Why do individuals preserve their eggs or embryos?
Deminishing Ovarian Reserve
By the time women are:30 years old, 12% of eggs are left
40 years old, 3% of eggs are left
Cancer Treatment- 2018 ASCO GUIDELINES"Recommendation 1.1. People with cancer are interested in discussing fertility preservation. Health care providers caring for adult and pediatric patients with cancer (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, surgeons, and others) should address the possibility of infertility as early as possible before treatment starts."
Cancer Treatment- 2018 ASCO GUIDELINES
"Recommendation 1.1. People with cancer are interested in discussing fertility preservation. Health care providers caring for adult and pediatric patients with cancer (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, surgeons, and others) should address the possibility of infertility as early as possible before treatment starts."
"Recommendation 1.2. Health care providers should refer patients who express an interest in fertility preservation (and those who are ambivalent) to reproductive specialists."
Transgender Patients According to the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH) they recommend discussing and offering fertility preservation options prior to starting gender affirming therapy Male-to-Female (MtF) "patients, especially those who have not already reproduced, should be informed about sperm-preservation options and encouraged to consider banking their sperm prior to hormone therapy." Female to Male (FtM) "patients might include oocyte (egg) or embryo freezing. The frozen gametes and embryo could later be used with a surrogate woman to carry to pregnancy."
According to the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH) they recommend discussing and offering fertility preservation options prior to starting gender affirming therapy Male-to-Female (MtF) "patients, especially those who have not already reproduced, should be informed about sperm-preservation options and encouraged to consider banking their sperm prior to hormone therapy." Female to Male (FtM) "patients might include oocyte (egg) or embryo freezing. The frozen gametes and embryo could later be used with a surrogate woman to carry to pregnancy."
According to the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH) they recommend discussing and offering fertility preservation options prior to starting gender affirming therapy
Male-to-Female (MtF) "patients, especially those who have not already reproduced, should be informed about sperm-preservation options and encouraged to consider banking their sperm prior to hormone therapy."
Female to Male (FtM) "patients might include oocyte (egg) or embryo freezing. The frozen gametes and embryo could later be used with a surrogate woman to carry to pregnancy."
Infertility Women in general- 1 in 8 women experience infertility (12.5%)Female Physicians- 1 in 4 female physicians experience infertility (25%)Endometriosis - 1 in 2 individuals with endometriosis experience infertility (50%)Male Factor infertility can include low sperm count, low mobility, etc.
Women in general- 1 in 8 women experience infertility (12.5%)
Female Physicians- 1 in 4 female physicians experience infertility (25%)
Endometriosis - 1 in 2 individuals with endometriosis experience infertility (50%)
Male Factor infertility can include low sperm count, low mobility, etc.
Individuals hoping to preserve their fertility and post-pone childbearing
For example individuals in undergraduate or graduate education (medical school) who do not want to have a child until after they finish schooling which could be 8-10 years on the future
Here is a new article published in JAMA by medical students and physicians who looked at the bio-psycho-social barriers to family planning in medicine
Current Fertility Preservation Options:
Cryopreservation: which is the cooling of cells and tissues to sub-zero temperatures in order to stop all biologic activity and preserve them for future use. Read more at "Cryopreservation of Female Fertility" by Jack Yu Jen Huang, MD
Embryo cryopreservation- has been successfully carried out over the past 30 years with the first live birth from a frozen embryo occurring in 1984 (Huang, 2010)
Helpful if already have partner with sperm or sperm donor available
More durable than egg storage
Don't have to store as many eggs
Allows genetic testing especially if have family history of genetic diseases
Oocyte cryopreservation - freezing of just eggs after they have been stimulated through around 2 weeks of injections and a intra-vaginal retrieval while sedated (asleep)
Ovarian Tissue Cryopreservation
Ovarian Transposition- remove full ovary to freeze
Use either a fresh or frozen embryo
Individual with uterus takes weeks or months of injectable and oral medications to prepare uterus for implantation
How many eggs, oocytes, or blastocysts to preserve?
https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC7376799&blobtype=pdf
https://academic.oup.com/humrep/article/32/4/853/2968357
https://www.fertstert.org/article/S0015-0282(15)02037-3/fulltext
Things learned from first time I preserved:
Need infertility support group who understands what you are going through
Learned how to get medication covered by insurance
Daily protein in shakes is important to decrease risk of hyper-ovarian stimulation syndromeincreased protein ---> increased albumin in blood --> less fluid leakage out of blood vessels
increased protein ---> increased albumin in blood --> less fluid leakage out of blood vessels
Pain management strategies
Stress management strategies
Read & Learn about my Second Fertility Preservation Week-by-Week during M3 Clinicals
Initial Preparation Visit:
CBC: red blood cells, hemoglobin, platelet count, etc
CMP: Glucose, Calcium, Total protein, Albumin, Sodium, Potassium, CO2, Cloride, blood urea nitrogen, creatinine, liver enzymes (ALT and AST), Bilirubin, Alkaline Phosphatase
TSH: thyroid stimulating hormone
FSH: Follicle Stimulating hormone
Infectious Diseases: Hepatitis C: HCV Antibody, Hepatitis B: HBsAg HIV
Hepatitis C: HCV Antibody,
Blood Type:ABO GROUP, RH Type
AMH: Anti-mullerian hormoneIndividuals 26 - 30y: 1.03 - 11.10 Median 4.20
AMH: Anti-mullerian hormone
Individuals 26 - 30y: 1.03 - 11.10 Median 4.20
AMH concentrations of >= 1.06 ng/mL is correlated with a better response to ovarian stimulation, produced more retrievable oocytes and higher odds of live birth (Gleicher et al., 2011)
Individuals at risk of ovarian hyperstimulation syndrome or polycystic ovarian syndrome (PCOS) may exhibit elevated serum AMH concentrations. AMH levels from PCOS patients may be 2 to 5 fold higher than age-appropriate reference interval values (Gleicher et al., 2011)
Mine was .9 the first stimulation and this year it is 1.97!!! This is wonderful news but I didn't purposely try to change it. Maybe less stress in my life? haha
"Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age"
Intra-vaginal Ultra-sound:
Check ovaries for current ovarian phase and size of follicles at baseline
Check Uterine lining for uterine phase
Check for any uterine abnormalities
Semen exam:Sperm ConcentrationTotal sperm countMotilityAgglutination
1 Round of Medications for the Ovarian Follicle Stimulation costs around $10,000!See this article I wrote on The Endometriosis Foundation "An Inside Look into Infertility Care: Navigating Hidden Costs & Treatment" on how I was able to get 100% of my fertility medications covered by health insurance as required by my state law (in Illinois)
See this article I wrote on The Endometriosis Foundation "An Inside Look into Infertility Care: Navigating Hidden Costs & Treatment" on how I was able to get 100% of my fertility medications covered by health insurance as required by my state law (in Illinois)
Organization of Medications helps reduce stress
The first time I just kept all my medications in the multiple boxes they arrived in
This time I am using the MyVitro Organizing Box which has cut the amount of boxes I am holding on my medications into just one storage container
On the top shelf: I put the items I will use the most includding cleaning pads, gauze, and numbing medicationI also did a section for all the medications in small bottles (every one has a slightly different formula of medications)Next I did a section for empty small syringes
I put the items I will use the most includding cleaning pads, gauze, and numbing medication
I also did a section for all the medications in small bottles (every one has a slightly different formula of medications)
Next I did a section for empty small syringes
On the Middle shelf I did another section of empty small syringesThen I seperated the rest of the space with half being the NaCl (the gray and pink caps in my medication version) and the other half being the Menopur medication (the orange caps in my medication version)
I did another section of empty small syringes
Then I seperated the rest of the space with half being the NaCl (the gray and pink caps in my medication version) and the other half being the Menopur medication (the orange caps in my medication version)
The Bottom ShelfI included all the medications that were in large containers that couldn't be broken downI also included the long empty syringesThe Heparin injections (in yellow)And the bottle covers for the second shelf medications
I included all the medications that were in large containers that couldn't be broken down
I also included the long empty syringes
The Heparin injections (in yellow)
And the bottle covers for the second shelf medications
Transportation of medications
Dealing with Pain and Endometriosis Flares:
Last time when my Estrogen rose to 1000 units I was in horrible endometriosis flare pain every day for weeks because the estrogen led my lesions to enlarge. Additionally as the follicles enlarged they touched my peritoneal tissue which has endometriosis- again more pain!
This time we are going to try to keep my Estrogen lower and “cook” my ovarian follicles more slowly before removal.
" Pain. Exhaustion. Soreness everywhere."
Massage tools - Theragun by Therabody
Tens units- Power Dots by Therabody
Miralax, Suppositories, fiber for Constipation
Clothing that doesn't compress abdominal area (sweats, skirts, jumpsuits, scrubs, dresses, nightgowns)
There are multiple barriers and challenges in Medicine in regards to family planning
Check out this JAMA article and picture by Dr. Salles, MD
For more Check out my Blog Post & Podcast Episodes "Fertility Preservation During Medical School"
Check out my resources on Living with Infertility which includes support groups, books, videos, articles, & more!
Doyle JO, Richter KS, Lim J, Stillman RJ, Graham JR, Tucker MJ. Successful elective and medically indicated oocyte vitrification and warming for autologous in vitro fertilization, with predicted birth probabilities for fertility preservation according to number of cryopreserved oocytes and age at retrieval. Fertil Steril. 2016 Feb;105(2):459-66.e2. doi: 10.1016/j.fertnstert.2015.10.026. Epub 2015 Nov 18. PMID: 26604065.
Oktay et al. Fertility Preservation in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 36, 2018
Gleicher N, Weghofer A, Barad DH. Defining ovarian reserve to better understand ovarian aging. Reprod Biol Endocrinol. 2011 Feb 7;9:23. doi: 10.1186/1477-7827-9-23. PMID: 21299886; PMCID: PMC3042920
Coleman, Eli & Bockting, Walter & Botzer, Marsha & Cohen-Kettenis, Peggy & Cuypere, Griet & Feldman, Jamie & Fraser, Lin & Green, Jamison & Knudson, Gail & Meyer, Walter & Monstrey, Stan & Adler, Richard & Brown, George & Devor, Aaron & Ehrbar, Randall & Ettner, Randi & Eyler, Evan & Garofalo, Robert & Karasic, Dan & Zucker, Kenneth. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 13. 165-232. 10.1080/15532739.2011.700873.
R.H. Goldman, C. Racowsky, L.V. Farland, S. Munné, L. Ribustello, J.H. Fox, Predicting the likelihood of live birth for elective oocyte cryopreservation: a counseling tool for physicians and patients, Human Reproduction, Volume 32, Issue 4, April 2017, Pages 853–859, https://doi.org/10.1093/humrep/dex008
Maslow BL, Guarnaccia MM, Ramirez L, Klein JU. Likelihood of achieving a 50%, 60%, or 70% estimated live birth rate threshold with 1 or 2 cycles of planned oocyte cryopreservation. Journal of Assisted Reproduction and Genetics. 2020 Jul;37(7):1637-1643. DOI: 10.1007/s10815-020-01791-w. PMID: 32418136; PMCID: PMC7376799.
Zeilmaker GH wt al. Fertil Steril. 1984 Aug;42(2):293-6.
Steiner AZ, Pritchard D, Stanczyk FZ, Kesner JS, Meadows JW, Herring AH, Baird DD. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. 2017 Oct 10;318(14):1367-1376. doi: 10.1001/jama.2017.14588. PMID: 29049585; PMCID: PMC5744252.
King Z, Zhang Q, Liang JW, et al. Barriers to Family Building Among Physicians and Medical Students. JAMA Netw Open. 2023;6(12):e2349937. doi:10.1001/jamanetworkopen.2023.49937
***This Blog Post is for educational purposes only and is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. This does not imply a doctor-patient relationship. All opinions are the opinions of the writer and not reflective of any institution or employer. Please follow up with your health provider and therapist for any additional questions or support.***