Fertility Preservation By Dr Mary Birdsall Chair, Fertility Associates
Freezing Sperm • 60 years ago first human pregnancy from frozen sperm • 60 years ago first sperm bank • Able to freeze low numbers • Use insemination or ICSI
Who Should Freeze Sperm? • Chemotherapy or radiotherapy or experimental medications • Surgery eg prostatectomy or major pelvic surgery or orchidectomy • Pre vasectomy or geographical challenges • Pre gender reassignment surgery • Sperm donors • Klinefelters 47 XXY
Heterosexual couples
Single women
Donor Sperm
Lesbian couples
Freezing testicular sperm • • • •
Unable to ejaculate Spinal injury Vasectomy Congenital bilateral absence of vas • Azospermia • Testicular cancer
Should young men freeze sperm for later? • Sperm quality reduces with age • Increase in schizophrenia, autism, achondroplasia with increasing paternal age
Prepubertal boys and fertility preservation • No mature spermatogenesis • Testicular tissue currently not being frozen • No proven method to transform immature germ cells into functional sperm • In mice: germ cell extraction, cryopreservation and re-injection with recovery of fertility
Spermatogenesis
Funding and the Law • Pre cancer treatment sperm may be frozen free of charge • Usual criteria for public funding for partners apply (woman less than 40, non smoker, BMI 19 to 32) • May be stored for 10 years then must be discarded unless application for extension for storage made to ECART
Women
AMH
Embryo Freezing • First pregnancy - 1983 • Slow cooling • Vitrification • Need consent from both parties to thaw and use • Who freezes embryos ?: surplus from IVF, pre chemo if have a partner and time, social, reduced ovarian reserve
Slow cooling
Vitrification
Programmed equipment
RT
Equlibration with cryoprotectant
Equlibration with cryoprotectant RT
-6째C
seeding
Slow cooling rate
-35째C
LN2
LN2
time time
Vitrification 2013 • • • • •
262 warming cycles 289 embryos warmed (1.1 per cycle) 279 embryos survived (96%) 258 embryo replacement cycles (98%) 115 pregnancies (44%)
Perinatal outcomes in Fresh IVF cycles vs Frozen cycles
Frozen vs Fresh: antepartum haemorrhage
Frozen vs Fresh: SGA
Frozen vs Fresh: perinatal mortality
Fetal Abnormalities Frozen vs Fresh • Reproductive Technologies and the Risk of Birth Defects M Davies et al NEJM 2012 366 1803-13 • South Australia population cohort study of more than 327,000 births • Birth defects 8.3% after IVF vs 5.8% in spontaneous OR 1.47 (CI 1.33-1.62) • No increased risk seen in frozen embryos
Summary Fresh IVF vs Frozen • Frozen embryo cycles appear to have fewer obstetric and perinatal complications compared with fresh IVF cycles • Suggests that ovarian stimulation may have a detrimental impact ? on endometrium • So are frozen embryo pregnancy cycles comparable to spontaneous pregnancies?
Singletons after frozen transfer vs singletons after spontaneous conception Outcome
FET pregnancies
Overall effect (RR, 95% CI)
Caesarean section
2947
1.76 (1.65 - 1.87)
Birthweight <2500g
2947
1.27 (1.05 – 1.52)
Birthweight <1500g
2787
1.51 (1.01 – 2.27)
Delivery at < 37 weeks
2947
1.39 (1.20 – 1.61)
Delivery at < 32 weeks
2947
1.45 (0.98 - 2.13)
Egg Freezing Fertility preservation: cancer, social, religious or ethical objections to embryo freezing, no sperm at IVF, rapid reduction of ovarian reserve • Vitrification • Not funded $10,000 • 3000 babies
Ovarian Tissue Cryopreservation
Ovarian Tissue Cryopreservation • Oncological fertility preservation • Only option for pre-pubescent girls • Laparoscopy required • Malignant cells being re-implanted a concern • 32 babies in world • HRT
Ovarian cryopreservation in NZ â&#x20AC;˘ 46 ovarian tissue samples stored â&#x20AC;˘ Permission to store but not yet an approved procedure â&#x20AC;˘ 2 pregnancies in Australia
Summary • Men: can freeze sperm or testicular tissue • Prepubertal boys: no options • Couples: can freeze embryos • Women: can freeze eggs or ovarian tissue or embryos with donor sperm • Prepubertal girls: can freeze ovarian tissue
Questions from the floor