Preserving Fertility in Female Cancer Patients

Julie Zeplin-Nelson, RN
Clinical Education Coordinator
IVPCARE

Each year, thousands of women in the United States will be diagnosed with cancer before or during their reproductive years. Fertility in female cancer patients encompasses a variety of concerns including the effects of cancer treatments on fertility, available fertility preservation options, cancer risks associated with fertility treatments, pregnancy and the risks of birth defects.

The loss of fertility through cancer treatment is one of the most traumatic side effects experienced by women. Unfortunately, many women with cancer think of the possibility of losing fertility when diagnosed, but tend not to pursue discussing fertility preservation options with their oncologist prior to treatment. In a fight to eradicate the cancer, many oncologists are not thinking about fertility after treatment and therefore, preservation options are never discussed with their patient prior to treatment.

In order for female cancer patients to preserve their reproductive options post treatment, it is imperative that decisions regarding fertility be made between diagnosis and the onset of treatment. This can only be accomplished with the patient’s oncologist working in collaboration with a reproductive endocrinologist. By discussing options to preserve fertility at the earliest phase of the treatment plan, the patient has more control of her future.

Fertility Risks with Cancer Treatments

The risk of infertility due to cancer treatments depends on certain factors such as:

• Age
  Infertility is affected by age. Women in their thirties are capable of tolerating much higher doses of chemotherapy without experiencing menopause, either temporarily or permanent, than women in their forties or older.
• Type of Cancer
  Some cancers require treatments that are more harmful to the reproductive organs than others
• Type of Treatments
  
  Chemotherapy
  
  The goal of chemotherapy treatment is to kill the cancerous cells while not harming the adjacent healthy cells. However, chemotherapeutic agents can cause immediate or reduced fertility by targeting both cancer cells and some normal healthy cells. Chemotherapy can also damage the layer of cells that protects the eggs, thus reducing the number of eggs in the ovary or by causing early menopause.
  
  During chemotherapy treatment and for a period of time after treatment is complete, ovaries can temporarily or permanently stop functioning. The younger the patient is when receiving chemotherapy, the better her chances are that her ovaries will regain total function. The nearer a patient is to natural menopause; the more likely it is that the chemotherapy treatments will make the patient permanently infertile
  
  Higher risks of infertility are associated with:
  
  1. Women who are 35 or older at the time of treatment
  2. A higher total dose of chemotherapy
  3. Treatment with certain classes of chemotherapy drugs, such as alkylating agents and platinums.
  
  It is essential that women understand the importance of pregnancy prevention while undergoing chemotherapy treatment due to the risks of birth defects, stillborns, and miscarriages.
  
  Radiation
  
  Radiation therapy destroys cancer cells by bombarding them with x-rays or electrons, thus damaging the cancer cells which later die. The challenges that are faced using radiation therapy are how to deliver enough x-rays to destroy the cancer cells without damaging the surrounding healthy cells
  
  In female cancer patients, radiation to the abdominal or pelvic region could potentially damage the uterus, ovaries, or both, resulting in permanent sterility.  Radiation to certain areas of the brain can alter hormone production which can result in infertility.
  
  It is essential that the patient, along with her healthcare providers, consider such factors as: location, dose of radiation and age prior to initiating radiation treatments.
  
  Surgery
  
  Surgery to remove part or all of the reproductive organs may cause infertility depending on the organs affected and extent of the surgery.
  

Options to Increase Fertility Preservation in Women Prior to Cancer Treatment

The best way to improve the chances of having children after cancer treatment is to take action before treatment begins. A female cancer patient basically has two fertility-sparing options—surgical or medical. Factors such as age, type of cancer and type of treatment will determine which treatment option is recommended.

Surgical Options

Oophoropexy - This surgical procedure involves moving one or both ovaries via laparoscopy from the radiation area. Ovaries that are moved in this manner continue to function normally in terms of hormone production and ovulation. However, since the ovary is detached from the fallopian tube, the eggs or oocytes must be aspirated for an IVF procedure. The success rate of this procedure is approximately 50%.

*Ovarian Tissue Freezing - Currently, this is a highly experimental laparoscopic procedure that involves the removal of tissue from the ovary, dividing it into small strips and freezing it. The tissue is then thawed and re-implanted into the woman’s pelvis after the cancer treatments are complete.

Radical Trachelectomy - This is a surgical procedure for women with cervical cancer that involves the removal of the cervix, along with surrounding lymph nodes, but preserving the uterus. This procedure offers younger women the chance to effectively treat their disease while still preserving their ability to conceive and bear children.

Medical Options

*Embryo Freezing - Using standard IVF techniques, mature or immature eggs are removed, fertilized, frozen and stored until cancer treatments are complete. Currently, this medical procedure is the most successful (25%) in preserving fertility, but a partner or donor sperm is required.

*Egg (Oocyte) Freezing - This procedure remains highly experimental involving the removal of mature eggs which are then frozen without being fertilized.

GnRH Agonists - This is a manufactured hormone that suppresses ovulation by lowering the estrogen level, which halts egg production in the ovaries, thus preserving ovarian reserve. This treatment is recommended prior to cancer treatments. However, recent studies have shown that women receiving the GnRH agonists during cancer treatments have a better chance of preserving ovarian function.

Oral Contraceptive Pills (OCP’s) -Taking OCP’s have been found to have similar results as women taking GnRH agonists, suppressing ovulation which preserves ovarian reserve.

(*Can be done before or after cancer treatment)

Regardless of decided treatment, physicians advise waiting at least two years after cancer treatment to have children. This time frame is recommended because the highest risk of cancer recurrence comes in the years immediately following treatment.

It is important for patients to be made aware of certain signs and symptoms after cancer treatment that could suggest early menopause:

• Irregular menstrual cycles
• Amenorrhea (no menstrual cycle)
• Hot flashes
• Vaginal dryness
• Mood swings
• Insomnia
• Decreased breast size
• Loss of energy
• Low sex drive
  

It is especially important to counsel young female cancer survivors that even if they have normal ovarian function return after cancer treatment, this may not last.

Summary

In summary, understanding the risks of infertility before starting treatment is the best way to plan for the future. In order to accomplish this, it is crucial that patients talk with their doctor(s) about their risks and options.

Below is a list of sample questions that may be helpful when discussing the potential risks of infertility from cancer treatments with an oncologist.

1. Do I have a choice in cancer treatments?
2. Does a certain type of cancer treatment cause more infertility problems than others?
3. I want to start a family in the near future.  Can I delay treatment?
4. Will the chemotherapy / radiation make me infertile?
5. How will the treatments affect my monthly cycle?
6. What are my options to preserve my fertility?
7. Will I be able to have children after my treatments?
8. It is important that all the doctors involved in my treatment understand my concerns and desires regarding my fertility.  What do I need to do so that open communication exists?
9. Can you suggest some educational resources?

For additional information on this topic, a list of website links has been provided.

Fertility preservation in female cancer patients: current developments and future directions

Fertility preservation options for female patients with malignancies.

PATIENT’S FACT SHEET - Cancer and Fertility Preservation

I'm in remission from cancer. Do I need to know anything special before I get pregnant?

Fertile Hope - Helping Cancer Patients Maintain Fertility

Additional Resources