This blog is a segue into Egg Freezing. I realize that for most of the infertility community, egg freezing is not applicable, but I do get many questions about it. Plus, I suspect that many of you are the family fertility experts or the neighborhood fertility pros, unfortunately your struggles have made you experts, and you too may face questions about the topic. Some of this also applies to regular IVF, so it’s worth a read through.
If you wish you can start with the blog from 3/11/08, which goes over many of the basics and positive aspects of egg freezing.
I am writing today because a good understanding of IVF and egg freezing requires you to know the fine print. It’s not that the fine print is bad news; it’s just part of the full disclosure. This installment will deal with drug and procedure complications of IVF, which also applies to egg freezing. More specific egg freezing blogs will follow.
From a patients perspective, 95% of egg freezing is just like any other IVF cycle, which is summarized as follows. A woman takes 1-2 hormonal injections per day for about 2-3 weeks (depending on the protocol), and during that time she needs office monitoring, about every other day, where blood tests and ultrasounds are performed. We use the information from the monitoring to adjust the drug dose if necessary and to tell us when the right time is to remove the eggs. Once the time is right, a retrieval is performed. This is a procedure done usually in the office, but some programs have it done in their hospitals. It’s done under intravenous sedation, which means the woman is totally asleep, feels and remembers nothing, but is not intubated and breaths on her own. Using the ultrasound for guidance, a needle is passed through the vagina, into the ovaries and into one follicle at a time. A suction machine pulls the fluid from the follicle into a test tube, and in the fluid is one cell that’s the egg. Usually eggs are retrieved from follicles on both ovaries.
The test tube gets handed to the embryologist in the adjacent lab, who finds the egg in the fluid and then does the rest.
The retrieval procedure takes about 20 minutes, and when done you wake up right away. You are watched in the recovery room for one hour, and off you go home. The next day you would get a phone call to confirm the number of eggs that were retrieved and the number of eggs that were frozen (yes, in many cases there is a difference).
Sounds pretty simple? For most women but not all, it actually is relatively easy, but it requires time and of course money (we’ll get to that).
There are potential complications with any IVF or Egg freeze IVF cycle, but they are rare.
One is ovarian hyperstimulation. This is where the ovaries are very sensitive to the medications and become too large. Normally, the unstimulated ovaries are about the size of walnuts, and the medications may make them the size of lemons. This can be a good thing because if you are going through the trouble of the procedure, you would like to get as many eggs as you can, but within reason. Problems occur when the ovaries become too large, whereby they may leak fluid, and this fluid can spread to the abdomen and lungs and result in hospitalization. Very sick women may develop problems with their liver and kidneys and be at a high risks for blood clotting in their legs, lungs and other places.
What is happening is that as the fluid goes to places it’s not usually found, it leaves the circulatory system, making the blood thicker than usual. So there is too much fluid in the abdomen, but not enough in the bloodstream. The treatment keys are properly managing the fluid imbalances. If there is extra fluid in the abdomen or lungs, drainage is usually appropriate. If the blood becomes too dry, we need to add a little fluid there.
I realize this sounds hideous, but in fact severe ovarian hyperstimulation is very very rare in IVF and even rarer in women who freeze their eggs. Early pregnancy makes hyperstimulation worse, and since no immediate pregnancy will become of egg freezing, the odds of hyperstimulation become remote. I’m not saying it can’t happen, and mild and moderate forms of hyperstimulation are more common, but severe forms would be exceedingly rare. Plus a good infertility clinic should be able to treat this complication safely.
Still with me? What about the retrieval?
Well there’s the anesthesia. In my 20 years of being involved with 15,000 plus cycles, I have never seen a complication related to the anesthesia. Next topic.
What else? Well, we do push a needle into the abdomen, so there is a potential for bleeding and infection. The odds of needing a transfusion are less than 1 per thousand. The odds of getting a significant pelvic infection requiring hospitalization and IV antibiotics are similarly low. Women with a history of pelvic infection should receive prophylactic antibiotics at the retrieval to reduce their risk, because women with a past infection are more likely to get a second.
And then there’s torsion. The ovaries are inside your pelvis hanging by their blood vessels, not too different from the way testicle hangings on the outside. As the drugs increase the size of your ovaries, they get heavier and may make them more prone to spinning around, twisting the vessels and choking off the blood supply. You would know this is happening because it causes severe pain and nausea. Torsion can happen before the retrieval or after. It can even happen 1-2 months into the pregnancy (the ovaries of pregnant women may remain large for a couple of months after the drugs are stopped. This is because the hCG from the pregnancy stimulates the ovaries to retain their cysts to make more progesterone until the placenta takes over).
Of course for egg freezing, there is not an increased risk of torsion during a pregnancy because the pregnany will get started with the ovaries normal sized. Ovary-enlarging fertiltiy drugs are not used for the thaw cycle.
Torsion is rare event, occurring in less than 1 in 1000 cases. The ovary can be untwisted via an emergency laparoscopy. If it is untreated, the ovary can die from lack of circulation. However, we have not had this happen to anyone. The key is to call your doctor if you have pain. Losing an ovary does happen with torsion, but the usual scenario here is pain in a woman who is not undergoing fertility treatment, but develops any type of ovarian cyst that enlarges the ovary. Typically, she has pain for a while and is told to wait and see, and then she finally is told to go to the busy emergency room where she is given pain medications. Then many more hours go by waiting for the GYN consult, and by the time they get her to the operating room it’s too late. In the infertility world, your first phone call sets off the alarms and you are evaluated and treated in plenty of time.
And then there is the potential for the ectopic pregnancy. Check out the the ectopic bogs starting 5/31/07.
So that’s the yucky drugs and needles part.
Next time we talk about the pitfalls of egg freezing will try to answer the question, “Will egg freezing help me?”