10/19/2018 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 Center for Reproductive Health Evelyn Mok-Lin, MD Assistant Professor, Obstetrics, Gynecology and Reproductive Sciences Medical Director, UCSF Center for Reproductive Health 2 Why should women consider egg Infertility is a Common Disease freezing? To preserve a woman’s current fertility and • 12% of reproductive age women in the US have increase their chances of achieving pregnancy at infertility a later age • WHO ranks infertility as the 3 rd most serious disease worldwide www.elle.com 3 4 1
10/19/2018 Decreasing Egg Quantity with Age Age is the #1 Predictor of Fertility • Women are less likely to conceive and more likely to miscarry as they get older • Finite number of follicles at birth • 12% remaining at age 30 Heffner, NEJM 2004 • 3% remaining at age 40 Wallace and Kelsey, PLoS 2010 5 6 Increasing Rates of Chromosomal Abnormal Spindles in Older Eggs Abnormalities with Age 20-25 year old eggs – 17% of eggs with abnormal spindle assembly 40-45 year old eggs – 83% of eggs with abnormal spindle assembly Battaglia et al, Human Reproduction 1996 7 8 2
10/19/2018 Medical indications for egg freezing Elective indications for egg freezing 1. Need for medical or surgical treatments that 20,000 women in the U.S. reduce ovarian reserve and/or affect egg underwent elective egg quality cryo by 2018 • Chemotherapy • Pelvic radiation 1. Women who wish to • USO/BSO delay childbearing due to personal or • *Testosterone for gender dysphoria professional 2. Risk for early menopause circumstances • Family history of POI and/or personal history of diminished ovarian reserve (DOR) – If not otherwise ready to conceive – DOR does not equal poor egg quality or future infertility 3. Genetic mutation carrier • BRCA, FMR 9 10 Optimal timing for elective egg Elective indications for egg freezing freezing 2. Women/couples who want to have more than 1 • What is the ideal age? child • Is there a minimum or maximum age? Franasiak et al. Fertility and Sterility 2014 11 3
10/19/2018 Optimal timing for elective egg Mesen et al. 2015 freezing • 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) Mesen et al. Fertility and Sterility 2015 • Egg freezing was most cost-effective at age 37 yrs • Decision-tree model for egg freezing vs no action https://uncfertility.com/treatment-options/egg-calculator/ – ages 25-40 yrs – attempt at procreation 3, 5 or 7 years after – unassisted attempts for 6 months and then IVF 13 14 Embryo versus Egg Freezing Embryo versus Egg Freezing • Embryo cryopreservation • Oocyte cryopreservation – Well-established – More practical • Most data • Offers flexibility for use with sperm of choice • Highest success rates • Lower cost and logistically easier • Allows for assessment of embryo quality and preimplantation genetic testing (PGT) – Limitations: • Less long-term data – Limitations: – Short-term data with no increased risk of chromosomal or congenital anomalies • More expensive • Lower success rates • Requires male partner or donor sperm – Lab-dependent cryopreservation skills/techniques • Potential legal and ethical issues re: use / disposition – No data on egg quality so difficult to estimate subsequent success rates 15 16 4
10/19/2018 Egg freezing process and timeline Frequent monitoring visits 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 weeks 17 18 Egg retrieval with US guidance Fertility Preservation: Risks • No association with subsequent ovarian or breast malignancies • Stimulation and procedure-related risks include: – Ovarian hyperstimulation syndrome (OHSS) – Ovarian torsion – Bleeding Fertility Preservation Program Fertility Preservation Program – Infection – Injury to adjacent organs • Symptoms – Most common: bloating, cramping, headaches – Less common: nausea, mood swings, breast tenderness 19 20 5
10/19/2018 Success rates Predicting likelihood of live birth • Goldman et al., Human Reproduction 2017: What are the expected chances of live birth from frozen eggs? How many eggs should I freeze? 21 22 Decision regret and satisfaction Goldman et al., 2017 after elective egg freezing Surveyed 201 women after elective egg cryo • 167 (83 %) reported increased control over reproductive planning • 33 (16%) experienced mod-severe regret 23 24 6
10/19/2018 Greenwood et al. 2018 Greenwood et al., ASRM 2018 “It felt like a huge cloud that had been hanging over my head Increased regret had been lifted.” associated with: “The process helped me evaluate what I really want in life.” • Lower number “Just before egg freezing, I was considering marrying a man I of eggs knew I did not love because he wanted to have children soon cryopreserved and I knew he would be a sufficient father” “The process of freezing my eggs made me realize that I • Perceived wanted a baby more than I wanted a partner, and I decided to lower have a baby on my own.” adequacy of “I feel more worried now about my fertility than before. The information process gives you a lot of information about your fertility- and emotional sometimes that information will be great, sometimes not support great.” “It was extremely emotionally draining and I felt very lonely with a lack of support.” 25 26 Summary • A woman’s egg quantity and quality decline with increasing age • Egg freezing offers women the opportunity to Thank you preserve fertility for medical or elective reasons • Egg freezing is a safe, non-experimental procedure that is typically completed within 2 weeks • There may be emotional hazards and “false hope” associated with elective egg cryo • The decision to freeze or not freeze should be tailored to the patient’s individual clinical and personal situation 27 7
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