Fertility Preservation

Every year approximately 800,000 reproductive age men and women are diagnosed with cancer. A cancer diagnosis is devastating, but due to the advances made in the fields of oncology, diagnoses are made much earlier and treatments are becoming more successful leading to increased survival rates. Many cancers are now successfully treated allowing people to live long lives after their diagnosis. Unfortunately, a major complication of these increasingly effective cancer therapies is reproductive failure resulting in temporary and permanent infertility or sterility in both women and men.Cancer treatments such as chemotherapy, radiation therapy, radical surgery or bone marrow transplantation can affect future fertility by reducing the number of eggs/sperm, altering the blood supply to the reproductive organs or by removing necessary organs.

Cancer survivors often want to have families but their cancer treatment may have caused significant deterioration, or complete loss of fertility. The deleterious effects depend on multiple factors such as the patient’s age, dose and the type of the chemotherapy agent or radiation used, as well as the individual susceptibility to treatment. It is vital to consider fertility as an important factor for patients who have been diagnosed with cancer and other serious chronic conditions and diseases. Planning Fertility Preservation in advance can preserve sperm, eggs or embryos for future use. Arizona Associates for Reproductive Health is prepared to help you move through the process quickly so you can begin your cancer treatment and recovery.

Arizona Associate for Reproductive Health’s Fertility Preservation Program is designed to provide state-of-the-art options for reproductive-aged men or women who are about to begin treatments that may threaten their future fertility. We understand the time constraints and emotional stress of patients facing cancer treatment, as well as the concern over the potential negative impact on future fertility. We offer expedited, compassionate care at a discounted rate for egg or embryo freezing prior to cancer treatment. We partner with LIVESTRONG (Fertile Hope) to offer cancer patients help through the Sharing Hope Program. As a participating center in the Sharing Hope financial assistance program, AzARH works with LIVESTRONG to increase access to Fertility Preservation services for cancer patients by providing Fertility Preservation treatments and medications at a discount for qualifying patients. LIVESTRONG is a national, nonprofit organization dedicated to providing reproductive information and financial support to cancer patients and survivors whose medical treatments present the risk of infertility.

If you're a woman of child bearing age or a man who is concerned about his future ability to become a father, our services will allow you to approach and recover from your illness with the satisfaction that you have addressed this important aspect of your life, and will help you to realize your fertility goals following your treatments. Simply call Arizona Associates for Reproductive Health at 480-946-9900 and express your interest in Fertility Preservation to schedule an expedited appointment with one of our specialists. Most visits can be arranged within 24 to 72 hours of your call. You will have a thorough consultation with one of our reproductive endocrinologists and a customized plan of care will be created in conjunction with your oncologist.

Elective Fertility Preservation for purposes other than medical reasons has been an option for men for many years. Fortunately, due to exciting developments in the field of Assisted Reproductive Technology (ART), elective Fertility Preservation is now a realistic option for women who elect to delay child bearing for medical, professional or personal reasons.

Fertility Preservation for Women

Fertility Preservation may be used by women who elect to delay child bearing for medical, professional or personal reasons. The primary indications for Fertility Preservation include:

• For women diagnosed with cancer who wish to freeze eggs before starting chemo or radiation therapy which damages the eggs and may cause later infertility or sterility. Over 50,000 reproductive-aged women are diagnosed with cancer annually in the United States. Some chemotherapeutic and radiation regimens are toxic to the ovaries and destroy eggs. Combination chemotherapy regimens and radiotherapy commonly produce menstrual irregularities as well as infertility. Total-body irradiation used in the preparative regimens for bone marrow transplantation is damaging to endocrine and ovarian function. Ovarian damage is drug- and dose-dependent and is related to age at the time of treatment, with progressively smaller doses producing ovarian failure as the patient’s age increases. Total body, abdominal, or pelvic irradiation may cause ovarian damage, depending on the dose, fractionation schedule, and age at time of treatment. Women should consult their reproductive endocrinologist and oncologist to evaluate their individual medical and personal needs in selecting the most appropriate Fertility Preservation technology. In the setting of a newly-diagnosed cancer, embryos, eggs, or ovarian tissue may be frozen as a medical emergency to minimize any delay of cancer treatments.
• Before treatment for autoimmune or benign systemic disease which may cause irreversible loss of fertility.
• Before removal of the ovary(ies) for benign tumors or endometriosis.
• Women with a family history of premature ovarian failure or premature menopause may select to preserve their fertility at a younger age. Some forms of early menopause (premature ovarian failure) are genetically linked. Fertility Preservation offers a chance to preserve eggs before they are depleted.
• To defer reproductive aging. Fertility preservation is an option for women who want or need to delay childbearing in order to pursue educational, career or other personal goals. Because fertility is scientifically proven to be age-dependent, freezing your eggs at an early reproductive age may improve your chance for a future pregnancy and decrease the incidence of birth defects associated with aged oocytes.

Technologies for Fertility Preservation in women include:

• Embryo freezing: Eggs are matured with the use of injectable hormones, removed, fertilized in vitro (outside the body) with sperm, frozen and stored. Embryo freezing is frequently used in regular IVF for extra non-transferred embryos. Embryo freezing has been performed successfully since the 1980s. Thousands of babies have been born using this technology and there is a large body of data confirming its safety. Embryos can be frozen at different stages of development using various freezing techniques. The survival of the embryos after the freezing and thawing is high, making embryo freezing an excellent option for Fertility Preservation.
• Egg freezing: Multiple eggs are matured with the use of injectable hormones, removed, frozen, and stored without being fertilized. Egg freezing is an option for patients without a partner who do not want to use donated sperm. For many years it was possible to freeze and preserve sperm and embryos, but the preservation of eggs was difficult due to the sensitivity of the egg to the freezing/thawing process. Recent improvements in oocyte cryopreservation (egg freezing), particularly the use of a special freezing methodology called vitrification has resulted in increased success.
• Ovarian tissue cryopreservation: Ovarian tissue freezing is sometimes done in patients who are having abdominal surgery or when it is not advisable to stimulate the ovaries to obtain embryos or eggs for freezing.
• Ovarian suppression: Medications are administered during cancer treatment to protect the ovaries and reduce the risk of infertility.
• Ovarian transposition: Surgically displacing the ovaries prior to radiation therapy to minimize damage.

Egg Freezing

Egg freezing, also known as oocyte cryopreservation, is now a reality in the specialty of reproductive endocrinology and infertility. It has opened new treatment options for assisting infertile patients and also has new applications for women wishing to preserve their fertility for medical indications or personal reasons.

Cryopreservation is not something new in the world of Assisted Reproductive Technologies (ART). Medical clinics have been freezing sperm since the 1950s and embryos since the 1980s. While sperm and embryo cryopreservation have become routine, egg freezing has presented greater challenges and is a relatively new technology. The first baby born from frozen eggs occurred in 1986.

Freezing of eggs can trigger premature hardening of the zona pellucida which surrounds the egg. Normally zona hardening occurs after the sperm penetrates the egg, thus protecting it from being penetrated by other sperm. Fortunately, hardening of the zona can be overcome with the use of Intracytoplasmic Sperm Injection (ICSI), a routine procedure already proven successful for many years in treating male infertility.

The high water content of eggs has also presented challenges since it increases the risk of cellular damage during the freeze-thaw process. Additionally, eggs are at a sensitive stage of the meiotic cell division cycle. The egg chromosomes are aligned within a fragile structure known as the spindle apparatus. These inherent difficulties have limited the success of egg freezing in the past. Recent studies over the last 5 years have reported improved results with adjustments in freezing protocols. In particular, extremely rapid cooling rates with a technique known as vitrification appear to minimize chromosomal damage and the formation of intracellular ice. Many fertility programs throughout the world have recently demonstrated good success with freezing and thawing of eggs with live births using egg vitrification technology. There have now been approximately 1600 babies born worldwide from frozen eggs.

Arizona Associates for Reproductive Health (AzARH) doctors and embryologists have been involved in research to develop successful techniques for freezing sperm and embryos for many years.  More recent research with an egg freezing process known as vitrification has allowed AzARH to offer egg freezing under IRB oversight for patients who may be reluctant to freeze embryos. Egg freezing may be used by women who wish to delay childbearing for different reasons. Three groups of patients can benefit from egg freezing:

• Before cancer treatment. Treatments for cancer such as chemotherapy and radiation may damage eggs and result in sterility or infertility. Freezing embryos remains the most successful approach, but is not possible for women who do not have a partner or do not wish to use donor sperm. Depending on the cancer diagnosis and recommendations from a woman’s oncologist, she may elect to freeze eggs before undergoing cancer treatment in order to preserve her fertility. In some cases, viable eggs may be present after cancer treatment. Fertility preserving options vary depending on age, type of cancer, and cancer-treatment plan. At your consultation, your physician will review your medical history and will outline your evaluation and treatment.
  
  
  

  Physician Consultation and Treatment Cycle Overview

  
  
  • We set up an appointment for you to meet with a physician to discuss your treatment options.
  • At the appointment your medical history and treatment plan is reviewed. The amount of time you have available prior to starting your oncology treatments is clarified, and appropriate options are discussed.
  • We help you decide between freezing eggs and embryos, or advise you on whether your oncology treatment is benign enough not to require Fertility Preservation.
  • Your insurance is checked to see if you have any coverage. If you do not have coverage, you may be a candidate for the Sharing Hope program and an application can be completed.
  • We then schedule an appointment with an IVF nurse for consultation and injection training. A start date for stimulation medications is decided based on the amount of time available prior to start of your oncology treatment and anticipated start of the menstrual cycle. The timeframe to complete the stimulation cycle and egg retrieval is usually about 3 weeks.
  • To begin treatment an ultrasound is performed to look at the ovaries and uterus. All the ultrasounds are done vaginally.
  • The injections are typically administered daily. You will be scheduled to have an ultrasound 3 to 5 days after the injections begin.
  • Ultrasounds are done every 2 to 3 days based on follicular development.
  • Egg retrieval typically happens 10 to 12 days after stimulation begins.
  • The egg retrieval is done in our office under anesthesia. You are required to have someone take you home and we recommend that they stay with you for several hours after the procedure.
• Women wishing to electively preserve their fertility. In today’s society, many women want to delay child bearing until they are older. Egg freezing provides fertility options for women who choose to delay pregnancy for either medical or elective reasons. Fertility decreases with age, slowly declining until age 30, then declining more quickly thereafter. By age 40, the chances of spontaneous pregnancy are less than 50% of what they were at age 30, and other risks such as miscarriage and Down’s syndrome are significantly higher. With the recent improvements in egg freezing technology, we can now offer women the option of freezing and storing their eggs at a younger age, allowing a woman to choose when she is ready for a family.
• Women undergoing IVF who do not wish to freeze embryos. In traditional IVF attempts, extra embryos are frozen for future use. However, some patients have ethical or religious concerns with creating extra embryos and making decisions about disposition once hey have completed their families. For some, freezing eggs before they are fertilized may be a better option.
• Women needing donor eggs. Donor egg banks are now a reality. Similar to large sperm banks, the advantage to donor recipients is a much larger selection of potential donors than would otherwise be possible. After freezing, donor eggs may be quarantined until repeat infectious disease testing can be completed, similar to donor sperm banking. Frozen donor eggs also eliminate the need to synchronize the donor’s and recipient’s menstrual cycles for treatment purposes.

While fertility specialists share much optimism that egg freezing provides options for groups of women who might otherwise have few or none, many in the scientific community still consider egg freezing to be experimental and consequently the process should be carefully considered. The American Society for Reproductive Medicine (ASRM) advises clinics to perform egg freezing under Institutional Review Board (IRB) approval and ongoing oversight. ASRM will continue to consider egg freezing experimental until published studies regarding risks, benefits and overall safety and efficacy are sufficient to regard the procedures as established medical practice.

Most assisted reproductive technologies are no longer considered experimental. The American Society for Reproductive Medicine (ASRM*) considers the following procedures to be established medical care:

• IVF
• Donor oocytes
• Embryo cryopreservation
• ICSI for male infertility
• Assisted Hatching
• Preimplantation Genetic Diagnosis

*Established in 1944, the ASRM comprises over 10,000 fertility specialists worldwide

Arizona Associates for Reproductive Health (AzARH) fully complies with the ASRM recommendation to provide egg freezing services under IRB review. AzARH only offers egg freezing after carefully reviewing IRB consents for egg freezing with each patient. The goal is for each patient to fully understand the possible risks, benefits and current success rates with egg freezing before deciding to pursue this treatment option. Providing egg freezing under the observant eye of an IRB helps ensure the freezing and storage of eggs is done using techniques that provide your best chance for success as well as long term safety of your eggs in storage. There are currently egg freezing programs that operate with no IRB approval or oversight. Ask any program you may be considering if they provide egg freezing under an ongoing, approved IRB certificate.

Three of the most important factors in determining your chances for potential success with egg freezing are your serum FSH, baseline follicle count of your ovaries and ovarian reserve testing. These studies are used to gain an understanding of the ability of your ovaries to produce healthy eggs that will allow for successful freezing, thawing, fertilization and embryo development. These are vital steps to establish a successful pregnancy. Due to the natural egg aging process, it is more ideal to freeze eggs in women who are younger than 38 years old. To date, there have been few ongoing pregnancies reported in women over 38 from frozen eggs. This is mostly due to lower age cutoffs in egg freezing studies. Pregnancies are routinely achieved in women up to age 43 using fresh embryos. We may find with further egg freezing research that we are able to mimic these fresh rates.

Please contact our office to schedule a pre-consultation evaluation of your Follicle Stimulating Hormone (FSH) and estradiol levels. These tests should be scheduled for the third day of your menstrual bleeding prior to your initial consultation with the doctor.At your consultation, your physician will review your medical history and will outline your evaluation and treatment. Based on your ovarian reserve, which is determined by your internal reproductive hormones, a stimulation protocol will be formulated by your physician.

Group 1 – Best Chances for Success
• Under age 32 years
• A serum FSH less than 7.1 mIU/ml on cycle day 3. Satisfactory ovarian reserve testing. If being treated for cancer, no prior exposure to chemo or radiation therapy.

Group 2 – Good Chances for Success
• Ages 33-35 years
• Serum FSH less than 8.1 mIU/ml on cycle day 3. Satisfactory ovarian reserve testing. If being treated for cancer, short term, limited exposure to radiation or chemotherapy with no direct radiation of ovaries.

Group 3 – Moderate Chances for Success
• Ages 35-37 years
• Serum FSH between 7.1 and 9.0 mIU/ml on cycle day 3. Satisfactory ovarian reserve testing. If being treated for cancer, short term, limited exposure to radiation or chemotherapy with no direct radiation of ovaries.

Group 4 – Lower Chance for Success
• Ages 38 to 39 years
• Serum FSH between 5.0 and 8.5 mIU/ml on cycle day 3. Satisfactory ovarian reserve testing. If being treated for cancer, no more than short term, limited exposure to radiation or chemotherapy with no direct radiation of ovaries.

Group 5 – Lowest Chance for Success
• Ages 40 to 42 years
• Serum FSH greater than 10.0 mIU/ml on cycle day 3. Satisfactory ovarian reserve testing. If being treated for cancer, no more than short term, limited exposure to radiation or chemotherapy with no direct radiation of ovaries.

Group 6 – Minimal to no Chance for Success – Not eligible for egg freezing at AzARH
• Over 42 years of age or any woman with unsatisfactory ovarian reserve testing outcomes.
• Serum FSH levels greater than 10.0 mIU/ml on cycle day 3 If being treated for cancer, extended chemotherapy or direct radiation of the ovaries. AzARH has elected to not offer egg freezing to women over age 42 or those with poor ovarian reserve testing because of minimal chance of success for women in this category.

The process for egg freezing is similar to a traditional IVF cycle and typically takes 3 to 6 weeks. Egg freezing uses standard protocols to stimulate egg production and retrieve the eggs. A woman usually takes birth control pills followed by hormone medications to stimulate the ovaries to produce multiple eggs. The eggs are retrieved and the mature eggs are frozen that same day. The eggs are stored in liquid nitrogen at temperatures where there is no cellular activity and, therefore, are not impacted by length of storage. The number of eggs produced and the percentage of mature eggs recovered is variable from person to person.

Once a woman is ready to conceive, an AzARH physician will coordinate with your oncologist to ensure you are healthy, able to use fertility medications, and ready to carry a pregnancy. Some patients may be unable or advised not to carry a pregnancy following cancer treatment. AzARH offers treatment using a gestational carrier (a woman who will carry the pregnancy for you). With approval from your oncologist, AzARH will allow transfer of embryos to women up to the age of 50. Patients starting a treatment cycle will begin taking medicine to prepare the uterus for pregnancy. The eggs are thawed and fertilized and then cultured for 3 to 5 days before embryo transfer. Extra embryos can be stored at AzARH.

Fertility Preservation for Men

Men have long been able to preserve their fertility by freezing their sperm. Tour de France champion Lance Armstrong's three children were conceived with sperm he banked before chemotherapy.
Fertility Preservation for men may be done for several reasons:

• Cancer patients before undergoing chemotherapy or radiation. Cancer treatment adversely affects sperm quality and can lead to infertility. We strongly encourage patients to freeze semen, preferably before initiation of cancer treatment to preserve fertility. Patients may need to undergo radiation, chemotherapy, or surgery as part of medical management. Each of these treatments has deleterious effects on sperm production and can contribute to infertility. Certain types of cancer may also affect sperm quality even prior to the beginning of treatment.  Recent studies have shown that semen from patients with many cancer types including testicular, seminoma, prostate, lymphoma, leukemia, and Hodgkin's can be successfully frozen, even when sperm counts are low. Due to potential genetic damage caused by chemotherapy or radiation, it is recommended that sperm be frozen before cancer treatment is initiated.
• Patients who are electing to have a vasectomy but wish to have sperm stored.
• Patients who are expecting to be unavailable at the time of insemination and wish to store sperm for their partner’s use.

Men with very low sperm counts or poor quality sperm may still successfully freeze sperm when used with assisted reproductive technologies such as IVF and ICSI.If there is complete absence of sperm there is still the possibility of cryopreserving sperm in some cases. As long as at least one testis has areas of sperm production, sperm can be retrieved surgically from the epididymis or the testicular tissue and frozen for future use with ICSI.
Technologies for Fertility Preservation in men include:

• Semen freezing: Semen is collected, frozen, and stored. Semen freezing is a well established procedure. The sperm can be stored for years and used later for intrauterine insemination (IUI) or Intracytoplasmic Sperm Injection (ICSI). For men undergoing chemotherapy, radiation or surgical castration, we recommend collection of multiple samples prior to the initiation of therapy. The semen sample is tested for quality and stored in a sperm bank for future use.
• Percutaneous sperm aspiration (PESA): Sperm are obtained through a needle aspiration of the epidydimis (the sperm storage area outside the testis), frozen and stored.
• Testicular sperm extraction: Testicular tissue is obtained through an open biopsy or with a biopsy gun. The sperm cells and cells that produce the sperm are frozen and stored.