1. THE DELICATE ART OF EGG FREEZING AN UPDATE OF SUCCESSES AND CHALLENGES

2.  Co-founder Donor Egg Bank USA DISCLOSURES

3.  Review the history of egg freezing  Explore the efficiency of the egg freezing model  Appreciate the nuances of quality management  Identify best practices  Review mechanisms to monitor for future success OBJECTIVES

4.  1953- First human birth from frozen sperm  1986- First birth from a frozen oocyte using slow freezing technique  1999- First birth from vitrified autologous eggs, Bologna, Italy –Luca Gianoroli’s program. Kuleshova, et al, 1999  2012- ASRM Practice Committee lifted experimental status from oocyte cryopreservation but does not recommend for widespread elective use. ASRM/SART Practice Committees, Mature oocyte cryopreservation: a guideline, Fertil Steril. 2013;99:37-43  2011 World Egg Bank announces relationship with CARE Fertility to export eggs to the UK and 2013 exports to Australia  2013 Health Canada “Not Illegal to import ova from an egg bank.” Published letter to Downie and Baylis, July 30, 2013.  2014- Google and Facebook announce coverage for egg freezing & Citigroup, JP Morgan Chase join in  90% of reported births have been since 2004 “Mature oocyte cryopreservation: a guideline”, Fertility and Sterility, Vol 99, No.1, January 2013, 37-43 HISTORY OF EGG FREEZING

5. WE’VE ARRIVED!

6.  New York Post On-line: Career women are having ‘egg-freezing parties’ August 13, 2014  U.S. News & World Report: Should I freeze my eggs? October 20, 2014  Today.com: 8 Things I wish I’d Known before Freezing my Eggs, December 10, 2014  Forbes: What Women are Saying about the Real Costs of Freezing, October 17, 2014  The Washington Post: How Fear Fuels the Business of Egg Freezing, March 6, 2015 ELECTIVE EGG FREEZING: PTS AND MEDIA ARE DRIVING FORCE

7. “It cannot be overstated how fraught with potential pitfalls the process of setting up and running a donor egg bank can be.” “Suffice to say, not all donors are suitable to be banked, not all oocytes are suitable for cryostorage, and not all laboratory technologists have the wherewithal to be consistent in their approach to this technology.” “…fickle technology…” Tucker M, Wright G, Morton P, Shanguo L, Massey J & Kort H. Hum Reprod 1996;11:1513. THE DELICATE ART OF EGG BANKING

8. FREEZING EGGS – HOW FICKLE OR DELICATE IS IT? USING DONOR EGGS TO EXPLORE QUALITY SUCCESS & CHALLENGES

9. AN EARLY START

10. DONOR EGG BANKING

11. EGG FREEZING FICKLENESS

12.  Donor/Autologous  Stimulation*  Inherent Oocyte Potential  Oocyte Response to Vitrification*  Quantity of eggs*  Vitrification Cooling Technique*  Storage & Handling  Thaw  Vitrification Warming Technique*  Sperm/Male Factor  Embryology Quality  Endometrium Preparation *to focus on in future slides SUCCESSFUL CYCLE OR POTENTIAL CHALLENGES

13. PREGNANCY OUTCOMES BY STIMULATION GRADING (2012–2014) Dose will vary based on AFC/AMH, weight and prior response – adjusted for ovarian responsiveness. HMG added (unless stimulation requires reduction). Typical stimulation duration 10 – 11 days. Lupron trigger to reduce OHSS. **Time from egg retrieval to egg vit (optimize egg quality with minimal cellular aging)

14. PREGNANCY OUTCOME BY NUMBER OF EGGS RETRIEVED (2012-2013) #Eggs # Transfers Ongoing >4014459 (41%) 30-3917985 (47%) 20-2919980 (40%) 15-199540 (42%) <152612 (46%) Total:643276 (43%) #M2s # Transfers Ongoing >40104 (40%) 30-3915261 (40%) 20-2920397 (48%) 15-1917373 (42%) <1510541 (39%) Total:643276 (43%)

15. PREGNANCY OUTCOME BY NUMBER OF EGGS AVAILABLE (2012–2014)

16. OOCYTE RESPONSE TO VITRIFICATION  Case Study: Donor AB  4 Fresh Cycles with 10 live births (SGFC 1:3 program)  2 Frozen Cycles (6 egg lots) with 0 live births  Experienced Freeze Tech  Risk: Frozen eggs that do not perform well after a vitrified state  Conclusion: Not all donor eggs freeze well & Research is needed to better understand basis and frequency for occurrence.

17. TECHNIQUE: CATCHER, PITCHER OR SHORT STOP?

18. VITRIFICATION COOLING TECHNIQUE

19. OUTCOMES BY EMBRYOLOGIST – BEFORE/AFTER INTERVENTION

20. OUTCOMES BY EMBRYOLOGIST – EGG WARMING

21. EMBRYOLOGIST FREEZE VS THAW DIFFERENTIALS

22. VARIABILITY IS THE ENEMY OF QUALITY

23. QUALITY TRACKING FREEZE & THAW MONTHLY SNAPSHOT Thaw Tech# of Thaws% Clinical% On-Going/ Thaw% On-Going/ ET% with Cryo Embrologist 11070.0% 87.5%60.0% Embrologist 2666.7% 50.0% Embrologist 3875.0%62.5% 25.0% Embrologist 41560.0% Embrologist 51662.5%56.3%64.3%68.8% Embrologist 6966.7%55.6%71.4%44.4% Embrologist 7955.6% 71.4%55.6% Embrologist 81163.6%45.5%50.0%36.4% Embrologist 92152.4%42.9%45.0%38.1% Embrologist 106445.3%42.2%44.3%51.6% Embrologist 113844.7%42.1%47.1%42.1% Embrologist 122458.3%41.7%43.5%62.5% Embrologist 132544.0%40.0%43.5%60.0% Embrologist 147944.3%39.2%41.9%40.5% Embrologist 15850.0%25.0%28.6%50.0% Embrologist 161233.3%25.0%27.3%41.7%

24. QUALITY TRACKING FREEZE & THAW QUARTERLY RANKFreeze Tech % Survival % Fert % Cleaved % Ok Day 3 % Clinical % On- Going/ Thaw % On- Going/ ET % Cancelled % Freeze All # of Thaws 1Embryology 197.4%68.4%100.0%76.9%83.3%66.7% 0.0% 6 2Embryology 271.4%83.7%90.2%89.2%72.7%63.6% 9.1%0.0%11 3Embryology 368.2%85.0%96.1%79.6%58.3% 0.0% 12 4Embryology 486.3%74.7%95.4%77.9%55.6% 62.5%11.1%0.0%27 5Embryology 584.8%77.2%94.2%82.2%54.8%52.4%55.0%4.8%0.0%42 6Embryology 683.6%73.3%100.0%78.8%62.5%50.0% 0.0% 8 6Embryology 770.9%74.4%96.6%42.9%50.0% 57.1%12.5%0.0%8 8Embryology 885.0%79.2%94.7%63.9%44.4% 50.0%0.0%11.1%9 9Embryology 994.1%79.2%97.4%91.9%71.4%42.9% 0.0% 7 21Embryology 2190.2%77.1%97.8%70.8%28.6%23.8% 0.0% 21 22Embryology 2290.0%77.8%85.7%61.1%20.0% 25.0%0.0%20.0%5

25. A DELICATE BALANCE – MONITORING FOR SUCCESS Mechanism for root cause analysis Clinical flexibility –Stimulation Measured response & yield (18 – 26 M2s) –Endometrium Estrogen duration Progesterone start Endometrial lining >8mm

26. A DELICATE BALANCE – MONITORING FOR SUCCESS Laboratory optimization – practice, staffing & timely retrievals –Retrievals 90 minutes apart –Singular focus on egg vit/thaw –Identify & minimize # technologist Review skill sets, VS draw down, identify oocytes timely, adherence to protocol –Timer – Every time –Optimize lab set-up & culture conditions Storage tank access

27. Challenges  Quality may deteriorate if process is not optimized.  Egg vitrification is technically challenging.  Data management & analysis is key to recognizing areas for improvement.  Lab environment and setup deficiencies can compromise success  Research is limited in these early days. Successes  Significant logistical and economic benefits to freezing eggs.  Optimization yields results equivalent to fresh.  Egg freezing is the latest ART frontier affording new exploration and applications. CONCLUSIONS –BALANCING FOR SUCCESS