As a reproductive specialist, board certified in reproductive endocrinology and infertility, this blog post has special significance for me. While you may not need the information provided here, you may know someone who does. Please “Pay It Forward”, “Pass It On”.
Women experiencing a cancer diagnosis is a life-altering experience; however, so is infertility. Breast cancer treatment is one cancer type that can have permanent effects on fertility because ovarian removal, injury (i.e., chemotherapy or radiation) and/or suppression is often part of the treatment strategy. Additionally, each year approximately 71,500 women in the United States are diagnosed with a gynecologic cancer, according to the Center for Disease Control (CDC). These cancers include cervical, gestational trophoblastic disease (GTD), primary peritoneal, ovarian, uterine/endometrial, vaginal and vulvar cancers. Because of the nature of cancer as it relates to fertility, I would like to provide more information about fertility options at the point of a cancer diagnosis so that patients can benefit from fertility preservation strategies before treatment begins because three out of four patients are interested in having a family one day.
How Treatment Affects Fertility
Treatment, including chemotherapy, radiation, and surgery can cause damage to organs involved in reproduction, such as the ovaries, fallopian tubes, uterus, and cervix. Ovarian suppression, used to slow or stop estrogen-receptor positive cancers, can be reversed following treatment. However, other treatments such as chemotherapy, radiation and some surgeries can cause women to experience early and permanent menopause.
Weighing the Options Before Treatment
There are several methods to preserve future fertility if patients are able to compete one of these prior to chemotherapy or radiation.
Embryo freezing is a primary method of fertility preservation for women, according to Cancer.Net a patient site from the American Society of Clinical Oncology (ASCO). After taking fertility drugs for two weeks a woman’s eggs are collected and fertilized by sperm though in vitro fertilization. The embryos are frozen until the woman is ready to become pregnant. Although fertility drugs increase estrogen during fertility treatment, aromatase inhibitors can keep the levels low for women with estrogen-sensitive cancers thereafter.
Oocyte (unfertilized egg) freezing is similar to embryo freezing, except that the eggs are frozen without being fertilized by sperm. This is a particularly important option for women who are not currently “partnered” or do not want to choose a sperm donor.
Fertility-preserving surgery is an option for cervical or ovarian cancer. Surgery can treat the cancer and help preserve a woman’s fertility. Surgery may also be used to “move the ovaries” out of harm’s way, should radiation be needed in an anatomically adjacent area. The ovaries can be “put back” in their normal location at a later time if needed for future fertility.
For girls who have not yet reached puberty, an experimental option is to try ovarian tissue cryopreservation, a process where an ovary or ovaries are actually removed from the body and frozen in pieces until needed following cancer treatment. At that time, the ovary or a part thereof can be re-implanted in the arm, abdomen or other easily accessible location for future egg retrieval. While this sounds like science fiction, some babies have already been born using this process.
During treatment, the oncology team may try ovarian shielding to ensure that the ovaries are not harmed during radiation therapy. In an effort to protect the ovary by reducing its exposure to chemotherapy an attempt can be made to “turn off/turn down” the ovary’s blood supply using other medications. This approach has had mixed results, but has few downsides. One cancer treatment has commenced and premature menopause results, patients may consider surrogacy or adoption in addition to the options listed above.
Guidelines Broaden the Discussion
In 2013 the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline on fertility preservation. One of the pivotal updates to the guideline was the change from the word “oncologist” to “healthcare provider”, to broaden the responsibility to more members of the medical team who can help lead discussions with patients to help them better understand their fertility preservation options. While I applaud this approach, I prefer that these men and women be called “healthcare professionals”.
The Future of Oncofertility
Because patients with cancer are enjoying greater survival rates in large numbers, there is a need to address the whole person, not just the removal of the cancer, because survivorship, for many, also includes raising a family. Teresa K. Woodruff, PhD, of Northwestern University Feinberg School of Medicine in Chicago and Thomas J. Watkins, MD professor of obstetrics and gynecology at Northwestern, coined the term “oncofertility” to describe oncologists and reproductive specialists working together preserve patients’ fertility while treating their disease.
Medical professionals can ensure that patients and their families have all the decision-making tools available about fertility preservation. Members of the ob/gyn and also oncology teams should address the future fertility options with patients at the point of cancer diagnosis and prior to initiating treatment.
Top Tips for Discussing Fertility with Patients
1. Discuss fertility preservation with all patients prior to and of reproductive age if infertility is a potential risk of therapy.
2. Refer patients who express an interest in fertility preservation (and patients who are ambivalent) to reproductive specialists.
3. Address fertility preservation as early as possible, before treatment starts.
4. Document fertility preservation discussions in the medical record.
5. Answer basic questions about whether fertility preservation may have an impact on successful cancer treatment.
6. Refer patients to psychosocial providers if they experience distress about potential infertility.
7. Encourage patients to participate in registries and clinical studies.
Reference: Key Recommendations: Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update
Top 10 Questions to Ask your Doctor about Fertility and Cancer Care
1. How does cancer affect my fertility?
2. Which cancer treatments can affect my fertility?
3. Which fertility preservation methods should I consider before cancer treatment begins?
4. How does the process of egg preservation work?
5. How long does this procedure take?
6. How soon after cancer treatment can I plan for a pregnancy?
7. My cancer type requires ovarian suppression. When can I become pregnant after ovarian suppression is reversed?
8. What are the side effects of these procedures?
9. I’m already pregnant and diagnosed with cancer. Will I be able to have children in the future?
10. Will my insurance cover these procedures?
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