Fertility Centers of Illinois1 How to best implement and
advertise a strong fertility preservation program Eve Feinberg, MD
Fertility Centers of Illinois
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Fertility Centers of Illinois2 Fertility preservation Cancer
Gynecologic conditions endometriosis Diseases associated with
ovarian failure Turner mosaic Autoimmune polyglandular syndrome
Fragile X premutation carriers BRCA mutation carriers Delayed
motherhood
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Fertility Centers of Illinois3 Implementation of a program
Starts in your own laboratory Proof of concept: can you
successfully vitrify and warm oocytes? Not all labs are the same
Anyone can freeze an oocyte Sibling oocyte study 10 patients using
donor oocytes Vitrified half of the cohort x 2 hours then warmed,
ICSI and cultured Preferentially transferred from vit group
Excellent pregnancy rates and fertilization, blast development
rates are the same
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Fertility Centers of Illinois4 Implementation of a program
QA/QC measures on an ongoing basis Issues of storage Store on site
vs. off site Payment/collections Future use for oocyte donation,
need for FDA testing Program setup Rapid appointments Continuous
IVF, no series
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Fertility Centers of Illinois5 Implementation of a program
Mucowski et al, USC. Survey study of 62 fertility clinics offering
elective oocyte cryopreservation Low utilization = storage
issues
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Fertility Centers of Illinois6 Implementation Who is a
candidate to freeze eggs? FCI SOP Age < 43 FSH < 20 AFC >4
AMH detectable
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Fertility Centers of Illinois7 Implementation Careful
counseling NO guarantee of future pregnancy How many eggs does one
need? Sibling oocyte study age 30-39 Infertile patients undergoing
IVF 22 patients who had > 8 oocytes at retrieval Half of each
cohort were vitrified and half were used fresh Only embryos from
vitrified oocytes were transferred Chang et al., Fertil Steril
2013
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Fertility Centers of Illinois8 How many eggs does one need?
Outcomes compared between patients 30-36 and 37-39 Chang et al.,
Fertil Steril 2013 n=12n=29
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Fertility Centers of Illinois9 Study limitations Infertile
population At least one prior IVF cycle Likely an over-estimation
of numbers needed NYU data 8 oocytes equivalent live birth rates to
fresh IVF Devine K et al., Fertil Steril 2015
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Fertility Centers of Illinois10 How many eggs does one get?
Devine K et al., Fertil Steril 2015
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Fertility Centers of Illinois11 VitrificationEffect on
Aneuploidy Rates? Age 8 MIIs Sibling oocyte study, half oocytes
vitrified then warmed after 15 minutes Microarray-based CCS on all
blasts Single best blast from each group transferred, if available,
vs. best two DNA fingerprinting used to determine which embryo
implanted in monozygotic gestations @ 9 weeks (maternal serum) or
neonatal buccal swab Forman EL, et al: Fertil Steril 98:644-649,
2012
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Fertility Centers of Illinois12 No differences in aneuploidy
Forman EL, et al: Fertil Steril 98:644-649, 2012
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Fertility Centers of Illinois13 Long term vitrification and
aneuploidy Compared outcomes of 24 chromosome PGS from
cryopreserved thawed oocytes to outcomes using fresh oocytes = no
differences in aneuploidy rates Goldman K, et al, Fertil Steril
2015 Oocytes cryopreserved median 3.5 years, range 0-6.5 years
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Fertility Centers of Illinois14 10 studies, 2,265 thaw cycles,
1,805 patients Oocytes were cryopreserved because embryo freezing
was illegal or patient request (infertile population) Calculated
age specific probability of live birth 1,957 vitrified oocytes
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slow freezing vitrification
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Fertility Centers of Illinois16 Implementation of egg freezing
program: track your own data
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Fertility Centers of Illinois17 Success rates of vitrified
oocytes Success rates lower after 40 but not significantly
different between 40 and 42
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Fertility Centers of Illinois18 Careful counseling - data
driven
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Fertility Centers of Illinois19 Establishing expertise Cancer
Gynecologic conditions endometriosis Diseases associated with
ovarian failure Turner mosaic Autoimmune polyglandular syndrome
(APS) Fragile X premutation carriers BRCA mutation carriers Delayed
motherhood
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Fertility Centers of Illinois20 Establishing expertise in
cancer Gain familiarity with the different types of cancers that
affect reproductive age women Breast cancer 25% of breast cancer
patients
Fertility Centers of Illinois27 Clinical considerations Oocyte
vitrification best option Random start stimulation Adjuvant
treatment with letrozole Titrate to keep E2 below 500ng/mL Can
titrate up to 10mg, start 2.5mg PGD in future, needs higher number
oocytes Start stimulation same day Can start follicular or luteal
phase GA with lead follicle >14mm Lupron trigger Back to back
stimulation if time Shanghai protocol Kuang Y, et al Reprod Biomed
Online 2014
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Fertility Centers of Illinois28 Shanghai protocol Kuang Y, et
al Reprod Biomed Online 2014
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Fertility Centers of Illinois29 Establishing expertise
Fertility preservation not just for cancer but conditions known to
impact future fertility Endometriosis Turner Mosaic Fragile X
premutation carriers Polyglandular autoimmune syndrome Education
and outreach is key Pediatricians Peds Endocrine Internal
medicine
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Fertility Centers of Illinois30 Fertility preservation Cancer
Gynecologic conditions endometriosis Diseases associated with
ovarian failure Turner mosaic Autoimmune polyglandular syndrome
(APS) Fragile X premutation carriers BRCA mutation carriers Delayed
motherhood
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Fertility Centers of Illinois31 Fertility preservation -
Endometriosis Progressive disease Can cause decline in ovarian
reserve Intrinsic to disease Surgical intervention Association with
infertility and need for future IVF Consider banking at young age
with first diagnosis
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Fertility Centers of Illinois32 Fertility preservation - Turner
mosaic Born with same size follicular pool Follicles undergo rapid
atresia Ovarian failure in late teens/early 20s Potential to
undergo ovarian stimulation/oocyte banking before onset of ovarian
failure Would require PGS in future Careful cardiac screening,
consider GC Oktay K., Fertil Steril 2010
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Fertility Centers of Illinois33 Fertility preservation
Endocrine disorders Autoimmune polyglandular syndrome APS -1:
Addisons, chronic candidiasis, hypoparathyroidism 40.8% likely to
develop ovarian failure Consider screening and oocyte vitrification
for young women who are affected Reato G. et al, J Clin Endocrinol
Metab 2011 Consider oocyte vitrification at a younger age
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Fertility Centers of Illinois34 Fertility preservation FMR1
Consider oocyte vitrification in known premutation carriers Fully
expanded form of mutation leads to Fragile X CGG triple repeats
determine disease status Premutation 55-199 repeats and 13-26% of
women will have POF/POI Risk increases with increasing repeat
numbers 55-99 High normal repeat numbers (35-54) not associated
with decreased reserve Wittenberger et al, Fertil Steril 2007
Schufreider et al, ASRM 2014
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Fertility Centers of Illinois35 Fertility preservation - BRCA
Recommendation to have oophorectomy age 40 or sooner Many will
elect to do PGD for BRCA Association between BRCA and DOR Encourage
childbearing at a younger age or oocyte/embryo vitrification Pavone
ME et al., Reprod Sci 2014 Titus S et al., Sci Transl Med 2013
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Fertility Centers of Illinois36 Fertility preservation Cancer
Gynecologic conditions endometriosis Diseases associated with
ovarian failure Turner mosaic Autoimmune polyglandular syndrome
(APS) Fragile X premutation carriers BRCA mutation carriers Delayed
motherhood
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Fertility Centers of Illinois37 Why egg freezing? Changing role
of women Delayed childbearing for educational, professional and
personal pursuits Average age of first live birth has risen
steadily since the 1970s Universal truth that fertility declines
sharply with advancing age Unintended childlessness is often the
consequence of delayed childbearing
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Fertility Centers of Illinois38 Egg freezing has become
mainstream
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Fertility Centers of Illinois39 Delayed motherhood
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Fertility Centers of Illinois41
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Fertility Centers of Illinois42 Mean age of women at first
childbirth Average age in USA is 25
www.oecd.org/social/family/database
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Fertility Centers of Illinois43 First Births by Age of the
Mother, U.S. 1970-2006 www.oecd.org/social/family/database Increase
in the proportion of first births to women after the age of 35
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Fertility Centers of Illinois44 How old is too old?
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Fertility Centers of Illinois45 Why worry about age? Decline in
quantity of oocytes Decline in quality of oocytes Decreased
fecundability Increased infertility Increases in aneuploidy rates
Increases in SAB rates Obstetric and perinatal outcomes
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Fertility Centers of Illinois46 Natural Fertility 35 years old
Homan GF et al, Human Reproduction Update, 2007.
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Fertility Centers of Illinois47 ART canNOT overcome age Success
of ART is dependent on age In woman with DOR and/or advanced age
donor egg is often necessary Autologous oocytes Donor oocytes
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Fertility Centers of Illinois48 Implementation of egg freezing
program Education is key Patient education events Referring MD
education Psychological support Must tailor program to specific
population Paperwork Consents
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Fertility Centers of Illinois49 Marketing Direct to patient
Fertility Awareness program Use of Social Media PR, News
Marketing/Education to referring physicians
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Fertility Centers of Illinois50
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Fertility Centers of Illinois51 Fertility Awareness Program $90
Baseline ultrasound, AFC, FSH, E2 Semen analysis Nurse call to
review results Follow up consultation offered with FCI MD
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Fertility Centers of Illinois52 Fertility Awareness Program CBS
News
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Fertility Centers of Illinois53 FCI Ladies Night Out
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Fertility Centers of Illinois54 Partner with other entities:
Egg Banxx egg freezing parties
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Fertility Centers of Illinois55 Controversy re: egg freezing
parties Critics say delaying motherhood is nothing to party about
Focus on creating work-life balance Creating better policies to
support parents in the workforce. Best to avoid alcohol at a
medical sponsored event
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Fertility Centers of Illinois56 Summary: building,
implementation & advertising a fertility preservation program
Establish success in own laboratory Track your program data Become
an expert in fertility preservation for all indications Educate
your community and colleagues Careful counseling
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To promote health and alleviate the mental and physical
distress of individuals and couples diagnosed with infertility
through education and financial assistance
www.lifefindsaway.org