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Taking Steps toward Future Fertility

by Kara Goldman, MD, and James Grifo, MD, PhD

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For many survivors, maintaining the potential for parenthood is essential to leading a complete and meaningful life. However, many treatments necessitate surgery, radiation, and chemotherapy that may impair fertility. Women who wish to have children after cancer treatment must work together with their doctors to plan for future fertility.

To determine the best fertility preservation approach, it’s important to consider the type of treatment you will require, the amount of time available for fertility preservation, your age and type of cancer, and whether you have a partner. Fertility preservation options can be classified into two approaches:
1. measures taken to preserve eggs or embryos before beginning potentially damaging treatment
2. strategies used during cancer treatment to protect the ovaries

The most effective way to preserve fertility before chemotherapy, radiation, or surgery is cryopreservation (freezing) of embryos or oocytes (eggs). Cryopreservation of embryos is a well-studied and effective technique that provides an optimal solution for couples intending to pursue parenthood after the woman completes her necessary treatment. Women without partners who are interested in embryo cryopreservation can opt to use donor sperm to fertilize their eggs. Embryos can be safely frozen for prolonged periods and subsequently transferred when a woman has completed treatment and is ready for parenthood.

If you think you may want to have children after cancer treatment, you should consult with your doctors to discuss an individualized approach to fertility preservation.

Author of Article photo

Dr. Kara Goldman

Women without partners at the time of cancer diagnosis may choose to pursue oocyte cryopreservation, or egg freezing. While oocyte cryopreservation is more challenging than cryopreservation of embryos due to the increased fragility of the oocytes, data support that egg freezing leads to pregnancy rates and outcomes similar to in vitro fertilization using fresh eggs. Some physicians have begun to freeze ovarian tissue as a means of preserving fertility; however, this practice remains strictly experimental and is not widely available.

Couples or individuals pursuing either oocyte or embryo cryopreservation will require at least two to three weeks for ovarian stimulation and egg retrieval. Since chemotherapy, radiation, and surgical treatments often begin soon after diagnosis, women must discuss with their oncologists the safety of delaying treatment for cryopreservation.

Author of Article photo

Dr. James Grifo

While cryopreservation of embryos and eggs is typically initiated prior to cancer treatment, interventions are available to protect ovarian function during treatment for women undergoing radiation or chemotherapy. Oophoropexy, or transposition of the ovaries, involves the surgical repositioning of the ovaries away from the pelvic radiation field. For women undergoing radiation at sites distant from the pelvis, the ovaries can be shielded to decrease the effects of dispersed radiation. An experimental option for women undergoing pelvic radiation involves autotransplantation, or transplanting an unaffected ovary to the woman’s own upper extremity to remove the ovary from the radiation field. Women undergoing chemotherapy treatment may be offered ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists for potential fertility preservation, but additional studies are needed to determine the efficacy of this approach.

If you think you may want to have children after cancer treatment, you should consult with your doctors to discuss an individualized approach to fertility preservation. Some women may not be candidates for ovarian stimulation or may require altered medication regimens. For women with estrogensensitive breast cancers seeking to undergo oocyte or embryo cryopreservation, medications known as aromatase inhibitors can be used along with gonadotropins to prevent high serum estrogen levels. Certain women with cervical cancer may be candidates for radical trachelectomy, or surgical removal of the cervix, instead of hysterectomy to preserve the uterus for future childbearing. Young women with endometrial cancer may be candidates for hormonal suppression and possible childbearing prior to planned hysterectomy.

Women unable to use their own eggs may use donor eggs with a partner’s sperm or with donor sperm. Donor embryos may provide another option. For women without a uterus or in whom pregnancy would be unsafe, a gestational carrier, or surrogate, may be an option. Additionally, adoption remains an alternative for many individuals and couples wishing to have children after cancer treatment.

The best approach to cancer treatment takes into consideration how your treatment will affect your life after cancer. Achieving a cancer cure is only the beginning. With appropriate fertility-sparing measures, survivors can look forward to building a family once treatment ends.

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Dr. Kara Goldman is a fellow in Reproductive Endocrinology and Infertility at the New York University School of Medicine in New York, NY. Dr. James Grifo is the director of the division of Reproductive Endocrinology and Infertility at the NYU School of Medicine and the program director of the NYU Fertility Center.

This article was published in Coping® with Cancer magazine, March/April 2013.