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Preserving All Your Options: Eggs, Embryos and Sperm

Preserving All Your Options—Eggs, Embryos and Sperm

Making the decision to preserve your fertility isn't always an easy one.

Dr. Nidhee Sachdev demystifies the process of freezing eggs, embryos and sperm in this video, including:

Video Transcript

Below is an auto-generated transcript of the webinar. Any mistakes are inadvertent. Thank you for your understanding.

Dr. Nidhee Sachdev: Hey everybody, I'm Dr. Nidhee Sachdev from OC Fertility. Today we're going to be spending some time talking about fertility preservation and what that means.

So the point of this talk is to talk about fertility preservation, what that means, and what are the options for fertility preservation.

Some people think it means it's for people who are undergoing a medical diagnosis or a medical procedure or cancer. But really, it means for people who are considering starting a family, but they're just not ready yet. And that pertains to men who are interested in baking sperm or couples who want to bake embryos, or a woman interested in preserving her fertility by freezing eggs.

So let's dive in.

So the concept of fertility preservation means taking steps to optimize your chances of having a biological offspring. If you're unable to conceive in the future. So what that means is that you're taking steps to preserve your fertility right now as it is so that way if you decide that you want to conceive in the future. Or if you are having trouble conceiving in the future. You're then given options because we all know that biology and age can have an effect on fertility and or underlying medical conditions might have an effect on our fertility

So let's first talk about male fertility. Okay. And so what this who are candidates for a male preservation. So we'll one any male who's undergoing cancer treatment. So that could be chemotherapy, radiation or surgery. So the reason chemotherapy is important because chemotherapy is used to attack your cancer cells. Typically those cancer cells are cells that are going to be more actively active and more cells that are actively dividing in the process of attacking the cancer cells. They can also attack what we call germ cells. So the cells that are later going on to become sperm.

So what happens is that is to take chemotherapy that's working to attack the cancer cells, and although it happens to improve your situation and cure you of cancer. Ideally, it might leave you in a situation where it's completely depleted, you have all those cells needed to create for. So fertility preservation for men is really important for anybody undergoing chemotherapy or even radiation and surgery, depending upon the location of the cancer. Oftentimes testicular cancer will need for removal of one or both testicles. So that obviously is going to affect your fertility.

So some men might be in a situation where their provider or doctor recommends that they take exogenous testosterone therapy. So when men take testosterone therapy for whatever underlying reasons that can actually significantly affect their own natural fertility. What that means is that when you take testosterone, your brain thinks that you're not actually making any testosterone. So the testicles stop making testosterone. And in order for sperm to develop and to be made. You need to have a high concentration of local testosterone in the testicles. So even though if you took a blood test by taking the exemptions testosterone. If you had a high level of testosterone in the blood. The testicles wouldn't see that and so therefore you wouldn't make testosterone. You wouldn't make sperm. So if it's imperative for your health, your underlying medical condition to take testosterone. It might benefit you to preserve your sperm. So that if when you do take the testosterone. If it does negatively affect your sperm count, you have a backup. So that way, if you're unable to get off the testosterone or when you stop the testosterone. You don't see a rebound in your sperm count as quickly, or as the way that you would expect, you have a backup.

So a form of male contraception. Right. And the goal of a vasectomy is to say that it's a form of long term contraception, if that person has done having kids. However, oftentimes, people may change their mind or they may be in new relationships. So, one option is to preserve their sperm by producing a sample and freezing it before the vasectomy. That way if they undergo vasectomy. They've later on, decide that they want to conceive. They have some spring that they can then use to either using insemination or during IGF help create embryos with their partner.

It's a really important concept for preservation or for transgender patients. So any patient who's making a transformation from male to female might want to consider; making sperm prior to initiation of hormone therapy. Once they start that hormone therapy, it's going to significantly suppress their sperm production and if they are considering or one of the options open. Later on, for having biological children preserving a sperm sample before undergoing hormone transition therapy is really important.

It's a for anybody who's not sure when they want to have kids if they want to consider, you know, not having kids for the next 5 to 10 years, preserving your sperm is a good option, and also an important one. It may be less relevant now in the era of code but prior to that, we will see that a lot of couples would have their partners traveling lot either the partner travel a lot, or they are out of town for business or they just weren't available. Or sometimes patients have jobs where they work shifts like some medical providers or other providers, where they're unable to, you know, be around their partner at the time when there are relating or might make it difficult. So one option is preserving the sperm in a semen analysis and freezing sperm. We can then use that sperm later to do insemination if, at the time when you're ovulating, you're not going to be around your partner or due to their work schedule and their shifts, you're not going to be around each other.

So what, so how does it work? So, one important thing to think about is advanced maternal age and infertility. So we always talk about female infertility with age. But it's important to talk about paternal agent infertility. So what we do know is that there is a decline in male fertility after the age of 40. This has been shown by changes and semen parameters that we see during the semen analysis now varying studies will have different changes. So we'll have some effects and volume, some effects and motility. It's not exactly clear and there's not as clear of a linear relationship as there is with female fertility. But we do see that there is a decline in fertility. This has manifested by longer time to conception. Finally, increased rates of miscarriages, and the recently there have been some studies that show there are higher rates of autism and schizophrenia and the offspring born two males who are older age. Now, a lot of patients will say, Well, does that mean that I'm not going to be able to have a healthy baby, given that my partner is older, and that's not necessarily the case. I think an important thing to think about is that, you know, we all know that their rates of autism might be higher than one would have expected. But when looking at these studies, it's important to think that, you know, we're not looking at, you know, if the rate of autism is, you know, 5-7% of the natural population. And saying that somebody who's 40 or 50 has a higher rate of autism. It's not raising your rate from what that baseline is you have to take into consideration that, not, you know, that in a whole population of people, the majority of people who are having kids.

The maternal age is not 40 or 50 or above, they're typically younger. So although the studies have shown that you're increasing the rate of autism is schizophrenia in offspring of men who are older, you have to kind of take everything and put it into perspective.

So how does the freezing sperm process work right. So when we're obtaining sperm. There's two main ways that we can obtain sperm. One is via ejaculation, and the other is surgical extraction. Now, the more common way that we obtained sperm is ejaculation, and regardless of how we obtained sperm the semen analysis is done. And so it's important concepts and the semen analysis or one sperm count. So the sperm count is also the sperm concentration. How much sperm is in that sample. That we also want to look at the motility. Right? It's a sperm moving because when a couple is trying to conceive and male and women are having intercourse, the sperm is then responsible from traveling from the vagina through the cervix into the uterus into the fallopian tube to then fertilize the egg. More so if you put the sperm in the act together the modal sperm are the ones that are more likely to fertilize. So we look at the motility.

Then we also look at the morphology. What is the shape of the sperm. Does it look appropriate or does it look at normal because the more appropriate looking sperm are the ones that are more likely to fertilize. So in important thing that we calculate when looking at a semen analysis is something called the total modal count, we calculate that by looking at the at the volume, at the concentration. So we calculate that by looking at the volume at the concentration at the motility. So if you take the concentration of the sperm and you multiply it by the volume, you're going to get the total amount of sperm in that sample. Okay, you multiply that by the motility. The percent of sperm that are moving. That's going to give us the total amount of moving sperm in that sample, we call that the total modal sperm. And what's important to understand is that when you have a sample that you've gotten either via calculation or surgical extraction that sample oftentimes it's going to be frozen into multiple files.

With the goal of obtaining at least 10 million moving sperm in each of aisle, because that's the minimum that we need. Whereas if somebody were to do and insemination. And we had a fresh sample and it wasn't frozen, we would take all that sperm process it and use a concentrated amount for an insemination, which means that you might have a higher amount of sperm in a fresh sample versa frozen. So like I said, a typical sample will get from ejaculated sperm, which means that a male produces the sample by ejaculate in that sample, then the analyze it will be frozen oftentimes in multiple files.

Occasionally, if there's an underlying medical condition or if there's an enterprise perspective me where there's a blockage. Intentional blockage, or if there's an underlying medical condition in which were unable to obtain sperm being ejaculate, we can then go in and surgically extract the sperm. Typically a male fertility doctor a urologist will do this. And it's a procedure in which the testicles or the an area of the male reproductive tract called epididymis is then gone in using a needle or procedure which you can extract sperm. The sperm can then be frozen depending upon the underlying medical condition, the concentration of sperm that you get from extracted sperm oftentimes is not nearly as high as an ejaculated sample. So oftentimes the samples will be frozen into multiple files but there won't be as high of a concentration and so when sperm is surgically extracted that sample is been unable to be used for an insemination, and patients who want to use that after require IVF for in vitro fertilization.

So, people always ask, well, what are the outcomes is frozen sperm first freshman like am I better off using fresh burgers Rosen's for him. Okay. And so, studies have shown that there's no significant difference in outcome with fresh versus frozen. But there are variations based on the concentration and quality of sample. So, meaning that you know if you have a sample and that samples frozen into multiple files that you have multiple chances of insemination.

That file is likely to have less sperm in it. Then if you had a fresh sample, which means that your outcome might be a little bit different because you have inherently less Berman, and if you had a fresh sample, but the act of freezing sperm and volume does not have an effect on the outcomes. So again, you have to also think about the number of viruses burn created and that there might be a lower total modal count because you took that one sample and frozen into multiples.

The important thing to consider that each cycle utilizes typically one vial the frozen sperm. So if somebody produces a sample and that's frozen into three different files a sperm that will give you about three IUI cycles.

Okay, so if you are someone is reading sperm and you want to optimize your chances of getting pregnant, depending upon your partner's age and their underlying fertility factors, you may want to consider more than one sample that you're freezing so that you can have multiple files and that might give you multiple chances and other an IUI or IVF cycle. Doesn't done often but in the event that there's limited availability of sperm. IVF during the IVF process. There is something called the chip away method where they're able to not only part of the sample instead of using all of it and use Whatever sperm, they get from part of that sample. So, in the event that you know somebody underwent cancer and doesn't have any sperm left and they have only a little bit of sperm. And you want to preserve their main your sperm for any potential further IDF cycles that is something that's possible, however, depending on the sperm quality and may not be recommended.

So how does the process work for a male who's looking to freeze. Typically you make an appointment. If you're going to be able to produce a sample by ejaculating you produce a sample or you schedule a surgical procedure that the same data you produce the sample or the procedures done semen analysis.

Now moving on to female fertility. Okay, so I think female fertility is more commonly talked about. But I think the important thing to talk about as well who is a candidate for female fertility preservation. So one is somebody who's not ready to conceive and to kind of the same boat or people who have undergone cancer treatments or who's going to initiate chemotherapy, radiation or surgery. And also the same boat transgender. So someone who's transitioning from female to male prior to initiate testosterone treatment. It might benefit them to undergo a procedure in which they freeze her eggs so that way after they've undergone their hormone treatment, it may not affect their fertility and also, for a lot of people. Once you've gone that transition and they're transitioning from female to male. It's actually, they might feel that the process of going through and freeze their eggs is purely emasculating and so they don't want to go down that route again.

So an important concept to understand his age-related infertility when talking about women so men and women differ and that men have the ability to produce sperm even later ages. Right? Whereas women were born with all the eggs we have. And over time, our pool of X is going to deplete, which is why age-related infertility is much more pronounced and females and males. So when talking about eggs is to basic concepts. One is quantity and quality. So we're talking about quantity, we're talking about our ovarian reserve the number of eggs that we have. So imagine if you had a million women and you line them up youngest, to oldest right and on the y axis you have our ovarian reserve, you're going to see that our ovarian reserve starts to decline as we hit our late 20s early 30s, it goes down much sharper as we hit our mid 30s and then it goes down really sharp as we hit our 40s, because we see over time, our pool of X is depleting. But imagine if you zoomed in on this line and looks smooth from a distance. But if you zoom in on that line, you're going to see it actually is his jacket and it fluctuates, and there's variations from person to person meeting, not every 35 year old is going to have the exact same ovarian reserve some 35 year olds are going to have robust ovarian reserve or some are going to have a lower one.

We can assess your ovarian reserve by various different factors, but another important factor is the quality of the x. So the best way to talk about quality of the ends of the chromosomes. As women. We have 46 chromosomes to our exes. And so we're 46 XX and males have 46 chromosomes have an X and Y. So if we all have to set the chromosomes, we effectively got have 23 for my dad, which is the sperm and 23 from our mom, which is the egg equal 46. Now since men are constantly making sperm, even as they get into the 15th and 16th, the process of making sure that the sperm has only 23 chromosomes typically will work well. And so a sperm will likely have the right number of chromosomes. However, since women were born with all the eggs. We have if you're 38 and trying to get pregnant. That egg that's being emulated at the age of 38. It's at that point that it makes sure it has only 23 chromosomes. So the older we are that mechanism is more likely to make mistakes and have errors.

So we're as a 25 year old and a 35 year olds will automate the 35 year old might have egg would either too much or too little chromosomes was a 25 year old is more likely to have the appropriate number of chromosomes. So if the egg has an extra are missing a copy of chromosome and the sperm has the appropriate ones. Maybe they won't fertilize or maybe if they fertilize the won't grow and divide to become embryos, or if it does become an embryo and an implant. It's more likely to lead to a miscarriage. So for that reason as we get older, we have a harder time getting pregnant as women because we have fewer eggs, possibly, but the quality of the eggs may not be as good.

So how do we assess your fertility. So when someone comes saying you don't considering a fertility preservation cycle. Some of the basic tests that we do are assessing the fertility so one test we do is called an anti malaria and hormone or an age. This is a test that gives us a sense of your ovarian reserve along with an anthropological count. And natural follicle count is actually an ultrasound done typically at the beginning part of your menstrual cycle, in which will look at the number of resting follicles that you have with the with the thought that the greater number of follicles that we can senior ovary is going to correlate to the greater ovarian reserve.

There's also labs that we use called day two or day three extra dial or FSH so we use those as a sense to say, you know, do you have an appropriate FSH level or is it elevated, meaning that if you have a smaller pool of eggs, you're going to have less of a hormone called inhibitor, which causes a negative feedback on a hormone called FSH, and if you have a smaller pool of follicles or if there's a higher likely to, you know, to not to that for that pool of X function as well. At the beginning part of your menstrual cycle, you're likely to have a higher FSH, so we do occasionally see women have an average to a robust VM each level by the slightly elevated FSH, what that means is that you might have a good pool of eggs, but maybe the quality of the eggs may not be as good. So all of these tests are kind of put together to help us council patients. So for anybody considering fertility preservation is a female. So there's a basic labs that we do and they're the same labs are similar to patients who are undergoing idea.

So we undergo a basic blood count, we want to make sure there's no signs of significant anemia or abnormalities within the platelets. Your blood type is important. We just want to make sure, just for health maintenance that you have up to date. Pap smear, and you you're up to date your woman exam infectious disease panels important so that includes like HIV, hepatitis and syphilis. And then there's a basic hormones that I just mentioned, you know, your day to FSH and extra guy or an anti malaria and hormone and depending upon the patient and their goals will often check your thyroid and some other hormones like a prolactin and vitamin D and consider talking about screening you for diabetes.

If you're not actively trying to get pregnant. We don't spend a lot of time looking at the uterus and the fallopian tubes, although that is a conversation that we might have in a different stage are undergoing if you have other issues that we're talking about.

Now he doesn't care your screening is important to talk about because it can be done. Whether you're freezing eggs or embryos. The purpose of genetic carrier screening is to do a blood test to see, hey, am I a carrier for any diseases, I can pass on to my kids. Now, as a woman, there's two types of genetic screening that's important to understand. Are you a carrier for a disease that's called autism or recessive, meaning that takes you and the sperm source to have the same, the same mutation in the same disease. If that's the case, then if you and sperm source your partner donor sperm, whoever that might be, both have the same mutation that means that your future two kids have about a 25% chance of being affected with that disease.

If, as a woman, you have something called an excellent recessive. That means that there's the mutation on a gene that's part of our X chromosome. Now, as women we have two X chromosomes. So if we have a mutation on a gene on one of our X chromosomes. The others is going to function appropriately and counteract that one so we may not have any symptoms of disease. But when we go to have kids in our exes separate our sons get their extra months. So when you go to give that x year son, you could give the extra the defective gene or the X with the appropriate gene. Which means that if you have an excellent disease if you carry a disease for an excellent disease, you have a 50% chance of having a son effective event disease.

So oftentimes when patients are freezing their eggs I talked about the genetic carrier screening and although they may not know who the partner is going to be at that time to test her partner, oftentimes, it's important to understand that there are things that you as a woman can pass on to your son. And I might be important information, you know, prior to freezing your eggs, oftentimes that may not preclude you from freezing your eggs, you're likely still to do it, but it's just important information to know. And for some patients, they say, Well, you know what I want to do this when I'm ready to use those extra to get pregnant because we know technology is improving and the panels that we have now I become more expansive and comprehensive in the future. 

If you're considering making embryos, this might be an important thing to do because if you and the person that you're making embryos with or the donor sperm are curious for the same disease you then have the opportunity to do something called PGD. Like for medical diagnosis in which you can then look for that specific disease in the embryo. And so semen analysis is not relevant. If you're freezing your eggs. But if you are deciding to freeze embryos with your significant other or a partner.

In the semen analysis important for them to undergo so that we can assess the amount of sperm. They have and motility, so that way when we're undergoing the procedure. We're not surprised to make sure we have enough sperm. So when talking about female fertility preservation. There's really two options right there's egg freezing and there's embryo banking.

So what's the difference? Well, the process of egg freezing is harvesting oh sites which are eggs in crowd preserving them with the option to fertilize and create embryos in the future. Whereas embryo banking means you're taking the eggs in your fertilizing with them was firm, be it sperm from a significant other, a partner or a donor sperm and you're creating embryos to be used in the future when you want to. So what's the main difference between freezing eggs or embryos will most important difference is ownership when you freeze eggs. Those eggs are yours and only yours, and they can be. Then use in the future to be fertilized if and when you want to. When you make embryos depending upon your background and your own ethical considerations. Many consider that to be a life which is one factor.

But the other is that they're those embryos are created with sperm. So if you're creating embryos with a partner those embryos don't belong to the two of you. So if in the future you both have differing ideas of the use of those embryos, there could be some difficulty in using that or if you're no longer with that partner than those embryos are not likely are not able to be used.

Or you create embryos, but using a donor sperm, which means that that sperm has been donated from somebody, and that person has no legal rights that. That embryo. So it's ownership is really important to understand and the other aspect is knowledge, meaning you have a better knowledge of the outcomes of that cycle, which I'll get into in a little bit.

So how does it work? So whether you're freezing your eggs or your banking embryos, the process is the exact same for the patient. So typically being start at the beginning part of our menstrual cycle. So either from a spontaneous menstrual cycle or if timing is important. Or if you're on the birth control pill. It can be the menstrual cycle off the birth control pill.

So an important concept to understand is that every month, whether we're trying to get pregnant or not or whether we're on the birth control or not our body as women are just recruiting hundreds of eggs. And every month when we're obviating our body will have dominance section takeover and will recruit just one egg. What happens, those other eggs that were recruited that we're starting to be recruited but not picked up the heavyweight Well those are just gone forever.

So the process of freezing your eggs or IVF or banking embryos is that we're trying to take advantage of these eggs that were recruited but are never going to be used. So we're not doing anything that it's affecting your fertility in the future. We're just taking advantage of these potential eggs that are never going to be used.

Okay. So at the beginning part of your menstrual cycle and you come in for an evaluation we do an ultrasound. And at that point, we have you started taking medications in the form of injections to slowly grow these follicles.

So here you see all these resting follicles, the goal that we slowly grow them to be larger over the course of nine to 12 days in that process, you tend to see us here in the office for blood and ultrasound. So we can carefully and watch how these follicles grow. Once we feel like the eggs are of appropriate size and they're ready to be taken out you undergo procedure called an egg retrieval or transnational

Aspiration so this procedures done under anesthesia with an actual anesthesiologist. You get anesthesia. We call it general anesthesia. It's not the same as if someone having their appendix taken out, meaning the two down your throat to breathe for you. But it's more involved and say someone having a colonoscopy, where they're getting twilight anesthesia. The point is that you're not in pain, but you're walking up quickly after.

The procedure takes about 15 to 20 minutes and it's done using ultrasound, the transactional ultrasound in which needles place Vasily into the ovary. The process of this that we go into the ovary and we aspirate out all the eggs within it. Okay. In the operating room is actually attached to the embryology room. So the eggs are taken directly from you and pass into the embryologist where they've been evaluated and looked to look at the X. So the day of the egg retrieval will find will find out the number of eggs that you have okay, so it's, again, the process of we're having your extra move. It's an outpatient procedure, procedure itself takes about less than an hour.

You have anesthesia, but you're, you're not in pain during the procedure, and you wake up pretty quickly. It's a national procedures so that there are no incisions. And if you're baking embryos and you're making embryos, either with donor sperm or with a partner. This is the time in which we have to make sure we have sperm.

So here's just a quick overview of the process. So again, it's about two weeks of active involvement from the patient, whether you're freezing eggs or you're freezing embryos. You come in at the beginning part of your cycle we have you take injections. So the type of injections, you take are called subcutaneous injections, meaning that they're going into the fat.

So, it typically say where are you can pinch an inch, most people tend to do it underneath their belly or you can do it in your thigh. And you're taking two to eventually have three injections, a day, and although that seems really daunting. Most people who've done, it will say the injections weren't really that bad.

So you start taking injections, on average, for about 10 to 12 days rejections and you see us about five to eight times during that time. And when you come in and you're getting blood and ultrasound. So we're actually evaluating you and you're seeing one of our providers as you're going through the whole process.

And important thing to understand is that during this process, we need you to be available to us so that we can see if we can monitor your cycle. Again, maybe less relevant in the era of COVID-19. However, in the past, when people were traveling more. We wanted to make sure that they were not traveling. During this time, and they were here.

Another really big factor is exercise. So, in the process your ovaries are going to get bigger, right, because this is what your ovary looks like at baseline and then the process we're making them bigger by growing more follicles. Your ovaries are actually attached to your body via a blood supply, which kind of acts like a pendulum. So if you have an enlarged ovary attached to your body with blood supply. If you're doing a lot of physical activity. It has the potential to kind of twist on itself and in the worst case situation, it could actually kind of cut off the blood supply to the ovary.

Although that's a very rare thing that happens to decrease our risk of that we ask our patients not to exercise during the stimulation and they can still walk, they can do some forms of yoga and upper body exercise, but no spin class, crossFit or things of that sort. Which truthfully is really hard for a lot of our patients because for many of us, that's a form that's a stress reliever and that's a way for us to get out some energy during the week but that's just really important to understand that we've limit your exercise. Once you start this process.

So another thing about the procedure is that because you're getting anesthesia, you need a driver to take you home for the procedure, we can't let you take a rideshare or Uber and you need a chaperone because you're having a procedure we want somebody to be around and with you for about 24 hours, or at least that evening after your procedure.

Now patients always asked, Well, how many eggs. Am I going to get. And that's where we go back to your ovarian reserve analysis and your age level. So based upon your age and your annual follicle count will be able to talk to you about what we expect. Now our typical number of eggs is between six to 12 that we get.

Now, this varies wildly from person to person, depending upon their age, any prior medical conditions they have in their, their age level and with our annual follicle count is but our average across kind of all of our patients is about six to 12. Now in order to understand what the processes and the outcomes of freezing your eggs. It's important to understand what the overall process of freezing embryos and IVF is. So now the day of the procedure, as I mentioned, will know the number of eggs that we retrieved, which means that we went into the procedure and we got the exam.

Now, it's important to understand that not every egg is going to be able to be fertilized. So when talking about eggs. We talked about them kind of in two forms.

Mature eggs and immature eggs. So as we're undergoing the process and we're doing ultrasounds, we're actually measuring the size of the follicles, which are in your ovaries Batavia X and side and we're looking at the size of the mall as the of the follicles as a way to kind of assess which of these follicles is more likely to have a mature egg in there.

Now, the typical stimulation. We expect the follicle size has to be kind of like a bell curve distribution. And from that, we anticipate about 80% of the eggs to be mature, which means that not every single egg that we get is likely to be mature. So, the day of the procedure will find out how many eggs we get. But if you're freezing your eggs. We're only able to freeze the maturity.

So it's the next day that we really find out how many extra frozen. Okay, so, but let's say you're not freezing your eggs and you're making embryos. So the same thing, we get the eggs and later that day. The eggs are then attempted to be fertilized with the sperm. Okay, so if you have 12 times retrieved typically about 10 will be mature. Now, we expect that 70 to 90% of the eggs to fertilize. So let's say you have 10 eggs and seven fertilized on the lower side. Now, not all of these fertilized eggs are going to grow and divide to become embryos, on average, we see about 30 to 50%, which means that if you had 10 eggs and seven fertilized on the higher end we'd see about four blastocyst or embryos developed. Now, if you're making embryos, you have two options. From here we can take the embryos like this and we can transfer them in one or two at a time. Right, we can freeze them and then in the subsequent cycle transfer them in one or two in time, or we could actually biopsy the embryos and look at the chromosomes. So by biasing them. We're taking a few of the cells from the embryo and analyzing them to look at the chromosomes.

Meeting does this the embryo. Did it come from an egg with the right number of chromosomes and it does equal 46 meeting as females 46 x x or as a male 46 X, Y, or is it something that we call Andy point, meaning it has an extra copy of something or it's missing a copy of something. By doing that, we can assess which ones are more likely to lead to a pregnancy.

 

So if you go back and we talked about age-related infertility and we talked about age has as women as we get older, we have a higher rate of abnormal chromosomes that are in the embryos, we created from our eggs. We're going to see that the percentage of embryos that we have that are chromosome a normal decreases with age, meaning that if you are 30 and you have for embryos frozen. I would expect to see about three of those embryos to be chromosomally normal. Okay. However, if you're 35 or 36 the percentage of embryos that unlikely to be normal goes down. So if you are 35 or 36 and you have for embryos. Why expect about have to be a normal, so I'd expect to only about two to be normal which means that if you have these four embryos, if we knew which ones are normal. Then we could focus on the ones that are Chrome is only normal and transfer those and discard the ones that are at that are abnormal. Now what's important to understand is that no matter who you are or how you're trying to get pregnant, the mechanisms of of conceiving are the same.

First you have to have the egg. The egg and the sperm have to fertilize that fertilized egg needs to grow and divide to become an embryo and then you have to hope that that embryo came from an egg with the appropriate number of chromosomes, it's going to implant and they told pregnancy.

The difference with IVF is that we're just taking out more eggs and fertilizing them and having more to choose from. The process of biopsy the embryos isn't actually changing anything within the embryo all his selection tool. So instead of saying, oh, I have four embryos, you can then say, okay, out of these four I know embryos 123 or chromosome and normal and those are the ones are more likely to get me pregnant. Okay. Now the question is, well, how do these outcomes change if you froze eggs.

So if you were to freeze your eggs. This is where the process stops you have these eggs, Frozen, they're yours and only yours to be used if and when you want to. Now, an important thing to know is it for eggs are eggs are typically frozen in lots of two or three. Which means that depending upon the number of eggs you have made in your situation when you come back to use it, you may decide not to thawed fertilize them all so but important, important to understand the mechanisms and the outcomes. So let's take it back a step.

So let's say someone comes back to the other eggs and to use them. So we go to all the eggs, and given that technologies and proved out of 10 frozen eggs, I expect at least nine to survive the fall. Okay. Now, when we go to fertilize these frozen and thought eggs. We expect the fertilization rates to be about the same. Okay, so at a nine eggs. Let's say seven fertilize the part that we might see a little bit of a difference is this right here, the rate of conversion from these fertilized eggs to embryos to blastocyst. We might see that this rate is a little bit lower. So whereas we might see that 50% of these fertilized eggs become embryos, we might see that it's actually lowered about 30%. So whereas the seven fertilized eggs from fresh eggs like to for embryos, the seven fertilized eggs that came from DOD eggs might lead to maybe two embryos. Now, the percentage of these embryos that are going to be chromosomally normal should it change if you froze or eggs or use fresh eggs.

But if the absolute number of embryos, you have here as a little bit lower in frozen experts is fresh. The overall number of chromosome a normal embryos that you have is likely to be less with frozen X versus fresh. So when deciding whether to pursue eggs versus embryos. An important thing to think about is, okay, well if you're in a situation where you have a partner that this is the person that you intend to build your family when you might make sense to freeze embryos over eggs because at the end of the cycle. You might have a slightly improved outcome, and more importantly, you'll know what the result is. You'll know okay I did this and I have four frozen embryos. Or, if you test them, you'll say, Okay, I did this and now I have two chromosomally normal embryos and I know that my give me a chance of having it gives me a really good chance to having one baby, but it gives me, you know, pretty good chance of having two kids.

Because the important thing to understand is that once you have a chromosomally normal embryo, whether that embryo came from you whether you were 30 or 35 your chances of getting pregnant and having an actual baby per normal embryo is about 65 to 70%. So the benefit of this is that if you freeze your eggs. When you're 30 and you come back to us and when you're 35, your chances of having a normal embryo are related to when you're 30 not when you're 35 because that's when the eggs came from. So even though you're 35 you have a higher chance of having a normal embryo from these eggs from when you're 30 versus your extra when you're 35.

And on the flip side, if you froze these eggs are you frozen embryos when you're 30 and you now come back at 39, well, your chances of getting pregnant or not that of a typical 39 year old because you've already done the work to make the embryos. Now we just have to implant them so it allows you the opportunity to have the fertility of a younger you per se. Okay? And the real thing is that by doing this, it allows you the opportunity to use yourself as your own daughter, meaning that it will we have patients who are in a position where they're trying to get pregnant on their own and they're not able to succeed use no eggs.

They have the opportunity to use a donor egg that if somebody who's younger with a prior proven fertility. Now they can still do that and go on down a baby. But if it's important to them to have a biological child of theirs then freezing their eggs is an important option so that when you come back in the future if your own X don't work, you have a backup.

Here's just another diagram kind of explaining what we call the fertility funnel.That at every step, there's a little bit of attrition in this attrition tends to get narrower and this funnel tends to get narrower and steeper as we get older. Because of the age-related infertility and seeing that there is going to be a higher percentage of Chrome is only abnormal embryos, as we get older. But the important thing is that once we make it to a chromosomally normal embryo, that we have a high success rates with implantation having live births.

So here's just another diagram that kind of talks about the difference of freezing eggs versus embryos, when you have frozen eggs. We expect the majority of them to survive the fall because the technology that we're using now to freeze eggs is far superior to the technology that we use 5 to 10 years ago. When you're looking at frozen eggs versus fresh eggs. We expect the fertilization rates to be about the same.

But the difference that we see is the embryo development. We said we see that that tends to be a little bit less when embryos are created from Frozen eggs versus fresh, but once you make that embryo, the implantation rates tend to be about the same whether they came from Frozen X refreshing.

Um, so another important question is okay well I froze my eggs or I froze embryos and then. But what happens when I come back.

Well, that all kind of depends on the situation that you're in. Okay, depending upon your age. If you're, you know, if you and if you have a good ovarian reserve, we might have a conversation that says, well, let's try on your own. If you can get pregnant spontaneously. That would be wonderful. Right? Or we might say, Okay, well let's try to get pregnant on your own. But let's try some lesser invasive options like an entry uterine insemination. Again, we might say, depending upon the number of eggs you have frozen in your situation of what's going on, and we might say, Okay, well let's try to get pregnant now with your own eggs. Let's do it. If, if that's what we need to do to make embryos. And then in the event that you know you get pregnant with one, but you want to come back for another baby later when you're older and which might make it harder then we can go back and use those frozen eggs. Or we might say, Let's go straight to using your eggs and calling them. So we saw them we fertilize them we make the embryos.

Okay, but then those embryos and have to go back in and what we call an embryo transfer and that's called the frozen embryo transfer cycle. So whether you're having embryos from Frozen eggs or fresh eggs of frozen embryo transfer cycles essentially the same.

And the way that we make these decisions is really dependent upon you and what's going on in your age, you're very reserved and kind of what your family goals.

Okay. So not everybody who is important thing to understand is not everybody who freezes your eggs ends up using the frozen eggs because if they get pregnant spontaneously.

Then they didn't have the users frozen eggs or they maybe they end up using it for their second or third child.

But the importance is that just because you have the frozen eggs, doesn't mean you have to use it, you have to go back and saw them. However, if that's something that makes sense for you. And that's what you want to do, then they're available to do that. So with that, I am gonna leave it open to any questions that we may have here.

So we have a few questions here from the audience. So I'm going to go through and answer them. Okay.

So one question we have is just taking the birth control pill have any side effects to our bodies and and if there are no side effects for the short term. What about the long term. So that's a good question. So I think a lot of people are concerned about how taking birth control pills might affect their fertility in the future. And if you're taking birth control pills for the purpose of, for the purpose of contraception important thing to say is that it's not going to affect your overall fertility what it might do is kind of mass some underlying things that are going on.

I think a lot of women might have your regular cycles, but have no concept of it because they're taking the birth control pill for so long, and they have no idea what their menstrual cycle is like. But aside from kind of masking the underlying issues that's going on the act of taking, it doesn't have any long term effects on it.

Okay. One question we have another one that says I'm 31 of my OB suggested I look into. I look into fertility preservation, but given COVID-19, and everything that's going on. Can I wait, I think an important thing to understand is, what are the risks and benefits versus waiting right COVID-19 is a really real concept and, you know, the risk of exposure by entering a clinic and by seeing other people is real. So I think that's something to acknowledge.

The other thing to talk about is, you know, given the age of 31 just waiting two or three months, make a difference. No, it's not going to affect your overall outcomes. But assessing what your underlying ovarian reserve is is really important when assessing that, because depending upon that you may talk with your provider, but have a number of cycles you want to do.

Which kind of takes me to an important question. I think a lot of people who are freeze their eggs. Want to know, well how many eggs do I need, what's the ideal number of eggs to freeze.

And that's a really good question. And it's hard to give a really specific answer.

Because it depends on a lot of factors. But what I generally say is that obviously the younger you are, the less eggs you need, right? And the older you are, the more eggs you need, but typically in patients who were kind of in the 3536 or under range. I say we can freeze 10 eggs that gives us a good chance of optimizing our chances to having one normal embryo. And by having one normal embryo. They give you a really good chance of having one baby. Now, nothing is 100% and there's no guarantees, but that optimizes our chances. So, depending upon your situation right if you're that age group. And you say, well, I really want to have two kids and I don't know when I'm going to come back and be ready to have a baby, so oftentimes patients might consider doing two cycles to try to increase the amount of cumulative eggs with the frozen.

Any of my patients who are, you know, nearing 40 or above, I say, you know, 10 could be enough for you. But if you really want to optimize the situation. I try to aim for about 20 optimize giving us you know at least one, if not two normal embryos, because the problem is that if you're 40 and then you come back.

In three or four years your fertility is going to declined significantly, which means that you're not going to have the option to use your own eggs, maybe, and you're going to be dependent upon these frozen eggs.

So for patients who were younger we oftentimes might recommend depending upon your goals, being a little bit more proactive and consider doing more than one cycle.

Okay. Well, another good question is well how does monitoring that our clinic work. So that's really important to know because you know for two weeks, you're going to be seeing this a lot.

So the way it works at our clinic is that we will see you for blood and ultrasound, kind of as needed during the stimulation typically four to six times.

And so you're seeing here by us, by one of our providers. So there's two providers myself and Dr Moines area and we do all of our own ultrasounds.

So my patients cycling with me. I try to see them as much as I can. But if I'm in a procedure or if I'm available that time and

We'll see you. So in our clinic ultrasound monitoring will be done by one of two doctors and we work together as a team.

So we typically do all of our results in our IBS decisions together. So regardless if we you see your provider is going to ultimately be making helping to make those decisions about what happens in your in your protocol in your stimulation

So another good question. We're getting is, well, what happens to my unused eggs or embryos. So those that that is a great question. So you have options. One, you can donate your eggs or embryos which, oftentimes, is not necessarily anonymous. It depends upon the underlying situation, but you could donate it to a friend or a family member. Or you could donate it to research if that's something you're comfortable with every embryology lab and various different institutions are doing research to improve the science and improve how we do things or you have the option to just discard them.


Another question I have is: So I read an article that shows that there is not an exponential drop in our fertility at 35, but 40 is a bigger drop off. What's difference between those ages, given that there might be cost concerns. So that is a great question. So when I counsel patients I talked about how for better for worse, we are lumping women together based on prognosis by age. Okay, the best prognosis group tends to be under 35 right obviously a 25 year old may not have the same prognosis as a 34 year old. However, the under 35 age group tends to do pretty well. The next group of 35 to 37 it truthfully 35, 36, 37 year olds do comparable to 34, 33 year olds. We start to see a sharper decline in the quality of eggs and really the percentage of chromosomes. We're going to see that are normal as we hit 3839 and 40 we see significant differences between 38, 39 or 40 and much so after 40,41 and 42. So now the question is, well, does it make sense to freeze your eggs at 40. This is the part of the conversation where we start to talk about, well, if you're not in a position to be in relationship with somebody and know who you want to have a family when there's the option to freeze your eggs. But the problem is that when you freeze your eggs is that you don't know what's going to happen when you come back to them. And the older we are, the less likely we are to have chromosome a normal embryos. So by doing the cycle and freezing our eggs at the age of 40, that very well could lead to an embryo that leads to a baby, or may not, so one option, when I talk to patients, I say, well, maybe they consider making some embryos with a donor sperm. Now, obviously that's not necessarily for everybody. But a question I typically last my patients and say, well, from where you're sitting today. Is your goal to optimize your chances of having a biological child, or is your chances of optimizing your chances of having a biological child should you be in a situation to have a child with somebody that you want to have a child with. If it's the latter then, freezing eggs is the right is the right option. But if you're somebody that thinks that you might be in a position where you might consider having a child with a donor sperm in the future. That might be to your benefit to freeze embryos with a donor sperm versus just eggs, and for many patients will do half and half will freeze half eggs and half embryos depending upon the number of eggs. Because the differences with the embryos, you have a little bit more of a tangible outcome of what happened. You can walk away say okay, I have one normal embryo made with donor sperm and I have some eggs. So should I come back in the future and say, Okay, I'm ready to have a baby on my own. I have that here. And now I don't have to worry about my fertility. At the age of 42 or 43 and using an egg donor and I have that or should you beat someone in the future. Then, then you have those eggs. But for somebody who says, You know, I'm not comfortable committing myself to having a baby with donor sperm, then freezing eggs is your option, but knowing that in the future if it doesn't work, then donor egg is an option that's available to many people. Some people may not be comfortable with that, at that point in time, but maybe over time they might be. But that is a good question. Awesome.

Alright, so I think we have one last question here before we wrap up and says, so this is a couple: We have a younger, younger woman without significant without partner who is older and a 16th partner had a reversal at the end of last year, but then COVID-19 happened and given the concerns for COVID-19, so some concerns about moving forward. Should we hurry up because of his age. Well, that is an excellent question. So we know that we talked about male fertility. There are some effects with male fertility and age. So there are some association with potential increase in autism is get to friend yet. It's not as linear of an increase as we've seen with female age and, you know, Down syndrome and access chromosomes like trisomy 13 and 18 but it's an association that's there. And I think that the important thing is first and now analyzing his sperm count. Now he's had a reversal. But sometimes we can see that will see sperm there and that sperm count may diminish over time, maybe due to changes surgical changes that happen after the procedure or just age-related infertility, so I will start off by getting a recent semen analysis. If you haven't already gotten one and consider potentially banking his sperm.

The other thing that you could do is consider banking embryos. If the concern is being pregnant during COVID-19 versus doing treatment if the concern is pregnancy during COVID-19 it might make sense to just bank embryos and wait till things seem to improve, which hopefully they will. But if the concern is increasing exposure to Cove and it might make sense to at least get a semen analysis free some sperm and then once things seem to be in a better position for you, where you feel more comfortable proceeding, but I think the important thing is that, you know, for male fertility. The difference between 60 and 60 and a half is not as significant as it is for women who are 41 and a half to 42. And I think that's important to understand.

Well, this was great, thank you for some of these wonderful questions. This was really exciting to have all these questions. Thank you everybody for joining us. If you have any other questions about fertility preservation. Whether that means banking sperm banking, eggs or freezing embryos, please feel free to reach out to us. You can ask us questions and social media at ocfertility.com. You can email info@ocfertility.com. Our social media handle is @ocfertility, you can reach out to me personally, I'm at @DrNidheeSachdev or you can email us at info@ocfertility.com.

Thank you very much for your time. We look forward to continuing to educate you here at OC Fertility.

We hope you find this helpful! If you would like to see specific content from us or have a question, email us at info@ocfertility.com or phone 949-706-2229.

You can also schedule directly on our website.

Video Transcript
Below is an auto-generated transcript of the webinar. Any mistakes are inadvertent. Thank you for your understanding.

Dr. Nidhee Sachdev: Hey everybody, I'm Dr. Nidhee Sachdev from OC Fertility. Today we're going to be spending some time talking about fertility preservation and what that means.

So the point of this talk is to talk about fertility preservation, what that means, and what are the options for fertility preservation.

Some people think it means it's for people who are undergoing a medical diagnosis or a medical procedure or cancer. But really, it means for people who are considering starting a family, but they're just not ready yet. And that pertains to men who are interested in baking sperm or couples who want to bake embryos, or a woman interested in preserving her fertility by freezing eggs.

So let's dive in.

So the concept of fertility preservation means taking steps to optimize your chances of having a biological offspring. If you're unable to conceive in the future. So what that means is that you're taking steps to preserve your fertility right now as it is so that way if you decide that you want to conceive in the future. Or if you are having trouble conceiving in the future. You're then given options because we all know that biology and age can have an effect on fertility and or underlying medical conditions might have an effect on our fertility

So let's first talk about male fertility. Okay. And so what this who are candidates for a male preservation. So we'll one any male who's undergoing cancer treatment. So that could be chemotherapy, radiation or surgery. So the reason chemotherapy is important because chemotherapy is used to attack your cancer cells. Typically those cancer cells are cells that are going to be more actively active and more cells that are actively dividing in the process of attacking the cancer cells. They can also attack what we call germ cells. So the cells that are later going on to become sperm.

So what happens is that is to take chemotherapy that's working to attack the cancer cells, and although it happens to improve your situation and cure you of cancer. Ideally, it might leave you in a situation where it's completely depleted, you have all those cells needed to create for. So fertility preservation for men is really important for anybody undergoing chemotherapy or even radiation and surgery, depending upon the location of the cancer. Oftentimes testicular cancer will need for removal of one or both testicles. So that obviously is going to affect your fertility.

So some men might be in a situation where their provider or doctor recommends that they take exogenous testosterone therapy. So when men take testosterone therapy for whatever underlying reasons that can actually significantly affect their own natural fertility. What that means is that when you take testosterone, your brain thinks that you're not actually making any testosterone. So the testicles stop making testosterone. And in order for sperm to develop and to be made. You need to have a high concentration of local testosterone in the testicles. So even though if you took a blood test by taking the exemptions testosterone. If you had a high level of testosterone in the blood. The testicles wouldn't see that and so therefore you wouldn't make testosterone. You wouldn't make sperm. So if it's imperative for your health, your underlying medical condition to take testosterone. It might benefit you to preserve your sperm. So that if when you do take the testosterone. If it does negatively affect your sperm count, you have a backup. So that way, if you're unable to get off the testosterone or when you stop the testosterone. You don't see a rebound in your sperm count as quickly, or as the way that you would expect, you have a backup.

So a form of male contraception. Right. And the goal of a vasectomy is to say that it's a form of long term contraception, if that person has done having kids. However, oftentimes, people may change their mind or they may be in new relationships. So, one option is to preserve their sperm by producing a sample and freezing it before the vasectomy. That way if they undergo vasectomy. They've later on, decide that they want to conceive. They have some spring that they can then use to either using insemination or during IGF help create embryos with their partner.

It's a really important concept for preservation or for transgender patients. So any patient who's making a transformation from male to female might want to consider; making sperm prior to initiation of hormone therapy. Once they start that hormone therapy, it's going to significantly suppress their sperm production and if they are considering or one of the options open. Later on, for having biological children preserving a sperm sample before undergoing hormone transition therapy is really important.

It's a for anybody who's not sure when they want to have kids if they want to consider, you know, not having kids for the next 5 to 10 years, preserving your sperm is a good option, and also an important one. It may be less relevant now in the era of code but prior to that, we will see that a lot of couples would have their partners traveling lot either the partner travel a lot, or they are out of town for business or they just weren't available. Or sometimes patients have jobs where they work shifts like some medical providers or other providers, where they're unable to, you know, be around their partner at the time when there are relating or might make it difficult. So one option is preserving the sperm in a semen analysis and freezing sperm. We can then use that sperm later to do insemination if, at the time when you're ovulating, you're not going to be around your partner or due to their work schedule and their shifts, you're not going to be around each other.

So what, so how does it work? So, one important thing to think about is advanced maternal age and infertility. So we always talk about female infertility with age. But it's important to talk about paternal agent infertility. So what we do know is that there is a decline in male fertility after the age of 40. This has been shown by changes and semen parameters that we see during the semen analysis now varying studies will have different changes. So we'll have some effects and volume, some effects and motility. It's not exactly clear and there's not as clear of a linear relationship as there is with female fertility. But we do see that there is a decline in fertility. This has manifested by longer time to conception. Finally, increased rates of miscarriages, and the recently there have been some studies that show there are higher rates of autism and schizophrenia and the offspring born two males who are older age. Now, a lot of patients will say, Well, does that mean that I'm not going to be able to have a healthy baby, given that my partner is older, and that's not necessarily the case. I think an important thing to think about is that, you know, we all know that their rates of autism might be higher than one would have expected. But when looking at these studies, it's important to think that, you know, we're not looking at, you know, if the rate of autism is, you know, 5-7% of the natural population. And saying that somebody who's 40 or 50 has a higher rate of autism. It's not raising your rate from what that baseline is you have to take into consideration that, not, you know, that in a whole population of people, the majority of people who are having kids.

The maternal age is not 40 or 50 or above, they're typically younger. So although the studies have shown that you're increasing the rate of autism is schizophrenia in offspring of men who are older, you have to kind of take everything and put it into perspective.

So how does the freezing sperm process work right. So when we're obtaining sperm. There's two main ways that we can obtain sperm. One is via ejaculation, and the other is surgical extraction. Now, the more common way that we obtained sperm is ejaculation, and regardless of how we obtained sperm the semen analysis is done. And so it's important concepts and the semen analysis or one sperm count. So the sperm count is also the sperm concentration. How much sperm is in that sample. That we also want to look at the motility. Right? It's a sperm moving because when a couple is trying to conceive and male and women are having intercourse, the sperm is then responsible from traveling from the vagina through the cervix into the uterus into the fallopian tube to then fertilize the egg. More so if you put the sperm in the act together the modal sperm are the ones that are more likely to fertilize. So we look at the motility.

Then we also look at the

Author
Dr. Nidhee Sachdev Dr. Nidhee Sachdev Nidhee Sachdev, MD has trained among the most prestigious and diverse medical programs in the country, including fellowship training in reproductive endocrinology and infertility at the prestigious New York University (NYU) Langone Fertility Center in New York City where she conducted research on preimplantation genetic screening (PGS) and the University of Chicago Medical Center, where she earned the academic distinction of chief resident in obstetrics and gynecology, and trained under a top recurrent pregnancy loss expert. Dr. Sachdev is passionate about providing individualized, collaborative patient care. She started her medical career right here in Orange County, earning her Doctor of Medicine at the University of California, Irvine, School of Medicine.

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