Options for Preserving a Woman's Fertility
By: Laura Detti, MD • Posted on June 19, 2020
Most women desire to become mothers sometime in their lifetime. However, many women do not know that their ability to conceive significantly decreases as they age. And the idea that women can conceive until they go into menopause is a myth. In fact, at the peak of fertility, women are in their early 20s and the chance of conceiving is only 25 percent with every menstrual cycle. (Yes, human beings are not so efficient at reproduction compared to other mammals!) Women’s chances of conception exponentially decrease as they reach their early 40s, becoming < 5%, and <1% after age 45.
A Woman's Shortened Reproductive Window
A woman’s reproductive window becomes all the more so short when they undergo treatment for cancer, autoimmune disease, or some hematologic disorders, as these therapies may damage the ovaries and decrease the number of eggs. Depending on the number of remaining eggs, women experience Decreased Ovarian Reserve (DOR) or even Primary Ovarian Insufficiency (POI). DOR manifests with irregular menses or infertility, while POI manifests as premature menopause.
Children and Adolescents
Children and adolescents are not exempted by the consequences of egg or sperm damage from cancer therapies. Childhood cancer survivors may show various degrees of DOR, from delayed puberty, to irregular menses, to growth delay, or menopause even before they reach the age for puberty! In this last instance, young girls will need hormone therapy to undergo a medically-induced puberty. While hormone therapy in women with premature menopause may restore the ability to carry a pregnancy, it won’t restore the ability to have a baby with her own egg.
As society ages and more women have longer life expectancy and survive cancer, reproductive longevity has become more of a concern. There is no medical therapy currently that is capable of prolonging fertility. Taking birth control agents or other ovarian suppressants such as GnRH agonists does not slow down the progression of ovarian follicle depletion, whether age-dependent or medically induced.
Good News: Surgical Fertility Preservation
Over the last 20 years, however, surgical fertility preservation has gained general recognition. This encompasses two major techniques:
1. Egg Freezing
Egg freezing (Oocyte cryopreservation) is very similar to in vitro fertilization (IVF).
- It entails a powerful ovarian stimulation for a duration of 12-14 days to stimulate many follicles (one egg is harbored in each follicle) to grow at the same time.
- Ovarian stimulation culminates with an ultrasound-guided oocyte aspiration, where eggs are harvested from the large follicles.
- The eggs are then frozen using a technique termed “vitrification” and can be cryopreserved for many years (almost indefinitely).
- The eggs will be thawed and fertilized with sperm when the woman is ready to create a family.
This technique has been clinically implemented since 2012, is very effective, and the number of eggs needed to be preserved is based on the woman’s age and condition. Ovarian stimulation for oocyte cryopreservation requires that the woman is post-pubertal (childhood ovaries do not respond to stimulation) and that the woman’s condition allows at least 14 days to complete the stimulation and harvesting of the eggs. This technique is best suited for young breast cancer patients (link) and for many post-pubertal childhood cancer patients. In addition, it is best suited for women who would like to delay reproduction to later in life and desire to preempt future infertility, in what is known as “social” fertility preservation.
However, egg freezing is not suitable for pre-pubertal girls and for women of any age whose condition does not allow delays in life-saving therapies. A second, equally effective technique is available for those individuals.
2. Ovarian Tissue Freezing
- This technique encompasses a surgical procedure to harvest the ovarian tissue, which is then frozen and cryopreserved, similarly to eggs, for many years.
- When the girl/woman is disease-free and she desires to restore the benefits of ovarian hormone production and/or achieve pregnancy, portions of the preserved ovarian cortex are transplanted back to the pelvis.
- Ovarian function will resume typically within 6 months, allowing for fertility treatments (often encompassing IVF).
In addition to restoring fertility, this technique produces restoration of the ovarian hormonal production and in pre-pubertal girls this would lead to completion of a natural pubertal transition. In post-pubertal women, restoration of the ovarian hormonal production would rescue them from early menopause and end the need for hormone therapy.
The introduction of surgical fertility preservation has changed the lives of many women, extending their reproductive life and empowering them to strategize and manage their fertility.
Both surgical fertility preservation techniques are offered at the Cleveland Clinic. We welcome women and their families and clinicians to contact us at 216.445.2492 for a consultation.
Be Strong, Be Healthy, Be In Charge!
Laura Detti, MD
Chair, Dept of Subspecialty Care for Women’s Health
Laura Detti, MD has completed a Research Fellowship at Yale University and a Reproductive Endocrinology and Infertility Fellowship at Wayne State University School of Medicine in Michigan. She has done an Obstetrics & Gynecology Internship at the University of Virginia and completed her Obstetrics & Gynecology Residency at the University of Cincinnati.
Dr. Detti was appointed the Department Chair for the Cleveland Clinic Department of Subspecialty Care for Women's Health in the Ob/Gyn & Women's Health Institute in 2020.
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