Fertility Preservation for Patients with Cancer
Ringland Murray, MD


INTRODUCTION
The diagnosis and treatment of cancer often poses a threat to fertility, for both men and women. The diagnosis is not anticipated and patients usually have not considered that cancer might alter their child-bearing plans. Additionally, due to the urgency of treatment, patients and their oncologists sometimes have little time to address this important issue.

We believe it is a fundamental part of our practice to be a ready resource for cancer patients who wish to attempt to preserve their fertility. Our goal is to provide patients and their treating physicians with information regarding their options and to assist patients to the best of our ability to maintain their fertility.

Effect of Cancer on Fertility

There are many ways that cancer diagnosis and treatment can alter fertility. The severity of some cancers can alter a person’s metabolism, causing him or her to stop producing sperm or eggs. Certain cancers, such as testicular, ovarian or uterine may require removal of the testes and ovaries. Similarly other cancers, such as breast, gastrointestinal and leukemia may actually spread to the testicles or ovaries.

Effect of Cancer Treatment on Fertility

There are three basic types of cancer therapy: surgery, radiation and chemotherapy. The threat each of these poses to fertility is highly individual. The risk to fertility depends on the type of cancer and the specific treatment required. For females, the risk of infertility also increases with the age of the patient.

Surgery:

Unless a surgical procedure directly involves the reproductive organs, it is less likely that fertility will be at risk. However, operations which require abdominal surgery can result in scarring within the pelvis and lead to future fertility issues. Women who have had abdominal surgery should consider evaluation if they experience a delay in fertility. 

Radiation:

A well-established consequence of radiation directed to the pelvis is the depletion of sperm and eggs. The risk of sterility rises as the dose and duration of the radiation treatment increases. For example, patients with cervical cancer undergoing high dose radiation have a greater than 80% chance of sterility unless steps are taken to prevent it.[i]

Chemotherapy:

Similarly, some common chemotherapy agents lead to the depletion of eggs and sperm. Chemotherapy for bone marrow transplants, leukemia and lymphomas carry an especially high risk for sterility. Again, the risk of chemotherapy depends on the medication used, the dose and the age of the patient.[ii]^{, [iii]}

Cancer treatment will cause some women to delay childbearing, sometimes for several years.  A woman with breast cancer frequently undergoes treatment for five years. At the end of this therapy, her fertility may have declined significantly because of age alone.[iv]

Oncologists are generally the best individuals to counsel patients regarding the risks treatment poses to fertility. However, consultation with a Reproductive Endocrinologist will give patients further understanding of the unique risks that their specific cancer and treatment create. 

What Services Are Offered?

The primary goal of fertility sparing treatments is to limit and/or circumvent the effects of cancer treatment.  Since not all cancers pose the same risks to fertility and since not all cancers require treatment with the same urgency, some patients will have more options than others when it comes to fertility-sparing procedures and treatments.

For Men

Sperm Banking

The primary fertility-sparing option for men is known as sperm banking. Prior to, or early in treatment a man will collect several samples of sperm. The sperm is processed and then frozen. Later, the sperm may be used for intrauterine insemination of the female partner, or for in vitro fertilization, if needed.  Even when the samples are not used, sperm banking provides a measure of psychological comfort to men (and their spouse) during cancer treatment.[v]

Sperm Harvesting

Men who have had prostate surgery or surgery on other pelvic organs may develop an obstruction which prevents sperm from being ejaculated. Sperm can be harvested either by an office procedure or, if necessary, by same-day surgery performed by an urologist. The sperm obtained this way is generally sufficient to perform in vitro fertilization. 

For Women

In Vitro Fertilization with Embryo Freezing and Storage

In simple terms, in vitro fertilization (IVF) is a procedure in which eggs are harvested from a woman and fertilized in a laboratory dish. In vitro is Latin for “in glass”, and babies born this way are commonly referred to as test tube babies.

The actual process of IVF is more complicated. A woman is given hormone injections to stimulate the growth of her eggs. She requires numerous visits to the clinic so that the growth can be monitored by ultrasound and by blood work. Once mature, the eggs are harvested in the operating room, while the patient is under anesthesia, by an ultrasound-guided needle. The eggs are fertilized in the laboratory. The embryos which develop from these fertilized eggs are then frozen.

Frozen embryos can be stored for years and may be transferred back to the woman at a later time. The success of IVF depends mainly on the age of the woman at the time the eggs are harvested. However, other factors influence success as well, and a consultation with a reproductive endocrinologist will help you fully understand the likelihood you will succeed.

Worldwide, more than a million children have been conceived and delivered by this technique. Unfortunately, IVF is not suitable for every patient. Since IVF can take up to two months to complete, those who cannot delay their cancer treatments may not be eligible. If the patient does not have insurance coverage, the cost of IVF including medications, procedures, embryo storage and embryo storage can vary between $10,000 and $15,000.

Egg Freezing

Egg (or oocyte) freezing is an experimental procedure. It is similar to IVF in that a patient takes hormone injections until the eggs are mature. The eggs are harvested but they are not fertilized. The eggs are frozen and stored for later use, often many years later.

To date egg freezing is not as widely available, nor is it as successful as IVF. Since they are larger and have more water than do embryos, eggs do not survive freezing and thawing as well. It is not known how long frozen oocytes will survive.  World-wide there have been fewer than 200 babies born by this technology. The main candidates for this procedure are single women or couples who are ethically or religiously opposed to fertilization in a laboratory.  

The cost of egg freezing includes most of the expenses incurred with IVF, with a rough estimate of $9,000 to $10,000, including medications. After the eggs are thawed, additional laboratory expenses of fertilization and subsequent embryo culture and embryo transfer will cost another $1,500 to $4,000.

Ovarian Suppression

This treatment involves giving a woman an injection of leuprolide acetate, which causes the ovary to become inactive.  This is a controversial treatment, because it is not clear if this strategy works. The theory behind ovarian suppression is simple:

1.   Prepubertal girls have inactive ovaries. (they are not producing eggs).

2.   When prepubertal girls are given chemotherapy, their eggs are more resistant to damage than are women who are menstruating.

3.   The logic follows that if one can make a menstruating woman have inactive ovaries, then she would be less likely to have damage to her eggs when given chemotherapy.

So far, studies on this treatment strategy have shown mixed results; however, none of the studies is adequate to address the issue. Current studies are being undertaken to evaluate the effectiveness of this treatment.  Nevertheless, many patients will elect to receive this treatment because it is relatively inexpensive and poses no known significant risks.

The cost of ovarian suppression depends on a patient’s insurance, the drug used and the duration of use. Without insurance, a 3 month supply of medication is approximately $1,600.

Egg Donation

Women who have significantly impaired fertility can opt to receive eggs from another woman. The donor can either be known to the patient, such as a family member or friend, or she can be anonymous.

The process is a form of IVF. The donor undergoes egg stimulation and retrieval, just as in routine IVF. Her eggs are then fertilized with sperm from the patient’s husband. The embryos which develop are then transferred into the patient.  Because eggs are obtained from young women, success rates with egg donation are the highest achieved with the IVF process. The benefit is that the child is genetically related to her husband. The patient is biologically and emotionally connected to the child through carrying, delivering and raising the baby. 

Egg donation is expensive. Screening and selection of donors usually costs about $6,000. This is added to the cost of IVF.

Ovarian Transposition

Also known as oophoropexy, this treatment is specifically designed to prevent damage from radiation. Prior to a woman receiving radiation to the pelvis, she undergoes a same day surgery to free the ovary from its connection to the pelvic organs and move it farther from the area receiving radiation.

Little long-term data are available to say how effective this treatment is regarding actual fertility. Approximately 50% of women maintain their menstrual function with this therapy. Frequently a second surgery is required after radiation to restore the ovary to its proper anatomic location.¹

The major costs associated with ovarian transposition are those related to surgery. In fact, the patient may require two surgeries: one to move the ovaries out of the area of radiation, and the second to restore normal anatomy. Anesthesia, hospital charges and operative charges will generally range between $6,000 and $9,000 per procedure.

Ovarian Tissue Cryopreservation

This is another experimental procedure offered by a handful of centers.  Prior to cancer treatment, the ovaries are either removed or biopsied for freezing.  If the entire ovary is removed, it is cut into smaller pieces and then frozen.  After cancer treatment, the pieces of ovary are then placed back into the woman, either in the pelvis or under the skin of the arm or abdomen. If the ovary is placed anywhere but the pelvis, she will need in vitro fertilization. 

To date, only one possible pregnancy has occurred with this technique.[vi] This pregnancy was obtained in a woman who had ovarian biopsies. The tissue was later placed back into the pelvis and she conceived spontaneously. Since she still had her ovaries, it is not completely certain whether the pregnancy was a result the transplant or the ovarian tissue which had been left behind. 

Risks

Each treatment option has risks inherent to the individual procedures. Risks will be modified by the age of the patient, as well as the cancer diagnosis. The risks of IVF and Egg Donation are discussed in brief under our section on infertility treatments.  To date, there is no known increased risk of genetic abnormalities or malformations for patients who get infertility treatment due to a risk of cancer. There is also no known increased cancer risk to offspring of cancer patients.

Breast cancer can be stimulated by estrogen. Patients with a history of breast cancer have been generally encouraged to avoid situations which elevate estrogen levels. IVF and pregnancy both increase the body’s production of estrogen. Despite the caution against elevated estrogen, there are no consistent data to say that breast cancer recurrence is higher in women who subsequently become pregnant.[vii] It is unknown if IVF itself increases breast cancer risk or prognosis; however, there are several strategies to limit estrogen production in these patients.[viii]  Any individual treatment, its benefits and risks should be addressed during your consultation with a reproductive endocrinologist.

Consultations

Given the need for rapid treatment of many cancers, there is often a finite window available for fertility-sparing treatments. Due to this inherent urgency, at Fertility Associates of Memphis, we make a priority out of seeing newly diagnosed patients, often the same day as they are referred. Physicians or patients should call 901-747-2229 to make appointments.

Costs: These are simply estimates. These rates are subject to change without notice, but should be generally accurate. These rates assume no insurance coverage is applicable. Patients with insurance may pay less.  We have financial counselors who can assist patients to fully explore all their resources.