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Monthly Archives: January 2012

Egg Freezing

The ability to freeze a human egg offers at least two important options for women: fertility preservation for women faced with potentially sterilizing therapies and individuals postponing childbearing, as well as couples requiring in vitro fertilization (IVF) who are ethically opposed to freezing (pre)embryos.  Being able to freeze eggs also allows for the establishment of egg banks, greatly improving the efficiency and lowering costs for donor egg IVF.

We have been able to freeze (pre)embryos since the early 80’s, a technique that is routinely performed in most reproductive medicine programs.  Freezing an unfertilized egg is much more difficult because of the large size and water content, i.e. as the egg cools ice crystals develop which can damage the working components known as organelles.  When a (pre)embryo is frozen, the essential task of these organelles has already been performed.

The first pregnancy from a frozen egg was achieved by Dr. Chen in 1986.  Following this pregnancy there were no other pregnancies until the early 90’s.  With the abolishment of (pre)embryo freezing by the Italian government there was a resurgence in egg freezing technology.  Dr. Borini and others refined the protocols for egg freezing, and with the advent of intracytoplasmic sperm injection (ICSI), whereby a single sperm could be injected into an egg the efficiency of egg freezing increased.  Dr. Dunsong Yang, the head of embryology at the Florida Institute for Reproductive Medicine, was one of the early pioneers in refining the egg freezing protocol, greatly improving its efficiency.

The Florida Institute for Reproductive Medicine has one of the largest experiences with egg freezing in the nation with over 63 babies born, including the first baby born in the world to a cancer patient who froze her eggs prior to chemotherapy.  Currently we are seeing pregnancy efficiencies of approximately 10 eggs equating with an ongoing pregnancy for egg donors 35 years or less and approximately 14 mature eggs for those 36-38 years of age.  In general, we do not freeze eggs beyond 38 because of the high percentage of abnormal eggs.  Our work on egg freezing has been chronicled in People, Self, Pink, Conceive, and Woman magazines as well as on CBS, NBC, BBC News, and the Today Show.

To date, in the world there are approximately 3,000 babies born from frozen eggs.  Health data on these infants continues to be very reassuring.  Until, however, high numbers of these children have reached adulthood and reproduced, the absolute safety of this technology cannot be asserted.  For that reason egg cryopreservation is still recommended to be done under an IRB (institutional review board) approved protocol.  At the Florida Institute for Reproductive Medicine we keep yearly surveys of our cryo egg births through annual questionnaires to parents and pediatricians.  Costs for egg freezing at the Florida Institute for Reproductive Medicine mimic those of an IVF cycle, i.e. approximately $10,500.

We will store eggs at no charge for a period of five years, after that time there is an annual storage fee of $400.  For our cancer patients seeking fertility preservation, we have been able to get medicines donated by the Ferring drug company, saving patients approximately $3500.  The longest an individual has stored eggs to date and had a successful pregnancy is 6 ½ years.  We do not believe there likely is a shelf life to frozen eggs.

Post Tubal Ligation Tubal Reanastomosis Versus In Vitro Fertilization

Approximately 10% of women who undergo tubal ligation subsequently wish to have another child – the most common reason being a new male partner who has never fathered children.  Tubal ligation involves the interruption of the tube, typically in the mid portion or rarely resection of the distal end of the tube.  All tubal ligation patients have the option of in vitro fertilization (IVF), assuming they have good ovarian reserve, i.e. a reasonable number of good quality eggs left in their ovaries.  Ovarian reserve can be checked by a variety of means, the most accurate being an ultrasound count of follicles in the ovary along with a blood test known as antimullerian hormone level.

To be a candidate for tubal reconstructive surgery it must be ascertained that the patient has sufficient healthy remaining tube and that the distal working end of the tube has not been removed or damaged.  If a tubal ligation has been performed using cautery often extensive tube damage has occurred.  These individuals in general are not good candidates for surgery.  Prior to considering tubal surgery a semen analysis to rule out a severe male factor should be performed.  If a severe male factor is found, IVF using intracytoplasmic sperm injection (ICSI) is likely to be the best option.

If the female partner is older than 35, despite good ovarian reserve she is likely to have an increased proportion of poor quality eggs, often resulting in a significant delay to conception.  For the older patient IVF is likely to be the preferable option.  If ovarian reserve is poor, donor egg in vitro fertilization is the most realistic option.  If the female partner is 35 years or less with good ovarian reserve pregnancy rates of approximately 70% can be expected with surgery, comparable to cumulative pregnancy rates with IVF.

At the Florida Institute for Reproductive Medicine tubal reanastomosis is being performed on an outpatient basis with the use of the da Vinci robot allowing individuals to return to work typically within one to three days.  Surgery is associated with a significant increase in the risk of an ectopic pregnancy, i.e. a pregnancy getting “stuck” in the tube.  This condition can be serious requiring emergent surgery.  If a couple decides they only want a single pregnancy the issue of future contraception must be addressed.   At the Florida Institute for Reproductive Medicine, using the robotic laparoscopic approach we are able to offer this surgery at a cost of $6,750 (cost for an average IVF cycle is $11,000).  The primary disadvantage of IVF is a high multiple pregnancy rate.  For individuals less than 38 years of age multiple pregnancy rates range from 20-40%, 98% of these being twins.  While the great majority of twins do very well there is an increased risk of morbidity and mortality.  Almost all multiple pregnancies are delivered by cesarean section.  The issue of a multiple pregnancy can be avoided by electing to transfer a single embryo.  For couples who are ethically opposed to IVF because of the issue of freezing (pre)embryos, this can be avoided through egg freezing.  Because of the disadvantages associated with surgery approximately 9 out of 10 couples at our center are electing IVF as opposed to surgery.  With the advent of the low cost outpatient robotic approach, we believe this ratio will decrease.

An Explanation of IVF Success Rates

Following passage of the Wyden bill in 1991, fertility programs in the United States were required to report their in vitro fertilization (IVF) pregnancy data to the Centers for Disease Control (CDC). This bill was intended to give the consumer a means of evaluating a particular IVF program. While the majority of programs in this country do report some do not. The penalty for not reporting is minimal – these programs are simply listed by the CDC as non-reporting. Reporting programs are subject to unannounced audits by qualified embryologists to verify data. At the Florida Institute for Reproductive Medicine over the last 21 years, we have been audited on two occasions and have passed both. A program not reporting their data to the CDC can report whatever data they wish, knowing they are not going to be audited. For that reason, it is wise to avoid any non-reporting program. To check and see if a program is a reporting program, check the website www.cdc.gov/art/art2010 (/art2009, /art2008, etc). I would suggest checking for at least the last three to four years as some clinics may report their data only when it is favorable.

When evaluating IVF success rates, it is important to look at live pregnancies from both fresh and frozen cycles. Some programs may report clinical or chemical pregnancy rates, approximately 5-20% of these pregnancies will end in miscarriage. Probably the biggest difference in cumulative pregnancy rates between programs is the difference with cryopreserved embryos. At the Florida Institute for Reproductive Medicine our fresh and frozen embryos have consistently been in the top ten percentile of programs nationwide. When evaluating pregnancy rates, it is also very important to look at the average number of embryos transferred. Many programs reporting very high pregnancy rates are achieving these results by transferring inappropriately high numbers of embryos. This practice inevitably results in a high percentage of multiple pregnancies. Multiple pregnancies are associated with increased morbidity and mortality to both fetuses and mother. At the Florida Institute for Reproductive Medicine for most individuals 38 years or less we are transferring two day 5/6 blastocyst embryos. For individuals less than 35 who are in a very good prognostic category we frequently will transfer a single blastocyst. For women older than 38 we may transfer up to three day 5/6 blastocyst embryos.

Florida Institute for Reproductive Medicine proudly serving patients in North Florida and South Georgia including Savannah, Columbus, Jacksonville, Jacksonville Beach, Orange Park, St. Marys, Palm Coast, St. Augustine, Palatka, Lake City, Tallahassee, Daytona, Ponte Vedra, Gainesville, Orlando, Melbourne, Ormond Beach, New Smyrna, Port Orange, Brunswick, St. Simons Island, Thomasville, Tifton, Albany, Brunswick, Valdosta and Dothan Alabama.

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