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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?

To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com.

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Leading researchers are urging the medical community to rethink how they treat patients who experience severe menopausal symptoms. Mache Seibel, MD., former 20-year veteran of Harvard Medical School faculty, editor of My Menopause Magazine and Professor of OB/GYN, University of Massachusetts –was inspired by his wife’s experience, and took it upon himself to help her and countless others, manage this important phase of life. Dr. Seibel studied the hormones given to women to treat symptoms and revisited the research in the Women’s Health Initiative (WHI) from 2002. After an up-close look at the data, he realized that further educating people about the role of hormones in health was necessary.


Jane Doe Lost Her Mojo
Many women who are in the prime of their lives and height of careers struggle with the debilitating symptoms associated with menopause. Consider this scenario: A healthy woman, aged 51, is looking forward to engaging in a night of foreplay, fun and sex with her partner, but is unable to enjoy herself, because of the lack of natural moisture she’s had all of her life until now. The “dry sex” she now has leads to pain during intercourse–two common symptoms of menopause. Following an unsatisfying sexual experience, she eventually falls asleep, only to be awakened by hot flashes and night sweats, soaking her sheets. The next day she wakes up tired, frustrated, and in a mental fog, only to have this experience happen the next night, and the next, and the next, and again the week after that. Knowing that sexual desire for women starts in the brain, she became unsure about how to connect her desire for intimacy with her body’s sexual response the way she used to, and her overwhelming fatigue makes her wonder if it’s worth the effort. The good news is that the experience of the menopausal transition can be positive, given the appropriate treatment, which varies depending on the age and health-status of each woman.

Understanding Menopause
The process of menopause is like the process of puberty—but in reverse, says Dr. Seibel in his revolutionary book, “The Estrogen Window: The Breakthrough Guide to Being Healthy, Energized, and Hormonally Balanced–through Perimenopause, Menopause, and Beyond.” Although puberty is well understood, menopause, which effects every woman, is less so. Women may assume that the surge of estrogen during early menses will suddenly shut off like a spigot, but it is more subtle and takes longer than one might imagine, leaving in its wake, uncomfortable symptoms, which were broadly treated with hormones such as estrogen and synthetic progesterone (progestin) until the WHI study results were released in 2002.

The WHI hormone studies have increasingly come under fire for the way they were designed, most importantly the inclusion of women up to age 79 years. The results of these studies have reverberated through the medical community as the changes they caused may have been both too broadly applied and in some cases simply incorrect. The findings that hormone therapy was putting many women at risk for certain conditions such as breast cancer and cardiovascular conditions caused many women to go off their hormone-replacement therapy “cold turkey” without knowing how to address the consequences, and not fully understanding the risks versus rewards. For example, some of the patients in the WHI study were already at risk for cancer or cardiovascular disease because of life-long smoking, being overweight and the age at which they started hormone therapy. However, otherwise healthy women should be able to use these therapies to ward off the symptoms that affect sexual health and pleasure.

Opening the Estrogen Window
Dr. Seibel calls the estrogen window, the “decade-long time-frame between the ages of 50 and 60, or 10 years from the time of menopause,” which is defined as at least 12 consecutive months menstrual period-free.

His book outlines important recommendations that are not a one-size fits all approach. Here are several key takeaways for improving and maintaining sexual vitality:

Low estrogen levels at midlife are common causes for genitourinary syndrome of menopause that causes bladder leakage, vaginal dryness, and elasticity in vaginal tissue to change–leading to discomfort during sex (location 3014).

The estrogen window for vaginal estrogen always remains open; it never closes (location 836).

Estrogen alternatives exist for women with medical histories (e.g., breast or endometrial cancers, blood clots, liver disease, pregnancy, undiagnosed uterine bleeding) that make it inadvisable to take estrogen (location ,787 814).

This book is available online and at the website drmache.com/Estrogen-window-book. This website contains downloadable bonus material, including the Menopause Checklist, Sleep Diary, and much more. Armed with this information, a visit to your gynecologist can lead to better overall health and importantly, a continuation of a satisfying sex life, well into advanced age.

To learn more please call the office at (202)293-1000 or email the practice at info@intimmedicine.com.

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