Should women with endometriosis freeze their eggs?
Answer from: Dimitris Papanikolaou, MD
Egg freezing became more effective the last few years – that is the big difference. 20 years down the line, it was not as effective. Yes, we were speaking about egg freezing but practically you had much smaller chances compared to freezing embryos so, that was something that nobody could recommend. Now, the freezing process and the thawing process has evolved so much for the eggs that I can tell that at my clinic the last thawing that I did with eggs was a 100% thaw rate. 10 years before it was a miracle and now in a good lab it is standard procedure. This makes the difference on the egg preservation, the process evolved a lot in the last 10 years. There are kits on the market that ensure from 80 to 100% thawing rate, so it is wonderful for the eggs.
Answer from: Ahmed Elgheriany, MRCOG, MD, MSc
Fertility preservation with endometriosis, nowadays, I will recommend if any women came to my clinic asking about fertility preservation and I suspected that she has endometriosis or she has endometriosis gland or endometriotic nodules, endometrioma any kind, any stage of endometriosis. If you haven’t completed your family, please do fertility preservation. What kind of fertility preservation you can do according to your regulation in your country, at least egg freezing. We can take the eggs from your womb, doing stimulation, take the eggs from your womb and freeze it.
One point, many literature said that egg frozen from endometriosis woman will just be more affected when we de-freeze these eggs (thaw these eggs) so if per say the normal woman will have like 86% survival rate of her eggs, endometriosis patient will have 80% survival of her eggs after freezing and thawing process and the quality of the eggs, as I said, it could be affected by endometriosis. You can do this early in your life because by time, nobody knows what the effect of endometriosis and your fertility so you are aware that you have a good quality eggs while you are very young and these eggs can perform better while we de-freeze them later on, rather than waiting for longer time, have your journey between doctors about endometriosis and then came after eight years and asking for egg freezing…very very problematic at that time and the quality of egg itself, after we fertilize them, may not perform properly. So this is a point to consider.
The other thing of fertility preservation could be embryo freezing. If you are with your partner and you want to freeze embryos, so the embryo can survive better than the egg itself and if we keep the embryos in the storage for a longer time, there is no effect on the embryo. If you are not ready to make your family now and you have your partner and you are on contraception and you’re suspecting that you’re having endometriosis, please consider embryo freezing and when you are ready – start.
Answer from: Anu Chawla, MRCOG, MBBS, M.S., DNB
Definitely! This is a fantastic question and such interviews are only meaningful when we give messages like that to patients and their decision making, definitely it enhances their decision so, egg freezing is a very powerful tool it is having a very special place in cases of endometriosis that if it is done early so, a younger egg, any day, would have lesser genetic abnormalities as compared to the older again. That is the main difference between the younger egg and the older egg. I would like to go back two steps on the physiology part for a bit so, every woman is born with a fixed set of eggs unlike men who can form the de-novo sperms so, sperms can be present in the coming three-four months which were never present in their body a few months earlier because they are de-novo cells so they are created from the from the precursors but they are created de-novo. We, as women, are born with a fixed set of eggs and that decreases massively with age so, the central aspect is age. Over the age of 35 quality declines more steeply and then, after the age of 40 very steeply. After 43, even if the woman is pregnant with her own eggs, the percentage of the miscarriage is unfortunately 93% and that is the effect of age.
When it is compounded with the presence of endometriosis, the whole egg reserve and the egg quality that means both the quantity and the quality will be affected and the decline of that curve we cannot predict for individual women and hence an early egg freezing is very important, more important in women with endometriosis. In general cases where women are only freezing eggs for social reasons, we promote that they should freeze by the age of around 30, 31, 32 for best results and if the endometriosis is associated, I would say it would be late 20s or even mid-20s. There is there is no direct indicator of ovarian reserve but there are three indirect indicators of ovarian reserve: the first is age, the second is antral follicle count which is the set of follicles which come out of the reserve for that particular month and antral follicle count roughly remains the same but every month it can be a little different so, it is seen best in the ultrasound on day two or three or four of the cycle and the third indicator which tells us about the ovarian reserve, well how big is it, is a blood test called AMH which is the Anti-Mullerian hormone. Testing AMH which has changed the way we practice and it is not a very old discovery, this AMH has come into practice around 12 years back, 12 to 14 years back so, it’s relatively a newer advance. AMH can be done on any day of the cycle and it’s a very easy way to indirectly indicate the ovarian reserve. The only direct indicator of fertility is when the pregnancy is actually created, there is no other way but when the AMH is low that means this woman would definitely benefit from fertility preservation.
Because the younger eggs are going to have better outcome lesser eggs are needed, so just i’m telling you on the basis of studies although, we never know – it doesn’t apply to one particular woman but I’m just telling you the aggregate of the larger studies because these numbers would not apply to individual women necessarily because everybody can have a very different quality of eggs. So, generally a younger women will have better quality eggs, that means we need lesser eggs when a woman is younger to create one live birth in future but as the women advances, her egg quality deteriorates and this decline can be compounded with by the presence of endometriosis so, an older woman needs to freeze more number of eggs to guarantee the live birth although, nothing guarantees but just to increase the chance of one live birth. There are studies which have told us about what numbers but this should be left on the doctor’s decision, based on the individual patient I would say. The repetition of the cycles is generally required if the freezing is done after 35 years of age and not every follicle has egg and not every egg is mature and we are only going to freeze mature eggs and that is why the need for repeat cycles is there. Generally three cycles in a general population, mean that there should be enough mature eggs but the total number of mature eggs should be decided by the treating doctor for the individual. Roughly we say that each egg has a 5 to 6% chance to create a live birth in a later age group if it is done up to the age of 35 but I would again emphasize that this number should be decided by the treating doctor who has enough experience in egg freezing.
Vitrification is a very advanced technique and ART because we are, just imagine here, freezing one cell. When we are freezing the embryo, the embryo of Day 5 status which is the blastocyst has a few hundreds of cells and here we are talking about freezing one cell so, the freezing itself and the thawing, meaning the melting. When we’re using them, it is a lot of technology dependent process. We need to have a very good lab, the standard of the lab should be very good these days we use vitrification unfortunately, I am aware that even in very good cities some of the labs have still not completely shifted to vitrification, they still have been doing slow freezing which is an old a good tested way of freezing and a lot of eggs have been frozen like that and they are still being used but vitrification has been a very big thing. Especially at the time of thawing of eggs when they are used is a very technology and skill dependent process so, this also affects how this set of eggs are being used to create live birth but definitely the biggest power in a woman’s hand is the number of eggs that she is frozen at the right age.
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