Emergency IVF versus ovarian tissue cryopreservation decision making in fertility preservation for female cancer patients

Capsule:
This article examines emergency IVF and ovarian tissue storage and current data on their reproductive outcomes in cancer patients. These data challenge the concept that these techniques should be labeled “experimental.”

Authors:
Karine Chung, M.D., M.S.C.E., Jacques Donnez, M.D., Elizabeth Ginsburg, M.D., Dror Meirow, M.D.

Volume 99, Issue 6, Pages 1534-1542, May 2013

Abstract:

Hundreds of thousands of women in their reproductive years are diagnosed with cancer each year. As the number of female patients who survive cancer increases, the demand for effective and individualized fertility preservation options grows. Currently there are limited clinical options for fertility preservation, and the paucity of publications describing clinical experience and outcomes data has limited accessibility to these options. Decision-making for patients diagnosed with cancer requires up-to-date knowledge of the efficacy and safety of available techniques. This article describes a step-by-step approach to evaluation of the cancer patient and presents an accumulation of clinical experience with challenges unique to patients with breast cancer and leukemia. Current data on reproductive outcomes of fertility preservation techniques are examined, demonstrating increasing evidence that these techniques are becoming efficacious enough to offer routinely to patients facing gonadotoxic cancer therapies, including those still considered “experimental.”

  • Dr Sherman Silber

    the paper by chung et al on “emergency IVF versus ovarian tissue cryopreservation: decision making in fertility preservation for female cancer patients” in fertility and sterility this week attempts to give more credence to the choice of ovarian tissue freezing over egg freezing for preservation of fertility for cancer patients, but really does not go far enough in emphasizing the superiority for most cancers of ovarian
    tissue freezing. the reasons are:

    1) you can remove and freeze an ovary immediately, and the patient can go through her cancer treatment a day or two later. there is absolutely no need for delay, or for “emergency IVF”.

    2) “emergency IVF” often involves compromises in the stimulation protocol, and in fact can make the patient hyper-stimulate and not be ready for her cancer treatment for some time.

    3) to give a woman any assurance of a high chance of having a baby later, you would certainly prefer 3 to 4 cycles of stimulation and egg freezing to just one cycle. just one cycle could be giving her a very false sense of security that her future fertility is
    preserved.

    4) freezing ovarian tissue and later transplanting it back, are both simple outpatient procedures today, and the techniques have been more simplified and codified than the authors review implies. it is certainly much simpler than going through many cycles of ivf stimulation and transfer.

    5) with frozen ovarian tissue, the woman can have both her fertility preserved of course, but also her endocrine function, and for a very long time. these grafts have been shown to last much longer than previously expected, and the surgical
    techniques have been well perfected.

    6) there are over 33 babies, healthy live births so far in cancer patients from frozen ovarian tissue, and very few, maybe zero to a few, live babies born yet to cancer patients from frozen eggs. so contrary to the widespread myth, emergency egg freezing for cancer patients is clearly more “experimental” than ovary tissue freezing.

    7) the risk for cancer cells being introduced has clearly vaporized, which all these
    healthy cancer survivors and their babies demonstrates. furthermore, studies from denmark this past year even show it very unlikely for the one cancer you would worry about, leukemia, to be transmitted via ovary tissue transplantation.

    so my criticism of the chung et al paper is that it obfuscates what is now readily apparent, that ovary tissue freezing is a preferred approach to preserving fertility in
    cancer patients, and should definitely NOT be labelled as “experimental” if egg freezing is not so labelled.

    • Jacques Donnez

      I agree with Sherman Silber. In case of prepubertal girls or when no delay before chemotherapy is possible, ovarian tissue cryopreservation is the only option available. But, in some circumstances, when a delay is allowed, there is no doubt that other alternatives should, at least be proposed.

      Cakmak and Rosen, as well as Oktay and col have particularly well explained the different options and their respective indications in the last Views and Reviews on fertility preservation. In my review, I clearly explained the place of ovarian tissue cryopreservantion. Obviously, when some delay is allowed, ovarian tissue cryopreservation could be performed followed immediately by random start stimulation (see Cakmak and Rosen).

      This combined technique will offer a maximum of chances for these women to be pregnant when their disease is cured. I am really convinced that each department should be able to propose ALL techniques of fertility preservation in order to choose the most “adapted” technique which offers a maximum of chances according to the age, the ovarian reserve, he marital status, the socio-economic status…….

      In conclusion, the future is a “tailor-made” fertility preservation method.

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