10/16/2015 Disclosure No one involved in the planning or presentation of this activity has any relevant financial relationships with a commercial interest to disclose. Oocyte Cryopreservation Fertility Preservation Program (aka Egg Freezing) Fertility Preservation Program Evelyn Mok-Lin, MD Assistant Professor Department of Obstetrics, Gynecology and Reproductive Sciences Division of Reproductive Endocrinology and Infertility 2 Overview Audience Poll • Indications In the last year, how often have you – Why, who, when? discussed egg freezing with your patients? • The Science 43% 39% – Embryo vs egg freezing A. Never – Success rates Fertility Preservation Program Fertility Preservation Program B. Rarely 13% • The Procedure C. At least once per month 5% – Timeline and logistics D. At least once per week – Risks y r h k e l v e t e e r n e a o w N R m r – How to prepare your patient e r e p p e c e c n n o o t s t s a a e l e l t t A A 3 4 1
10/16/2015 Indications: Why? • Why consider egg freezing? – To preserve a woman’s current fertility and increase their chances of achieving pregnancy at a later age Fertility Preservation Program Fertility Preservation Program www.elle.com Wallace and Kelsey, PLoS 2010 5 6 Indications: Who? • Who should consider egg freezing? – Women who require medical or surgical treatments that reduce ovarian reserve • Cancer • Other conditions requiring chemotherapy (SLE, thalassemia) • Complex and/or recurrent ovarian cysts Fertility Preservation Program • BRCA mutation carriers – Women at risk for early menopause Heffner, NEJM 2004 • Family history of primary ovarian insufficiency (POI) • Personal history of diminished ovarian reserve (DOR) 7 8 2
10/16/2015 Indications: Who? Indications: Who? • Elective (“Social”) Egg Freezing • Elective (“Social”) Egg Freezing – Women who wish to delay childbearing due to – Women/couples who want to have more than 1 child personal or professional circumstances 9 10 Optimal timing for elective egg Indications: When? freezing • What is the optimal age? Mesen et al. Fertility and Sterility 2015 • Decision-tree model for egg freezing vs no action – ages 25-40 yrs, attempting procreation 3, 5 or 7 years after – unassisted attempts for 6 months and then IVF Franasiak et al. Fertility and Sterility 2014 – conception rates and cost estimates for fresh IVF cycles vs egg freezing, storage and subsequent usage 11 12 3
10/16/2015 Indications: When? • When should a woman undergo egg freezing? – Early to mid-30s is ideal – Take personal timeline into consideration – No absolute age cut-off Mesen et al. Fertility and Sterility 2015 • Live birth rate (LBR) highest when egg freezing performed at <34 yrs (>70%) – Steadily declines with increasing age to 26.2% at age 40 yrs • Greatest improvement in LBR at age 37 yrs – 30% difference in chance of live birth with egg freezing compared to no action (51.6% vs 21.9%) Little benefit at ages 25-30 yrs (2.6-7.1% increase) • • Egg freezing was most cost-effective at age 37 yrs 13 14 Embryo versus Egg Freezing Embryo versus Egg Freezing • Embryo cryopreservation • Oocyte cryopreservation – Well-established – More practical • Most data • Future sperm of choice • Highest success rates • Lower initial cost – Higher survival • Logistically more simple – Pre-implantation genetic screening (PGS) – No longer “experimental” (ASRM 2012) Fertility Preservation Program Fertility Preservation Program – Limitations: – Limitations: • Requires male partner or donor sperm • Less long-term data • Legal and ethical issues – Short-term data with no increased risk of chromosomal or congenital anomalies • Lower success rates – Unknown fertilization rates and embryo quality 15 16 4
10/16/2015 Success Rates Success Rates 17 18 Egg Freezing Procedure Egg Freezing Procedure Egg Retrieval FSH+LH 1 3 5 7 9 11 13 Days Fertility Preservation Program Fertility Preservation Program hCG trigger • The procedure is typically completed within 2 • Each visit during ovarian stimulation involves weeks monitoring of estradiol levels and follicle sizes 19 20 5
10/16/2015 Risks of Egg Freezing Egg Freezing Procedure • Ovarian hyperstimulation syndrome (OHSS) • Ovarian torsion • Bleeding • Infection • Damage to adjacent organs Fertility Preservation Program Fertility Preservation Program • No association with long-term risks to the patient: • Egg retrieval is performed under MAC anesthesia – Breast cancer – Ovarian cancer • Mature eggs are cryopreserved (unless cancer) – Premature menopause • Once frozen, quality of eggs does not change 21 22 Preparing your patient for egg Summary freezing • Initial work up • A woman’s egg quantity and quality decline with increasing age, particularly after her mid-30s – Ovarian reserve testing (AMH, day 3 FSH/E2) – *Additional labs: T+S, CBC, ID panel • Egg freezing offers women the opportunity to delay – Formal pelvic ultrasound not necessary childbearing for medical or elective reasons – Updated healthcare maintenance: pap smear, mammogram • Egg freezing is a safe, non-experimental procedure that is typically completed within 2 weeks Fertility Preservation Program Fertility Preservation Program • Hormonal contraceptives • The ideal candidate is a healthy woman in her early – Stop long-term OCPs temporarily to mid-30s with high ovarian reserve who is able to – Hold on replacing LARCs (except Paragard) freeze 20 mature eggs 23 24 6
10/16/2015 Thank you 7
Recommend
More recommend
