Fertility-Preservation Options for Cancer Survivors
by Leslie Appiah, MD
“I won my battle with cancer, but I lost my femininity in the process.”
This is a comment I hear from many of the women cancer survivors I care for in my practice as a gynecologist and reproductive health specialist. Underpinning this statement is a tone of resignation and frustration that a good outcome in one area could only occur at the cost of the other. On the one hand, the survivor is grateful to have overcome a life-threatening diagnosis, but on the other, her quality of life is significantly altered by the same lifesaving treatments that got her there.
Over the last several decades, breakthroughs in science and medicine have improved cancer survival rates to greater than 85 percent for adolescents and young adults. The focus has now appropriately shifted to include quality of life in survivorship care planning. As the ability to have children and build a family is an important quality of life indicator for many cancer survivors, fertility preservation has become an important aspect of cancer care.
When should I talk to my doctor about fertility preservation after a cancer diagnosis?
A cancer diagnosis can be overwhelming. It can be difficult to “hear” or process discussions about how a cancer diagnosis may affect your fertility right after hearing the words “you have cancer.” Therefore, cancer survivors should have a separate conversation about fertility with a reproductive specialist very soon after their initial diagnosis. Fertility-preservation counseling should occur within days of confirming a cancer diagnosis so that fertility-preservation options can be implemented as soon as possible.
The best time to implement fertility preservation methods is before cancer treatment begins, as this is when you have the most options available and sperm and egg quality are at their best.
What are my options for preserving my fertility?
Standard fertility preservation options include freezing eggs, embryos, sperm, and now ovarian tissue. Many survivors express concerns that pursuing fertility preservation will delay their cancer treatment. However, for women who wish to freeze eggs or embryos, only two weeks of preparation is needed due to new “quick-start” methods. This does not typically cause a treatment delay and can usually be completed during the time your cancer therapy plan is being finalized. For men, sperm banking only takes one or two days to accomplish.
A newer option, ovarian tissue freezing for future fertility, became standard of care in December 2019 and is now available to children and adults at most medical centers. With over 200 babies born from this method, ovarian tissue freezing is a good choice for women at high risk of infertility who cannot delay therapy and for girls who are too young to freeze their eggs. Freezing ovarian tissue offers a dual benefit for survivors who choose this method. Not only does it preserve fertility, but it also restores hormone function for two to ten years after the tissue is transplanted back to the survivor.
Preserving More Than Just Your Fertility
It’s important for both you and your healthcare provider to remember that fertility is not the only aspect of survivorship care that should be addressed. Overall well-being is equally, if not more, important. The loss of hormones due to cancer treatment can have a profoundly negative effect on both your mental and physical health.
For women, hormone insufficiency or premature menopause due to cancer therapy can result in hot flashes, night sweats, sleep disturbances, osteoporosis, and vaginal pain (both in general and during intercourse). Women who experience decreased estrogen levels prior to natural menopause also have an increased risk of cardiovascular disease and may experience cognitive decline. Moreover, the associated lack of sleep can lead to mood disturbances, difficulty focusing, irritability, and strained relationships.
Hormone replacement is beneficial and safe for most women. You should discuss hormone replacement with your doctor before and after cancer therapy. Women with hormone-sensitive cancers, such as breast cancer, will need non-estrogen-containing therapies and should speak with a specialist trained in this area.
Additionally, temporary suppression of ovarian function during cancer treatment has been shown to improve pregnancy success rates in women with certain types of breast cancer. Studies suggest that for women with other cancers, ovarian suppression may improve ovulation once cancer treatment ends.
For male cancer survivors, testicular tissue freezing remains an investigational option for those at high risk of infertility who have not yet entered puberty but is standard care for adults.
What can I do to protect my fertility once cancer treatment ends?
Monitoring reproductive function after cancer treatment is an important aspect of survivorship. Regular menses do not predict fertility; therefore, survivors at risk of ovarian dysfunction from cancer treatments need further medical evaluation. Routine follow-up with a reproductive specialist can help identify whether you are at risk, and your
specialist can help you develop a long-term fertility plan.
There is currently no gold standard for monitoring fertility after treatment; however, a combination of bloodwork and ultrasounds may be the best course. For those survivors who have low ovarian function, pursuing fertility preservation methods after cancer therapy may be warranted.
What if I’m not sure I want to have children?
Not every cancer survivor wants to have children. However, family building can be a rewarding aspect of survivorship for those who desire it. Moreover, regardless of their parental aspirations, cancer survivors experience less regret and greater quality of life when they talk to their doctors about their fertility preservation options before beginning treatment, even if none are pursued.
Cancer can do many things, but we can’t allow it to shatter hope. Through a multidisciplinary team approach, most cancer survivors can hold on to the very real hope of becoming parents after cancer treatment.
Dr. Leslie Appiah is a board-certified obstetrician-gynecologist with specialty training in pediatric and adolescent gynecology and expertise in fertility preservation and reproductive health in cancer survivorship. She is an associate professor in the Department of Obstetrics and Gynecology and the director of the Fertility Preservation and Reproductive Late Effects Program at the University of Colorado Anschutz Medical Campus in Denver, CO.
This article was published in Coping® with Cancer magazine, January/February 2022.