Creating a Family after Transplant: Medically Assisted Reproduction and Adoption Options

Presenter: Serena Dovey MD, Unversity of Colorado School of Medicine

Presenter: Melanie Stachelski MA, Colorado Cancer Counseling, and transplant survivor

This 45-minute video is a recording of a workshop at the 2018 Celebrating a Second Chance at Life Survivorship Symposium in Aurora, Colorado.

Summary:

Most, but not all, survivors are infertile after a bone marrow, stem cell or cord blood transplant.  Men may be able to preserve sperm, and some women may be able to collect and store eggs or embryos prior to transplant. Transplant survivors can build families after transplant through medically assisted reproduction or adoption.

Highlights of Talk:

• Women may be able to use their own eggs or embryos that were collected and stored prior to transplant, or donor eggs to achieve a pregnancy after transplant
• Men may be able to use their own sperm collected before transplant or donor sperm to help create an embryo after transplant
• Women who had total body irradiation (TBI) prior to transplant are less likely to get pregnant, have a higher risk of pre-term delivery, and a higher risk of a low birth weight baby than the general population
• Adoption has been used by transplant survivors to build a family

Key Points:

01:16  How do you know if a woman is fertile after transplant?

05:20  Why women become infertile after transplant

06:13  Semen analysis can determine if a male is fertile after transplant

09:46  Fertility options for women with ovarian failure

10:32  Pregnancy with eggs frozen prior to transplant or donor eggs

14:49  Pregnancy with embryos frozen prior to transplant

15:52  Success rates for pregnancies using frozen eggs or embryos

18:56  Assisted reproduction using an egg donor

28:06  Is it safe to get pregnant after transplant?

30:30  Fertility options for men after transplant

33:26  Adopting children after transplant 

Transcript of Presentation:

00:02  Introduction:  I'm Serena Dovey, and it's great to have the opportunity to talk here today. And I'm just going to talk, kind of go through some very basic things that we do in our practice to help both men and women have a family after transplant. We'll talk about what that evaluation of fertility may look like and options.

00:21  Outline of talk:  I'm going to primarily talk about assisted reproductive technology options after bone marrow or stem cell transplants, and that's what  ART stands for. I'm first just going to talk about some different testing we can look at for both men and women to figure out if you are infertile after having a transplant. And then I'm going to talk about fertility options for women, including IVF, using eggs or embryos that might've been frozen before the transplant, IVF using an egg donor, and also IVF using donated embryos.  We'll also talk a little bit about safety issues with pregnancy after transplant, and questions to ask to determine if it is safe to carry a pregnancy. And then we'll also talk about fertility options for men at the end.

01:16  How do you know if you are fertile after transplant?   So, the first question that really comes up after a transplant is whether your fertility has been affected and unfortunately, you know, when we look at the types of treatments we have for a variety of cancers, having a bone marrow transplant, generally, is in one of the higher risk categories for having infertility issues after.

For women, one of the first questions I would ask to determine someone's fertility status is, “are you having regular periods?” If your periods come back after you complete your transplant than it does suggest that you are releasing an egg every month, and there may be a window for fertility. This has to be kind of determined though, not on birth control pills, or anything like that, because for women on birth control pills, that's going to give you an artificial period, that the period you're having is related just to the hormones and the birth control pill and doesn't really reflect anything that your ovaries are doing.

There’s additional testing we can do, whether you are, or are not, having a period after treatment, to assess the health of the ovaries and if there are any eggs remaining. So some of the initial testing we do for women who are still having a period, we typically look at hormone levels and we like to do that early in the menstrual cycle.

02:46  Tests to see if eggs remain in ovaries after transplant: This is a little cartoon of the follicular growth we see typically in the ovary when the ovaries are functioning normally. Women have a pool of primary or primordial follicles, which is an egg and support cells around the egg, that help it grow. And then the follicle basically develops, typically over the course of a few months, before it actually gets to the point where it is released. We can do testing to better look at the number of eggs that might be remaining in the ovaries after transplantation.

03:22  Level of follicle stimulating hormone (FSH) indicates number of eggs remaining in ovaries:  The FSH hormone we measure - that stands for follicle stimulating hormone - and that is a hormone that your brain releases, causes a follicle to go from being at this small stage, up to a larger stage, and it basically is what governs ovulation for women. If a substantial [number] or all of the eggs were killed during the transplant procedure, then the brain will sense that there's no longer any eggs there, based on hormone signaling from the ovary back to the brain, and the FSH typically rises. If it's very high, it tells us that the number of eggs in the ovaries has dramatically decreased, or there are no more eggs remaining. Basically, all women, when they go through menopause, their FSH will go very high. So it just tells us about the function of the ovary.

04:14  Anti-mullerian hormone measures whether eggs are growing in ovaries:  Another hormone we measure is called AMH, or anti-mullerian hormone. That's a hormone that's made in your ovaries. It's typically secreted from this little pool of follicles here. And again, when I say follicle, I basically just mean your egg and then the support cells around the egg that help it grow.

So once the follicle starts to grow, it will make AMH hormone, and we can measure that in your blood. The more AMH hormone we can measure tells us that there's a pool of eggs that are still growing in the ovary. Even if you're not having your period at all, we can still measure these hormones to get information about whether the ovaries have failed or if there are still some eggs remaining.

04:55  Pelvic ultrasound provides look at how many eggs and ovaries and clues about how long they will survive:  And then finally we like to do an internal ultrasound or a pelvic ultrasound to look at the ovaries. And we can typically see follicles once they've reached this size, and we can actually count how many of the follicles we see as one more measure of how many eggs remain in the ovaries after transplant. And also, potentially, look a little bit at the window of how long they may continue to function if the number is low.

05:20  Why women become infertile after transplant:  One of the reasons that female fertility can be significantly affected by transplant is because we're born with all the eggs that we're ever going to have. And then the number slowly declines over the course of our reproductive years and falls off more rapidly at the end of the reproductive years, typically in the late thirties or early forties for typical women. At the point where we get to having no remaining eggs in the ovaries, that's typically when menopause occurs. Concern with bone marrow transplant is that either the chemotherapeutic agents that were given for conditioning, or the radiation that might've been given for conditioning can substantially damage the ovaries as well and kill some, or potentially all, of those follicles. And so it might put your curve on a much quicker trajectory towards very low or no egg number.

06:13  Semen analysis can determine if a male is fertile after transplant?  So, what about for men? How do we test most men's fertility, because we don't really have a clear marker, like the period, like we do for women?  The main way we test fertility for men is to do a semen analysis. And what the semen analysis looks for, we basically look at a few different parameters. We look at whether there's sperm in the ejaculate at all, and if so, what the count is. Is it normal, or is it low, or is the sperm absent? They also look at the morphology, and that just basically means the shape of the sperm, to see if we have a normal percentage of normally shaped sperm.  And then finally, we look at the motility to see if the sperm is moving, which is how we know it is alive and viable, and is it moving forward appropriately, or just maybe twitching in place. And so looking at these parameters can give us a picture of men's fertility after transplantation.

Typically, I recommend not doing a semen analysis for at least nine to 12 months after you've finished any medication or anything given for the transplant because in the testicles, basically men have stem cells that make sperm, and they make sperm throughout a man's life. It's those stem cells that, if they are killed off by any of the chemotherapy or radiation given for transplant, that can cause men to be infertile. But from the time a stem cell makes a very first division. Until the time that the sperm is mature enough and is actually ejaculated, that's about a three-month process. So, typically all the dividing sperm is killed by the chemotherapy agents given for conditioning. But if the stem cell pool, if there's some remaining stem cells that are healthy, then they can start to divide again after treatment's finished. And so we might see replenishment of sperm where a man might have no sperm in the analysis three months after transplant, but we might see sperm again about a year after. So we usually give it a little time to let a few cycles of that sperm production go by so we can get a more accurate sense of whether a guy's continuing to make sperm after transplant. Generally speaking, most men who are going to maintain sperm production after transplant, typically we'll see that within the first one to two years after transplant.  If you have a semen analysis two years or longer after transplant and we see no sperm, the chances that the sperm is going to come back is very low, but I never say impossible.

08:48  Women who want children after transplant should be tested early to determine if viable eggs remain in ovaries:  Now let's talk about some fertility treatment options for women after transplant. This is going to depend a lot on whether you're having regular periods, versus if you're not having periods and our testing shows that the ovaries have failed.

For women who are having regular periods, that does suggest that you are releasing an egg every month. So once you've been cleared by your transplant team and your general physicians say that it's okay to try for pregnancy, you could go ahead and start trying to get pregnant. If you haven't gotten pregnant in about six months, I usually recommend seeing a physician. It's possible that a significant number of the eggs might have been damaged with the transplant and that fertility window might be shorter, so we typically like to see pretty quickly to see if there's any fertility options that we can consider with your eggs, and so we'll do fertility testing.

09:46  Fertility options for women with ovarian failure:  For women who are diagnosed with ovarian failure after transplant, there are a variety of options to build your family. If you saw somebody like me before your transplant, we might have talked about actually trying to freeze your eggs or freeze embryos before you had any medications for your transplant. And if you did IVF and froze your eggs or froze embryos, then we could look at using those eggs or embryos to help you get pregnant. If you didn't freeze eggs or embryos prior to the transplant, it is still possible to consider IVF and carry the pregnancy yourself with using an egg donor. And then finally, there's also the option to do IVF with what we call donated embryos, and I will talk about that a little bit, and then Melanie's going to talk about adoption at the end.

10:32  Pregnancy with eggs frozen prior to transplant or donor eggs:  If you've been diagnosed with ovarian failure and you froze your eggs or embryos prior to your transplant, then they can be used to help you get pregnant. And if not, options through, again, ART, which is assisted reproductive technology, can include IVF with a fresh egg donor, IVF with donor eggs that have been frozen already, and embryo donation.

I think sometimes it's helpful just to see the pictures of what we do, in terms of fertility treatments through IVF and assisted reproductive technology. So for a woman who froze her eggs prior to transplant, basically they're sitting here in our storage tanks where they're frozen. We can warm those eggs, take a semen sample from your partner, and with frozen eggs we fertilize the eggs through a procedure called ICSI, or intracytoplasmic sperm injection. And that means that we're going to actually stick a needle into the egg with a sperm and actually stick the sperm directly into the egg. And that's primarily because this shell around the egg can get a little bit hardened when we freeze it and thaw it, and so we fertilize them best when we do this ICSI procedure.

At this point, the embryos are monitored by the embryology team. And so the first day after the fertilization, we're going to take a look and see if the egg fertilized successfully, and we can tell that by seeing two nuclei within the egg, one from the egg and one from the sperm. And from here, we hope to see the eggs start to divide and make these division steps to turn into a more advanced embryo called a blastocyst. The blastocyst can then be transferred into the uterine cavity to help you get pregnant.

12:24  Building the uterine lining for pregnancy :  So, what do you do while we're creating embryos in the lab? For women who are undergoing IVF with their frozen eggs, they need to build the lining of the uterus so that it's ready for the embryo to be implanted. Generally, what that involves is taking estrogen. And oftentimes we give it in patch form, which is what this photo is showing here.  But it can be given by mouth, it can be given vaginally, there are different ways we can give it. But, basically, what estrogen does is it allows the lining of the uterus to become thicker and allow for a nice house for the embryo to implant.

This is a photo of a vaginal ultrasound, which is what we do once a woman has been on the hormones, the estrogen, for about two weeks. This area right here is the lining of the uterus, and we can measure it to see how thick the lining got with the hormones and what the pattern looks like, and that gives us information about whether the embryo might implant appropriately.

Once the lining is thick enough and we liked the pattern, then we start a second hormone and that's called progesterone. What progesterone does is it open the window for implantation in the uterus. So the uterus needs both estrogen and progesterone for the embryo to be able to implant. Progesterone is often given as an injection, so women will start progesterone injections daily, and then we will typically time the transfer of the embryo once a woman's been on progesterone injections for several days.

13:57  Transferring embryos to the uterus:  In order to transfer the embryo, it's not too much more invasive than having a pap smear done. Basically [they] put a speculum in, and put a small catheter through the cervix, into the uterus, and that's what this photo is demonstrating here. This bright white line is the transfer catheter that we've sneaked into the uterus. And then we typically release the embryo or embryos here at the top of the uterine cavity.  From here, a woman would continue both her estrogen support and the progesterone injections for another nine to 12 days, and then we would do a pregnancy test to see if the embryo implanted appropriately. If someone is pregnant after the transfer, then we would continue them on the hormones, the estrogen, progesterone for up to 10 weeks of pregnancy. And then typically, we'll do an ultrasound a few weeks later to see if the pregnancy looks viable.

14:49  Pregnancy with embryos frozen prior to transplant:  So what about if you froze embryos prior to bone marrow transplant? It's an embryo basically, similar to the little cartoon here. If you had your eggs harvested and then we fertilized them prior to freezing, then the embryo can be frozen here at this more advanced stage called a blastocyst. So we've had that blastocyst frozen, very similar to what we would do for using frozen eggs, we would take the embryos out of our freezer, thaw them, or at least thaw the number that we wanted to transfer, and then do the transfer procedure just like I described it. And then similarly, we will check for pregnancy nine to 12 days later and then check to see if the pregnancy was viable. So basically the process is exactly the same. Someone having an embryo transfer is also just like a woman who has frozen eggs, is going to be on estrogen hormone for two weeks, to build the lining of the uterus and then start progesterone.

15:52  Success rates for pregnancies using frozen eggs or embryos:  So how likely is this to work? It really depends on a lot on how old you were when you froze your eggs. All women have fertility decline, typically starting in our early thirties and more notably in the later thirties. So, it depends a lot if you have frozen eggs, on how old you were when you froze your eggs and also how many eggs you have frozen. And then in terms of frozen embryos, same thing. Basically it depends a lot on how old you were when you froze the embryos, and how many you have. And one thing that we have the capacity to do now, within our IVF lab, is to test the embryos to see if they are chromosomally normal. Because embryos can make a lot of mistakes when they're dividing, and sometimes it might not be a normal embryo, where there's a very small chance that it would implant. And if a chromosomal assessment was done on the embryos, then the chance that that embryo is going to implant once we place it inside the uterus is usually about 60 to 70 percent. So typically the best guarantee for pregnancy is having frozen embryos where we've done chromosome testing and we know that some of them are normal.

17:03  Pre-implantation genetic screening (PGS):  What that chromosome testing is called PGS, or pre-implantation genetic screening. What PGS is, a little cartoon here of how our embryology team does this procedure, but when the embryo is at its more advanced stage, called the blastocyst, it's differentiated basically into this little blob, here you can see, called an inner cell mass. And then these external cells, we call those the trophectoderm.  The inner cell mass is ultimately what becomes the fetus in your uterus, and these external cells, the trophectoderm, are what become the placenta. And so we can safely take out about five or six cells from the placental layer and do genetic testing to see if the number of chromosomes in those cells is normal.

17:49  Impact of age on health of eggs:  One of the reasons that it's harder for women to get pregnant as we get older, and one of the reasons that IVF might not be as successful for women as they get older, is because the health of the eggs in our ovaries declines with time.

This is just a graph that shows, based on female age, how likely the embryos are to be abnormal when we biopsy them. So for women who are under 35 when they have their eggs harvested and create embryos, generally about 43 percent of the embryos tested will be abnormal, and generally about 92 percent of women will have at least one or more healthy embryos to transfer back to get pregnant.

As you can see, for women who are over 42, when we do embryo biopsies, there's about 84 percent that are abnormal, and only about one in three women over the age of 42 will have a healthy embryo from her own eggs to transfer back. And this is not at all related to bone marrow transplant, this is just kind of a natural truth about female biology is that it declines as we get older.

18:56  Assisted reproduction using an egg donor:  Okay. So, let's say if you didn't freeze eggs or freeze embryos, if there was not time for that before you had to have a transplant, which oftentimes there's not, and if we diagnose you with ovarian failure through testing, then IVF, using an egg donor, might be a possibility. There are two different ways we can use egg donors or do a donation. We can either use what we call fresh eggs, which means that somebody has gone through stimulation cycle and we've harvested them fresh, but we can aso use eggs that have been frozen through an egg bank, and I'm going to talk about both of those options here.

19:35  Fresh egg donation:  Fresh egg donation basically means that women who want to donate their eggs for altruistic reasons or, you know, they also get paid a small amount of money for this, they typically work through either an agency or an IVF practice to undergo fertility testing to see if they'd be inappropriate candidate and if they have good fertility.  Generally speaking, most agencies or practices will only use women who are 30 or under for egg donation because we want to maximize women's pregnancy chances with an egg donor. The potential donors can then be selected by the person who wants to use an egg donor to undergo stimulation and egg harvest.

So if we have an egg donor in our practice going through a cycle, she typically needs to take hormone injections for several days, typically about nine to 14, so that multiple eggs in the ovaries can grow. This is a little cartoon of what those eggs look like, or the follicles that are growing. And we typically do ultrasounds, typically every other day, while someone's taking hormone injections so we can see how many follicles are growing.

Once we see that there are enough large follicles that we think the majority of the eggs that have grown would be mature, then we will do a procedure called an egg harvest. And this is a minor surgery done under sedation. It takes about 20 to 30 minutes. So we basically placed the needle directly through the vaginal wall, right into the ovary and we remove the fluid from each of these follicles. And if the egg has matured appropriately, it's typically floating in that fluid at that point. We can collect all the fluid in the little test tube, and then our embryology team looks through all that fluid microscopically to identify the eggs.

And then typically from here, once we've harvested the eggs from the donor, we would take the female patient who's trying to get pregnant with the egg donor, take her partner's sperm and fertilize those eggs.

21:33  Transferring fresh eggs from donor to patient:  While the donor's going through those injections and going through the process of stimulating her ovaries to have the eggs harvested, the recipient or the woman who wants to try to get pregnant would be on hormones - the estrogen patches, again - typically for a couple of weeks to build the lining of the uterus so that her uterus is ready to accept those embryos when we've created them.

Once the embryo or embryos have been created from the egg donor, then we would transfer one into the uterus of the recipient to help her get pregnant. And then, just like I showed you before, we would do a pregnancy test in nine to 12 days, and if the pregnancy test is positive, then the woman who's pregnant will continue her estrogen and her progesterone for about 10 weeks.

One common question I get when I'm in the office seeing women who have been diagnosed with ovarian failure and who are doing, looking at doing IVF with an egg donor is, ‘well, can I even carry a pregnancy if my ovaries have failed? Is that even possible?’

 But interestingly, you know, we're going to support the pregnancy for those first 10 weeks with the estrogen patches and with progesterone injections, and at that point the placenta actually makes all the hormones it needs for the rest of the pregnancy. So you don't have to have functioning ovaries to carry a pregnancy and to deliver a child. It's one of the magical marvels of science.

23:01  Egg banks:    Okay. So as of probably about eight to 10 years now, I'd say, there's another option that women can look at who want to use IVF, who want to undergo IVF with an egg donor. We have more successfully been able to freeze and thaw eggs with high success rates, in terms of them surviving and turning into healthy embryos, with advancements in freezing technology. And so now, just like there are sperm banks around the country for women who may not have a partner or who are in a same sex relationship, who want to get pregnant, now we have egg banks as well.

So, for women who want to donate their eggs, they can go to one of these egg banks, undergo the stimulation cycle we just talked about, and have the eggs harvested and then frozen. And so it's possible to actually purchase eggs that have already been donated to the egg bank. You can purchase them and do IVF with these frozen eggs. Basically, there are practices all around the country or egg banks around the country, so if you find a donor or find eggs in an egg bank from California that you want to use, you can purchase them and then ship them to your local fertility clinic. At that point, they're thawed, just like we talked about before, and fertilized with the partner's sperm to create embryos. And the embryo will then be transferred into the woman who's trying to get pregnant, her uterus, after the hormone preparation that we've talked about.

24:25 Benefits of using frozen eggs versus fresh eggs:  So, what's the benefit or drawback of frozen eggs versus fresh eggs? One of the benefits of using frozen donor egg, is that sometimes it can be a little less expensive, and oftentimes you may have more selection of egg donors.

So why is it less expensive? Basically, because for women who do IVF with an egg donor, oftentimes that donor might produce a lot more eggs than you actually need to get pregnant. So for example, if we were doing a fresh donor egg cycle and we stimulated a donor and harvested her eggs, it's possible we may create 10 or more embryos from that cycle. And the chance when you're using an egg donor of getting pregnant is about 50 percent or better when we put one embryo in your uterus. So if a woman who only wants to have one child uses an egg donor and gets pregnant [with] the first embryo we put in, there might be nine extra embryos that they might not ever use again. And so because we know that donors can make more eggs than might be necessary for one pregnancy, the egg bank idea came about. And so oftentimes when you purchase eggs from an egg bank, they send you, or you purchased six, and six is the number that we see that gives a pretty good chance of pregnancy. But since you're not using all the eggs from that donor, the cost is shared between other people who might use a donor too. Also because the egg banks are kind of all over the country and recruit donors from around the country, there's generally a better selection of women who are donating through banks versus if you use a local agency in Denver or wherever, you know, wherever your local town is.

25:58  Benefits of using fresh versus frozen eggs:  However, there are some benefits of still thinking about doing a fresh donation cycle the way we've traditionally done it for many years. There are slightly better pregnancy rates. So typically, about 60 percent if you're using a fresh donor, versus about 40 to 50 if you use the frozen eggs. This is primarily because when you use a fresh donor, you might be starting with 20 eggs and taking the very best embryo from all of those eggs. Whereas with using the donor eggs, we're starting with only six, so there's just a better chance of getting a good embryo if you start with higher numbers.

And for women who are young, so let's say you have a transplant when you're a teenager, and you’re diagnosed with ovarian failure, you might want to have a few kids. So, for you it might be better to use a fresh egg donor because you might want to have all 10 of those embryos at the end of your cycle, because you might be able to have more than one baby from those embryos. So for people who are considering more than one child through egg donation, oftentimes I'll recommend considering a fresh donor.

26:57  Using donated embryos:  And then finally, I'm just going to briefly touch on this. Embryo donation's not done as frequently as IVF with your own eggs or with donor eggs. But it is something that sometimes couples who want to consider. So, couples who've already gone through IVF, for whatever reason, oftentimes may have frozen embryos that they're not going to use any longer that they would prefer to donate so that someone else could try to get pregnant, rather than just discard those embryos.

So, if you use frozen embryos, they would just be thawed and transferred, like we've discussed. One of the benefits of using frozen embryos is that because the embryo has already been created, most of the cost of making that embryo is already gone.  And so it actually can be a lot less expensive to use a donated embryo than to use an egg donor. The main drawback is that there's just limited availability of donated embryos. Not all practices do embryo donation, so it's a little bit more limited in terms of what's available, but it's still certainly an option that people can look at.

28:06  Is it safe to get pregnant after transplant:  The final thing I just wanted to talk about is, if you have had a transplant, trying to figure out whether it's safe for you to get pregnant. There are a couple issues I always think about when I'm meeting with couples or for women in the office.

So, the first one is whether you had radiation. Sometimes total body irradiation is used as a conditioning parameter, and radiation can affect the uterus. Studies have shown that women who received total body irradiation before their transplant have, generally, a lower chance for pregnancy, a higher risk for having a preterm delivery, and potentially a higher risk for a low birth weight baby. 

So, there are some tests we like to do if you've had total body irradiation to look at the uterus, to see if the blood flow to the uterus looks appropriate. Sometimes we might even do a practice cycle where we put you on that estrogen hormone for a couple of weeks to see if the lining develops appropriately.

I usually also like women to see a type of OBGYN specialist called a maternal fetal medicine doctor—that's a doctor who takes care of higher risk pregnancies— to see if they have any concerns about you carrying a pregnancy if you've had radiation to the uterus.  If we feel that it really isn’t  safe or there's a high chance for having pregnancy complications because of the radiation, it is possible to use a gestational carrier. That basically means having another woman carry your pregnancy for you. The main downside of using a gestational carrier is it can be expensive.

And then the other thing that we'd like to look at is did you get any type of chemotherapeutic agent and what agents were they. There are some types of chemotherapy that can cause damage to other organs. And I'm sure the audience is familiar with that. A couple of the organs we worry about from a pregnancy standpoint is your heart and your lungs and whether those are functioning appropriately. Depending on how much of a specific agent you got, that could make pregnancy more risky. And again, I typically have people meet with a specialized maternal fetal medicine doctor to talk about the chemotherapy they received to see if there's any concern, and if there's any additional testing we want to do prior to pregnancy. That sometimes may include doing an echocardiogram of the heart or other testing to see if we have any concerns about pregnancy.

30:30  Fertility options for men after transplant:  Okay. Now let's talk about options for men. One of the things we try to offer men who are undergoing a transplant is to freeze sperm prior to transplant, because there is a high risk they may not make sperm again after the transplants is complete. If you froze your sperm prior to transplant, then there are two fertility treatment options we can do with frozen sperm.

The first one is intrauterine insemination or IUI. Generally, we need about 10 million swimming sperm to get the best chance for pregnancy with an IUI. Itt depends a bit on your partner's age as well, but the chance for pregnancy if you do IUI treatment is about 10 percent. So sometimes you might need several tries of IUI to actually achieve a pregnancy.

The other option is IVF, which we've talked about a fair amount already.  So the benefits of IVF with frozen sperm is that you need way less sperm to be able to do IVF and generally the chance for pregnancy can range from 30 to 60 percent each cycle. And that again depends a lot on how old your partner is when you guys are doing IVF.

31:41  How intrauterine insemination works: So this is just a little cartoon about how an IUI works. We'll take the sperm, we will thaw it, if it hasn't already been washed we do a washing procedure with the sperm so that we can get all the additional cells out that we wouldn't want to put in your partner's uterus. And then we basically re-suspend that sperm in a small volume of fluid. And then, with the catheter, we can take the laser catheter through your partners cervix, up to the top of the uterus, and then place the sperm here in the uterine cavity. And we do that right around the time of ovulation to, hopefully, push sperm there to hopefully fertilize that oncoming egg.

32:16  IVF with frozen sperm:  The other option is IVF, and I've shown you many pictures about IVF. But basically your partner would go through the several days of hormone injections so that we could stimulate the ovaries and harvest eggs. Once we have the eggs after retrieval we can fertilize them in two different ways. Either we can mix thousands of sperm per egg in a dish and allow the sperm to bind to the egg on its own, or we could do that procedure I mentioned already, the ICSI, or intracytoplasmic sperm injection, where we inject a single sperm into each egg to help it achieve fertilization.

 If the sperm numbers are low or if the sperm amount we have is limited, we typically recommend doing ICSI. From there, we create embryos and then would do a transfer into your partner's uterus. If men did not, were not able to freeze sperm prior to transplant and then they do a semen analysis after their transplant that shows they're not making sperm any longer, then the other option would be to use a sperm donor to help your partner get pregnant, or adoption. Okay. Now I'm going to turn the mic over to Melanie so she can talk a little bit about adoption and then we'll both be here to take questions.

33:26  Experience of Melanie Stachelski who adopted children after transplant:  Hi Guys. I'm Melanie. I'm a therapist in my private practice, but for this session, I'm not here as an expert. I am just here as a mom. My husband and I are the proud parents of two gorgeous boys through adoption, these are our kids. Lucas just turned four and Cole will be one next week. And Lucas is curious, and wild, and funny, and he loves to laugh. He's always trying to figure out a way to be laughing all the time. Cole is just sweet, and laid back, and just the sweetest baby you've ever met.

34:18  Learning she would be infertile after transplant:  My husband and I had just celebrated our first wedding anniversary when I was diagnosed with AML, acute myeloid leukemia and they told us, you're going to need a bone marrow transplant. And we said, what's a bone marrow transplant? We had never known anybody to go through this and so it was completely new to us. And as I was getting ready to do my consolidation treatment and getting prepared for transplant, they told us— and I so vividly remember this doctor's appointment where they sat us down and they said ‘we've never known anyone to go through the treatments that we have laid out for you and gone on to have their own children.’ And so on the car ride home, one of us said, ‘hey, so what do you think about adoption?” And the other one was kind of like, ‘oh yeah, I guess so’, you know, but we had a lot bigger fish to fry at that point.

35:18  The adoption process:  So it wasn't until a couple of years after my transplant that we got into the adoption process. We used two different agencies and so we had two really different experiences with the boys. But I'm just going to say the couple of things that I think that you really want to know. And I think this is the most important thing: iwe were completely open and honest about my cancer history when we went through the adoption process. And I think it probably could have scared some birth families off, but I know for a fact that we were actually chosen because of my cancer history. They, these birth families, actually saw us as a couple who had been so resilient that we had really overcome so much that they saw, how strong we were as a couple for going through this.  And they knew that we weren't able to have our own children. So I know that story, that that's why they chose us.

After, you know, a transplant and then having kids, I was exhausted. I was sick all the time. These kids still wear me out and that was the same story with every other mom of young kids that I knew. I don't think it was different from me, having gone through what I went through. The challenges were the same. So we used two different agencies and I'll just tell you a couple of quick stories and then we can just answer some questions.

For Lucas, my four-year-old, we used a really small agency. It took us three years to be placed with somebody. I think that was one of the downsides of using a really small agency. But when we were matched, we met Lucas' birth mom about 10 days before she gave birth and we were able to get to know her a little bit. 

When she was in the hospital, and we're from Denver, so this was just downtown Denver, the hospital gave us our own room. We were just a few doors down from her in the hospital. The doctors treated us so well. They were giving us all the same reports as they were [giving] her. We actually got to spend the night with Lucas. We met him about 10 hours after he was born. So it was just a lovely experience.

Something that's going to be interesting to you guys. We were able, because we had this relationship with his mom ahead of time, we were able to ask her if it would be okay if the doctor preserved her cord blood after the delivery, which is something we didn't even know about before me going through a transplant, but we knew, gosh, that would be such an advantage to have for him as he gets older.  So we actually pay every year to keep his cord blood banked up just in case, you know, down the road.

When his birth mom was getting ready to be discharged from the hospital, we all went down to the hospital chapel and we did this beautiful ceremony where we had letters for her. We had a little box that she could keep pictures and some keepsakes, and we did this beautiful ceremony. We had roses and we had white roses that represented Lucas' birth mom, and we had red roses that represented us as the adoptive family, and then pink roses that represented Lucas as kind of the blending of that family. So it was just so meaningful. We were all sobbing, of course, but it was just really such a special day.

For Cole, we worked with kind of a medium size agency and it took less than a year to be placed with his birth family. So that was the, I think advantage. The average wait, I think it's about 18 months. So we were kind of on the long end with Lucas and more on the short end with Cole.

When we got the call with Cole, he was already born, so we had no time to prepare. We literally got a call at 1:00 in the afternoon and they said, can you be here at 6:00 tonight to meet your new baby? So it happened so fast, so we actually went that day to meet him, and then the birth family wanted to spend one more night with him to kind of just say good-bye and kind of transition.

And so, the next day we were supposed to meet up for the real kind of placement and I had all these ideas about that ceremony, which had meant so much to us with Lucas.  So I had all the roses and the letters, and they got stuck in traffic on their way to our house. They were coming from north of Denver and they weren't going to make it in time. So our agent said, can you meet them halfway? So we got in the car, we had picked our son up from school. Um, no, no, Lucas was still at school, so this was just my husband and I. We drove up to a random restaurant on the side of the highway and we met the birth family there. And we're going in and my husband is saying this is so messed up, we're going into this, you know, the little dive diner on the side of the highway and we're hopefully leaving with a baby. It was just like so bizarre and seems so wrong. But, so we're in this little diner. It's in the middle of the afternoon, so no one's really there. And I'm crying, giving out these roses, talking about our blended families. And the waitress is, you know, over my shoulder, like, can I refill your iced tea, anybody need a snack here? It was just so awkward and strange.

totally different experience. But you know, now Lucas is four, Cole's one, we see Lucas's birth mom about four times a year. We just have a great relationship with her. She just loves him with her whole heart and just really wants to see that he's doing well. And Lucas has a half-sister, so we get together with them and they get to play and take pictures and we keep her updated with everything that's going on.

Cole's birth family. We have a lot of contact with his birth grandparents, and also two half-sisters, but his birth parents haven't been ready, in a place where they wanted to meet us. So we call both of our adoptions, open adoptions. But those look really different.

I think the last thing I want to say is, I'm going to get choked up about this, but if I could've had someone time travel back to me, you know, when I was post-transplant and just say, your family's not going to look how you thought it was. Your life doesn't turn out how you thought it was, but show me these pictures and say, it's even better than you thought. So, that's just what I want to offer to you that this might not be how you thought you were going to create a family, but it can be even better than you imagined. 

Does anybody have any questions for either of us?

Questions from audience:

42:33  Stem cell therapy to enable sperm production: So, my son had his transplant when he was six, so there was no option to bank anything because there was nothing to bank. He's definitely sterile, like there's not, we haven't tested, we don't need to test, like there's no hope.

But you said that there are stem cells. So when a male is infertile it's because the stem cells that create the sperm were killed off. Is there any kind of hope, and he's only 14 now, so we're not in a huge hurry, but is there any kind of hope for that kind of stem cell therapy to be able to recreate that ability?

Answer:  Yeah, that's a great question. It's all very pre-clinical arena. I mean there are scientists who have the capacity to like take a skin cell and sort of do genetics.

It's kind of crazy, I'm not an expert on it, but they can basically try to revert a very differentiated cell, like a skin cell, and take it back to a stem cell that hasn't really differentiated yet. And there are different types of stem cells in the testes. There are spermatagonial stem cells, so differentiated to the point where they are spermatagonial, but not completely, not a stem cell that can turn into anything. So I'm not aware of any clinical trials right now that are doing anything like that, but if your son is 14, I would certainly pay attention to the science because there are people who are definitely trying to do that.

Nowadays too, one of the other things, and it's still considered experimental, some centers have it, some don't, but for children who need a stem cell transplant who haven't even gotten close to puberty yet, for boys, one of the things that we're trying to do is actually do a surgery to take out a part of one of the testicle. Boys are not making mature sperm yet, they don't make mature sperm until they go through puberty, but they do have stem cells there and that's what divides and it produces sperm once puberty is initiated. So, the hope is that we're going to preserve those stem cells from the testes and then potentially transplant them back in after a transplant when he's ready for a family.

Audience:  Too late for him though, but that's exciting.

45:18  Expense of undergoing assisted reproduction or adoption:  And then my other question is, all this sounds very expensive. I know adoption is very expensive. I know all this other, and I know insurance, this is all going to be considered optional. Like insurance is never going to cover this. So is there any kind of support systems for people who have survived things like this. Are there any kind of organizations that you know of that might help with some of that?

Answer:   From a fertility IVF standpoint? There are organizations who may have some grants and things like that. My experiences are pretty limited so it's not a very, it's not like an easy thing. There's the Livestrong Foundation and Fertile Hope, for people who are trying to sometimes bank before cancer, will provide funds for that. Unfortunately it's not nearly as robust as I wish that it was, but one, I'm hoping optimistic thing. That is a huge issue for a lot of my patients is cost.

In Rhode Island, there was a law passed within the past year that mandates insurance providers cover fertility preservation procedures, meaning sperm banking, egg banking, embryo banking, prior to treatment. And I'm hoping that that's going to become more widespread and potentially spread to, you know, costs for after treatment too, if you're going through IVF or something like that after treatment to get, to achieve your family.

Melanie Answer:  I would echo the Livestrong Foundation. I know that's the fertility assistance that I know about and for adoption, there's a pretty good adoption tax credit that you, you get back after taxes. So that was really helpful.