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Fertility Preservation

WHAT IS FERTILITY PRESERVATION?

Fertility preservation is an effort to help the patients, retain their fertility by preserving their eggs, sperms, embryos or reproductive tissue so that they can have their own biological off springs in future.
 
It can be done for 2 main reasons:
 
1. Medical reasons: It is well known that most cancer treatments like chemotherapy/radiotherapy are gonadotoxic thus putting patients at risk of
subsequent infertility. Also, few other conditions like endometriosis, haematological disorders (thalassemia, aplastic anaemia), autoimmune
disorders (SLE, Rheumatoid arthritis) often require treatment that may impair future fertility. The gonadotoxicity of these treatments depend on
multiple factors, such as age of the patient at the time of treatment, ovarian reserve, type of therapies (chemotherapy/ radiotherapy/
immunotherapy/ surgery) and their doses and duration. Fertility preservation is thus essential for all these women or couples. Counselling should
be offered to all patients who are suffering from some disease which can impair future fertility or who require some treatment which is
potentially gonadotoxic.
 
2. Social reasons: It is the elective freezing of eggs, sperms or reproductive tissues in couples who do not have any specific medical disorder, but
want to delay marriage or pregnancy. It can be due to various reasons like career, economic stability or any other social reason. This is more
important for women as the quality and quantity of eggs reduce over period of time and might pose a problem when trying to get pregnant later
on. Freezing eggs or embryos at an early age ensures better quality and hence is helpful for the couple.

WHO NEEDS IT?

MALES WITH FOLLOWING CONDITIONS REQUIRE FERTILITY PRESERVATION
 
1. Cancers and its treatment like chemotherapy or radiotherapy

2. Heat and Exposure to toxins [ work place]

3. Autoimmune disorder which requires immunotherapy or chemotherapy

4. Conditions which require gonadectomy

5. Occupation [Jobs with Military or staying away from the family]
 
MARRIED WOMEN WITH FOLLOWING CONDITIONS REQUIRE FERTILITY PRESERVATION
 
1. Cancers [Breast cancers, Cervical cancers or Endometrial cancers]

2. Chemotherapy / radiotherapy or Prophylactic oophorectomy [ BRCA-1/ BRCA-2 mutation] for those cancers.

3. Genetic / chromosomal disorders which may affect future fertility

4. Autoimmune disorder requiring chemotherapy or immunotherapy [SLE, MS, Rheumatoid Arthritis, etc.]

5. Disease which affects ovarian reserve and requires repeated surgery on ovaries like Endometriosis

6. Social reasons [wants to delay child bearing, financial barriers, career aspirations, problem in family, etc.]
 
UNMARRIED WOMEN / GIRLS WITH FOLLOWING CONDITIONS REQUIRE FERTILITY PRESERVATION
 
1. Childhood cancers [ Leukemia, lymphoma, CNS tumors, etc.]

2. Benign ovarian tumors and other cancers like Breast cancer, etc

3. Family history of premature ovarian insufficiency

4. Disease requiring repeated surgery on ovaries [Endometriosis]

5. Genetic / chromosomal disorder [Turner syndrome]

6. Autoimmune disorder requiring chemotherapy or immunotherapy [SLE, MS, Rheumatoid Arthritis, etc]

7. Social reasons [late marriage, career aspiration, not finding the right partner]

WHAT ARE THE TREATMENT OPTIONS AVAILABLE?

 
TREATMENT OPTIONS FOR MEN –
 
1. SPERM CRYOPRESERVATION

In adult men, fertility can be preserved by cryopreservation of mature spermatozoa. It is most commonly used & established method for an adult male. Cryopreservation should preferably be done prior to initiation of cancer therapy. Semen sample is collected via masturbation. It is advisable to have multiple semen samples collected and stored as one sample can be used for a single attempt at pregnancy only. In patients with a low sperm count, invasive surgical techniques like TESA/micro- TESE etc can be used to obtain spermatozoa. The standard storage period for sperm is normally 10 years. With the help of assisted reproduction (intracytoplasmic sperm injection), sperm cells are used to fertilise the ovum, followed by embryo creation.

 
2. TESTICULAR BIOPSY

In patients with a low sperm count or in those men who are unable to produce an ejaculate, invasive surgical techniques like TESA, PESA, micro-TESE, etc. can be used to obtain spermatozoa. Sperms thus obtained from testicular biopsy are preserved. This is useful in cancer patients where spermatozoa obtained prior to chemotherapy are cryopreserved. After recovery from cancer or when the couple is ready, these can be used to fertilize the oocytes and create embryos.

 
3. TESTICULAR TISSUE/ SSCs CRYOPRESERVATION (EXPERIMENTAL)

This option is in experimental stage but can be promising in prepubertal male. Cryopreservation of testicular tissue and Spermatogonial stem cells [SSCs] is done prior to cancer treatment. SSCs obtained from frozen testicular tissue are transplanted into seminiferous tubules. It undergoes self – renewal and spermatogenesis is established, which should allow natural conception without further fertility treatment.

 
TREATMENT OPTIONS FOR WOMEN –
 
1. MATURE OOCYTE CRYOPRESERVATION

This method is ideal for unmarried women, post pubertal girls [adolescent girls in whom periods have started] or for those who do not have a stable partner. It is a well-established method of fertility preservation and is the recommendation of choice by the European Society of Human Reproduction and Embryology. It is done by controlled ovarian stimulation and oocyte retrieval. Mature eggs [metaphase stage – M-ll oocytes] are collected and cryopreserved. Later frozen eggs are thawed & fertilized by use of ART/IVF technique. This method is also useful for married females whose partners are away from home for a long period of time.

 
2. EMBRYO CRYOPRESERVATION

It is one of the best & established method for fertility preservation in a married couple. Partner availability is a must for embryo freezing method. It requires ovarian stimulation, followed by egg retrieval, fertilization & cryopreservation of the embryos. Frozen embryos can be stored up to 5 years. A frozen embryo transfer can be done at any time when the couple is ready.

 
3. IMMATURE OOCYTE CRYOPRESERVATION & IN VITRO MATURATION (EXPERIMENTAL)

It is a newer strategy to overcome the delay in anticancer treatment. Immature eggs are retrieved trans-vaginally and egg maturation takes place in specialized medium, after that mature eggs can be cryopreserved or if partner is available embryo can be formed by ART and freezing can be done. Advantage of this method is that, there is no delay in initiation of chemo/radiotherapy.

 
4. OVARIAN TISSUE CRYOPRESERVATION (EXPERIMENTAL)

It is an experimental option. This can be an option for those women who cannot delay their treatments like chemotherapy or radiotherapy. It can be done any time during menstrual cycle. It is a surgical procedure and requires general anesthesia. In this method ovarian cortex containing primordial follicles or the whole ovary can be cryopreserved. This cryopreserved tissue is thawed and transplanted back into the patient after completion of treatment. It should be preferably done in young women as ovarian reserve depletes with age. The average duration of ovarian endocrine function after transplantation is about 5 years. It carries slight risk of reintroduction of malignant cells via transplantation of ovarian tissue depending upon the type of cancer.

FOR HOW LONG CAN THESE BE FROZEN?

 

Eggs, sperms, embryos and tissues are frozen at -196 degree Celsius. At this temperature, all metabolic processes within these cells come to a standstill, hence there is no degradation in their quality. Ideal time for storing is up to 10 years, but pregnancies has been documented after even longer periods of time.

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