Steps to Egg Banking
The first step towards fertility preservation through egg banking is to meet with one of our fertility specialists to review your medical history and provide a comprehensive overview of the options and processes. At this consultation, you will also have the opportunity to meet with other members of your team, including your nurse clinician and financial counselor. The financial counselor will help determine your insurance benefits and provide information about other financial options that may apply. You can expect this entire visit to last up to two hours.
Ovarian Reserve Testing
Ovarian reserve testing is performed on the 3rd day of your menstrual cycle. The testing involves an ultrasound and bloodwork, which are extremely important in determining the current level of ovarian function. The results are instrumental in allowing the physician to identify an ideal protocol and medication dose to optimize the number of eggs produced during the stimulation phase of the egg banking cycle.
The specific tests we use to determine ovarian reserve are:
- Antral follicle count (AFC): This ultrasound is performed to count antral follicles, which are the 2-10mm fluid sacs within the ovary that contain an egg and represent the next wave of ovulation. This is a transvaginal ultrasound performed on cycle day 3, when the ovaries are still quiet and you have not recruited a dominant follicle yet (which obscures the antral follicle count). In general, the more antral follicles visualized, the better the prognosis. We like to see at least 10 follicles between both ovaries.
- Cycle Day 3 blood work: We measure Follicle Stimulating Hormone (FSH), estradiol, Lutenizing Hormone (LH) levels, prolactin and Thyroid Stimulating Hormone (TSH). Higher than normal levels of FSH indicate a potentially reduced fertility potential.
- Anti-Mullerian Hormone (AMH): While the above testing is generally performed at Shady Grove, the last blood test is collected at another facility, such as Labcorp or Quest. AMH has proven to be a very reliable hormone for accurately dosing stimulation medications. A higher AMH level is more reassuring.
Both the ultrasound and blood tests are excellent indicators of fertility potential, and together they give an impression of the number and quality of eggs in the ovary, allowing us to more accurately predict outcomes and protocols for our patients. This testing can take approximately one hour to complete.
Many treatment protocols include oral contraceptive pills to be taken for 2 to 3 weeks before hormones (called gonadotropins) are started. This is done in order to synchronize the development of follicles (fluid filled sacs in the ovaries that contain eggs), prevent ovarian cyst formation, and help with scheduling your cycle. Side effects of oral contraceptive pills can include unscheduled bleeding, headache, breast tenderness, nausea, swelling/bloating, and the rare risk of blood clots or stroke.
Timing and Flexibility
The clinical team provides a calendar with approximate dates for monitoring visits and the egg retrieval. This date may shift because of the individual response each person has to stimulation medications. Because of this, it is very important to have several days of flexibility around the timing of monitoring visits during stimulation and egg retrieval.
Protocols are individualized based on your test results and diagnosis, in order to optimize ovarian response. The sequence and dosage of medication have been tailored specifically to you, so it is very likely your friend will not have the same treatment as you because of these differences in hormone levels.
Medication orders are based on the average duration of stimulation. We know there is variability in the individual response to medications; some people will have a shorter and some a longer stimulation. Based on the blood tests and ultrasounds done during stimulation, dosing may be increased or decreased in order to optimize the response. The physician will decide on any dosing changes, and a nurse will contact you to relay this information.
Your prescreening tests can be performed at our center or with your GYN depending on your insurance coverage. Once your stimulation starts, it is preferable to have all bloodwork and ultrasounds performed at our center to guarantee the best consistency and accuracy of testing.
Bloodwork and transvaginal ultrasounds are done frequently while you are using the stimulation medications, and may be required daily closer to the egg retrieval procedure. These appointments must be done in the early morning so we are able to obtain results and give instructions on medication dosages the same afternoon. During this critical two week window (sometimes longer), it is very important that your schedule has flexibility in the mornings, and you avoid travel.
You will be required to give yourself daily subcutaneous (just beneath the skin) hormone injections leading up to the egg retrieval. These injections stimulate the follicles (which contain eggs) in your ovaries to grow. Sometimes these injections will be more than once per day. We strongly recommend you enroll in one of our injection classes so you feel confident and comfortable with the technique of self-administration of injections. For those that do require nursing assistance, there are private agencies that can be contracted to provide this service for an additional fee.
The trigger shot is the single most important and final injection that is administered prior to collection of eggs. This is a very time sensitive injection, which may be subcutaneous or intramuscular, depending on your protocol. A nurse will typically review this process with you at the monitoring visit on the day it is required. The retrieval is performed exactly 36 hours after this injection and therefore should be given at the exact time you are instructed, in order to optimize your egg yield.
Scheduling the Egg Retrieval
Egg retrievals cannot be scheduled ahead of time as the timing is completely dependent on each individual’s response to the medications. The timing of this procedure is selected to optimize the maximum yield of eggs. In addition, the OR is not able to honor specific scheduling times. Patients should schedule to be off from work on the day of the procedure and can return to work the next day.
An ultrasound-guided collection of the fluid in the follicles (where the eggs are developing) from both ovaries is scheduled in our accredited ambulatory surgery center under light intravenous sedation using close monitoring. You will be asleep, breathing on your own (no breathing tube is involved), and comfortable throughout the 20-30 minute egg retrieval process. Most patients will have some discomfort, bloating, and menstrual-type cramping following the procedure. Patients return home with a prescription for pain medication if it is needed, though some individuals are fine with Tylenol alone. Though most people are able to return to work the next day, some may need an additional day or two of recovery at home following the procedure.
Egg Preparation and Vitrification
Once the fluid is collected from the follicles, in the embryology laboratory, the eggs are identified in this fluid under a microscope. The embryologist then places the eggs in special solutions to remove the water and protect the egg during the freezing process known as vitrification.
Optimal Number of Eggs
While we do want to collect a good number of eggs during your cycle, we don’t want to over or under-stimulate the ovaries. Over-stimulation of the ovaries prolongs the recovery period, and can be associated with pain and other medical complications. Under-stimulation limits the number of eggs available for future use. Only eggs that are “mature” at the time of retrieval are able to fertilize and become a normal pregnancy, so be aware that not all eggs collected are suitable for freezing. We recommend that women consider banking 15-18 eggs, but please know that age is a large factor is determining how many eggs will be produced during your treatment. Our goal is to achieve this number in a single cycle, but women can require more than one cycle to get to this point.
Cryopreserved eggs are securely stored in sealed, uniquely identified cyro-vials filled with liquid nitrogen. These vials are stored in carefully monitored storage tanks under strict laboratory conditions until needed. Multiple back-up systems are in place to protect eggs from unforeseen circumstances, such as power-outages or natural disaster. There is an annual storage fee for banked eggs. The eggs are stored until the patient is ready to use them, and should you wish to have your frozen eggs later shipped to an alternate long-term facility, we can assist you with this.
How Long Can Eggs Be Stored?
This question has not yet been answered definitively, though storage for years appears safe. Human egg freezing is relatively new, so not enough time has accumulated for studies of long duration storage. Frozen eggs are already known to remain viable for many months, and in the case of eggs from younger women, years. Frozen embryos are known to survive five (5) years or more, and human sperm have been shown to remain viable and capable of producing healthy pregnancies for decades.
No post-procedure ultrasound is necessary during the routine recovery from an egg retrieval. Bloating and discomfort is expected, and will usually resolve with the subsequent menstrual period. However, if there are any concerns, please contact us to discuss.
Typically on the first business day following the procedure, you will be notified by a member of your clinical team regarding the final number of mature eggs frozen. A letter from our office will be sent to your GYN that will describe the procedure. All routine care will be performed by your GYN, until you are ready to come back to SGF to complete the process of embryo formation.
When You Are Ready to Use Your Eggs
When you are ready to conceive using the frozen eggs banked months or years earlier, please call our office to schedule your consultation with your doctor to begin the second half of the IVF process. For your safety, repeat blood tests, ultrasounds, and testing of the uterine cavity will be done prior to beginning any treatment. If moving forward in treatment with a partner, they will be required to have testing as well. There will be additional costs associated with testing and treatment when you are ready to proceed.
Once some or all of the eggs are thawed, each is injected with a single sperm from your male partner of donor to bring about fertilization in a procedure called ICSI (intracytoplasmic sperm injection). The fertilized eggs (called embryos) are cultured in our embryology laboratory. Generally, one or two of the best embryos are transferred into the uterus using a thin transfer catheter at a specific time in the cycle. Other embryos that are high quality, but not transferred may be cryopreserved (they need to be adequate quality to survive freeze and thaw, and give you reasonable expectations of success). These frozen embryos may then be used for another attempt at conception if the first embryo transfer is not successful, or for another baby if the first transfer is successful. Embryo development is variable with each case, so we are unable to predict ahead of time if there will be surplus embryos to freeze. There is no evidence that freezing once as an egg, and re-freezing again as an embryo has a negative impact.
Ovaries are enlarged during and after the egg retrieval due to the stimulation, and may remain so for several weeks. This results in the symptoms and precautions described below. This resolves naturally over time and rarely have any negative impact on menstrual cycles.
Bloating: During stimulation and after egg retrieval, bloating is expected and common. Specific instructions will be given after egg retrieval along with precautions.
Exercise: Light physical exercise is fine during the stimulation phase. We do recommend refraining from heavy physical activity and exercise for 1-2 weeks after the retrieval, to allow the ovaries to recover.
Intercourse: Before the egg retrieval is performed, sexual activity is okay as long as it does not result in discomfort. It is important to avoid sexual activity following the trigger shot until the subsequent menstrual period due to the possibility of an unintended pregnancy.
Your cycle should return to normal the month after the procedure, though there are exceptions to this. Spotting can occur anytime after the retrieval, and a period will occur somewhere from one to two weeks following the procedure. If a cycle does not start within two weeks of the procedure, you should call our office to discuss with your nurse.
Ovarian stimulation, whether for egg banking or embryo formation, is a process that has been performed on millions of women throughout the world, without evidence of long-term medical consequences beyond the stimulation/collection period.
Though women have a finite number of eggs in the ovaries, only a very small percentage can respond to hormones each month. During your normal monthly cycle, only one of the group of responsive eggs is selected to mature, and the remainder of the group is degraded by the body. Our goal with egg banking is to stimulate the rest of the group to grow and mature also, so we can freeze a larger number of mature eggs. Therefore, this process does not “deplete” your fertility potential – it just captures the eggs that would have been otherwise degraded by your body. Each of these eggs has the potential to become an embryo, and data thus far on these pregnancies does not suggest any increased risk of genetic abnormalities beyond normal.