Fertility Preservation

Recent attention has been placed not only on treatment of infertility but on preservation of fertility. Optimization of reproductive health can include maintaining a body weight within 15% of ideal weight, avoiding smoking, limiting caffeinated beverages, and avoiding unprotected intercourse to minimize the likelihood of acquiring a sexually transmitted disease. Additionally, awareness of the realities of female reproductive aging have led to new strategies to combat the normal aging process, thereby creating exciting fertility preservation alternatives.

Fertility preservation refers to the medical interventions made to collect gametes (cells involved in reproduction that contain one copy of chromosomes) in an attempt to preserve or maintain the level of fertility of the individual at the time the gametes were harvested. Gametes and embryos are stored in liquid nitrogen at very low temperatures, which stops all cellular processes. This allows them to be stored indefinitely, without change in reproductive potential due to length of storage. Fertility preservation may be pursued when faced with a medical treatment that puts the patient at risk of sterility, either through chemotherapy or removal of ovaries or testicles; when delaying childbirth; or prior to pursuing voluntary sterilization procedures. RMA of New York is able to provide fertility preservation and long term storage to patients through a partnership with Extend Fertility^TM and California Cryobank. RMA of New York is also a proud supporter of Fertile Hope and their efforts to support patient education regarding fertility preservation. Fertility preservation can be an emotional time, and we encourage patients to take advantage of emotional support available though our complementary care team.

Fertility Preservation Options For Women

Embryo Cryopreservation, also known as embryo freezing

• The process
  To create the embryos for cryopreservation, the individual or couple, will begin an in vitro fertilization (IVF) treatment cycle. In vitro fertilization (IVF) is the process of retrieving eggs and sperm and manually fertilizing them in a laboratory dish outside the womb. An  IVF cycle consists of four steps:

Stage I: Ovarian Stimulation and Monitoring - In order to maximize the patient's chances for successful fertilization, a patient undergoing IVF usually takes hormones, in the form of injections, to increase the number of eggs produced in a given month. Frequent monitoring is performed to continuously follow a woman's ovarian response, allowing the physician to adjust and time medication dosage appropriately.

Stage II: Egg (Ovum) Retrieval- Under sedation, the reproductive specialist extracts mature eggs via ultrasound guidance. Egg retrieval is a minimally invasive procedure that normally takes less than 15 minutes. Patients typically can resume normal activity within the next day.

Stage III: Culture and Fertilization- Embryologists use high-power microscopes and steady precision to fertilize the eggs with sperm in the embryology laboratory. At times, the sperm are released on top of the egg to fertilize it. In other cases, especially when there are less than one million living sperm, intracytoplasmic sperm injection (ICSI) is used where a single sperm is microinjected directly into the cytoplasm of the egg.

Stage IV: Embryo Transfer and/or Cryopreservation-

Preserving Embryos only: Depending on the number of embryos available for cryopreservation, an embryologist will place the embryos in multiple containers, called straws. These straws are then cryopreserved and stored in liquid nitrogen. If many embryos are available, placing them in multiple straws allows for the potential to have more than one future treatment cycle, as only one straw would be thawed at a time.

Attempting pregnancy: A fertility specialist will transfer the minimum number of healthy and mature embryo(s) back into the uterus, with the goal of implantation in the uterine wall. This procedure usually does not involve any sedation. The physician will use ultrasound to guide a small catheter through the cervix and deposit the embryo(s) in the uterus. The embryo transfer procedure takes only a few minutes and recovery time is less than a day. Remaining viable embryos can be cryopreserved and used for subsequent transfer cycles. A pregnancy test is performed 11 days after the embryo transfer to evaluate whether implantation successfully occurred.

• Considerations in pursuing embryo cryopreservation for fertility preservation
   Embryo cryopreservation, and subsequent use in frozen embryo transfer cycles, is well-documented and has been successful in thousands of cases since 1983. There appears to be no increased risk of birth defects from cryopreserved embryos. Due to the knowledge and success of embryo cryopreservation, this is a good option for couples preserving fertility or women who are comfortable using donor sperm to create the embryo. Despite the success rates, embryo cryopreservation is not without risks, as almost 40 percent of cryopreserved embryos do not survive the freezing and thawing process. Depending on the age of the female and number of embryos available for freezing, more than one cycle to freeze embryos may be recommended by the physician.

Oocyte Cryopreservation, also known as egg freezing

RMA of New York is a proud partner of Extend Fertility in offering oocyte cryopreservation and long term storage.

1. The process
   Oocyte cryopreservation involves the extraction of a woman's unfertilized eggs from her ovaries. The process is the same as stage I and II of an in vitro fertilization cycle. Stage III in an oocyte cryopreservation cycle is the actual freezing process.

Stage I: Ovarian Stimulation and Monitoring - In order to maximize the patient's chances to obtain a number of eggs for storage, a patient undergoing oocyte cryopreservation usually takes hormones, in the form of injections, to increase the number of eggs produced in a given month. Frequent monitoring is performed to continuously follow a woman's ovarian response, allowing the physician to adjust and time medication dosage appropriately.

Stage II: Egg (Oocyte) Retrieval- Under sedation, the reproductive specialist extracts mature eggs via ultrasound guidance. Egg retrieval is a minimally invasive procedure that normally takes less than 15 minutes. Patients typically can resume normal activity within the next day.

Stage III: Egg (Oocyte) Cryopreservation- Depending on the number of eggs available for cryopreservation, an embryologist will place the eggs in multiple containers, called straws. These straws are then dehydrated and slowly cooled during the cryopreservation process, then stored in liquid nitrogen. By placing the retrieved eggs in multiple straws, there is the potential to have more than one future treatment cycle, as only one straw would be thawed at a time. Upon completion of the cryopreservation process, the frozen eggs are shipped to Extend Fertility's long term storage facility.

When the woman becomes ready to attempt pregnancy, a fertility specialist team will thaw the stored eggs, attempt to fertilize the eggs and transfer subsequent embryos. See also Stages III and IV of an IVF cycle

• Considerations in pursuing oocyte cryopreservation for fertility preservation
  Eggs are more delicate than embryos when it comes to the freezing and thawing process, but significant advances have been made in the cryopreservation technique, and RMA of New York's own study has demonstrated the clinical success rates. Due to the known challenges of freezing and thawing eggs, many patients, along with their physician, choose to pursue more than one cycle.
  
  Currently, ASRM recommends oocyte cryopreservation only be introduced into clinical practice on an investigational basis and under the strict guidance and oversight of an Institutional Review Board (IRB) in order to protect the well-being and rights of the patients. RMA of New York, as an Extend Fertility partner clinic, currently offers oocyte cryopreservation for long term fertility preservation under an IRB's oversight and only after full informed consent and counseling of our patients.

Those interested in learning more about egg freezing can also visit Extend Fertility's website.

 Fertility Preservation Options for Men

RMA of New York is a proud partner of California Cryobank to offer male fertility preservation and long term storage.

Sperm Cryopreservation

• The process
  The male produces a specimen into a sterile collection cup. Once it is confirmed that the specimen contains motile sperm, cryoprotectant is added and the specimen is frozen in one or multiple vials. An andrologist will analyze the specimen, either pre-freeze or post-thaw, and document a number of characteristics including volume, concentration, motility, forward progression, and any other defining characteristics. Upon completion of the cryopreservation process, the frozen sperm sample(s) are shipped to a long term sperm storage facility.

Electroejaculation
In the event the male is unable to produce a specimen, but does not have a blockage in the vas deferens, an electroejaculation procedure may be performed. During an electroejaculation procedure, the doctor inserts an electrical stimulation probe into the rectum. The doctor controls the amount of electrical stimulation delivered so that an ejaculation occurs. This can be done either in the office or in the operating room with anesthesia, depending on the sensory status of the patient. After the specimen is collected, the andrology laboratory performs the same process to freeze the sample as used during traditional specimen collection.

• Considerations in pursuing sperm cryopreservation for fertility preservation
  Sperm cryopreservation has been a successful technique since the early 1950's; in fact, babies have been born from sperm that have been frozen for over 20 years. There appears to be no increased risk of birth defects from cryopreserved sperm. Cryopreserved sperm may be used for insemination procedures or in vitro fertilization procedures.

Testicular Tissue Cryopreservation

• The process
  Testicular tissue cryopreservation may be recommended if a semen sample cannot be collected or there is an absence of sperm in the semen. Collection of the tissue is done via a simple outpatient procedure. The urologist will perform a testicular sperm aspiration (TESA). TESA procedures are preformed either percutaneously or microscopically.

Percutaneous testicular sperm retrieval
When dealing with obstructive azoospermia (a blockage exists but normal sperm production is present), a simple percutaneous extraction of sperm is recommended. This procedure is performed under anesthesia (local or general) whereby a biopsy needle is utilized to extract a very small amount of testicular tissue. The wound is closed with a few small absorbable stitches.

Microscopic testicular sperm retrieval
In very rare cases, a microsurgical testicular sperm extraction may be performed. In this scenario, under general anesthesia, the TESA is performed using an operating microscope to search for testicular tubules that appear more developed and contain mature sperm. A microscopic TESA may take several hours.

The collected tissue will be brought to the laboratory where part of the specimen will be analyzed. The sperm count, motility and forward progression will be documented. The sample used for analysis, and all other tissue collected, will be frozen in one or more vials. Upon completion of the cryopreservation process, the frozen testicular tissue sample(s) are shipped to California Cryobank's long term storage facility.

• Considerations in pursuing testicular tissue cryopreservation for fertility preservation
  Testicular tissue cryopreservation is a successful method to store the sperm for future use. As a more invasive procedure, it does require more preparation and has increased associated costs. In addition, when attempting pregnancy with the sample, in vitro fertilization with intracytoplasmic sperm injection (ICSI) must be used.

Fertility Preservation In The News

• RMA of New York Participates in HOPE Study for Egg Freezing Patients
• Marie Claire Magazine Writer Writes About Her Egg Freezing Experience at RMA of New York and appears with Dr. Tanmoy Mukherjee on Fox Channel's Mike and Juliet Show
• WCBS Health Watch: Egg Freezing
• Extend Fertility and Reproductive Medicine Associates of New York Report Encouraging New Egg Freezing Results
• Wall Street Journal Article: Why Some Single Women Choose to Freeze Their Eggs

Fertility Preservation Events

The Biological Clock: Take Control of Your Fertility
Wednesday, July 29, 2009 6:30 pm-8:00 pm
Where: RMA of New York Manhattan Office, 10th Floor
Light refreshments will be served

Whether you are trying to advance your career, stabilize your finances, or have yet to meet that certain someone whom you wish to settle down with, the inexorable truth is there is no snooze button on your biological clock. You may feel increasing anxiety about starting your own family, especially as your peers start to marry and conceive. Learn steps that you can take to preserve your fertility that will allow you to enjoying dating or pursue alternative goals with renewed confidence.

This intimate panel discussion will focus on the biological clock and fertility preservation. The panelists include RMA of New York's Dr. Eric Flisser and Dr. Georgia Witkin, along with Lucia Vazquez, an Extend Fertility client who froze her eggs in her early 30's. Topics will include the latest advances in assisted reproductive technology and fertility preservation, fertility basics and myths, and how the reality of the biological clock impacts interpersonal relationships and personal decision-making. Light refreshments will be served.

To register, visit http://extendfertility.com/experts/events.php