More and more patients seeking infertility
treatment at TFC have been recently diagnosed with cancer or other
chronic diseases. When they come to see us, they want to understand
the available options that will hopefully allow them to preserve
their fertility. In the past, all we could do for these patients
was bank sperm or embryos and hope that a few would survive their
cancer long enough to return for a chance for pregnancy. As a
result of significant advances in cancer treatment, however, more
and more patients are surviving their cancers and they are therefore
very interested in subsequent fertility. After winning their battle
against their disease, they understandably have high expectations
for a successful outcome. Fortunately, there have been many recent
advances in gamete and embryo cryopreservation that allow us to
offer these patients significant hope for achieving a family of
their own.
Fertility threatening treatments, whether for
cancer or other types of chronic disease such as rheumatoid
arthritis or others, primarily include chemotherapy, radiation
therapy and surgery. Factors to consider when trying to determine
the best alternatives and approaches for fertility preservation
include the age of the patient, the site of treatment, and the types
of medication or other therapy that will be administered to treat
the underlying disease.
There are many different types of
chemotherapeutic protocols and medications that are widely used
today. Some medications are well known to have a profound adverse
effect on subsequent fertility, whereas others are much more mild.
The chemotherapeutic agents that appear to have the most severe
adverse effects on fertility include drugs such as cytoxan,
cisplatin, and procarbazine, whereas medications such as
methotrexate or 5-flourouracil appear to have a substantially milder
effect. Obviously the timing of your therapy, as well as the choice
of specific drugs is up to your oncologist. Nevertheless, we will
work closely with your other physicians to allow you to cryopreserve
as many gametes as possible without interfering with your
chemotherapeutic plan.
The effects of ionizing radiation on fertility
can also vary markedly – depending primarily on the dose
administered and the site(s) being treated. While effective gonadal
shielding may serve to limit total radiation exposure, there are
other options available to patients as well. As survival rates have
improved, the radiation oncologists have become much more sensitive
to fertility preservation. They will, therefore, thoroughly discuss
your options with you prior to the initiation of treatment.
Surgical treatment may involve resection or
removal of the ovaries or the testicles, as well as other parts of
the reproductive anatomy. Adjunctive treatment with either
chemotherapy or radiation therapy is frequently given either before
or after surgical resection. Advance planning, through inclusion of
your TFC physician in the treatment process, can serve to maximize
your opportunity for fertility preservation.
As a result of recent research that has been
performed in our field, we now have fertility preservation options
that can be employed very effectively – preferably before – but
frequently even after chemotherapy, radiation, or surgery. In the
event that male patients contact us prior to undergoing treatment,
we can offer sperm banking, freezing of testicular tissue, or
testicular sperm extraction. Women who seek assistance prior to
chemotherapy or radiation can have their oocytes retrieved for
either oocyte cryopreservation or embryo cryopreservation. In
addition, some women who are going to subsequently undergo
chemotherapy or radiation therapy may elect to have treatment with
medications such as Depot Lupron, in the hope of minimizing the
adverse effect of the cancer therapy on their ovaries. Similarly,
women who are going to undergo radiation therapy may desire to have
their ovaries surgically relocated within the pelvis. Ovaries can
be placed higher in the pelvis and potentially out of the area that
will subsequently be affected by radiation, minimizing the overall
dose of radiation they receive.
The resumption of normal testicular or ovarian
function following chemotherapy, radiation, or surgical treatment is
very variable. Even if hormonal production becomes normal again,
that does not guarantee that gamete production will do so as well.
Fortunately, men do occasionally recover enough sperm production to
cause a pregnancy – sometimes even without fertility treatment.
Women, depending upon their resulting ovarian function, can
sometimes conceive naturally as well. Other patients may require
the use of gametes or embryos that were frozen prior to their cancer
treatment. Even in the worst case scenario, in which either the man
or the woman has no remaining reproductive function following
treatment, successful fertility treatment is usually still available
in the form of donor eggs, donor embryos, donor sperm, or
traditional surrogacy.
In the overwhelming majority of cases,
pregnancy following cancer treatment does appear to be safe. This
holds true even following treatment for breast cancer. Although
oocytes may be damaged temporarily, and ovarian function may be
significantly impaired – even resulting in menopausal symptoms –
ovarian function does occasionally return to a pretreatment state.
Similarly, although sperm cells may be damaged by either
chemotherapy or radiation, there are studies that suggest that the
cells may very well become normal again at a later date.
Several studies have evaluated the rate of
birth defects in children born to cancer survivors. These rates
fortunately do not appear to be any greater than that of the normal
population, ranging from 2 % to 6%. In addition, with the exception
of families who have true genetic cancer syndromes, there does not
appear to be any increased risk of cancer in offspring of cancer
survivors.
In summary, fertility preservation is a very
viable option for most patients undergoing treatment for cancer or
other chronic diseases. Inclusion of your TFC physician as early as
possible in the treatment planning process is important in order to
achieve the best results.
