Fertility preservation presentation v2

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