Background
The principal purpose of CHR’s FPC is to offer a preventive, forward looking service, attempting to avoid future infertility. Especially in women, the decline in fertility, associated with advancing age, is reasonably predictable and is called physiological ovarian aging: Fertility declines from menarche (1st menses) but this decline is relatively slow and minor until approximately age 37-38 years. After that age it, however, accelerates quite rapidly and most women reach functional menopause (i.e. inability to achieve pregnancy with use of their own eggs) between ages 43 and 45 years, ca. 6-8 years before full menopause, which is usually reached at approximately age 51 years and characterized by cessation of menstrual periods.
As women in modern society frequently consciously delay child bearing into older ages, the concept of fertility preservation at younger ages, to assure to a reasonable degree that the chance of pregnancy remains preserved at older ages, starts making considerable sense.
Approximately 10 percent of all women, on top of it, are believed to “age” their ovaries prematurely. Investigators at CHR, who have published extensively on this condition, have coined the term premature ovarian aging (POA) to define this very unique group of patients who, frequently, go undiagnosed, - even in better fertility centers.
CHR has developed modalities to prospectively identify young women at increased risk towards POA by demonstrating that POA is statistically highly associated with certain findings on the FMR1 (fragile X) gene and with autoimmunity. Once patients are identified to be at increased risk, their ovarian reserve (OR) can prospectively be monitored with improved accuracy by using so-called age-specific ovarian reserve markers, also first developed and published by CHR investigators.
Research at CHR over the last few years, thus, has greatly improved the timely diagnosis of POA and, by doing so, has opened opportunities of fertility preservation to a group of younger women, who previously never considered themselves at risk for POA and, by the time they finally reached an accurate diagnosis, often, were already beyond reasonable fertility preservation efforts.
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Threatening Loss of Reproductive Function Due to Cancer or Other Medical Diseases
Chemo- and/or radiation-therapies, given to cancer patients, but also various medical treatments given for other medical conditions, such as chronic hepatitis or autoimmune diseases, can irreversibly harm ovaries and testicles (testes). As more and more young women and men, due to modern treatments, fully recover from their respective medical conditions, future fertility has become a very relevant issue.
This has given rise to a brand new field within fertility preservation, which concerns itself primarily with cancer patients (and other similar medical situations), where very rapid interventions are required to maintain fertility potential. Such rapid responses, of course, require appropriate set ups which allow for fertility preservation attempts on short notice.
The classical example is the young female (sometimes a child), diagnosed with a potentially curable cancer. She/he is usually scheduled within weeks from diagnosis for surgery and/or chemo-/radiation therapy, which, likely, will adversely affect her/his gametes and, with considerable likelihood, will render her/him sterile.
Such a scenario unfortunately plays out almost daily in a large city, like New York, and requires fertility preservation centers, which can respond quickly and decisively in attempting to maintain future fertility potential for these young individuals within the short time period between diagnosis and onset of therapy. CHR is set up to provide such services and welcomes inquiries from our medical and surgical oncology colleagues, pediatric oncologists, hepatologists and rheumatologists.
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Timely Fertility Preservation
Timely fertility preservation is of crucial importance because the “younger“” ovaries are at time of fertility preservation, the more eggs will they yield per fertility preservation attempt, the better will be their quality and the higher will be the overall pregnancy chance later in life, deriving from one such attempt. In contrast, the “older” the ovaries, the more attempts at fertility preservation will have to be made to equalize any future pregnancy potential.
In cases, where fertility preservation is mandated by the diagnosis of medical conditions, which require treatments, potentially toxic to ovaries or testes, the timing of fertility preservation attempts if, of course, driven by the timing of clinical diagnosis and mandated treatments. This is, however not the case where fertility preservation is more “elective”.
CHR, therefore, now offers elective ovarian reserve screening for young women of all ages through FMR1 (fragile X), autoimmune and age-specific ovarian reserve testing. These tests will not detect all women at risk for POA (there are many other etiologies that can lead to POA, some still unknown) but will allow for the identification of many women at risk, which will give them more time to ponder their reproductive future and, if so desired, take fertility preserving steps.
For women concerned about the physiological aging of their ovaries, CHR recommends that, if at all possible, fertility preserving interventions be undertaken before age 38 years. As noted before, at that age the decline in female infertility accelerates in speed and all fertility treatments, including attempts at fertility preservation, very quickly loose efficiency.
This, of course, does not mean that fertility preservation cannot be attempted after age 38, but such attempts will be less efficient in their results and more gametes will have to be preserved to achieve reasonable expectations of fertility preservation for later in life.
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What Fertility Preserving Procedure to Choose?
Fertility preservation can take various routes: In women, eggs (oocytes), embryos or even ovarian tissue can be cryopreserved. In men, semen or testicular tissue can be frozen. Which fertility preserving technology is best suited will vary from case to case, and will depend on medical and social circumstances.
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The Experimental Nature of Fertility Preservation
Various applied technologies of fertility preservation, and even many of the procedures to diagnose women who may benefit from fertility preservation, are new and, therefore, have, according to CHR’s standards, not yet undergone rigid enough evaluations to consider them established main stream. CHR, therefore, offers selected tests and procedures only under the understanding that they are still considered experimental. Patients will, therefore, as part of the informed consent process, be asked to sign appropriate experimental procedure informed consents.
It is important to recognize that the long-term preservation of fertility can NEVER be guaranteed. Every attempt at fertility preservation is exactly that; - an ATTEMPT! While your physician should be able to quote you the approximate likelihood of success with use of varying fertility preserving techniques, accuracy of such predictions will, based on current knowledge levels, always be limited and will vary between different techniques. For example, the ability of predicting success with embryo cryopreservation is better than predicting success with oocytes freezing.
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What Happens If It Is Too Late for Fertility Preservation?
Despite best attempts, sometimes there is not enough time to take appropriate steps in attempts to preserve fertility and at other times patients’ ovarian function may no longer permit fertility preservation. CHR is known for its special expertise in treating diminished ovarian reserve (DOR). Successfully treated patients with DOR from all over the world are witnesses to this very special expertise [LINK].
And if everything else fails, CHR also offers what is, likely, the largest pool of carefully prescreened egg donors anywhere in the world. With approximately 150-200 active donors in the pool, CHR can, as a last resort, match almost any patient, of any ethnicity, within 24-48 hours with an excellent egg donor.
