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When to Consider Fertility Preservation Options
When it comes to starting a family, everyone's plan is different — and sometimes, life doesn't go according to plan. Cancer treatments like radiation and chemotherapy, conditions such as endometriosis that cause infertility, and career or financial readiness all can affect the timing.
Because fertility naturally declines with age and is affected by certain medical conditions and treatments, some people choose to freeze their eggs, sperm, ovarian tissue, or embryos until they are ready and able to conceive. Fertility preservation is a way to give people more time and control over their family planning decisions.
Why might someone want to preserve their fertility? Here are a few possible reasons for the decision.
Personal Preference
The desire to delay childbearing is one reason to pursue fertility preservation. "Many people simply aren't ready to build a family yet because of career demands, financial readiness, not having the right partner, or just needing more time," says Li-Shei Lin, MD, PhD, a board-certified obstetrician-gynecologist and a reproductive endocrinologist at Reproductive Partners Fertility Center in San Diego.
As women get older, the number and quality of their eggs decline and it becomes harder to conceive. Men also experience some degree of declining fertility as they age. By age 40, the chance of getting pregnant naturally is less than 5 percent per menstrual cycle. Freezing eggs, sperm, or embryos can offer more reproductive flexibility to those who decide to wait.
Cancer Treatment
Cancer treatments like chemotherapy and radiation can sometimes damage the reproductive organs. "Preserving fertility before those treatments begin gives patients a chance to protect their ability to have biological children in the future," says Dr. Lin.
Each type of cancer therapy has different effects on reproductive health:
- Chemotherapy kills the cells that produce the hormones needed to release eggs from the ovaries.
- Radiation therapy can damage reproductive organs like the uterus, cervix, and ovaries.
- Hormone therapy may lead to early menopause.
- Surgery on the uterus or other reproductive organs may make it difficult or impossible to conceive and carry a baby.
"For individuals facing a life-threatening diagnosis who need to pursue treatment that could have the unintended consequence of infertility, an option is to do upfront fertility preservation before they get chemotherapy or medication or radiation, to try to bank materials that will never be exposed to these medical interventions," says Jessica Walter, MD, a reproductive endocrinology and infertility specialist at Northwestern Medicine in Chicago. After treatment ends, they can use those materials to try to conceive.
Reproductive Conditions
Endometriosis or uterine fibroids can make it harder to get pregnant. In endometriosis, tissue that looks and acts like the lining of the uterus implants in other parts of the abdomen. If that tissue grows around the ovaries or fallopian tubes, it can inflame and scar these organs. Up to 50 percent of people with endometriosis may experience infertility.
Fibroids are noncancerous growths that grow in the wall of the uterus. Depending on their size, fibroids can change the shape of the uterus or block eggs from moving from the fallopian tube to the uterus to reach the sperm. These growths can also reduce blood flow to the uterus, preventing an embryo from implanting in the uterine wall and growing.
Autoimmune Diseases
In autoimmune diseases, the immune system mistakenly attacks healthy cells and tissues. Sometimes it damages reproductive organs like the ovaries, making it difficult to conceive or carry a pregnancy to term, or putting the body into early menopause. Medicines like cyclophosphamide (Cytoxan) that are prescribed to treat autoimmune diseases can also be harmful to the ovaries and testicles.
The autoimmune diseases that are most likely to contribute to fertility problems are:
- Lupus
- Autoimmune thyroiditis, such as Hashimoto’s
- Type 1 diabetes
- Celiac disease
- Myasthenia gravis
Transgender Care
Gender-affirming care may involve taking hormones or having gender-affirming surgery. Both treatments can affect the ability to conceive. A fertility preservation treatment like sperm banking or egg or embryo freezing before the transition helps transgender people retain the ability to have their own biological children.
The timing of fertility preservation is important. How soon to start treatment depends on your gender and situation.
When Should You Freeze Your Eggs?
"Biologically speaking, the earlier the better," says Lin. The quantity and quality of eggs start to decline in a woman's thirties, and drop more steeply after age 35.
"The 'sweet spot' for most people is from the mid-twenties to the late thirties. Egg quality and quantity are highest during this period, which increases the chances of success," she says. If a woman’s eggs are frozen before age 40 there’s a better chance of conceiving with them later in life.
When Should You Freeze Sperm?
Age also reduces sperm quality and numbers. The best time to freeze (or bank) sperm is in the late twenties to early thirties. In that age range, sperm is healthiest and has the greatest chance of fertilizing an egg.
When Should You Freeze Embryos?
Freezing embryos in your early- to mid-thirties is most likely to result in a pregnancy, although it's still possible for some women to get pregnant from embryos that were frozen in their forties.
Going through surgery and then freezing embryos is a big step, says Dr. Walter. It's important to carefully consider the decision when time is available. But the decision about when to freeze eggs or embryos may not be up to you. People who have a serious medical condition like cancer and want to conceive will need to undergo fertility preservation before they start any treatment that might damage their reproductive organs.
"Today, many oncologists include fertility preservation as part of the initial consultation," says Lin. "Ideally, we begin the egg or embryo freezing process as soon as possible after diagnosis. With newer protocols, we can often start treatment within days and complete the egg retrieval process in as little as two weeks."
If there isn't enough time to do fertility preservation before treatment, there may still be things a specialist can do afterward to improve the chance of starting a family, says Walter.
Your doctor will recommend fertility preservation options depending on your gender, age, and reason for wanting to preserve your fertility.
Egg Freezing
Some women choose to freeze their eggs, also called egg cryopreservation, to delay having children or when a disease has damaged their ovaries. Walter says this process is similar to in vitro fertilization (IVF) treatment for infertility. It starts with taking hormone medications that stimulate the ovaries to grow and produce several eggs (this is called ovarian stimulation). Once the eggs have matured, the doctor removes them during an outpatient procedure. The eggs are stored in liquid nitrogen tanks until you are ready to conceive.
The hormones used for ovarian stimulation can cause side effects like mood swings, hot flashes, headaches, and nausea, but they are usually mild. Some people experience cramps, bloating, and bleeding after the egg retrieval procedure.
Sperm Freezing
The decision to freeze sperm is often made because of cancer treatment, low sperm count or quality, or for the option to have children after a vasectomy. Collecting the sperm is relatively easy. The fertility clinic will provide a special container to masturbate into. They'll treat the semen with a special chemical to protect it from the cold temperatures, and then store it in a tank containing liquid nitrogen.
There's no risk involved with collecting the semen sample. But sometimes sperm can become damaged during the freezing process.
Embryo Freezing
The process of freezing embryos is very similar to egg freezing. First, the eggs are removed from the ovaries. Then they're fertilized with sperm from a partner or donor to produce embryos. Finally, the embryos are frozen. They can be thawed later and transferred into the uterus.
Whether to freeze eggs or sperm, or to create embryos and then freeze them, depends on the situation and family-building goals. "If you have an individual who's in a long-term relationship or who is anticipating starting a family very soon and has a partner or is planning to use donor sperm, it can be more straightforward to freeze embryos," says Walter.
Embryos can be damaged during the freezing process. Sometimes a transplanted embryo doesn't result in a pregnancy. And when more than one embryo is implanted in the uterus, it may result in a multiple pregnancy.
Ovarian or Testicular Tissue Freezing
"This is a more advanced technique, typically reserved for prepubescent patients or those who need to begin cancer treatment urgently," says Lin. Part of the ovary containing immature eggs is removed during a surgical procedure. The tissue is then frozen until cancer treatment is finished and the person is ready to start a family.
The ovarian tissue is reimplanted later, with the hope that it will start to produce eggs or hormones and restore fertility. Transplanting ovarian tissue results in a pregnancy about one-third of the time.
Testicular tissue freezing is still experimental. It's not clear whether sperm will grow once the tissue is unfrozen, because the technology is so new.
Ovarian and testicular tissue harvesting carry the same risks as other surgical procedures that are performed with anesthesia. In people who have cancer, there is a risk that implanting the thawed ovarian tissue might reintroduce cancer cells. Testicular tissue harvesting may leave the affected testicle slightly smaller.
Ovarian Transposition
This minimally invasive procedure, also called oophoropexy, can be an option for women who get radiation treatment to their pelvis (for example, to treat a gastrointestinal or pelvic cancer) and want to preserve their fertility. The surgeon separates the ovaries and sometimes the fallopian tubes from the uterus and moves them outside of the radiation field to reduce the risk of damage.
Because the ovaries can't be reattached in the future, and the uterus may be damaged or made inflexible by the radiation, it probably won't be possible to conceive naturally or grow a fetus to term. People who have ovarian transposition will likely need to use IVF and a gestational carrier (surrogate).
If you're interested in fertility preservation, start the process by seeing a reproductive endocrinologist — a specialist who is trained in techniques like ovarian stimulation, egg removal, and IVF. A gynecologist or gynecologic oncologist can perform ovarian transposition. Ovarian tissue freezing may be done by a pediatric surgeon in a child or teen, or by a reproductive endocrinologist in an adult, says Walter.
If you've been diagnosed with cancer, ask your oncologist for a referral. "Many cancer centers now have a network of fertility specialists they trust and collaborate with," says Lin. You can also check the website of a professional organization like the American Society for Reproductive Medicine (ASRM) or the Society for Assisted Reproductive Technology (SART) to locate a fertility center near you.
To ensure the best outcome, look for a doctor who is board-certified in reproductive endocrinology and infertility, and who has a good track record with many positive patient reviews, says Lin.
- Fertility preservation involves freezing eggs, sperm, embryos, or tissue from the ovaries or testicles to start a family later.
- This technique may be an option for people who are undergoing treatments for cancer, autoimmune diseases, or other conditions that may affect their fertility.
- Some people choose fertility preservation when they want to delay conception because of their career, relationship, or other life decisions.
- Reproductive endocrinologists and fertility specialists work together with oncologists and other doctors to plan and perform fertility preservation techniques.
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