|Subject:||Cryopreservation of Oocytes or Ovarian Tissue|
|Policy #:||MED.00080||Current Effective Date:||01/05/2016|
|Status:||Reviewed||Last Review Date:||11/05/2015|
This document addresses oocyte and ovarian tissue cryopreservation which are alternative techniques to embryo cryopreservation for women who are at risk of infertility due to gonadotoxic therapies such as chemotherapy or radiation therapy.
Cryopreservation of mature oocytes is considered medically necessary in post-pubertal females facing anticipated infertility resulting from chemotherapy or radiation therapy.
Investigational and Not Medically Necessary:
Cryopreservation of oocytes is considered investigational and not medically necessary when the criteria above are not met.
Cryopreservation of ovarian tissue is considered investigational and not medically necessary as treatment for anticipated infertility.
Therapies to treat medical conditions, such as cancer, may compromise fertility for females. The American Society of Clinical Oncologists (ASCO®) article Fertility and Cancer Treatment (2013) lists chemotherapy agents that are linked to fertility issues, including: cisplatin, alkylators, such as cyclophosphamide, chlorambucil, busulfan, procarbazine, carmustine, iomustine, mechlorethamine and melphalan. Radiation therapy may also have potential side effects that may affect fertility, including total body irradiation, radiation of the abdomen, pelvis, ovaries and uterus. ASCO encourages providers to have an individualized "Discussion of fertility preservation with all females of reproductive age (and with parents or guardians of children and adolescents) if infertility is a potential risk of therapy." This discussion is recommended "As early as possible in the treatment process so as to allow for the widest array of options for fertility preservation" (Loren, 2013).
Options to preserve fertility for females who may become infertile as a result of planned gonadotoxic treatments include cryopreservation of oocyte and ovarian tissue. However, there are many factors such as age, cancer type, timing and the type of treatment regimen, etc., to consider.
In 2013, the Practice Committees for both American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) updated the guideline for cryopreservation of mature oocytes. The guideline concluded that over the past decade, "Oocyte cryopreservation has improved dramatically, and preliminary data for safety are reassuring. Therefore, this technique should no longer be considered experimental." ASRM and SART noted individuals receiving gonadotoxic therapies for cancer are at high risk for infertility, therefore, the option of oocyte cryopreservation with appropriate counseling is recommended.
The Practice Committee for ASRM (2013) published a committee opinion on fertility preservation for individuals undergoing gonadotoxic therapy or gonadectomy which includes embryo and oocyte cryopreservation as "established modalities for fertility preservation."
The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice published an opinion on oocyte cryopreservation in 2014. The committee endorsed the ASRM and SART guideline for cryopreservation of mature oocytes. The ACOG committee also noted there is "not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women."
The National Comprehensive Cancer Network® (NCCN) Clinical Practice Guidelines for Adolescent and Young Adult Oncology (2016) include oophoropexy for females receiving radiation therapy. For individuals where treatment can be delayed long enough for a cycle of oocyte stimulation, then embryo cryopreservation should be discussed. "Mature oocyte cryopreservation is no longer considered investigational. Ovarian tissue grafting is still considered investigational."
Cryopreservation of Oocytes
Cryopreservation of oocytes is less commonly performed in the setting of malignancy due to the time constraints inherent in ovarian stimulation. The mature oocyte is very fragile due to its large size, high water content and chromosomal arrangement. For example, the mature oocyte is arrested in meiosis, and may be easily damaged both in freezing and thawing. Due to these factors, survival of cryopreserved oocytes after thawing may be impacted. Vitrification is an improved technique to freeze the oocytes and reduce the negative effects of cryopreservation.
Cobo (2011) performed a systematic review and meta-analysis of five eligible randomized controlled trials that compared oocyte vitrification with slow-freezing and fresh oocytes. The studies involved 4282 vitrified oocytes, 3524 fresh oocytes, and 361 slow-frozen oocytes between 2005 and 2009. The vitrification process resulted in a higher oocyte survival rate compared to the slow-frozen oocytes (odds ratio [OR] 2.46, 95% confidence interval [CI] 1.82–3.32). The rate of fertilization and a higher rate of top-quality embryo were also observed with the oocytes that were preserved by vitrification. The rates of ongoing pregnancy, top-quality embryo, embryo cleavage, and fertilization did not differ between the vitrification and the fresh oocyte groups. The authors concluded vitrification is an "Efficient method to preserve oocytes, although more large controlled clinical trials are needed to strengthen this conclusion."
The ASCO guideline (Loren, 2013) addressing fertility preservation for those with cancer was updated after a systematic review of published literature from 2006 through January 2013. The guideline was modified after a review of the evidence:
Present both embryo and oocyte cryopreservation as established fertility preservation methods.
Discuss the option of ovarian transposition (oophoropexy) when pelvic radiation therapy is performed as cancer treatment.
Inform patients of conservative gynecologic surgery and radiation therapy options.
Cryopreservation of unfertilized oocytes: Cryopreservation of unfertilized oocytes is an option, particularly for patients who do not have a male partner, do not wish to use donor sperm, or have religious or ethical objections to embryo freezing.
Oocyte cryopreservation should be performed in centers with the necessary expertise. As of October 2012, the American Society for Reproductive Medicine no longer deems this procedure experimental. More flexible ovarian stimulation protocols for oocyte collection are now available. Timing of this procedure no longer depends on the menstrual cycle in most cases, and stimulation can be initiated with less delay compared with old protocols. Thus, oocyte harvesting for the purpose of oocyte or embryo cryopreservation is now possible on a cycle day–independent schedule.
National Institute for Health and Clinical Excellence updated the guidance on fertility in 2013. The recommendations include the following:
Offer oocyte or embryo cryopreservation as appropriate to women of reproductive age (including adolescent girls) who are preparing for medical treatment for cancer that is likely to make them infertile if:
In cryopreservation of oocytes and embryos, use vitrification instead of controlled-rate freezing if the necessary equipment and expertise is available.
Cil and colleagues (2013) reported data from a meta-analysis of 1805 individual patient data (IPD) involving 2265 oocyte cryopreservation freeze-thaw cycles. The goal of the study was to analyze slow-freezing (SF) and vitrification (VF) of oocyte cryopreservation and determine the probability of live birth as a function of age, cryopreservation method and number of oocytes thawed, injected or embryos transferred. The participants' mean ages at oocyte freezing was 33.8 ± 4.0 (range, 20-48) for SF and 34.1 ± 4.7 (range, 20-51) years for VF. The overall oocyte survival and fertilization rates for VF (85% and 79%) were significantly higher (P<0.001) compared to SF (65% and 74%). The authors concluded the VF process has improved success rates compared to SF.
Cryopreservation of Ovarian Tissue
Cryopreservation of ovarian tissue with subsequent autologous or heterotopic transplantation has been researched as a technique to sustain the reproductive function of females who are faced with infertility resulting from procedures such as chemotherapy, radiation therapy or surgery that are frequently utilized to treat malignant diseases. A variety of articles have focused on the technical feasibility of these options, and there are retrospective case reports of successful pregnancies using this technique. However, in general, the technique is not standardized, and there is ongoing investigation of the following unresolved issues (Donnez, 2010; Imbert, 2014; Kim, 2001):
The ASRM Practice Committee updated a 2008 committee opinion on ovarian tissue cryopreservation. Based on the established criteria of ASRM, "Ovarian tissue cryopreservation and transplantation is experimental." The committee also noted:
Ovarian tissue cryopreservation is an option for patients who require immediate gonadotoxic treatment and is the only option available for prepubertal girls...Ovarian tissue cryopreservation and subsequent transplant may be offered to carefully selected patients as an experimental protocol.
In addition, the Practice Committee for ASRM (2013) published a committee opinion on fertility preservation for individuals undergoing gonadotoxic therapy or gonadectomy, noting ovarian tissue cryopreservation "should be viewed as investigational."
The updated ASCO guideline (Loren, 2013) addressed ovarian tissue cryopreservation and transplantation:
Ovarian tissue cryopreservation for the purpose of future transplantation does not require ovarian stimulation or sexual maturity and hence may be the only method available in children. It is considered experimental and should be performed only in centers with the necessary expertise, under IRB-approved protocols that include follow-up for recurrent cancer. A theoretic concern with reimplanting ovarian tissue is the potential for reintroducing cancer cells depending on the type and stage of cancer, although so far there have been no reports of cancer recurrence.
Note: IRB is an abbreviation for Institutional Review Board.
There are recruiting and ongoing clinical trials studying ovarian tissue cryopreservation as well as cryopreservation and use of immature oocytes. However, to date, results from these studies have not been published. Although there have been case reports of successful live births after cryopreservation, thawing, and implantation of ovarian tissue, there are still many unanswered questions about this technology. Data from prospective, randomized, long-term studies are needed to determine the safety and efficacy of ovarian tissue cryopreservation as a method to preserve fertility.
Cryopreservation of spermand embryos are established techniques in the treatment of preserving fertility in individuals facing medical treatment that may result in infertility. However, cryopreservation of oocytes, ovarian tissue segments or the entire ovary has been more problematic.
Cryopreservation of Oocytes
Due to the high water content and fragility of their chromosomal arrangement, mature oocytes encounter problems with the freezing and thawing components of cryopreservation. These problems may impact the subsequent embryos. However, different techniques for freezing oocytes and the improved viability and success rates with vitrification compared to outcomes utilizing fresh oocytes have made cryopreservation of oocytes a recommended option to preserve fertility in select women.
Clinical studies of oocyte cryopreservation continue to investigate improved techniques to further reduce cellular damage, and to identify factors such as, age at procurement, duration of cryopreservation, freeze-thaw techniques, etc., that impact optimal outcomes.
Cryopreservation of Ovarian Tissue
Ovarian tissue cryopreservation is a technique that addresses the fertility potential for those with prepubertal cancer or adults with cancer who do not have the luxury of the time required to undergo ovarian stimulation as part of an in vitro fertilization procedure followed by embryo cryopreservation. The cryopreserved ovarian tissue can either be autografted back into the host at a later date, or primordial follicles can be extracted from the ovarian tissue and then allowed to mature in vitro. In contrast to the limited number of mature oocytes that can be harvested after ovarian stimulation, ovarian tissue typically contains an abundant number of primordial follicles.
At present, cryopreservation of ovarian tissue is being studied in clinical trials, as the safety and possibilities for fertility preservation in humans are not yet proven.
Cryopreservation: The process of preserving and storing living systems in a viable condition at low temperatures for future use.
Gonad: A reproductive cell-producing gland, such as an ovary.
Gonadotoxic: Having a deleterious effect on the gonads, such as chemotherapy or radiation therapy.
Institutional review board (IRB): An institutional review board is a group that has been formally designated to approve, monitor and review biomedical and behavioral research involving humans with the aim to protect the rights and welfare of the subjects. The Food and Drug Administration and the Office of Protection from Research Risks (part of the National Institutes of Health) set the guidelines and regulations governing human subject research and IRBs.
Oocyte: The egg cell produced in the ovaries; also called the ovum or gamete.
Oophoropexy (ovarian transposition): A surgical procedure that involves moving the ovaries to another place in the body, away from where radiation therapy will be directed.
Ovarian: Having to do with the ovaries, the female reproductive glands in which the ova (eggs) are formed. The ovaries are located in the pelvis, one on each side of the uterus.
Vitrification: Ultra-rapid freezing process resulting in a glass-like solid that is free of any crystal formation.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
|89337||Cryopreservation, mature oocyte(s)|
|89346||Storage (per year); oocyte(s)|
|89356||Thawing of cryopreserved; oocytes, each aliquot|
When services are Investigational and Not Medically Necessary:
For the procedure code listed above when criteria are not met.
When services are also Investigational and Not Medically Necessary:
|89344||Storage, (per year); reproductive tissue, testicular/ovarian [specified as ovarian tissue]|
|89354||Thawing of cryopreserved; reproductive tissue, testicular/ovarian [specified as ovarian tissue]|
|0058T||Cryopreservation; reproductive tissue, ovarian|
|0357T||Cryopreservation; immature oocyte(s)|
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Cryopreservation of Oocytes or Ovarian Tissue
|Reviewed||11/05/2015||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Reviewed||11/04/2015||Hematology/Oncology Subcommittee review. Updated Rationale and References sections. Updated Coding section to add 89346, 89356; removed ICD-9 codes.|
|Reviewed||11/12/2014||Hematology/Oncology Subcommittee review. Updated Rationale and References sections. Updated Coding section with 01/01/2015 CPT changes; removed 0059T deleted 12/31/2014.|
|Revised||11/13/2013||Hematology/Oncology Subcommittee review. Added "radiation therapy" to the medically necessary criterion. Updated References sections.|
|Revised||07/11/2013||Hematology/Oncology Subcommittee review. Added medically necessary indication for cryopreservation of oocytes. Clarified investigational and not medically necessary criteria. Updated Rationale, Background/Overview, Coding and References sections.|
|Reviewed||08/09/2012||MPTAC review. Rationale, References and Web Sites updated.|
|Reviewed||08/18/2011||MPTAC review. References updated.|
|01/01/2011||Updated Coding section with 01/01/2011 CPT changes.|
|Reviewed||08/19/2010||MPTAC review. References updated.|
|Reviewed||08/27/2009||MPTAC review. References updated. Updated Coding section with 10/01/2009 ICD-9 changes.|
|01/01/2009||Updated Coding section with 01/01/2009 CPT changes; removed CPT 0058T, 0059T deleted 12/31/2008.|
|Reviewed||08/28/2008||MPTAC review. References updated.|
|02/21/2008||The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.|
|Reviewed||08/23/2007||MPTAC review. References updated.|
|Reviewed||09/14/2006||MPTAC review. References updated.|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|WellPoint Health Networks, Inc.||04/28/2005||2.09.16||Cryopreservation of Oocytes or Ovarian Tissue|