|Year : 2021 | Volume
| Issue : 1 | Page : 35-37
Choosing wisely between oocyte versus embryo cryopreservation: A clinical vignette
Puneet Rana Arora1, Mir Jaffar2, Syed Waseem Andrabi3
1 Centre for Infertility and Assisted Reproduction, Gurugram, Haryana, India
2 Department of Reproductive Medicine, Milann – The Fertility Centre, Bengaluru, Karnataka, India
3 Department of Embryology and Fertility, Cloud Nine Hospital, Gurugram, Haryana, India
|Date of Submission||06-Feb-2021|
|Date of Acceptance||23-Apr-2021|
|Date of Web Publication||17-Dec-2021|
Dr. Puneet Rana Arora
Centre for Infertility and Assisted Reproduction, Gurugram, Haryana.
Source of Support: None, Conflict of Interest: None
In this case vignette, we highlight that embryo cryopreservation may not be an automatic choice for fertility preservation in married females but that oocyte cryopreservation also has a place. A 32-year-old married woman with breast cancer, who was initially proceeding for embryo cryopreservation to preserve her fertility before starting cancer treatment, eventually had oocyte preservation because her spouse declined to donate sperm. We discuss the need for detailed and continuous counseling.
Keywords: Breast cancer, counseling, embryo cryopreservation, fertility preservation, oocyte cryopreservation, reproductive rights
|How to cite this article:|
Arora PR, Jaffar M, Andrabi SW. Choosing wisely between oocyte versus embryo cryopreservation: A clinical vignette. Onco Fertil J 2021;4:35-7
|How to cite this URL:|
Arora PR, Jaffar M, Andrabi SW. Choosing wisely between oocyte versus embryo cryopreservation: A clinical vignette. Onco Fertil J [serial online] 2021 [cited 2022 Jan 19];4:35-7. Available from: https://www.tofjonline.org/text.asp?2021/4/1/35/332637
| Introduction|| |
Fertility preservation, where indicated, is now regarded as an integral part of modern-day management of cancer. In 2006, the American Society of Clinical Oncology (ASCO) for the first time published their recommendations for fertility preservation in cancer patients. At that time, embryo cryopreservation was regarded as the standard modality, while oocyte cryopreservation was still investigational in view of relatively poor live birth rates. Outcomes following oocyte cryopreservation have since improved and are now at par with embryo cryopreservation. The 2018 ASCO guidelines recommend cryopreservation of unfertilized oocytes as a standard option, which may be especially well suited to women who do not have a male partner, do not wish to use donor sperm, or have religious or ethical objections to embryo freezing.
Still, embryo cryopreservation has been the most common method of fertility preservation among female cancer patients, particularly among those with stable partners., Although there are no published data from India, our experience suggests that the same is true in India as well. In this case report, we aim to highlight that embryo cryopreservation may not be an automatic choice for fertility preservation in married females but that oocyte cryopreservation also has a place.
| Case report|| |
A 32-year-old married female diagnosed with invasive ductal breast cancer was planned for a mastectomy followed by 6 cycles of anthracycline-based chemotherapy. Her treating oncologist had discussed the potential adverse effects of chemotherapy on her fertility. She had been married for 5 years, and the couple had been trying actively to conceive for the past 6 months before her diagnosis. On referral to our tertiary fertility clinic with the provision of fertility preservation services, they were shared information on the effect of cancer treatment on fertility and underwent detailed counseling by a fertility specialist and psychologist counselor. As they were trying for pregnancy, the couple decided to preserve fertility by undergoing embryo cryopreservation.
Baseline assessment of ovarian reserve of the patient was done, which included anti-Mullerian hormone (AMH) level of 1.5 ng/ml and an antral follicular count of 10. With the onset of her menstrual cycle, she was started on controlled ovarian stimulation with a flexible antagonist protocol for preserving her embryos. This involved daily injections of gonadotropins till the time three or more oocytes had attained a diameter of 18–20 mm. When the dominant follicle reached 12 mm, she was commenced on an antagonist. Her oocyte retrieval was done after 11 days of stimulation with the above protocol.
Her spouse was asked for backup semen freezing on day 3 of her stimulation, but he informed his unavailability because of mild illness. He was called again on day 5 and day 7 of stimulation but did not turn up again and stated that he was busy with professional commitments. He assured the team that he will be available on the day of oocyte retrieval. On the 8th day of stimulation cycle, her spouse was contacted by a psychological counselor who had a very detailed discussion with the spouse, and at this time, he refused to give a semen sample for freezing and also expressed second thoughts about the whole procedure of fertility preservation and over his participation in the procedure for embryo freezing. He also mentioned that he has discussed this with the patient and advised her not to undergo the procedure of embryo freezing.
The patient was in the clinic that day for her follicular monitoring. A conference call was arranged after consent from both the spouse and the patient to resolve this. The spouse stated that he had withdrawn consent from the procedure, while the patient remained keen to continue. At this point, available fertility preservation options were again discussed. The patient was thoroughly counseled by a team of doctors, counselors, and embryologist with regard to her options and future implications of oocyte freezing. The patient now agreed for preserving her oocytes and was happy to continue without her spouse’s consent. She underwent oocyte collection after day 11 of stimulation. A total of 10 oocytes were retrieved which fortunately were all found to be mature (metaphase II stage) and were vitrified. Vitrification was employed to freeze all mature oocytes in an open system and stored in LN2 (‒196°C).
The patient, having completed her breast cancer treatment, is now in her 2nd year of follow-up with the oncologist and is in constant touch with her reproductive team. Her AMH at 18 months of her follow-up was 0.01 ng/ml. Her oocytes are frozen till date. She has ended her previous marriage and is now in a stable relationship in her second marriage and is very keen for pregnancy. She is awaiting approval from the oncologist before taking further reproductive treatment.
| Discussion|| |
The procedures of fertility preservation are being offered at a time when an individual is going through a difficult part of their life. The discussion of fertility-related issues and fertility preservation has to be done in an empathetic way, with multidisciplinary team approach involving psychosocial counselors. It is logical to assume that embryo cryopreservation would be the most appropriate choice in married females seeking fertility preservation, as there is the greatest degree of experience with this modality. Indeed, that has also been the published experience., Embryo cryopreservation however comes with greater ethical and legal issues as compared to oocyte cryopreservation, and our experience has highlighted the same. Dissolution of a marriage/relationship or death of one of the partners in a couple can create problems in subsequent implantation of the preserved embryo or on rights on use of the embryos.,
In our case, as the couple was married and was trying for pregnancy, hence, the counseling was more inclined toward embryo freezing, even though option of oocyte freezing was discussed with the patient. The diagnosis of cancer itself is a big social challenge and is considered a social stigma for some. It can lead to coping difficulties; hence, decisions for fertility preservation and counseling have to be dealt with great care. Throughout the time, while the couple was having the procedure of fertility preservation, they were in contact with our psychosocial team. Individual oocyte freezing should be considered an important option especially as it gives reproductive autonomy to the patient. If a decision is taken for oocyte freezing, we must consider referring patients to accredited centers, which have the expertise in oocyte freezing to get the best possible outcome.
In recognition of the challenges that may occur following embryo cryopreservation, clinics in Europe and North America are now offering oocyte cryopreservation even to those women with partners. They undergo detailed reproductive counseling and are informed of the local law according to which both partners must still be together at the time of using the frozen embryo for fertility treatment in the future. Because of this constraint, there has been a shift in patient preference from embryo cryopreservation to oocyte cryopreservation to avoid potential disputes regarding embryo control and future use.
In summary, through this case vignette, we want to highlight that couples need to be adequately counseled on the options of fertility preservation available to them in the case that the female is diagnosed with cancer. Our case also highlights that the diagnosis of cancer can add emotional and relationship anxieties in a couple actively seeking treatment for infertility. While embryo cryopreservation would seem the better choice, it should not be an automatic choice but chosen after careful deliberation and discussion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lee SJ, Schover LR, Partridge AH, Patrizio P, Wallace WH, Hagerty K, et al
. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006;24:2917-31.
Oktay K, Harvey BE, Partridge AH, Quinn GP, Reinecke J, Taylor HS, et al
. Fertility preservation in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol 2018;36:1994-2001.
Lawrenz B, Jauckus J, Kupka MS, Strowitzki T, von Wolff M. Fertility preservation in>1,000 patients: Patient’s characteristics, spectrum, efficacy and risks of applied preservation techniques. Arch Gynecol Obstet 2011;283:651-6.
Klock SC, Zhang JX, Kazer RR. Fertility preservation for female cancer patients: Early clinical experience. Fertil Steril 2010;94:149-55.
Bankowski BJ, Lyerly AD, Faden RR, Wallach EE. The social implications of embryo cryopreservation. Fertil Steril 2005;84:823-32.
Fournier EM. Oncofertility and the rights to future fertility. JAMA Oncol 2016;2:249-52.
Gracia CR, Crockin SL. Legal battles over embryos after in vitro
fertilization: Is there a way to avoid them? JAMA Oncol 2016;2:182-4.
Rodriguez-Wallberg KA, Marklund A, Lundberg F, Wikander I, Milenkovic M, Anastacio A, et al
. A prospective study of women and girls undergoing fertility preservation due to oncologic and non-oncologic indications in Sweden-Trends in patients’ choices and benefit of the chosen methods after long-term follow up. Acta Obstet Gynecol Scand 2019;98:604-15.