Table of Contents

Fertility preservation

In recent years, significant progress in pediatric cancer research has led to higher survival rates, with many patients reaching an age where fertility becomes a concern. As a result, fertility preservation is increasingly important for individuals facing pediatric cancer.

Individuals with certain health conditions or life situations may consider fertility preservation options. These scenarios include exposure to harmful chemicals in work or military environments, having conditions like endometriosis or uterine fibroids, undergoing cancer treatment, treatment for autoimmune diseases such as lupus, having a genetic condition impacting fertility, or choosing to delay childbearing.

Your future ability to conceive might be jeopardized by specific health issues, either due to the illness itself or the treatments involved. Aging is a known factor that diminishes fertility, hence those planning to start families later in life often consider fertility preservation.

Fertility preservation might be a viable option under circumstances such as:

– Age: Delaying childbirth for career, educational, or personal reasons could necessitate preserving eggs or sperm.

– Cancer Treatments: Therapies like chemotherapy, radiation, and surgical procedures can impact fertility.

– Autoimmune Conditions: Illnesses like lupus and rheumatoid arthritis, along with their treatments, may lead to fertility complications.

– Reproductive Health Issues: Conditions like endometriosis and fibroids can pose challenges to pregnancy.

– Transgender Care: Gender-affirming treatments can affect reproductive capabilities, making the preservation of embryos, eggs, or sperm a consideration before undergoing treatment.

Fertility Preservation Options:

– Utilizing protective measures for the genital and pelvic area.

– Administering Gonadotropin Agonist injections to reduce ovarian or testicular function before chemotherapy.

– Preserving eggs through cryopreservation for future use.

– Storing sperm by freezing for later use.

– Employing tissue banking techniques to freeze ovarian cortex or testicular tissue, which can be reimplanted and hormonally stimulated later to produce eggs and sperm. Researchers are actively working on enhancing this method.

Therapeutic options for male

Sperm Cryopreservation

  For post-pubertal male children, freezing sperm is often the preferred method. The onset of sperm development typically happens during the fourth genital Tanner Stage. Sperm freezing is generally suggested for those at least in Tanner Stage 3/4, with testicular volume between 10–12 ml and the presence of motile sperm. While semen is usually collected via masturbation, alternative methods like penile vibratory stimulation or electroejaculation can be used for those unable to do so. The stored sperm can later be utilized in reproductive techniques such as intrauterine insemination, in vitro fertilization, or intracytoplasmic sperm injection. Additionally, pre-pubertal boys might consider testicular tissue cryopreservation.

Hormonal Suppression

  Current literature points to hormonal suppression as a potential method for preserving gonadal tissue, though it is not broadly recommended due to uncertain success rates.

Testicular Tissue Cryopreservation

  For pre-pubertal male children lacking mature sperm, testicular tissue cryopreservation is an emerging option. This process involves surgically removing immature testicular tissue for freezing. As adults, these patients showed normal testosterone levels, smaller testicles, and altered levels of LH, FSH, inhibin B, and anti-Müllerian hormone. While promising, this approach is still in the experimental phase and awaits advancements in maturing spermatogonial stem cells into sperm.

Therapeutic options for female sex

Cryopreservation Techniques for Oocytes in Cancer Patients: Understanding the Options

Exploring the methods of cryopreservation for oocytes offers valuable insights for female cancer patients seeking fertility preservation. Ovarian tissue cryopreservation stands out as a significant technique, particularly effective for young girls pre-puberty or women who must urgently begin cancer treatment. This process involves freezing part or an entire ovary, divided into strips for future use.

For post-pubertal females, oocyte cryopreservation is more complex and time-intensive compared to male fertility preservation methods. It requires ovarian stimulation through multiple GnRH antagonist injections, typically starting on the second or third day of the menstrual cycle, and lasts about 12 days. Following this, transvaginal oocyte retrieval is performed, usually under sedation, making the entire process around 14 days. This method is suitable for in vitro fertilization or intracytoplasmic sperm injection in the future.

However, this technique is not recommended for hormone-dependent cancers like breast cancer, due to estrogen’s role in cancer progression. Alternative methods, such as controlled ovarian stimulation with letrozole, are being explored, though their long-term safety remains unproven.

Ovarian Suppression During Cancer Treatment

Once cancer treatment commences, options like ovarian suppression become viable for protecting fertility in post-pubertal patients. This involves using gonadotropin-releasing hormone agonist therapy to temporarily suppress ovarian activity, safeguarding the ovaries from chemotherapy effects. This experimental approach may reduce ovarian toxicity by inhibiting FSH and LH secretion, thus preventing follicular recruitment. However, this method is subject to debate due to concerns about the flare effect, which could cause a rise in sex steroids and bleeding, especially problematic in children with pancytopenia.

Advantages of Ovarian Tissue Cryopreservation

For patients needing immediate treatment, time-consuming ovarian stimulation methods are not advisable. Ovarian tissue cryopreservation is the preferred choice in such cases. It involves laparoscopic surgery to remove ovarian tissue, followed by cryopreservation of cortex fragments. This procedure doesn’t require hormonal stimulation and can be completed quickly. Post-treatment, the thawed tissue can be grafted back, potentially restoring endocrine function and fertility. This is the only non-experimental option for children who haven’t reached puberty.

Oophoropexy: An Alternative for Urgent Treatments

Oophoropexy, or ovarian tissue transplantation, is another option for urgent treatments in both pre-pubertal and post-pubertal patients. Indicated primarily for patients undergoing pelvic irradiation, this surgical procedure involves relocating ovarian fragments away from the radiation field. The relocated tissue can be repositioned post-treatment to restore reproductive function. However, this too is considered experimental, with varying success rates due to radiation scatter.

Ovarian Shielding

  Ovarian shielding, also known as gonadal shielding, is a technique where a protective barrier is placed externally over the ovaries and other reproductive organs to guard them against stray radiation.

– Radical Trachelectomy

  Radical trachelectomy, or radical cervicectomy, is a surgical procedure for women with early-stage cervical cancer who wish to preserve fertility. It involves removing the cervix, nearby lymph nodes, and part of the upper vagina, followed by reattaching the uterus to the remaining vaginal segment using a special band that acts as an artificial cervix.

– Gonadotropin-Releasing Hormone Agonist Therapy

  This treatment involves using gonadotropin-releasing hormone agonists (GnRHa) to halt estrogen and progesterone production by the ovaries. Ongoing studies are evaluating the effectiveness of GnRHa in ovarian protection.

– Ovarian Transposition

  This surgical method relocates the ovaries outside the pelvis to reduce the risk of damage from pelvic ionizing radiation.

Additional Fertility Preservation Methods:

– Embryo Freezing

  Embryo freezing, or embryo cryopreservation, involves harvesting eggs from the ovaries, fertilizing them with sperm in a lab to create embryos, and then freezing these embryos for future use. This process might take 2-6 weeks.

– In Vitro Maturation (IVM) of Oocytes

  In this procedure, multiple immature eggs are collected without hormonal stimulation and are then matured in a lab setting, either before or after freezing. The advantage is the relatively quick collection of eggs, reducing delay in starting cancer treatment.

– Testicular Sperm Aspiration or Extraction

  This minor surgical method involves retrieving sperm directly from the epididymis or testes for freezing, used particularly when sperm cannot be obtained through ejaculation.

Additional Options

Exploring Alternative Fertility Options for Cancer-Affected Individuals: Donated Reproductive Material and Surrogacy

Individuals or couples impacted by cancer may opt for donated eggs, sperm, or embryos as a solution to fertility challenges. Single women planning to freeze embryos prior to cancer treatment might consider using donor sperm, especially when a partner is not in the picture. However, the process of finding a suitable donor could potentially delay cancer treatment. Women who become permanently infertile post-cancer treatment and did not preserve their eggs or embryos might explore the option of using donated ones.

Deciding to use donated reproductive material is a complex and personal decision, and it may not be the right choice for everyone. Religious beliefs might influence this decision, with some faiths disapproving of fertility treatments or the use of donors. It’s important to discuss any concerns with partners, family, or religious advisors. Fertility clinic staff can also provide guidance in this area.

Utilizing Donor Eggs in Cancer Aftermath

When cancer treatments irreversibly harm the ovaries, making egg production impossible, using donor eggs becomes a viable option. These eggs, donated either by someone known to the patient or an anonymous donor, undergo hormonal stimulation for maturation. The harvested eggs can then be fertilized with the sperm from the patient’s male partner, creating embryos that can be implanted into the patient’s uterus for pregnancy.

Choosing Donor Sperm Post-Cancer

Donor sperm is recommended when cancer treatments permanently damage the testes, rendering sperm production impossible. Sperm from either a known or anonymous donor can be used to facilitate pregnancy with the patient’s female partner.

Opting for a Gestational Surrogate

Cancer treatments that damage the uterus, preventing a woman from carrying a pregnancy, may necessitate a gestational surrogate. Embryos, created from the couple’s eggs and sperm, are transferred into the surrogate’s uterus, who then carries the pregnancy.

Considering Adoption

Adoption involves the legal transfer of all parental rights and responsibilities from the biological parent to the adoptive parent.

Embryo Donation from Other Couples

Couples who underwent fertility treatment and have surplus embryos often opt to donate these. Potential donors undergo a rigorous selection process:

– Matching is typically based on physical traits like eye and hair color, build, and ethnic origin.

– Donors must be healthy, with no significant medical history.

– Screening for infectious diseases and some genetic conditions is mandatory.

Alternatives: Adoption and Surrogacy

Women who have had their womb removed or received direct radiotherapy to the womb may only have adoption or surrogacy as options. Additionally, some women may choose to live a fulfilling life without undergoing fertility treatments, adoption, or surrogacy, as personal preferences vary greatly.

Post cancer fertility choices

Post-cancer treatment, if you’re considering parenthood and had previously preserved sperm, there are several options available:

– Sperm can be placed into uterus.

– Sperm can be combined with eggs in a lab setting.

– A single sperm cell can be directly injected into one of the eggs.

These fertility methods are generally considered safe and don’t pose significant risks to the child. However, it’s important to understand that they do not guarantee successful pregnancy. Consulting with a fertility specialist can provide more insight into these options.

In cases where cancer treatment has led to permanent infertility and you haven’t stored sperm, using donor sperm is an alternative. Donor sperm is carefully screened, though it’s worth noting that there is a donor shortage in the UK.

Testosterone replacement therapy, sometimes suggested for sexual function issues, can impact sperm production. If future fatherhood is a consideration, it’s crucial to discuss this with your healthcare provider before beginning testosterone therapy.

Barriers to fertility preservation

The challenges for fertility preservation stem from both external and internal factors. External factors include the accessibility and organization of healthcare services. High costs and the experimental nature of some treatments can limit availability and insurance coverage.

Internal factors involve the beliefs and values of clinicians and the perceptions and assumptions of parents. The balance between parental decision-making rights and the child’s capacity to contribute to decisions is crucial. Patient autonomy is key, yet ethical dilemmas arise due to the patients’ minor status. Consent and assent issues, combined with families’ limited understanding of fertility preservation, add to the complexity. Parents’ concerns about delaying cancer treatment for fertility preservation are also significant.

The initial consultation poses a major barrier, as it coincides with anxiety and urgency to begin treatment. This is particularly challenging when pediatric cancers require immediate treatment, making decisions about fertility preservation difficult under stressful circumstances. Cultural and religious considerations regarding the collection method and the fertility preservation technique also play a role, as some faiths have specific bioethical views on fertility.

Moreover, the theoretical risk of reimplanting gonadal tissue containing cancer cells and the potential impact on future gonadal function and the health of offspring are concerns that may hinder the fertility preservation process. Since infertility is not life-threatening and fertility treatments are elective, ensuring the safety of these techniques is paramount. Advances in techniques like polymerase chain reaction, flow cytometry, and xenotransplantation aim to mitigate these risks.

The establishment of oncofertility programs is seen as a solution to address many of these barriers. However, the global implementation of formal programs guiding the application of fertility preservation techniques remains limited.

Timing considerations

Should you be considering cancer treatment and wish to safeguard your fertility, it’s crucial to consult both your oncologist and a fertility expert promptly. A fertility expert can clarify your options, address any queries, and advocate for your fertility needs during your treatment journey.

Be aware that certain fertility preservation methods might not be viable under urgent treatment scenarios or if there are other pressing time constraints.

Facing a cancer diagnosis and undergoing treatment can be daunting. Yet, if fertility post-treatment is a concern, know that you have choices. Engage with your medical team about fertility preservation strategies before starting your cancer treatment to ensure well-informed decision-making.

Risks / Benefits

What Benefits Can Be Gained from Opting for Fertility Preservation Methods?

A primary benefit of fertility preservation techniques is the potential for individuals to have biological children, regardless of their medical conditions or life situations. This approach offers hope to those facing health challenges that may compromise their natural ability to conceive, allowing them to maintain the possibility of biological parenthood. Through advanced medical procedures, individuals can secure their biological material, such as eggs, sperm, or embryos, before undergoing treatments or encountering circumstances that might affect their fertility. This proactive step ensures that the option of having genetically related offspring remains open, providing a significant psychological and emotional advantage for many facing fertility-related obstacles.

What are the Potential Complications Associated with Fertility Preservation Techniques?

Fertility preservation techniques, while offering significant benefits, also carry certain risks that need consideration:

– Procedures to harvest eggs and sperm might lead to complications such as infection or bleeding.

– Utilizing in vitro fertilization (IVF) can potentially increase the likelihood of multiple pregnancies, premature births, low birth weight, miscarriages, and ectopic pregnancies.

– Laparoscopic methods used in these procedures are not without risks, including possible infections, bleeding, or damage to surrounding organs and tissues. Anesthesia-related risks such as adverse reactions, nerve damage, and postoperative confusion should also be considered.

– Hormonal treatments for ovarian stimulation can lead to increased estrogen levels, heightening the risk of blood clots and promoting the growth of estrogen-dependent cancers.

– Ovarian hyperstimulation syndrome is a potential complication of ovarian stimulation, which can be severe in some cases.

– Ovarian transposition, a method to preserve fertility, may lead to issues such as ovarian torsion or cyst formation, sometimes necessitating the removal of the ovaries (oophorectomy).

Recovery and Outlook

What is the Efficacy Rate of Fertility Preservation Techniques?

While fertility preservation techniques do not guarantee successful pregnancy outcomes, freezing eggs, sperm, and embryos remains the most prevalent and historically successful method. The effectiveness of other, less commonly used procedures is not as well-established. The likelihood of achieving a successful pregnancy through these techniques varies significantly and is influenced by numerous health and treatment factors. Consulting with a healthcare provider can provide a more personalized understanding of these factors and the potential for a successful pregnancy.

The success of in vitro fertilization (IVF) in particular is influenced by several individual factors, including:

– The age of the individual undergoing treatment.

– Body mass index (BMI).

– Existing health conditions.

– History of IVF treatments.

– Previous pregnancy experiences.

It’s crucial for those considering fertility preservation to discuss these aspects with their healthcare provider to gain a clearer picture of their chances for a successful IVF outcome.

When to Call the Doctor

When is the Ideal Time to Consult a Healthcare Professional Regarding Fertility Preservation Options?

Ideally, initiating fertility preservation should be done promptly. The most opportune moments for this are:

– Prior to the outset of any cancer treatment.

– Before starting gender-affirming therapies.

– For women not planning immediate childbirth, ideally before reaching the age of 35.

– Shortly following a diagnosis of any illness that might impact fertility.

For those who have undergone medical treatments in the past that could have adversely affected their fertility, it’s important to discuss potential fertility preservation strategies with a healthcare provider.

Other questions:

What are the available methods of preserving fertility in children?

Children who undergo treatment for cancer or other medical conditions might face fertility issues in the future. For them, options like freezing ovarian and testicular tissue are available. Once they reach puberty, they can also opt for sperm, egg, and embryo freezing. For prepubescent children, techniques like radiation shielding and ovarian transposition might be beneficial.

Is there a possibility that fertility preservation could hinder the effectiveness of cancer treatment or elevate the chances of cancer returning?

Current fertility preservation techniques have not been shown to directly impact the effectiveness of cancer treatments. Nonetheless, postponing surgery or chemotherapy to focus on fertility preservation could potentially affect the treatment outcome. While most fertility preservation methods do not seem to increase the risk of cancer recurrence, there is a concern about the potential reintroduction of cancer cells through the reimplantation of frozen tissue, which varies with the cancer type and stage.

Is There an Increased Risk of Health Issues in Offspring Conceived Post-Cancer Treatment?

Evidence suggests that as long as the fetus is not exposed to cancer treatments during pregnancy, these treatments do not typically heighten the risk of birth defects or other health issues in children conceived later. Nevertheless, if your cancer treatment has impacted your heart or lung function, or if you have undergone radiation therapy in the pelvic region, it is advisable to consult with a specialist prior to pregnancy to discuss and plan for any potential complications during pregnancy.

How can I identify the most suitable fertility preservation method for my situation?

Your healthcare providers will assess factors such as your specific cancer type, your treatment regimen, and the time available before starting treatment to recommend the most appropriate fertility preservation strategy. Despite the daunting nature of a cancer diagnosis and treatment, if fertility post-treatment is a concern, remember that there are various options available. Promptly exploring these fertility preservation techniques before commencing cancer treatment is crucial for making a well-informed decision.