Fertility preservation

Cancer treatment can make it harder for both males and females to have children. This is why we explain the risk of infertility to all our patients and their families before we start treatment. The effect of cancer treatment can be unpredictable. But we know how some treatments may affect you.

Some factors that influence the risk of infertility include

• The patient's age at the time of cancer diagnosis
• Location and extent of surgery
• Use of radiation therapy
• Exposure to certain chemotherapy agents

Many adolescent and young adult patients will feel uncomfortable talking about fertility issues. They likely will be more focused on their cancer diagnosis and will be resistant to these discussions. But they may also be unaware of their options for fertility preservation.

Years after receiving cancer treatment, a patient may regret not taking more steps to preserve their fertility. Providing our patients with all their options to preserve fertility is part of our goal to provide the best cancer care. It's best to start talking about these issues at a patient's first clinic appointment, or while in the hospital, when they first learn of their cancer diagnosis. This allows time for the patient to consider options.

There are two standard options for post-pubertal males with cancer who wish to preserve their fertility:

Radiation shielding

For patients receiving radiation therapy to areas near the testes, radiation shielding is an effective method of protecting testicular tissue from the gonadotoxic effects of radiation. However there are very few patients who receive isolated pelvic radiation without chemotherapy, so patients who fit these criteria will be relatively few. The treating oncologist should discuss radiation shielding with radiation oncology and, when applicable, surgery.  Each case will require specialized managed given the rarity of this approach.

Sperm banking

Cryopreservation of sperm, also known as “sperm banking” is the gold standard methodology of fertility preservation in the post-pubertal male. It is imperative that every effort is made to coordinate sperm banking for all post-pubertal males prior to starting therapy. All male patients who have gone through puberty will be strongly encouraged to sperm bank prior to starting treatment and will be referred to our designated partners who assist in the processing and cryopreservation process. In addition, we have resources to help patients with the logistic and financial details of sperm banking.

For individuals unable to sperm bank, there are alternative options that may be available to collect sperm for cryopreservation. We encourage discussing these options with your oncologist at the time of cancer diagnosis.

After cancer treatment is completed and the patient is in remission, some patients may want to have fertility testing repeated. Please discuss with your oncologist if you are interested in this opportunity.

Fertility preservation in boys before puberty

Currently, all procedures to preserve sperm from prepubertal boys are considered experimental. The most common technique is cryopreservation of testicular tissue. Please ask your oncologist for details if you are interested in these techniques.

For females diagnosed with cancer, it is also critical to discuss fertility risk prior to starting treatment. The significant incidences of premature ovarian failure and infertility are related to treatment intensity. Chemotherapy's toxic effects to the reproductive organs worsen with increased age, which is related to the reserve of eggs in the ovaries.

Discussion about fertility issues must be held prior to treatment, whenever possible, allowing for a consideration of fertility options.

Menstrual suppression

We recommend treating all patients with oral contraceptive therapy to suppress menses during chemotherapy. Most patients receive progesterone based therapy, although in some cases a combination of estrogen and progesterone analogues are used. Not only does this decrease the need for both blood and platelet transfusions during therapy, there are some studies that suggest oral contraceptives can preserve ovarian function in post-pubescent females.

We do not recommend the use of gonadotropin-releasing hormone analogues (e.g. Lupron). There have been conflicting clinical trials and scientific studies investigating the efficacy of ovarian preservation with these agents. The side effects of these drugs (hot flashes, mood swings, etc.) are not insignificant.

Oocyte preservation

Ovarian preservation options are more complicated for females compared to male patients. Below are the most common options available for post-pubescent females. Please discuss these options with your oncologist at the time of diagnosis.

Embryo freezing

This method is the most widely accepted and most successful method for preserving fertility in females. Women are subjected to hormone stimulation to promote ovulation. The eggs are then retrieved and fertilized with donor sperm to create embryos. These are then frozen for future implantation.

The main advantage of this method is that it is the only proven method for fertility preservation in females and is considered standard of care for post-pubescent women. Disadvantages include timing (usually requires four to six weeks prior to starting cancer treatment), a requirement of donor sperm (which can be a challenge for young women not in a stable relationship), and cost.

Oocyte cryopreservation is no longer considered experimental by the American Society of Reproductive Medicine (ASRM) and is used routinely. The technique used to preserve eggs is called vitrification. Instead of forming ice crystals, the egg is formed into a solid with the molecular structure of a liquid. Survival rates are above 80 percent. Embryos produced from vitrified eggs implant at the same rate as embryos produced from fresh eggs. Additionally surplus embryos derived from vitrified eggs thaw and implant at the same rate as their “fresh egg” counterparts. Thus, the specimen can be vitrified twice without detriment to the embryo. Oocytes are retrieved and subsequently frozen until future in vitro fertilization and implantation.

Approximately 200 pregnancies have been created using this technique. Advantages include no requirement of donor sperm at the time of oocyte preservation. Disadvantages include timing (four to six weeks needed prior to starting cancer treatment), cost (about $10,000), and a lack of proven efficacy (still experimental).

Ovarian tissue banking

This is a highly experimental procedure (only a handful of pregnancies have been reported) in which ovarian tissue is removed surgically and cryopreserved. When the female is ready to have children, the ovarian tissue is thawed, the eggs are matured and fertilized with donor sperm in vitro and then implanted.

Advantages of this method are timing (no four to six week wait), no need for hormonal stimulation, and quantity of oocytes (many compared to oocyte or embryo freezing). The main disadvantage of this method is that it is an experimental method still under development. In most cases, it is only available as part of an Institutional Review Board (IRB) approved research protocol, and often requires travel to a participating medical center.

Ovarian pexy

In cases in which patients are to receive pelvic radiation, the ovaries can be surgically moved out of the radiation field, thus eliminating their exposure to potentially gonadotoxic doses of radiation. The advantage of this method is timing (can be done immediately prior to radiation). The disadvantages are its invasiveness (surgery), lack of effect on chemotherapy exposure, and possible negative effect on blood supply to the transposed ovary.