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| Cancer is a diagnosis nobody wants to receive, especially not a young woman who has yet to have her first child. Unfortunately, this news is heard by an estimated 50,000 women under age 40 each year, and that is just in the United States. While cure rates for some cancers are now over 90%, many of these life-saving treatments leave female patients infertile. Providing hope to these women, the Florida Institute for Reproductive Medicine (F.I.R.M.) has been working on the technology of egg cryopreservation since 1997. Under the direction of Dr. Kevin Winslow, Medical Director, and Dr. Dunsong Yang, Scientific Director, the clinic has become the nation’s leader with this technology. They have had more babies born, and by far the most efficient experience, with this technology than anywhere else in the world. In October the F.I.R.M. made history by enabling the world’s first live birth to a cancer patient who had cryopreserved her eggs prior to sterilizing cancer therapy. Jennifer Rutansky of Jacksonville became “Mom†to a healthy six-pound-twelve-ounce boy born in October of this year. The successful pregnancy occurred five years after Rutansky’s recovery from Hodgkin’s lymphoma. While men have been able to cryopreserve sperm for the past 40 years, cryopreservation of eggs is much more difficult. Eggs are very large cells with a high water content, and are therefore prone to ice crystal damage during the freezing process. Dr. Yang has refined the technology of drawing water out of the egg and re-hydrating it without cell damage to the point that it is now “a very useful clinical tool,†says Dr. Winslow. Patients utilizing cryopreservation of eggs tend to fall into three main categories. The first are young married or unmarried women who receive a cancer diagnosis, and want to preserve fertility from potentially sterilizing therapies. “They are a challenging group to work with,†says Winslow. “Frequently an oncologist calls and says, ‘I have a young lady who needs chemotherapy as soon as possible.’ We have to work very quickly getting their cycles turned off and getting them through stimulation, retrieval and freezing as soon as possible. These are undoubtedly my favorite patients. You can literally see the relief they get from knowing they have an option to preserve their fertility.†A second group of patients are women who are approaching their mid 30s and haven’t yet had a family. They may have been concentrating on a career or perhaps just haven’t met Mister Right. “As a woman ages, her eggs age also. With this we see an increase in incidence of genetically/chromosomally abnormal eggs, which makes conception difficult,†explains Winslow. The third group of patients are women who require in vitro fertilization, but may be morally opposed to freezing embryos. Cryopreservation of embryos has been available for more than 20 years, and is now done at most of the 460 clinics in the United States. Many infertile couples will not take advantage of the in vitro fertilization, however, because of their concerns over cryopreserving embryos. Preserving the unfertilized eggs removes this issue for them. Florida Institute for Reproductive Medicine is also working on establishing a viable donor bank of eggs, much like donor sperm banks. The advantages of a donor egg bank are several, explains Winslow. We can now quarantine eggs for six months, and re-test donors for a potentially incubating HIV infection. Being able to freeze eggs will also greatly extend the number of eggs available, thus alleviating waste. Egg freezing involves going through the same procedure as in vitro fertilization, with the exception that the eggs will be cryopreserved prior to fertilization. Patients receive medications called gonadotropins which bring about the production of multiple eggs from their ovaries. Normally, without these medications, only one egg is produced in each menstrual cycle. The drugs are administered daily by injection, typically for ten to fourteen days. While on these medications, the patient will be monitored approximately every third day with an ultrasound and a blood test to check her estradiol level. For patients who travel into Jacksonville from other cities, all this work may be done by her reproductive endocrinologist in her own home town. Close contact between her physician and the staff at F.I.R.M. ensures that everything is proceeding as it should. Once the majority of follicles are at an optimal size, human chorionic gonadotropin (hCG) will be administered to bring about final maturation. Thirty-five hours after the hCG is given, the eggs will be retrieved. Egg retrieval is done under IV sedation; the patient is still conscious, but will not feel pain. Retrieval typically takes from fifteen minutes to half an hour. The eggs are removed via a small-gauge needle passed through the wall of the vagina under ultrasound guidance into the ovary. Suction is applied and the eggs are removed. The eggs collected in culture media are handed off to the embryologist, who will identify them under the microscope and begin preparation for the freezing process. Before leaving, the patient is advised of the number of eggs retrieved, and she also receives a written report of this. The vast majority of patients experience no complications from the procedure, but there can be some. Ten percent of patients may experience mild bloating and tenderness from ovarian distention. Some patients may experience local redness and bruising in the area where blood is withdrawn and medications are injected. During the retrieval, there is a risk of bleeding from the vaginal wall and ovary. This is usually mild and can be controlled with direct pressure. One potential serious complication is ovarian hyperstimulation, but it occurs in less than half a percent of all patients. It can result in fluid in the abdomen and lungs that must be removed with a needle. Sometimes hospitalization is required. Careful monitoring during the process helps to reduce this risk. When it is time for the patient to use her cryopreserved eggs, her uterus is assessed for significant pathology such as polyps, fibroids, adhesions, or a collection of fluid in her tubes. If any of these are found, they must be treated before the embryos are transferred. Once the patient is cleared for egg use, her uterus is prepared utilizing estrogen and progesterone medications to build up a receptive lining. The patient’s spouse provides a semen specimen, and a single sperm is injected into each thawed egg, a process known as intracytoplasmic sperm injection (ICSI). Two to five days later, embryos are transferred back to the uterus. No anesthesia is required for the transfer. The patient remains at bed rest for 30 minutes following the transfer. She is asked to continue bed rest at home. The day after transfer, the patient can resume her normal activities. Her first pregnancy ultrasound is scheduled approximately 2½ weeks after a positive pregnancy test. She will remain on her estrogen and progesterone medications until pregnancy is determined. If pregnancy does occur, her estrogen and progesterone supplements will continue through eleven weeks, at which the time the placenta is fully developed. Currently, for patients 35 years or less, approximately ten mature eggs are yielding an ongoing pregnancy. The older patient may require more eggs because, again, a higher percentage of her eggs will be genetically abnormal, explains Dr. Winslow. A 35-year-old patient usually will get around ten to twelve mature eggs from a single stimulation. The older patient may need to undergo multiple cycles to get an adequate number of eggs. Due to the higher risk of genetic abnormality with age, cryopreservation of eggs is generally not offered to patients over age 38. On occasion, a patient may decide in the future not to use her preserved eggs. In this case, she has the option of making them available as donor eggs, and may choose to remain anonymous or to be available for contact with the recipient. Oocyte cryopreservation is an expensive infertility treatment, and is rarely covered by insurance. Cost for a single cycle of oocyte cryopreservation ranges between $9,000 and $11,000. For patients undergoing cryopreservation for a cancer indication, Florida Institute for Reproductive Medicine has been able to arrange a donation of fertility medications that save the patient an average of $3,000. Florida Institute for Reproductive Medicine was recently recognized by Child magazine as one of the top ten infertility clinics in the Nation. Dr. Winslow gives much of the credit to his staff, especially Dr. Yang and his colleagues, Dr. Samuel Brown, Dr. Daniel Duffy also Board Certified Endocrinologists, and a team of very caring nurses. As Dr. Winslow explains, “This is a team sport. We all work together to bring about the final result. It is a very rewarding area of medicine. Our patients are always coming by and bringing their babies in. For those whose hope of having a child has been realized the rewards are immeasurable,†Winslow says with a big smile. For More Information Florida Institute for Reproductive Medicine, 836 Prudential Drive, Suite 902, Jacksonville, Florida. Phone (904) 399-5620; www.firmjax.com or www.savemyeggs.com Jones Institute for Reproductive Medicine, www.jonesinstitute.org Society of Assisted Reproductive Technology, www.sart.org Society for Reproductive Endocrinology and Infertility, www.socrei.org |
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