ONCOFERTILITY – Preservation of fertility after cancer treatment.

Gynecologic malignancies account for 109 million new cancer cases worldwide consisting of about 12% of tumors affecting female population. About 10% of all female cancer survivors are younger than 40 years of age. Survivors have to face infertility or early menopause.

The field of oncofertility is focused on assisting cancer patients and survivors maximize their reproductive potential. Working together, oncologists and fertility specialists can address the impact life-saving cancer therapies have on fertility.

Cancer and Fertility

The standard treatment for gynecologic malignancies involves removal of reproductive organs, pelvic radiation, or chemotherapy, the effect of such treatment on fertility and options for fertility preservation are even more relevant than for other malignancies. In young women with new diagnoses of cervical, endometrial, or ovarian cancers, viable strategies for fertility preservation without compromising oncological outcome exist and should be considered.  It is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer.

Advances in cancer therapies have led to increased survival rates, but surgery, chemotherapy and radiation therapy can all result in reduced fertility.

Gonadotoxic chemotherapy drugs and substances cause temporary or permanent damage to the ovaries and testes. These drugs impact the ovarian reserve – by destroying immature and/or mature follicles and resulting in early menopause. Radiation to the abdomen or pelvis can also damage ovarian follicles or the reproductive organs. Even radiation to certain areas of the brain can lead to infertility by disrupting hormone production.

Chemotherapy and radiation can also impact sperm count, sperm motility or sperm morphology leading to male infertility. Surgical removal of the testicles and nerve damage that limits ejaculation are other causes of infertility.

Whole range of fertility preservation options should be given to the patient by fertility specialist before going for cancer treatment. Counsel patients along with spouse wherever applicable.

Patient should be referred to psychosocial providers if she or he depressed.

Oncofertility and treatment Options available for female 

Depending on patient age and other factors, there are a number of female fertility options available to women before, during and after cancer treatment:

Conservative medical therapy – Some cancers in early stages can be treated with hormones which do not affect fertility.

Conservative gynecologic surgery – In early stages of cancers and pre-cancerous stages only affected reproductive part (one side ovary, lower part of cervix) is removed and other parts of reproductive organs sufficient enough to enable conception later in life are retained.

Embryo cryopreservation – Mature eggs are harvested before the start of cancer treatment and fertilized through in vitro fertilization (IVF). The resulting embryos are then frozen for later use. This technique offers the best chance for later pregnancy. This can be done for patients who have partner.

Egg cryopreservation – Using ovarian stimulation, eggs (oocytes) are obtained and frozen for later use. This can be done for patients who do not have partner.

Ovarian tissue preservation – One of the ovaries is removed and the tissue that contains eggs is separated and stored for possible use in future

Ovarian shielding – Protects the ovaries and healthy tissue near the cancer site by shielding them from radiation exposure

Ovarian transposition – This technique involves surgically moving the ovaries away from the radiation treatment site to reduce the risk of damage

Donor eggs or embryos – Women whose ovaries have been damaged during cancer treatment can use eggs harvested from a known or anonymous donor. The eggs are then fertilized with sperm from the woman’s partner, or a donor, with the resulting embryos transferred into the woman’s uterus through IVF. Donor embryos may also be transferred.

Oncofertility and treatment options available for men

Fertility preservation options are also available to young men facing cancer treatment. These options include:

Sperm cryopreservation – Sperm freezing or banking uses sperm that has been collected prior to the start of cancer treatment. The sperm is collected through ejaculation or from the testes or epididymis through a minor surgical procedure and retained for later use

Gonadal shielding – This protects the testicles from any stray radiation particles resulting from treatment at other sites in the chest or abdomen

Experimental Fertility Preservation Options

The below experimental treatment options have shown promise for future use:

Ovarian tissue cryopreservation – This procedure involves the removal and freezing of egg-containing ovarian tissue. The thin slices of tissue are then frozen and can later be thawed and transplanted back into the body. This procedure does not require ovarian stimulation or sexual maturity. This is the only option available for children with cancer before puberty.This option can be used when cancer treatment cannot be delayed even for the 2 weeks it takes to have eggs and embryos frozen.

Ovarian suppression – Prior to the start of chemotherapy, injections of gonadotropin agonists are initiated and continued throughout treatment. These drugs help to slow ovarian activity and prevent egg maturation. There is some controversy as to the benefit of ovarian suppression in fertility preservation.

Testicular tissue freezing – During a minor biopsy procedure testicular tissue is harvested and frozen for later use. Considered the only potential option for young boys who have not reached puberty, the procedure remains experimental.

Growing survival rates among young cancer patients emphasizes the need for fertility preservation. Oncofertility addresses the future fertility impact of cancer treatment in this population