Fertility Preservation: Hope for the future
Written by Dr Kate Stern
60 Minutes featured a story on ovarian tissue grafting, a procedure that is attracting more attention for its ability to preserve a woman’s fertility until later in life. I was interviewed by 60 Minutes in relation to our research in this area, where the procedure is used to help women preserve ovarian tissue and hopefully eggs, prior to undergoing cancer treatment that may leave them infertile. What makes this procedure so exciting is the possibility of being able to preserve a woman’s fertility until she has recovered from cancer and is ready to start her family – sometimes years down the track.
The publicity around this procedure was very much welcomed. It helped raise awareness amongst the thousands of Australian women impacted by cancer in their reproductive years, and we received many enquiries from women who have had a cancer diagnosis either recently or in the past. We can’t stress enough the importance of women having the opportunity to discuss their options prior to undergoing cancer treatment, and we continue to look for ways to raise awareness amongst the public and the medical profession.
But as reported in the 60 Minutes story, the procedure has attracted publicity for reasons beyond helping cancer patients. A clinic in the US is advocating freezing the tissue of young women so that the tissue can be grafted later to help them conceive if required in their forties, thereby promoting the procedure to woman as a way to put their fertility ‘on ice’ as a form of reproductive insurance. It’s being touted the ‘future of fertility for all women’ - not just those who have had cancer - and there are now two clinics in the world that offer ovarian tissue freezing for social reasons so that women can have babies later in life, well into their 40s and even their 50s.
In Australia, ovarian tissue freezing and grafting has been performed for some years and the grafting is still considered an experimental form of treatment by all fertility specialists across the country. This is because around the world only 19 babies have been born, despite many many attempts. Fertility specialists around the world agree that it is very difficult to grow good eggs from grafted ovarian tissue. In fact some of the reported births are now thought to be spontaneous pregnancies in women whose own ovarian tissue has started to function again, rather than pregnancies from the grafted tissue!
Here, the technique is offered routinely for medical reasons only, and we believe there are very good reasons for this.
Ovarian tissue grafting involves removing a small piece of ovarian tissue from one ovary, slicing the tissue into tiny pieces and freezing them until the woman is ready to conceive. The tissue is then grafted back into the woman’s pelvis where the grafted ovarian tissue can start to produce reproductive hormones and follicular development. The idea is that pregnancy can be achieved either with ovarian stimulation and IVF, or perhaps even naturally.
The procedure is deemed suitable for girls in their teenage years and women in their 20s, when it is believed to yield a higher chance of success due to the abundance of immature and better eggs in the wall of the ovary. These women are often impacted by cancers such as leukaemia, Hodgkin’s lymphoma, breast cancer and ovarian cancer.
But it’s not a procedure that comes without its own risks. Laparoscopy is a procedure used to remove the tissue and then graft. This operation has a 1/1000 risk of complications and a 1/50000 risk of life-threatening complications. The removal of the tissue can potentially cause damage to the ovaries and it does reduce the number of eggs available for spontaneous ovulation and reproductive function. That is why we only remove the tissue when a woman’s ovarian function has a high chance of being severely damaged by the cancer treatment.
Also, should a woman undergo the procedure, then later on when she is ready, there is no guarantee that she will be able to achieve her so longed for baby. So to offer the procedure for non-medical reasons does not make medical sense. It also raises ethical questions about women beyond their natural reproductive years having children – perhaps a topic for another blog post.
For women seeking fertility preservation techniques for social reasons there is no doubt that despite the genuine desire to meet their life partner and start their family in their 20s or 30s, for many women this choice is dictated by circumstance. Our message to these women remains – ‘don’t put off having children’, however we realise this cannot always be avoided. These women should not be denied the option to preserve their fertility, but they should know that there are other options available.
Egg freezing is a method of freezing unfertilised eggs, with a view to them being used in the future. The eggs are thawed and fertilised with sperm to form an embryo so that it can be transferred back to the woman’s uterus with a subsequent chance of pregnancy. This is a good option for women in their early 30s who are concerned that they won’t have met their life partner before their eggs start to age and thus are less likely to produce a pregnancy. Melbourne IVF has been freezing eggs since 1999, mostly as a form of fertility preservation for patients facing cancer where other fertility preservation techniques are not suitable, but more commonly in the last 2 to 5 years for social reasons. The success rates of egg survival after freezing and thawing have improved significantly over the years with many babies born through our program, but, as with any form of fertility treatment, there are still no guarantees. For every 10 eggs frozen, we can expect to only obtain 2-3 good embryos, which means only 2-3 opportunities to conceive.
Likewise, while we know from our own and international experience that ovarian tissue grafting can be successful, it is by no means a golden solution. Worldwide there have been around19 babies born in the last 8 years and in Australia whilst we have come close, we are yet to welcome our first baby following the procedure. We have however successfully removed, frozen and grafted ovarian tissue for more than 10 women facing serious cancer diagnosis. To date only a couple of these women have actively been trying to conceive. However tissue freezing has given these the opportunity to take a positive step towards preserving their fertility – which is a chance at a future family of their own that would otherwise not have existed.
As part of the Fertility Preservation Service at Melbourne IVF and the Women’s Hospital, we have been performing ovarian tissue grafting since 2006. We believe we are not far from having our first birth with several patients now starting to undergo treatment currently with promising outcomes. This will be an enormous achievement that we hope will reinforce ovarian tissue grafting as a technique that can give hope to thousands of women facing cancer in Australia each year.
Dr Kate Stern is Head of the Fertility Preservation Service at Melbourne IVF and the Women’s Hospital in Melbourne.
Dr Kate Stern was recently interviewed on 60 Minutes about the ovarian tissue grafting procedure - read the full transcript here.