Fertility treatment

Preserving fertility

What is fertility preservation?

Fertility preservation is used to increase the chance of somebody having children in future. It can be used for medical reasons and personal circumstances. It is sometimes used before medical procedures and treatments that may cause infertility, such as cancer treatment and gender transitioning.

There are several methods of fertility preservation, including medication to protect a woman’s ovaries (GnRH agonists), and freezing (cryopreservation) of ovarian tissue, eggs or sperm.

Freezing eggs, embryos or ovarian tissue

Egg freezing

Egg freezing is a way of trying to preserve your fertility so you can attempt a pregnancy with IVF in future. Egg freezing offers the potential to preserve fertility but there is no guarantee of a baby, so it is important that you are well-informed about all aspects of egg freezing before you proceed.

In the UK, the Human Fertilisation and Embryology Authority reported that 18 per cent of women who used their own thawed eggs in IVF treatment had a baby.

In Victoria, egg freezing and thawing are increasing, but the total number of women using these services is still small. There were 4,048 women with eggs in storage at the end of 2019-20, compared with 3,124 women the previous year – a 30 per cent increase. But use of frozen eggs is still uncommon. In 2018-19, less than one per cent of all IVF cycles involved the use of thawed eggs, and 34 babies were born to women who used their own thawed eggs.

Why should I freeze my eggs?

You may consider freezing your eggs because you are:

• facing medical treatment that may affect your fertility, such as some forms of cancer treatment or gender transitioning
• not ready to have a child during your most fertile years for personal reasons
• concerned about your fertility declining as you get older and feel you are not currently in a position to have a child
• at risk of premature menopause or have endometriosis.

What is the process?

Your fertility specialist will come up with a plan for your treatment and prescribe medication to stimulate your ovaries. You will then have an egg collection procedure and your eggs will be frozen and stored.

Risks

A small proportion of women have an excessive response to the fertility drugs that are used to stimulate the ovaries. In rare cases this causes ovarian hyperstimulation syndrome (OHSS), a potentially serious condition. Bleeding and infection are very rare complications of the egg retrieval procedure. Egg freezing is still a relatively new technique and the long-term health of babies born as a result is not known. However, it is reassuring that their health at birth appears to be similar to that of other children.

Financial considerations

The cost of egg freezing varies between fertility clinics. In most cases there is only a Medicare rebate provided for egg freezing for medical reasons, which means that women who choose to freeze their eggs for other reasons may have considerable out-of-pocket expenses. Fertility clinics usually charge for:

• management of the hormone stimulation of your ovaries (devising a plan for your treatment and prescribing medication)
• the drugs used to stimulate the ovaries
• the egg collection procedure which may include admission to a private hospital and fees for an anaesthetist  
• freezing and storage of the eggs.

Medicare does not cover the storage of frozen eggs, regardless of whether they are stored for medical or other reasons. This may cost hundreds of dollars for each year of storage. Additionally, once you decide to use the eggs to try to conceive through IVF, the process of thawing the eggs, fertilising them with sperm, and growing embryos for transfer into the uterus can cost thousands of dollars in out-of-pocket expenses not covered by Medicare.

Questions to ask your fertility specialist

Information about egg freezing, success rates and costs on fertility clinic websites varies. It is important that you are well-informed about all aspects of egg freezing before you decide to proceed. Here are some questions you may wish to ask your doctor:

• What is the clinic’s success rate for egg freezing?
• How many eggs have been thawed at this clinic and how many live births have resulted from these thawed eggs?
• What is my chance of having a baby from frozen eggs, considering my personal circumstances such as my age and estimated ovarian reserve (a measure of how many eggs you are likely to produce)?
• How many eggs should I store to have a reasonable chance of having a baby? (You might require more than one stimulated cycle to retrieve enough eggs to give you an acceptable chance of success further down the track)
• What is the approximate total cost, bearing in mind that I may need more than one stimulation and egg retrieval procedure to yield enough eggs?

Freezing embryos

Freezing embryos can also be used for fertility preservation as part of fertility treatment. Read more about fertility treatment here.

Freezing ovarian tissue

Freezing ovarian tissue (ovarian tissue cryopreservation) is a relatively new approach used to help women undergoing chemotherapy preserve their fertility. It is a surgical procedure in which a small amount of ovarian tissue is collected, cut into slices, frozen and stored. These tissue slices can be thawed and transplanted back at a later date. The aim is for the woman to start producing hormones and release eggs.

Freezing sperm or testicular tissue

There are two methods used to preserve fertility in men.

Sperm freezing

You produce a semen or sperm sample through masturbation in a private room in the fertility clinic. A lubricant is not used as this can damage the sperm. Small amounts of sperm are placed in straws which are carefully labelled. These straws are then frozen and stored in a tank with liquid nitrogen at the clinic. If possible, several samples are stored to make sure there is enough sperm to conceive one or several children. While the freezing process usually affects the quality of the sperm, in most cases plenty of good quality sperm survive. This method is also used for men before they begin cancer treatment or gender transitioning.

Once you are ready to try for a baby, you can undergo fertility treatments such as IVF or artificial insemination with thawed sperm.

Testicular biopsy

Sometimes it is not possible to get a good sample of sperm through masturbation. In such cases your doctor will talk to you about testicular biopsy in which sperm are harvested directly from the testes.

Cancer and fertility

Some cancer treatments can affect your fertility. If you have been diagnosed with cancer, fertility preservation is an important consideration.  Depending on the type of cancer and its treatment, your fertility may recover, but the treatment may also cause temporary or permanent infertility.

Cancer and its treatment can affect:

• ovarian function and the production of sperm
• the ability to carry a pregnancy
• the ability to have sexual intercourse
• emotions and feelings, which can impact on relationships.

Some factors may reduce fertility including:

• The type of cancer. Testicular cancer or Hodgkin’s Lymphoma can result in poor sperm count or quality.
• The type of treatment. Radiation treatment to the pelvis is more likely to lead to infertility than radiation to other parts of the body. Chemotherapy using alkylating agents such as cyclophosphomide is more likely to affect fertility than treatment with other agents.
• The dosage. Higher doses of chemotherapy or radiotherapy used for a longer period of time are more likely to affect fertility than lower doses used for a shorter time.
• In general, the older a woman is at the time of diagnosis, the fewer eggs she will have, the poorer their quality will be, and the more vulnerable her ovaries will be to the effects of chemotherapy.

The good news is that there are a number of fertility preservation options for both men and women with cancer to provide you with a good chance of having a baby in the future.

Following a diagnosis

When you are diagnosed with cancer everything can seem overwhelming. For most, focussing on getting through treatment takes priority. However, it is important that you (and your partner, if any) speak with your doctor (oncologist or haematologist) about how the cancer and treatment can affect your fertility and ability to have a child in the future. Your doctor will be able to take you through the advantages and disadvantages of different treatment options. They can also refer you to a fertility specialist for fertility preservation (both before and after treatment) and the use of contraception to avoid unwanted pregnancy. 

What are my options?

Advances in technology mean that as time progresses, more fertility preservation options become available, each with advantages and disadvantages. For men, options include sperm freezing or gonadal shielding (for radiation therapy). For women, options include egg freezing, embryo freezing, gonadal shielding or ovarian transposition (for radiation therapy).

After treatment you can have a fertility assessment to see if your fertility has been affected. If not, you can try to conceive naturally. If your fertility has been affected, your fertility specialist will discuss the best option to use your stored eggs, sperms or embryos based on your personal circumstances. This may include using IVF, intrauterine insemination, or home insemination.

There are also options if you are unable to conceive naturally and did not have the opportunity to preserve your fertility before cancer treatment. These include:

• donor conception (donated eggs, sperm, or embryos)
• surrogacy
• adoption/permanent care

Options for transgender & gender diverse people

 Fertility preservation is an option for transgender and gender diverse people to have children in the future. 

There can be many things to consider when affirming your gender, including whether or not to pursue the option of medical transition. With so much to decide, taking a moment to think about whether you might like to have a family in the future, and understanding what you need to do in order to maximise your fertility options, can sometimes be forgotten in the process.

It is important to consult a fertility specialist before medical transition begins to discuss your options for fertility preservation specific to your circumstances. Your fertility specialist will be able to assist you before, during and after medical transition.

For trans men (assigned female at birth)

Using testosterone will create significant changes to your body, including ceasing your egg production and menstrual cycle. Fertility may be restored if testosterone is ceased, but that cannot be guaranteed. You can take steps to preserve your fertility before beginning hormone treatment. Other reproductive options also exist after transition.

Before transition

Traditional conception - Choosing to have a child (or children) by having sex or via insemination before undergoing hormone therapy may be an option for some people. Others may not want to proceed in this way for a variety of reasons, including the potential delay to medical transition.

Egg freezing - You may preserve your fertility via egg freezing before hormonal therapy begins. This would involve having treatment to develop multiple eggs which would be collected and stored for later use. It is similar to the first part of an IVF cycle in which injections are given and requires internal ultrasounds. Side effects from the medication may be experienced. It is important to keep in mind that egg freezing does not guarantee a successful pregnancy when you are eventually ready to start a family.

Fertility treatment - Another option is to create embryos using IVF. Sperm, either from a male partner or a donor will be needed to create an embryo using your eggs. Your embryos will be frozen for later use. If you are partnered with a woman, your partner will be able to carry the pregnancy. Surrogacy is also an option if you are partnered with a man or unable to carry the pregnancy.

After transition

If you are single or partnered with a man, and have preserved your fertility you could have a child using your stored eggs or embryos with the assistance of a surrogate.

You may be able to have a baby if you have not stored eggs or embryos. If you have not had surgery affecting your reproductive organs, it may be possible to cease hormone treatment, begin to produce eggs again, and try to conceive. This approach needs to be carefully managed medically. It may also create additional emotional challenges for you. It is not known whether the health of the child born may be affected by the hormone treatment. Seek additional support and guidance from your treating doctor and counsellor or therapist before and during this process.

If you are partnered with a woman you may consider using a sperm donor.  Surrogacy is also an option.

For trans women (assigned male at birth)

Using oestrogen (and antiandrogen) will, over time, cease the production of sperm and make it difficult (if not impossible) to achieve an erection or ejaculation. It is unlikely that fertility will be restored after a significant period of time on hormones. It is not possible to estimate how long it takes for fertility to be lost. However, reproductive options after transition also exist.

Before transition

Traditional conception - For those partnered with a woman, conception via intercourse or insemination is the simplest and least expensive method for starting a family although it may be emotionally challenging.

Sperm freezing - Sperm can be frozen before beginning hormone therapy. This is usually done via masturbation in a private room at a fertility clinic, although it may be possible to bring the sample from home. The sperm is then put in straws, carefully labelled, and frozen in liquid nitrogen. For those who are not able to produce a sample via masturbation it is possible to collect sperm via a testicular biopsy.

Fertility treatment - For people who are single before transitioning or partnered with a man, building a family will require the use of a donor egg or embryo and a surrogate. People building a family this way will be able to do so before or after transition.

After transition

I have sperm stored - If you are in a relationship with a woman and stored your sperm before transitioning, the sperm can be thawed and used in an IVF or ICSI procedure.  If you are partnered with a man, you may either use your stored sperm or your partner’s sperm. You will also need the help of an egg or embryo donor and a surrogate.

I don’t have sperm stored – It can be possible (if you have not had surgery affecting your reproductive organs) to cease hormone treatment and begin to produce sperm again. However, sperm production may not return. This approach needs to be carefully managed medically. It may also create additional emotional challenges for you. It is not known whether the health of the child born may be affected by the hormone treatment. It is suggested that you seek additional support and guidance from your treating doctor and counsellor/therapist before and during this process.

If you are partnered with a man, surrogacy with the use of an egg or embryo donor is an option. If you are partnered with a woman you have the option of using donor sperm treatment. Ask both the doctor supervising your transition and a fertility specialist about your options.