Egg Freezing-Oncology/Rheumatic Diseases
Why have I been suggested to undergo egg freezing?
The various cancer treatments such as surgery, chemotherapy and radiotherapy may affect fertility in young women. Chemotherapy and radiotherapy apart from targeting cancer cells also targets cells in the ovary causing ovarian failure. Certain cancer treatments may impact a woman’s ability to get pregnant more than others. Some of these treatments affect the egg reserve and hormone production dramatically leading to menopause post treatment and in others the fertility declines post treatment and they also tend to experience menopause earlier. Some medical disorders such as rheumatic diseases also require the use of gonadotoxic medication such as cyclophosphamide which can also render a woman subfertile post treatment.
However, fertility preservation methods such as egg freezing make it possible to preserve fertility prior to starting cancer treatment.
How long does the process of fertility preservation (egg freezing) take and is it safe to wait for that long to start cancer treatment?
The oncologist assesses the general health of each patient before referring for egg freezing (fertility preservation) and only if your health permits this will be taken forward. Your cancer specialist also would brief you on the effect of cancer and its related treatment on fertility(low risk, moderate risk, high risk) but it is difficult to be very precise. Your oncologist and fertility doctor will work closely together to make this process as safe for you as possible while maximizing the benefit. Usually the process of ovarian stimulation and egg collection takes about approximately 10-12 days and these days we do random start protocols which means that we can start stimulation on any day of the cycle as opposed to starting on day 2-3 of the cycle when we do routine IVF thereby saving valuable time.
What does the process of egg collection involve?
Oocyte collection process involves ovarian stimulation with FSH (Follicle Stimulating Hormone) injections to increase the number of oocytes retrieved and mature eggs will be frozen for future use. These hormone injections are usually administered either subcutaneously (under the skin) or occasionally in the arm (intramuscular) for around 9-10 days to facilitate this process. The response to these medications are monitored by serial vaginal ultrasound examinations and at times additional blood tests will be advised, possibly resulting in dosage changes if deemed necessary during the course of the ovarian stimulation process. Once the follicles- sac containing eggs reach the right size suggestive of presence of a mature egg, retrieval process will be scheduled.
The egg retrieval process usually happens under sedation/short anaesthetic. Retrieval of eggs through ultrasound guided aspiration is performed as a day care procedure taking approximately 15-30 minutes. The retrievals are done in theatre adjacent to the IVF laboratory. Under ultrasound guidance a needle is passed into the ovaries and the individual follicles are aspirated and the fluid is then passed on to the embryologist who checks for the presence of the egg in the follicular fluid .Once all the follicles are aspirated the procedure is completed.
How many eggs are collected from one cycle of ovarian stimulation?
This mainly depends on the current egg reserve and the response to medication given for ovarian stimulation. Though additional cycles of ovarian stimulation can be done to retrieve more oocytes if necessary, sometimes only one cycle is possible, as there is limited time prior to starting cancer treatment. We can discuss with oncologists and decide if additional cycles can be carried out.
Are there any risks associated with the process of ovarian stimulation and egg collection?
The oncologist assesses the general health of each patient before referring for fertility preservation and only if your health permits this will be taken forward. The usual risks associated with ovarian stimulation such as developing OHSS-(ovarian hyperstimulation Syndrome) can be greatly minimised by close monitoring and doing additional blood tests if needed and using safer protocols such as antagonist protocols and agonist trigger. In hormone sensitive cancers such as breast cancers additional usage of letrozole an antiestrogen helps in keeping the estrogen levels down during stimulation.
The risks associated with the process of egg collection such as bleeding necessitating further intervention is very rare and in general is very safe.
How are eggs frozen?
Recently the newer technique of freezing-vitrification is the method used for freezing eggs with excellent results when these eggs are thawed many years later. After the eggs are retrieved, the surrounding supporting cells called cumulus are removed and eggs are assessed for maturity. Only the mature eggs are frozen the same day within a few hours of retrieval by passing them through cryoprotectant solutions serially before storing them in devices which are then plunged in liquid nitrogen for storage till the time they are ready to be used. Any immature eggs present will be cultured in special media in the IVF lab for one more day to see whether they will mature (In Vitro Maturation) and if they become mature they will also be frozen.
Are there any risks associated with egg freezing?
Sometimes, the eggs may not survive the freezing and thawing process and even if they survive there is no guarantee that these eggs will result in embryos which has a potential of giving a pregnancy.
Are there any risk to children born out of frozen eggs?
There are many pregnancies to date resulting from embryos created using cryopreserved oocytes and the data is reassuring that it is safe.
Can I choose not to undergo egg freezing?
Yes, you can also choose not to undergo egg freezing. The effect of cancer treatment on fertility is based on egg reserve at the time of treatment, patient’s age and the effect of how damaging the specific cancer treatment is on the ovary. Not all treatments are equally damaging. The ovarian reserve can be reassessed post treatment and advice given. The other alternative if ovarian failure sets in post treatment is to consider using donor eggs to get pregnant.
How long can the eggs remain frozen?
According to the current Indian ART regulations, the oocytes can be stored for a period of 10 years and if extension of storage of gametes is needed beyond that time period, additional period of extension can be applied for by writing to National Registry.
How do I check my fertility status post cancer treatment and plan pregnancy?
Once the cancer treatment is completed and oncologist considers that you are safe to proceed to try for a pregnancy we can assess your ovarian reserve by tests -AMH and Transvaginal scans for AFC-antral follicle count and other fertility tests can be performed for your partner too and we will advice accordingly. If all factors are reassuring you can try to conceive naturally and if it does not materialize then you can try for advanced treatment like IVF and in the event of your egg numbers being very low post treatment you can utilize the eggs frozen to create embryos which can them be implanted to achieve a pregnancy. Not all patients who preserve eggs need to use them to achieve a pregnancy and this is a back up option if needed as the effect of cancer treatment on the ovary varies between individuals.
During chemotherapy usually periods stop due to the effect on the ovary. The periods may resume post cancer treatment in which case more likely the ovary is functioning and if periods do not return post treatment, frozen eggs can be used to create embryos to achieve pregnancy.
Ovarian tissue freezing-Oncology/Rheumatic Diseases
Why have I been suggested to undergo ovarian tissue freezing?
The various cancer treatments such as surgery, chemotherapy and radiotherapy may affect fertility to different degrees and some of these treatments may lead to ovarian failure. Chemotherapy and radiotherapy apart from targeting cancer cells also targets cells in the ovary causing ovarian failure. Some medical disorders such as rheumatic diseases also require the use of gonadotoxic medication such as cyclophosphamide which can also lead to ovarian failure. This will affect your child’s ability to have children in the future and hence ovarian tissue freezing is usually suggested. Some young women need to start chemotherapy urgently and in these instances standard fertility preservation options such as egg freezing is not an option and ovarian tissue freezing will be suggested to preserve fertility.
What is ovarian tissue cryopreservation?
Ovaries are part of female reproductive system and all the eggs that a girl child is ever born with is stored in the outer layer of the ovary medically called the “cortex” and this is the tissue which is frozen for future use. Freezing of the ovarian tissue is done using a latest technique called vitrification in which the tissue after being prepared is passed through a series of cryoprotectant solutions to safely freeze the tissue in liquid nitrogen. The cryopreservation technique helps preserve tissue at a very low temperature of -180 degree in the freezers until they are ready to be used.
How safe is the process of ovarian tissue cryopreservation?
This technique has been in practice for close to two decades. In the year 2000, this technique was introduced in clinical practice and since then ovarian tissue frozen have been transplanted again and several pregnancies and live births have been achieved worldwide and is now a well accepted method of preserving fertility as the safety of the procedure has been well established.
How is ovarian tissue collected and stored?
Using laparoscopy, which is a key hole surgery under general anaesthesia, the ovarian cortical tissue is obtained and transported to laboratory where the tissue is prepared and cut into thin slices which are then exposed to a series of cryoprotectant solutions before plunging in liquid nitrogen freezers where it is stored.
What is the procedure if I decide to go ahead with ovarian tissue freezing?
If you decide to go ahead you will be asked to sign detailed consent forms for storage of ovarian tissue and any further questions you have can be clarified prior to signing consent form. Subsequently, you will be referred to a laparoscopic surgeon who will perform the surgery to obtain ovarian cortical tissue under anaesthesia. This is usually done as a day care procedure which means you will be discharged home the same day after the procedure.
What does the process involve if I have to use the tissue in the future?
If in the future if you want to start a family and have premature ovarian failure, then the frozen stored ovarian tissue strips can be used to restore fertility. You need to meet the fertility specialist to discuss regarding the fertility issues and have to undergo laparoscopy again to reimplant the strips of ovarian tissue into the pelvis post which hormone function and egg production can be restored.
Is there a risk that the ovarian tissue frozen could have cancer cells?
The risk of cancer cells being present is there in certain cancers but not all cancers carry the same risk. At the time of freezing ovarian tissue strips, a test can be carried out to check for presence of cancer cells. Again prior to reimplantation of tissue, elaborate tests can be carried out to confirm for presence of cancer cells. Haematological cancers such as leukemia have higher risk than others. If there is evidence of micrometastasis, it will not be replaced.
What happens if I no longer need the tissue?
The consent form which you will be signing will have those details as to what you would want us to do in the event of your not going to use the tissue in the future. The tissue usually can be destroyed by incineration or if you have consented for research will be used for the same.
Can I choose not to undergo ovarian tissue freezing?
Yes, you can also choose not to undergo ovarian tissue freezing. The effect of cancer treatment on fertility is based on egg reserve at the time of treatment, patient’s age and the effect of how damaging the specific cancer treatment is on the ovary. Not all treatments are equally damaging. The ovarian reserve can be reassessed post treatment and advice given. The other alternative if ovarian failure sets in post treatment is to consider using donor eggs to get pregnant.
How long can the ovarian tissue remain frozen?
There are no national regulations on this in India. Currently, we can store it for as long as it is deemed necessary to be of use to you.
How do I check my fertility status post cancer treatment and plan pregnancy?
Once the cancer treatment is completed and oncologist considers that you are safe to proceed to try for a pregnancy we can assess your ovarian reserve by tests -AMH and Transvaginal scans for AFC-antral follicle count and other fertility tests can be performed for your partner too and we will advice accordingly. If all factors are reassuring you can try to conceive naturally and if it does not materialize then you can try for advanced treatment like IVF and in the event of ovarian failure setting in you can have the ovarian tissue strips reimplanted to initiate hormone production and egg growth. Not all patients who preserve ovarian tissue need to use them to achieve a pregnancy and this is a back up option if needed as the effect of cancer treatment on the ovary varies between individuals.
During chemotherapy usually periods stop due to the effect on the ovary. The periods may resume post cancer treatment in which case more likely the ovary is functioning and if periods do not return post treatment, frozen ovarian tissue can be used to achieve pregnancy.
Sperm Freezing-Oncology/Rheumatic Diseases
Why have I been suggested to undergo sperm freezing?
It is daunting to have a diagnosis of cancer for any patient, but younger patients with cancer diagnosis may also have to deal with the additional burden of how the various cancer treatments such as surgery, chemotherapy and radiotherapy may affect their fertility. Certain cancer treatments may impact testicular function rendering men infertile post treatment.
However, fertility preservation methods such as sperm freezing make it possible to preserve fertility prior to starting cancer treatment.
How many samples of sperm need to be frozen and how long does this process take?
Semen cryopreservation is relatively straightforward and once sample is given and the count and motility of the sperm is noted advice regarding further sample freezing is given. More than 1 sample can also be given the same day if possible and in 2/3 days based on the quality of the sperm the sample collection process can be completed with hardly any delay in starting the cancer treatment. The semen samples are collected by masturbation.
How are sperm samples frozen and stored?
The semen samples once obtained in a sterile container are mixed with cryoprotectant solution and stored in vials with each vial holding a volume of around 1 ml and then kept frozen in liquid nitrogen tanks till they are ready to be used.
Are there any risks associated with sperm freezing?
Sometimes, the sperm may not survive the freezing and thawing process and even if they survive there is no guarantee that the subsequent ART process undertaken which results in embryos being created will result in a pregnancy.
Are there any risk to children born out of frozen sperm?
There are many pregnancies to date resulting from embryos created using cryopreserved sperm and the data is reassuring that it is safe.
Can I choose not to undergo sperm freezing?
Yes, you can also choose not to undergo sperm freezing. But given the simple nature of the procedure with almost no extra delay in time needed to start cancer treatment it would be prudent to consider semen freezing. If sperm not frozen and post treatment if azoospermia sets in donor sperm treatment could be considered.
How long can the sperm remain frozen?
According to the current Indian ART regulations, the sperm can be stored for a period of 10 years and if extension of storage of gametes is needed beyond that time period, additional period of extension can be applied for by writing to National Registry.
