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Preservation of Fertility in Patients Undergoing Cancer Therapy

md0006131By Carolyn R. Kaplan, M.D.

Cancer Therapy and Women’s Fertility

Each year, cancer is estimated to occur in 113 per 100,000 women under age 50 in the United States. Treatment of cancer has improved dramatically over the past several years, and it is estimated that 77% of patients under 45 survive at least 5 years. The trend toward delaying childbearing means that many patients will not have had children when they are diagnosed. While there is recognition that cancer therapy can affect a patient’s fertility, less than 25% of oncologists inform their patients about their risks and options.

Chemotherapy or radiation therapy for malignant and nonmalignant diseases often results in premature ovarian failure and infertility. One of the strongest predictors of emotional well being in cancer survivors, besides sexual function, appearance, and employability, is feeling healthy enough to be a good parent. Cancer survivors are often fearful that their history of cancer or its treatment will have an adverse impact on their offspring by placing them at risk for malignancy, congenital anomalies, or impaired growth and development. They are also concerned about the risks of cancer recurrence, infertility, miscarriage, and achieving a successful pregnancy outcome.

Despite these concerns, surveys have reported that fewer than 60 percent of respondents had received information about fertility after cancer treatment.  There are several methods to preserve fertility in women diagnosed with cancer.

Fertility preservation requires individualization. The optimal approach depends upon the type of cancer treatment (radiation versus chemotherapy), time available, patient’s age, type of cancer, and whether the patient has a partner. However, there are no large randomized clinical trials evaluating the majority of the interventions described below, nor are there long-term follow-up studies assessing the possible impact of fertility treatment on cancer survivors.

One option includes In Vitro Fertilization and embryo cryopreservation. Women who must undergo chemotherapy or radiation therapy may go through early menopause. In vitro fertilization and embryo freezing will allow a woman to delay conception until she has completed her treatment, and deemed in remission, even if treatment causes early menopause. There are several steps to this including hormone therapy, egg retrieval, fertilization, laboratory development of the embryo, and freezing.  Frozen Embryos can survive for many years and once the patient is in remission and ready to use the embryos, the process of transferring the embryos can begin.

Any woman who has gone through normal puberty and still has regular menstrual cycles may be a candidate for embryo freezing. Success rates decline as women get older, and are best if women are under 38 years old. Some women may have poor ovarian function even at a young age, but fertility tests can predict success rates. Women who do not have a partner may have the option to freeze eggs. This new technology has led to live births, but is still considered experimental, and requires a specialized embryology laboratory.

Egg Donation is also another option. Egg donation allows a woman who has gone through menopause to carry a pregnancy. The process is similar to in vitro fertilization, except that a fertile woman (a relative, friend, or anonymous donor) is given fertility drugs to stimulate multiple eggs to develop. Once the eggs are harvested, they are fertilized with the infertile woman’s partner’s sperm (or donor sperm) and the embryos grown in the laboratory for several days.

The infertile woman receives hormone therapy to develop a normal uterine environment, and then the resulting embryos are placed in the infertile woman’s uterus. Hormone therapy is maintained for several weeks and then pregnancy progresses normally.

Cancer Therapy and Men’s Fertility

Male cancer patients have long been able to preserve their fertility by freezing their sperm. Unfortunately, sperm quality is often affected by cancer, and there may be poor sperm quality at the time of diagnosis. Sperm Banking is a great option for men. Most large cities have sperm banks that can freeze sperm. If a sperm bank is not located near your home, you can find sperm banks across the country that can provide long term sperm storage. The Internet is a great resource, and all reputable sperm banks have detailed websites.

Options for fertility treatment depend on how cancer therapy has affected the man’s fertility, and how normal the semen analysis is after treatment. Options may include artificial insemination with washed sperm if the sperm is relatively unaffected by cancer treatment, or if frozen sperm are available from before cancer therapy.

Insemination with donor sperm can allow conception when there are no sperm present after cancer treatment. If there are any sperm available, even very poor quality or extremely low numbers of sperm, than in vitro fertilization can allow conception. Once the eggs have been harvested from the patient’s wife, the embryologist can pick up a single sperm and inject each egg to ensure normal fertilization. Live birth rates are excellent with this procedure, and are largely dependent on the age of the patient’s wife.  In addition, adoption remains an option for family building. There are local and international adoption agencies, and private adoption through an attorney may also be possible. Unfortunately, adoption can be very expensive, and international adoption laws often change, causing frustration for infertile patients.

All of the above are viable and real options for cancer survivors who wish to have a family. As the oncology community becomes more aware of fertility preservation options, these are offered to more patients. There are advocacy organizations that can help, such as the Lance Armstrong Foundation, and Fertile Hope, to assist patients as they negotiate treatment options in their quest for a family.

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Carolyn R. Kaplan, M.D. is Director of In Vitro Fertilization at Georgia Reproductive Specialists and specializes in the initial diagnosis of infertility, egg donation, alternative approaches to the control of menopause and the holistic approach to infertility treatment. Visit www.ivf.com for more information.

4 comments

  1. DoLee…Contact info for the author can be found thru the website listed in the bio at the end of the article.

  2. Less than 25% of oncologists … that’s sickening, I’m stunned. I moderate online support groups for Hodgkin’s and non-Hodgkin’s lymphomas, and little surprise that we have a lot of young men and women newly diagnosed with HL and I rarely mention the issue of fertility unless someone asks, but I’m not a health care professional and don’t pretend to be one. I assume that their doctors have mentioned the risks associated with ABVD or R-CHOP, or radiation, because it seems unthinkable- unconscionable- not to. I realize that newly dx’ed patients are under a lot of stress and being hit with tons of information, but this is Hodgkin’s– hematology oncologists enjoy that rare luxury in cancer treatment of having a treatable, highly curable cancer. It’s no longer necessary to sacrifice the future to save today; long-term survival – including long-term dreams and goals of the patient- why aren’t these things considered an aspect of their care?

  3. Curious why there are no citations or referencesin this article? some of the data reported here should be cited to the appropriate authors and institutions as well as providing consumers with access to the original source

  4. While I am glad that 60% of women are instructed about their options for egg and embryo freezing prior to beginning a course of radiaion or chemotherapy treatment, I find it frustrating that 40% are never given that option. My cousin’s wife had cervical cancer and thankfully an oncologist who suggested egg retrieval and embryo freezing before she began treatment. Although the radiation treatment made her uterus an inhospitable environmnent, following her successful remission she was able use those 18 embryos frozen in storage to create her own family through surrogacy. I acted as their surrogate mom, and our surrogacy journey allowed her to step beyond her fear of the cancer and embrace hope and life again. Delivering a healthy baby girl to them to realize their dream of a family was the most fulfilling moment of my life, and the most joyful of theirs, and I hope some day soon no woman will have to forfeit that opportunity because a doctor did not educate her about her options. Thank you for helping to spread the word, as I am trying to do the same! I would be happy to share our journey with doctors, patients and survivors in any way that would be helpful.

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