Protecting fertility before cancer treatments

May 21, 2010Carole 1 Comment »

Everybody knows someone who has been diagnosed with cancer. The good news is that survival rates are getting better and better. But greater survivorship has shone a light on problems associated with chemotherapies and radiation treatments used to treat cancer. Chemotherapy and radiation therapy can permanently sterilize cancer patients.

Why am I telling you about fertility preservation? Two reasons. First, fertility preservation is very important to me because I have had cancer survivors come in and ask me why no one thought to tell them that chemotherapy could make them infertile.  Second, most patients who seek fertility preservation services find out  about these services from other sources besides their cancer doctor. Friends and family who heard about it on the TV, radio or read about it on someone’s blog are the ones who let newly-diagnosed cancer patients know about fertility preservation before cancer treatment.

So, it is up to you to tell your friend or family member that they have more options than they might think for protecting their fertility. Although the American Society of Clinical Oncology (ASCO) have specific practice  guidelines strongly encouraging their member oncologists to discuss fertility preservation with their patients, it’s the patients themselves and not doctors who are initiating most of those discussions. The American Society for Reproductive Medicine has also chimed in with an ethical opinion about fertility preservation.

For Men

Sperm banking is readily available through sperm banks and through many fertility centers. The support group Fertile Hope has a directory of sperm banks and centers that will bank sperm for cancer patients at a discount. If the patient is well enough, he can bank at least one sample before undergoing chemotherapy radiation therapy. With assisted reproductive techniques such as sperm injection, one sample frozen in multiple vials is often enough.

Adolescent boys who have entered puberty are also able to bank sperm. In rare cases, if the patient feels too unwell to produce a sample or the boy is pre-pubertal, surgical recovery of a sample  from the testis or epididymis (the sperm storage organ) is possible, especially if the patient is already going to the OR for cancer surgery.

Cancer treatments shut down sperm production. The testicle has rapidly dividing stem cells called spermatogonia which churn out sperm cells, completing production of each “batch” of sperm cells approximately every 70 days. Continuous batches of sperm are being produced daily from puberty well into old age. Chemotherapy and radiation kills dividing cells non-descriminately. Some survivors find that sperm production is completely and permanently shut down. Other men are able to recover their ability to make sperm and achieve normal sperm counts. Men who had low counts to begin with are more likely to be made permanently sterile. Even if the count returns to normal, men are commonly counseled to wait two years after completing treatment before trying to conceive a child  due to concerns that cancer treatments may introduce temporary genetic mutations in sperm while the genetic machinery is recovering after treatment.

For Women

As you might expect, the options for women and girls are more complicated and expensive. Chemotherapy drastically reduces ovarian reserve, meaning eggs are killed off and women enter menopause earlier. Unlike men, women aren’t able to replace the eggs that are destroyed, leaving them sub-fertile or infertile after cancer treatment.

Options for female fertility preservation include egg banking and embryo banking. Either option means the patient needs to delay her treatment for two to four weeks (depending on where she is in her cycle) to squeeze in a stimulation cycle so her  ovaries can be hyper stimulated to produce 12-20 eggs. To bank embryos, you need a sperm donor or a partner who is willing to contribute sperm to make embryos. There is a trend away from embryo banking unless the couple is married because if the relationship deteriorates, the embryos might not be useable by the patient because legally the embryos belong to both parties.

Depending on the clinic, the newer technique of egg freezing has become just about as effective as embryo freezing, so this option makes the most sense for unmarried women and young post-pubertal girls. FertileHope also has a financial aid plan called Sharing Hope to help make egg and embryo banking affordable.

For pre-pubertal girls (who can’t be stimulated) and women who can’t delay their oncology treatment, removing ovarian tissue before cancer treatment and freezing it for later may be an option, although freezing ovarian tissue is still considered experimental treatment, not standard of care.

Ovarian transplant successes. Although still at the research stage,  pregnancies have been reported from fresh ovarian pieces and whole ovary transplants, demonstrating that these surgical ovarian grafts can regain function. Pregnancies have also resulted from transplanted tissue that was cryopreserved and thawed, showing that even previously frozen tissue can regain full function after thawing and transplant.

Transplanting ovarian tissue is not an option for every patient. Patients with blood cancers are poor candidates for ovarian transplant because of the concern that cancer cells may have infiltrated the highly vascularized ovarian tissue, opening the door to reseeding the cancer after transplant. For these patients, research supported by the National Institutes of Health may provide another answer.

Ovarian tissue culture for egg harvest. Instead of transplanting the ovarian tissue back, some researchers are exploring the concept of growing pieces of ovarian tissue containing follicles in vitro to allow eggs to grow and mature. Mature eggs could be harvested from the in vitro culture system for use with in vitro fertilization, without any risk of reseeding cancer. This research has been successful in mice and shows promise with experiments performed with primate and human ovaries. Culturing ovaries in a dish to grow eggs is more difficult than it might sound, because ovarian tissue is very complex and depends on both spatial signals and hormonal regulation to normally grow an egg. Those conditions are proving challenging to replicate in the lab. Details about the current status of the research is available on the Oncofertility site also. Because the timeline to clinical use is years, not months, this option is best for young women or girls who can wait at least a decade before they want to use this tissue to have children.

Four research universities have united to form the Oncofertility Consortium which is funded by the NIH Roadmap for Medical Research/Common Fund.  The four core universities are Northwestern University, University of California, San Diego, University of Pennsylvania, and the Oregon Health and Science University. The NIH grant money goes toward basic research and patient education, advocacy and support.

Fertility Centers have partnered with the research program to get cutting-edge services to patients. Approximately sixty fertility centers around the United States have partnered with the consortium to provide fertility preservation services to patients and have been trained in the ovarian freezing protocols validated by the consortium. These partner centers are members of the  National Physicians Cooperative . If you call the patient hotline, called the FERTLINE, you will be given contact information for the nearest member center that is able to provide the fertility services you need.

Even though the research is cutting edge, the majority of patients don’t need the research services and are helped through the educational mission of the Consortium. Their patient website MyOncofertility is bursting with patient information and support for the patients (both male and female)  and their family members. There you will also find a directory of  dozens of other patient support links.

Warning about vetting clinics that freeze ovarian tissues. Lots of fertility centers have frozen ovarian tissue over the years for patients but only some of these tissues are useable today because proper techniques for surgical removal and freezing were not well understood.  Tissue harvesting was often done as a “favor” to the patient (or her oncology doctor) in an emergency, without much planning and forethought because it wasn’t part of the regular services the fertility center provided. Unless the center is working with the Oncofertility Consortium or another NIH-funded group to provide these services, chances are less that the tissue will be useful. I personally “inherited” tissues frozen with the best intentions in last minute interventions for half a dozen different cancer patients. To the best of my knowledge, none of that tissue has been useful to the patients because the protocols used weren’t cutting edge. It’s easy to throw tissue in the freezer. It’s much harder to get it to come back to life and full function after you thaw it. So use NPC centers for ovarian tissue centers. They are required to operate under current Institutional Review Board (IRB) protocols which protect patients engaged in research.

Disclosure: I have no financial interest in the Oncofertility Consortium.

© 2010, Carole. All rights reserved.

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