Preserving Fertility in Rheumatologic Disease
“About 2 years ago, the Italian government made the freezing of human embryos illegal in that country, meaning that all of the patients in Italy undergoing [in vitro fertilization] could only add sperm to eggs that could safely be returned to their uterus—usually two to three eggs,” Dr. Gerrity explained.
Faced with the prospect of having to waste the majority of eggs retrieved from patients, “the Italian scientists kicked into gear and solved the problem we've been working on for more than 20 years: They broke the code on how to freeze eggs, so now frozen eggs yield the same pregnancy and fertilization rates as fresh eggs,” she said. “For the patients needing to bank eggs before starting fertility-impairing drug treatment, at least they don't also have to select a sperm donor on the spot.”
Although the success rates associated with frozen egg fertilization are high, the technology is still considered investigational in the United States, “which of course is an issue when dealing with third-party payers.”
A new frontier for fertility preservation in women is ovarian tissue cryopreservation, whereby portions of the ovary or the entire ovary are removed and the cortical tissue is frozen and later reimplanted into the patient. “This is a technique that we are using extensively in young girls and prepubertal girls with cancer and in patients who have to begin so quickly that taking 3 weeks out to stimulate ovaries is just not possible,” said Dr. Gerrity. “Although the freezing of the tissue is simple, the challenge has been in 'waking it up' once it's reimplanted. This has been the focus of research over the last 2–3 years, and it has paid off. In the past 6 months, there have been reports of about 14 pregnancies with transplanted ovarian tissue following chronic treatment or chemotherapy.”
Upon implantation, all of the women began menstrual cycling again and became pregnant spontaneously, she said. This technique is only an option for those patients who can be withdrawn from their fertility-compromising drugs or drugs that are contraindicated in pregnancy for the period of conception and gestation, she added.
For patients who cannot carry a pregnancy because it would be unsafe or unwise to withdraw from therapy, “gestational carriers may be the best option,” said Dr. Gerrity. “Unlike true surrogates, who lend their eggs and their uterus, gestational surrogates just lend their uterus to the effort, carrying to term the fertilized embryos from the patient and her partner.”
In order to determine the best fertility preservation option for an individual patient, “it's important to have the patient sit down with a reproductive endocrinologist,” Dr. Gerrity stressed. “As the part of this process, it's critical that [the referring physician] keeps an open line of communication with the reproductive endocrinologist. Be clear about what you can do in terms of treatment,” she said.
