What is fertility preservation? Fertility preservation is used to increase the chance of somebody having children in future. It can be used for medical reasons and personal circumstances. It is sometimes used before medical procedures and treatments that may cause infertility, such as cancer treatment and gender transitioning. There are several methods of fertility preservation, including medication to protect a woman’s ovaries (GnRH agonists), and freezing (cryopreservation) of ovarian tissue, eggs or sperm. Freezing eggs, embryos or ovarian tissue Egg freezing Egg freezing is a way of trying to preserve your fertility so you can attempt a pregnancy with IVF in future. Egg freezing offers the potential to preserve fertility but there is no guarantee of a baby, so it is important that you are well-informed about all aspects of egg freezing before you proceed. In the UK, the Human Fertilisation and Embryology Authority reported that 18 per cent of women who used their own thawed eggs in IVF treatment had a baby. In Victoria, egg freezing and thawing are increasing, but the total number of women using these services is still small. There were 4,048 women with eggs in storage at the end of 2019-20, compared with 3,124 women the previous year – a 30 per cent increase. But use of frozen eggs is still uncommon. In 2018-19, less than one per cent of all IVF cycles involved the use of thawed eggs, and 34 babies were born to women who used their own thawed eggs. Why should I freeze my eggs? You may consider freezing your eggs because you are: facing medical treatment that may affect your fertility, such as some forms of cancer treatment or gender transitioning not ready to have a child during your most fertile years for personal reasons concerned about your fertility declining as you get older and feel you are not currently in a position to have a child at risk of premature menopause or have endometriosis. What is the process? Your fertility specialist will come up with a plan for your treatment and prescribe medication to stimulate your ovaries. You will then have an egg collection procedure and your eggs will be frozen and stored. Risks A small proportion of women have an excessive response to the fertility drugs that are used to stimulate the ovaries. In rare cases this causes ovarian hyperstimulation syndrome (OHSS), a potentially serious condition. Bleeding and infection are very rare complications of the egg retrieval procedure. Egg freezing is still a relatively new technique and the long-term health of babies born as a result is not known. However, it is reassuring that their health at birth appears to be similar to that of other children. Financial considerations The cost of egg freezing varies between fertility clinics. In most cases there is only a Medicare rebate provided for egg freezing for medical reasons, which means that women who choose to freeze their eggs for other reasons may have considerable out-of-pocket expenses. Fertility clinics usually charge for: management of the hormone stimulation of your ovaries (devising a plan for your treatment and prescribing medication) the drugs used to stimulate the ovaries the egg collection procedure which may include admission to a private hospital and fees for an anaesthetist   freezing and storage of the eggs. Medicare does not cover the storage of frozen eggs, regardless of whether they are stored for medical or other reasons. This may cost hundreds of dollars for each year of storage. Additionally, once you decide to use the eggs to try to conceive through IVF, the process of thawing the eggs, fertilising them with sperm, and growing embryos for transfer into the uterus can cost thousands of dollars in out-of-pocket expenses not covered by Medicare. Questions to ask your fertility specialist Information about egg freezing, success rates and costs on fertility clinic websites varies. It is important that you are well-informed about all aspects of egg freezing before you decide to proceed. Here are some questions you may wish to ask your doctor: What is the clinic’s success rate for egg freezing? How many eggs have been thawed at this clinic and how many live births have resulted from these thawed eggs? What is my chance of having a baby from frozen eggs, considering my personal circumstances such as my age and estimated ovarian reserve (a measure of how many eggs you are likely to produce)? How many eggs should I store to have a reasonable chance of having a baby? (You might require more than one stimulated cycle to retrieve enough eggs to give you an acceptable chance of success further down the track) What is the approximate total cost, bearing in mind that I may need more than one stimulation and egg retrieval procedure to yield enough eggs? Freezing embryos Freezing embryos can also be used for fertility preservation as part of fertility treatment. Read more about fertility treatment here. Freezing ovarian tissue Freezing ovarian tissue (ovarian tissue cryopreservation) is a relatively new approach used to help women undergoing chemotherapy preserve their fertility. It is a surgical procedure in which a small amount of ovarian tissue is collected, cut into slices, frozen and stored. These tissue slices can be thawed and transplanted back at a later date. The aim is for the woman to start producing hormones and release eggs. Freezing sperm or testicular tissue There are two methods used to preserve fertility in men. Sperm freezing You produce a semen or sperm sample through masturbation in a private room in the fertility clinic. A lubricant is not used as this can damage the sperm. Small amounts of sperm are placed in straws which are carefully labelled. These straws are then frozen and stored in a tank with liquid nitrogen at the clinic. If possible, several samples are stored to make sure there is enough sperm to conceive one or several children. While the freezing process usually affects the quality of the sperm, in most cases plenty of good quality sperm survive. This method is also used for men before they begin cancer treatment or gender transitioning. Once you are ready to try for a baby, you can undergo fertility treatments such as IVF or artificial insemination with thawed sperm. Testicular biopsy Sometimes it is not possible to get a good sample of sperm through masturbation. In such cases your doctor will talk to you about testicular biopsy in which sperm are harvested directly from the testes. Cancer and fertility Some cancer treatments can affect your fertility. If you have been diagnosed with cancer, fertility preservation is an important consideration.  Depending on the type of cancer and its treatment, your fertility may recover, but the treatment may also cause temporary or permanent infertility. Cancer and its treatment can affect: ovarian function and the production of sperm the ability to carry a pregnancy the ability to have sexual intercourse emotions and feelings, which can impact on relationships. Some factors may reduce fertility including: The type of cancer. Testicular cancer or Hodgkin’s Lymphoma can result in poor sperm count or quality. The type of treatment. Radiation treatment to the pelvis is more likely to lead to infertility than radiation to other parts of the body. Chemotherapy using alkylating agents such as cyclophosphomide is more likely to affect fertility than treatment with other agents. The dosage. Higher doses of chemotherapy or radiotherapy used for a longer period of time are more likely to affect fertility than lower doses used for a shorter time. In general, the older a woman is at the time of diagnosis, the fewer eggs she will have, the poorer their quality will be, and the more vulnerable her ovaries will be to the effects of chemotherapy. The good news is that there are a number of fertility preservation options for both men and women with cancer to provide you with a good chance of having a baby in the future. Following a diagnosis When you are diagnosed with cancer everything can seem overwhelming. For most, focussing on getting through treatment takes priority. However, it is important that you (and your partner, if any) speak with your doctor (oncologist or haematologist) about how the cancer and treatment can affect your fertility and ability to have a child in the future. Your doctor will be able to take you through the advantages and disadvantages of different treatment options. They can also refer you to a fertility specialist for fertility preservation (both before and after treatment) and the use of contraception to avoid unwanted pregnancy.  What are my options? Advances in technology mean that as time progresses, more fertility preservation options become available, each with advantages and disadvantages. For men, options include sperm freezing or gonadal shielding (for radiation therapy). For women, options include egg freezing, embryo freezing, gonadal shielding or ovarian transposition (for radiation therapy). After treatment you can have a fertility assessment to see if your fertility has been affected. If not, you can try to conceive naturally. If your fertility has been affected, your fertility specialist will discuss the best option to use your stored eggs, sperms or embryos based on your personal circumstances. This may include using IVF, intrauterine insemination, or home insemination. There are also options if you are unable to conceive naturally and did not have the opportunity to preserve your fertility before cancer treatment. These include: donor conception (donated eggs, sperm, or embryos) surrogacy adoption/permanent care Options for transgender & gender diverse people  Fertility preservation is an option for transgender and gender diverse people to have children in the future.  There can be many things to consider when affirming your gender, including whether or not to pursue the option of medical transition. With so much to decide, taking a moment to think about whether you might like to have a family in the future, and understanding what you need to do in order to maximise your fertility options, can sometimes be forgotten in the process. It is important to consult a fertility specialist before medical transition begins to discuss your options for fertility preservation specific to your circumstances. Your fertility specialist will be able to assist you before, during and after medical transition. For trans men (assigned female at birth) Using testosterone will create significant changes to your body, including ceasing your egg production and menstrual cycle. Fertility may be restored if testosterone is ceased, but that cannot be guaranteed. You can take steps to preserve your fertility before beginning hormone treatment. Other reproductive options also exist after transition. Before transition Traditional conception - Choosing to have a child (or children) by having sex or via insemination before undergoing hormone therapy may be an option for some people. Others may not want to proceed in this way for a variety of reasons, including the potential delay to medical transition. Egg freezing - You may preserve your fertility via egg freezing before hormonal therapy begins. This would involve having treatment to develop multiple eggs which would be collected and stored for later use. It is similar to the first part of an IVF cycle in which injections are given and requires internal ultrasounds. Side effects from the medication may be experienced. It is important to keep in mind that egg freezing does not guarantee a successful pregnancy when you are eventually ready to start a family. Fertility treatment - Another option is to create embryos using IVF. Sperm, either from a male partner or a donor will be needed to create an embryo using your eggs. Your embryos will be frozen for later use. If you are partnered with a woman, your partner will be able to carry the pregnancy. Surrogacy is also an option if you are partnered with a man or unable to carry the pregnancy. After transition If you are single or partnered with a man, and have preserved your fertility you could have a child using your stored eggs or embryos with the assistance of a surrogate. You may be able to have a baby if you have not stored eggs or embryos. If you have not had surgery affecting your reproductive organs, it may be possible to cease hormone treatment, begin to produce eggs again, and try to conceive. This approach needs to be carefully managed medically. It may also create additional emotional challenges for you. It is not known whether the health of the child born may be affected by the hormone treatment. Seek additional support and guidance from your treating doctor and counsellor or therapist before and during this process. If you are partnered with a woman you may consider using a sperm donor.  Surrogacy is also an option. For trans women (assigned male at birth) Using oestrogen (and antiandrogen) will, over time, cease the production of sperm and make it difficult (if not impossible) to achieve an erection or ejaculation. It is unlikely that fertility will be restored after a significant period of time on hormones. It is not possible to estimate how long it takes for fertility to be lost. However, reproductive options after transition also exist. Before transition Traditional conception - For those partnered with a woman, conception via intercourse or insemination is the simplest and least expensive method for starting a family although it may be emotionally challenging. Sperm freezing - Sperm can be frozen before beginning hormone therapy. This is usually done via masturbation in a private room at a fertility clinic, although it may be possible to bring the sample from home. The sperm is then put in straws, carefully labelled, and frozen in liquid nitrogen. For those who are not able to produce a sample via masturbation it is possible to collect sperm via a testicular biopsy. Fertility treatment - For people who are single before transitioning or partnered with a man, building a family will require the use of a donor egg or embryo and a surrogate. People building a family this way will be able to do so before or after transition. After transition I have sperm stored - If you are in a relationship with a woman and stored your sperm before transitioning, the sperm can be thawed and used in an IVF or ICSI procedure.  If you are partnered with a man, you may either use your stored sperm or your partner’s sperm. You will also need the help of an egg or embryo donor and a surrogate. I don’t have sperm stored – It can be possible (if you have not had surgery affecting your reproductive organs) to cease hormone treatment and begin to produce sperm again. However, sperm production may not return. This approach needs to be carefully managed medically. It may also create additional emotional challenges for you. It is not known whether the health of the child born may be affected by the hormone treatment. It is suggested that you seek additional support and guidance from your treating doctor and counsellor/therapist before and during this process. If you are partnered with a man, surrogacy with the use of an egg or embryo donor is an option. If you are partnered with a woman you have the option of using donor sperm treatment. Ask both the doctor supervising your transition and a fertility specialist about your options.

Semen can be frozen and stored long-term for future use. If you want to father a child at a later stage, the frozen semen is thawed and used in fertility treatments such as in vitro fertilisation (IVF).

Cancer and cancer treatments can affect your fertility. Before starting treatment, you should discuss fertility preservation options with your doctor.

Understanding fertility treatment There are many types of fertility treatments available, ranging from simple interventions such as medication to help a woman ovulate, through to more complicated procedures known as assisted reproductive treatment (ART). ART, also known as assisted reproductive technology, refers to medical and scientific methods used to help people conceive. Fertility treatments are used: to treat infertility for people who can’t become pregnant, carry a pregnancy or give birth to reduce the chance of a baby inheriting a genetic disease or abnormality to preserve fertility. Types of treatment Depending on the cause of infertility, the following types of treatment may be recommended by your fertility specialist. This information provides a general overview of techniques available. Speak to your fertility clinic for more information. Ovulation induction (OI) Ovulation induction (OI) can be used if a woman is not ovulating or not ovulating regularly. It involves taking a hormone medication (tablets or injections) to stimulate ovulation. The response to the hormones is monitored with ultrasound and when the time is right, an injection is given to trigger ovulation (the release of the egg). Timing intercourse to coincide with ovulation offers the chance of pregnancy. Artificial insemination or IUI Artificial insemination, which is sometimes called intrauterine insemination (IUI), involves insertion of the male partner’s (or a donor’s) sperm into a woman’s uterus at or just before the time of ovulation. IUI can help couples with so called unexplained infertility or couples where the male partner has minor sperm abnormalities. You can use the Unexplained infertility - exploring your options guide to better understand if IUI is a suitable option for you. IUI can be performed during a natural menstrual cycle, or in combination with ovulation induction (OI) if the woman has irregular menstrual cycles. If a pregnancy is not achieved after a few IUI attempts, IVF or intracytoplasmic sperm injection (ICSI) may be needed. In-vitro fertilisation (IVF) During IVF, the woman has hormone injections to stimulate her ovaries to produce multiple eggs. When the eggs are mature, they are retrieved in an ultrasound-guided procedure under light anaesthetic. The eggs and sperm from the male partner or a donor are placed in a culture dish in the laboratory to allow the eggs to hopefully fertilise, so embryos can develop. Three to five days later, if embryos have formed, one is placed into the woman's uterus in a procedure called embryo transfer. If there is more than one embryo, they can be frozen and used later. The IVF process: Is IVF safe? IVF is a safe procedure and medical complications are rare. But as with all medical procedures, there are some possible health effects for women and men undergoing treatment and for children born as a result of treatment. Read more about the possible health effects of IVF here. Understanding IVF success rates Clinics report success rates in different ways, so when comparing clinics’ success rates make sure you compare like with like or ’apples with apples’. Most importantly, you need to consider your own personal circumstances and medical history when you estimate your chance of having a baby with IVF. You can read more about interpreting success rates here. The chance of a live birth following IVF depends on many factors including the woman’s age, the man’s age and the cause of infertility. Research using the Australian and New Zealand Assisted Reproduction Database calculated the chance of a woman having a baby from her first cycle of IVF according to her age. The results below apply to women who used their own eggs, and it includes the use of frozen embryos produced by one cycle of IVF: Under 34: 44 per cent chance of a live birth 35-39: 31 per cent chance of a live birth 40-44: 11 per cent chance of a live birth 44 and above: one per cent chance of a live birth. Costs of IVF In Australia, Medicare and private health insurers cover some of the costs associated with IVF and ICSI but there are also substantial out-of-pocket costs. The difference between the Medicare contribution and the amount charged by the clinic is the ‘out-of-pocket cost’. These costs vary, depending on the treatment, the fertility clinic and whether a patient has reached the Medicare Safety Net threshold. You can read more about costs here.   Intracytoplasmic sperm injection (ICSI) ICSI (intracytoplasmic sperm injection) is used for the same reasons as IVF, but especially to overcome sperm problems. ICSI follows the same process as IVF, except ICSI involves the direct injection of a single sperm into each egg to hopefully achieve fertilisation. Because it requires technically advanced equipment, there are additional costs for ICSI. For couples with male factor infertility, ICSI is needed to fertilise the eggs and give them a chance of having a baby. But for couples who don’t have male factor infertility, ICSI offers no advantage over IVF in terms of the chance of having a baby. You can read more about what’s involved in 

Fertility is the ability to conceive a child. Most of us take our fertility for granted but the process of reproduction is complex, so some people may experience difficulties when trying for a baby. There are a range of factors that can affect fertility. Taking care of your preconception health by modifying your lifestyle can improve your chance of a pregnancy and the health of your future child. Medical conditions such as polycystic ovary syndrome (PCOS) and endometriosis can reduce fertility, however it may just take longer to get pregnant. In some cases, medical procedures can be used to preserve fertility. Fertility preservation (freezing of gametes for later use) is used by people who are not ready to have a baby during their most fertile years or for those facing medical treatment that might impair their fertility. Understanding reproduction It is useful to understand how eggs and sperm are normally formed, and how conception occurs to understand the causes of infertility and how they are targeted in fertility treatment. The hormones which control the production of sperm and eggs are called gonadotrophins. There are two types of gonadotrophins: follicle-stimulating hormone (FSH) and luteinising hormone (LH). In men, they stimulate the testicles to produce sperm and testosterone. In women, they act on the ovaries where the eggs develop. The female sex hormones, oestrogen and progesterone, are produced by the ovaries when eggs mature and are released (ovulation).   For women, the production of sex hormones and the release of an egg is known as the menstrual cycle. It is counted from the first day of the period until the day before the start of the next period. In an average cycle of 28 days, ovulation happens on day 14. However, cycle length varies between women, and it is important to note that ovulation occurs earlier in women with shorter cycles and later in women with longer cycles. Sperm are produced at the rate of about 300 million per day. They take some 80 days to mature. Each sperm has a head, which contains the genetic material, and a tail, which propels it up through the vagina, uterus, and fallopian tubes where the egg is fertilised. Conception occurs when an egg and a sperm come together. At ovulation, an egg is released from the ovary into the fallopian tube. If sperm is present at that time, the egg can be fertilised. The fertilised egg then starts to divide and becomes an embryo. After ovulation, the ovary produces progesterone which prepares the lining of the uterus - the endometrium - for the growing embryo. A few days after implantation, the embryo starts to produce human chorionic gonadotrophins (HCG) - the hormone that gives a positive pregnancy test reading. If an embryo does not form or attach to the endometrium (implantation), the level of progesterone drops and the next period starts.

If you've experienced multiple miscarriages or have been unable to conceive, your doctor may refer you to a fertility specialist.

What are the causes? Infertility is defined as the inability to conceive after 12 months or more of unprotected sex. If you have been trying to have a baby for a year or more, it is time to speak to your GP. If you are over 35, you should see a doctor if you have been trying to conceive for six months or more. About one in six Australian couples experience fertility difficulties. There are many reasons for this, some relating to the male partner, some to the female partner, and sometimes both. For many people, there is no medical explanation as to why they can’t conceive.  This is referred to as unexplained infertility. A diagnosis of infertility often comes as a shock and can be emotionally challenging. Unlike other adverse life events, which may have a clear resolution, infertility is uniquely distressing because it can last for many years and the outcome is uncertain. If you suspect a fertility problem, talk to your GP who will guide you through the steps of an infertility investigation. There are many reasons why pregnancy does not occur. About 20 per cent of infertility cases are due to male factors and 30 per cent are due to female factors. Sometimes both partners have a fertility problem, and in about 20 per cent of cases, there is no apparent cause of infertility (idiopathic or unexplained infertility). Many people are delaying starting a family beyond their most fertile years. If you are unable to conceive due to social circumstances, such as relationship, age, financial or practical reasons, and are concerned about your fertility declining, you might want to consider fertility preservation (e.g. freezing eggs or sperm for future use). The Better Health Channel has helpful information on infertility in men and infertility in women. Getting help Speak to a GP The first point of contact should be your GP who will start an infertility investigation. This involves a detailed medical history and a physical examination of both partners and some basic tests to make sure that the woman is ovulating and that the man produces sperm. If everything seems in order, your GP may advise you to keep trying for a little longer before consulting a fertility specialist. However, if your test results indicate a problem, your doctor will refer you to a fertility specialist straight away. The fertility specialist will do more tests to establish the cause of infertility and determine the type of fertility treatment you may need. The chance of fertility treatment working has greatly improved since the late seventies when the first IVF baby was born. Although your chance of having a baby with fertility treatment depends largely on factors that are beyond your control, there are some things that you can do to improve the odds. The lifestyle factors that influence the chance of natural conception for both men and women also affect your chance of success through fertility treatment. Finding a fertility specialist Fertility treatment is physically and emotionally demanding, and depending on your needs it can be expensive, so it is important to find a clinic and doctor that is right for you. You can ask your GP for advice about choosing a fertility specialist, but you can also do your own research before committing to a doctor and clinic. You can find out more about choosing a fertility clinic here. Finding a fertility counsellor If you want to speak to a private counsellor specialising in infertility, the Australian and New Zealand Infertility Counsellors Association (ANZICA) has a list of independent counsellors. You can also ask your fertility clinic about the counselling sessions included as part of your treatment.