undergoing treatment we have substantially decreased the costs of treatments for those that are uninsured. We also work with two programs, LIVESTRONG and FERRING Heart Beat programs which provide the medications to these patients at no charge. Our two mental healthcare professionals are available to these patients during this difficult time. We are completely committed to minimizing all road blocks for these patients.
Many women are choosing to delay childbearing. The age at which women are having their first child is increasing. In the past 20 years, there has been a 150% increase in women 35-39 years old having their first child in the United States. As women choose to delay marriage and childbearing, the likelihood of future infertility increases. For women without partners who desire fertility preservation due to cancer or life choices, oocyte vitrification is a great option. Fertility Centers of Illinois has been using vitrification technology for embryos for 12 years with greater than 95% survival rates upon warming.
An additional application of oocyte vitrification technology is the use of vitrified donor oocytes. Fertility Centers of Illinois has partnered with Donor Egg Bank USA and we offer the use of either fresh or frozen donor eggs to our patients. There is no difference in success rates between fresh and frozen eggs. As the technology continues to improve, it is likely that egg banks will become as popular as sperm banks for the use of donor gametes.
The literature has demonstrated comparable pregnancy rates between fresh and frozen oocytes. Follow up studies on egg vitrification has analyzed the number of eggs needed for > 80% cumulative pregnancy rates. Cobo et. al. (Fertility Sterility 2016); demonstrated that for woman < 35 years 8-10 metaphase II eggs are needed. Other groups have suggested 12 metaphase II eggs for woman less than 35 and 29 metaphase II eggs for women 36-39 years old (Chang et al. Fertility and Sterility 2013) Our very own lab at Fertility Centers of Illinois has demonstrated similar success rates with vitrification technology. We have vitrified 6000 oocytes to date from women with a mean age of 34.5 years. To date, we have warmed 600 oocytes with a clinical pregnancy rate of 48.5%.