Fertility preservation in cancer patients

Prof Igno Siebert, Aevitas’ fertility specialist spoke to Mari Hudson from RSG, about fertility preservation in cancer patients. To listen to the full interview in Afrikaans follow the link: http://www.rsg.co.za/Program-Vorige/297/Gesondheid and download the podcast ‘Gesondheid 20 Februarie 2019’. Alternatively, a summary of the interview follows below.

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If a young adult is diagnosed with cancer, what treatment options exist for them to have children in the future?

If a young person (child or someone in their reproductive years) is diagnosed with cancer and needs to undergo cancer treatment, such as radiotherapy or chemotherapy, it can negatively impact the ovaries or testis. If action to preserve fertility wasn’t made prior to starting cancer treatment, further efforts to preserve fertility will most likely be unsuccessful. For instance, Prof Siebert recently received a phone call from an Oncologist, regarding a 29-year-old patient diagnosed with breast cancer, six months into chemotherapy treatment. The Oncologist wanted to know if fertility preservation options still exist for this patient. Unfortunately, it’s already too late. Fertility preservation options need to be discussed prior to starting cancer treatment.

To determine what the best treatment option is, there are two key questions to be answered:

  1. Does the patient consider having children in the future?
  2. What stage cancer does the patient have?

The degree and histology of the cancer is very important to determine the best treatment plan for the patient. If the cancer is detected early on, the treatment could potentially be very conservative. For example, cervical cancer is very common in young females and if it’s detected during stage one, the treatment may purely consist of a biopsy to remove the cancerous tissue and the ovaries can potentially be reserved. However, if radiation is required to treat the cervical cancer, radiation will be performed over the pelvic area. Radiation of the pelvic area will damage the ovaries. To prevent this, the ovary can be loosened through surgery and placed outside of the radiation field. Through this surgery, there is a 95% chance that the function of the ovary can be retained.

When someone presents with breast-, bone- or blood cancer, the treatment option is usually chemotherapy. Chemotherapy is a gonadotoxic agent, which can put females in early menopause and cause infertility in both males and females.

Before chemotherapy is started there are different fertility preservation options:
The first option is egg freezing. If the patient has some time to spare prior to starting cancer treatment the female eggs can be frozen. This process begins with hormonal stimulation medication, after which the eggs are removed and frozen for later fertilisation through IVF.

The second option is ovarian tissue freezing. If there is no time for the process of egg retrieval and -freezing the ovarian tissue can be removed via laparoscopic procedure. The ovary is dissected into small pieces and then the tissue is frozen. Five years down the line, if the patient’s prognosis is good, the ovarian tissue which was initially frozen, can be transplanted into the remaining ovary.

What are the pregnancy success rates with fertility preservation in cancer patients?

Egg freezing. If the female is younger than 35 and approximately 15 eggs were retrieved and frozen, pregnancy success rates through IVF is 80 – 90%. If approximately 8 eggs were retrieved, the success rates are 40 – 45%. If the female is older than 35 years, the chances become naturally lower, due to a decrease in quality and quantity of eggs as females age.

Ovarian tissue freezing. Ovarian tissue freezing is still in an experimental phase and very little data exist worldwide on pregnancy success rates after ovarian tissue preservation. This being said, a few hundred pregnancies have been reported. Some women seem to react well to this treatment and others not so well, for reasons mostly unknown. Therefore, with ovarian tissue freezing, there are no guarantees, but if there is no alternative fertility preservation option it is a worthwhile trying.

What are the fertility preservation options for men?

Sperm freezing is performed for males as fertility preservation option. Sperm freezing is a low cost and simple process. All men that require cancer therapy, bladder-, urethra- or prostate surgery should be presented with the option of sperm freezing if they want to preserve their fertility. Reason being, cancer therapy could damage the ability to produce sperm, whereas bladder-, urethra or prostate surgery, could harm the urethra, with the effect that semen cannot exit the body. If sperm freezing was performed and the couple is ready to start their family, the sperm can be used through a simple procedure, called artificial insemination.

Have you seen successful pregnancies in  your practice from cancer survivors?

Most cancer patients we have seen are young, unmarried and wanting to preserve fertility for later in life. They therefore undergo egg freezing, to enable them to use their own eggs through IVF at a later stage. Statistics of women who freeze their own eggs for social reasons, is therefore a good indicator and it’s something we see in practice often. Furthermore, we currently have three patients starting fertility treatment, after five years or more of being cleared of cancer.

Do cancer patients know about fertility preservation options?

A study performed in the USA showed 50% of cancer patient received information about fertility preservation, but only 10% went through with the option to preserve fertility. This perhaps indicates that clinicians often do not spend enough time with patients to assist them in making these decisions.

Dr Siebert went on to explain that he recently had a 14-year-old patient who discovered she had bone cancer after a hockey injury to her leg struggled to heal. She decided to undergo egg freezing prior to starting cancer treatment.

Often when patients are so overwhelmed and struggle to process the news that they have been diagnosed with cancer, it is difficult to have to focus on making other decisions.

Message in a nutshell

If anybody (male or female) is diagnosed with cancer, it’s important to obtain information about egg- or sperm freezing, from their oncologist and/or a fertility specialist, prior to undergoing cancer treatment.