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Life after Cancer and Preserving Fertility for the Future

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October 19, 2012

As October's Breast Cancer Awareness Month is upon us, and awareness is raised of early detection and treatment, another aspect of cancer treatment is in the forefront for the fertility community: fertility preservation.

“In the past, the only goal of cancer therapy was survival,” says Mitchell Rosen, M.D., Assistant Professor at the University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, and Director of the UCSF Fertility Preservation Center. “However, as survival in patients of reproductive age has improved, the medical community increasingly has taken an interest in life after cancer, in particular paying attention to treatment-related infertility and reproductive health.”

Women are often not made aware of the impact cancer treatment may have on their fertility; however advocates such as Alice Crisci, founder of Fertile Action, a non-profit organization that works to ensure fertile women touched by disease have the option of preserving their fertility, are trying to change that.

“There's not enough awareness on the subject for so many reasons,” says Crisci. “It's hard to compete in the cancer space for attention when the majority of dollars and initiatives are going to research to find a cure for cancer. There are well over 250,000 young adult cancer survivors, and while we likely all would love a cure, we still need services to ensure that the 70 percent of all young adult women who do survive their cancers can live the life they imagine.”

Crisci explains that oncologists often feel they don’t have the appropriate knowledge to discuss fertility risks and preservation options with patients and may assume women can’t afford the price tag for procedures such as egg freezing. Additionally, some may feel that cancer patients should not become parents or should just look at adoption, which is often difficult for a cancer survivor as well as being expensive.

A study conducted earlier this year and published by Practical Radon Oncology, shows that oncologists are starting to discuss infertility with their younger patients, however, they are not referring patients for fertility preservation as frequently as they should be.

Equally, fertility doctors should also be addressing cancer screening and fertility preservation with their patients. Dr. William Schoolcraft of Colorado Center for Reproductive Medicine, encourages patients to have their recommended screening mammograms for breast cancer to rule out existing tumors before starting fertility treatment. Dr. Schoolcraft says: “fertility treatment doesn’t cause breast cancer”, but since estrogen in a fertility treatment cycle can potentially impact existing tumors, it is “nice to know you are starting treatment without silent or small tumors. Therefore, a screening mammogram is a good way to rule that out”.
Video: Do Fertility Treatments or Fertility Drugs Cause Breast Cancer?

How Cancer Treatment Affects a Woman’s Fertility

Cancer treatments such as chemotherapy, while life-saving, attacks follicles in the ovaries that contain a woman’s lifetime supply of eggs. Surgery, chemotherapy, radiation and system drugs may damage or destroy a woman’s eggs.

“It always has been known that chemotherapies, some more than others, can cause ovarian failure,” Dr. Rosen says. “However, we need a better a grasp of the impact, or potential compromise, on an individual woman and her individualized care.”

In a recent UCSF study published online in the journal Cancer, Dr. Rosen found that current estimates of the impact of chemotherapy on women’s reproductive health are too low. “Oncology studies in the past have used the presence of menses after cancer treatment as a sign of fertility,” he says. “In our study, we show that even in the presence of menses, infertility and early menopause are higher than what would be expected in the general population. Therefore, the presence of menses does not determine that there has been no damage.”

The researchers used the California Cancer Registry to ask women about their reproductive history before and after cancer treatment. They targeted five cancer types — leukemia, Hodgkin’s disease, non-Hodgkin lymphoma, breast cancer and gastrointestinal cancers — because they are common non-gynecologic cancer groups that can be treated with systemic chemotherapy. A total of 1,041 women diagnosed with one of five targeted cancers answered survey questions that addressed acute ovarian failure (cessation of menses after treatment), early menopause (menopause before 45 years old), and infertility (failed conception).

The researchers found:

  • The percentage of women reporting acute ovarian failure was 8 percent, 10 percent, 9 percent and 5 percent for Hodgkin’s disease, non-Hodgkin lymphoma, breast cancer, and gastrointestinal cancers respectively. Acute ovarian failure increased significantly with age at diagnosis.
  • In women without acute ovarian failure, the incidence of infertility increased significantly with age at diagnosis. For instance, the proportion of infertile women with Hodgkin’s disease was 18 percent at 20 years old and 57 percent at 35 years old.
  • The estimated probability of early menopause increased significantly with younger age at diagnosis. For example, using age as a predictor of early menopause in non-Hodgkin lymphoma, 56 percent of women 20 years old at diagnosis may experience menopause early, compared to 16 percent of those who were 35 years old at diagnosis.

Fertility Preservation Options

When a woman of childbearing age receives a cancer diagnosis, the important thing is to do research and ask questions about fertility preservation quickly.

“Patients need to ask their oncology team about the potential risks to fertility, even if it has not been on their mind to have a child, or they are unsure about their desire to have a child,” Dr. Rosen says. “They need to be vocal about their desires so they are able to make an active rather than a passive decision about their future fertility. There are established treatments for preserving fertility and seeking a fertility specialist as soon as possible will give them the most options.”

In many cases — but not all — women can take four to six weeks to preserve their fertility prior to starting cancer treatment and have time for options such as embryo freezing or egg freezing.

Egg freezing is an option that has improved dramatically over the last few years due to a faster freezing technique called vitrification. Fertility doctors stimulate a woman’s ovaries to produce eggs with fertility drugs and retrieve them in the same manner as is performed for in vitro fertilization (IVF).

For girls that have not gone through puberty or women who can’t delay cancer treatment, there is an option called ovarian tissue cryopreservation in which an ovary is removed via laparoscopy, an outpatient surgery that takes 30 to 45 minutes. The procedure requires no fertility drugs and does not delay cancer treatment for more than a couple of days. Tissue from the removed ovary is sliced into strips, frozen, and stored.

Most recently, a Swedish study suggests that women and young girls can have slices of ovarian tissue containing immature eggs frozen and chemically matured with a PTEN molecule inhibitor for IVF at a later date.

“Even experimental techniques like egg freezing and ovarian tissue freezing have produced babies,” Crisci says. “Egg freezing has over 1,000 babies born worldwide and ovarian tissue freezing has 15 children born worldwide. Embryo freezing is still the most successful, and using donor sperm if you are a single woman is OK! Ovarian suppression (drugs that stop the ovaries from functioning) has mixed data, but if it’s the only option available to a woman, take it!”

Paying for Treatment

The cost of procedures such as egg freezing is expensive, similar to that of IVF. There are non-profit organizations that provide assistance in paying for treatment.

Fertile Hope is a national LIVESTRONG initiative dedicated to providing reproductive information, support and hope to cancer patients and survivors whose medical treatments present the risk of infertility.

Fertile Action's mission is to eradicate cost as the primary barrier preventing these women currently from preserving their fertility. The organization has a network of physicians who donate their services. “We also secure medications from specialty pharmacies and Ferring Pharmaceutical to ensure patients pay next to nothing should they pursue fertility preservation,” Crisci says.

Fertility Rescue is a program founded by Dr. Drew Tortoriello at Sher Institutes for Reproductive Medicine which offers harvesting and freezing of eggs for cancer patients at significantly discounted costs. Egg retrieval and anesthesiology are free of charge while fertility drug costs are minimal. Egg storage is free for the first two years and discounted for cancer patients in subsequent years.

“We started the non-profit to eliminate cost as the barrier to women seeking fertility preservation, but expanded to eliminate costs as the barrier to motherhood period,” Crisci says. “Today, we include ALL family planning options: IVF, surrogacy, egg, sperm and embryo donation and adoption. Women are looking for ways to have a family after cancer whether they are infertile or not.”

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