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Life Beyond Cancer - Fertility Issues

Chances are, when you were first diagnosed with cancer, thinking about your fertility was not forefront in your mind.  What are the impacts of chemotherapy, radiation, and hormonal therapy on your future fertility?  What are the options for preserving fertility prior to treatment?  Being diagnosed with cancer is tough enough to deal with and, generally, thoughts are focused on getting the appropriate treatment to control the cancer; however, one of the most important issues for younger people who have not started a family is taking the time to better understand the impact of these drugs on fertility.  Family-building options are available before and after cancer treatment.  The earlier you understand what those options are, the greater your chances for preserving fertility.  Treatment is available for men and women who have been diagnosed with cancer but it is important that you raise this issue with your healthcare provider early in the process.  Below are some options that may be right for you.

Click on either link, and then scroll through that gender-specific content or go directly to a topic there.

Women & Fertility Issues

Certain types of chemotherapy and radiation treatments can destroy the reproductive system that supports your eggs until ovulation, damage the eggs themselves, or prevent a fertilized egg from successfully implanting in the uterus. This can predispose a woman to premature menopause or infertility. Each treatment is going to affect a woman differently and it depends on many factors. It’s important for you to have a tailored approach to fertility preservation so your best interests are kept in mind.

Options should be carefully discussed with your doctor before treatment. In some cases, you and your doctor may decide to try more than one option to preserve your fertility. Be sure that you understand the risks and chances of success of any fertility option you are interested in, keeping in mind that no method works 100% of the time. Women may want to include their partners in these discussions and decisions.

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Embryo Freezing

Embryo freezing is the most common and successful method of preserving fertility today. Mature eggs are removed from a woman's ovaries and fertilized in the lab. This is called in vitro fertilization (IVF). The embryos are then frozen for future use after cancer treatment. This option works well for women who already have a partner, though single women can still have in vitro fertilization using donor sperm.

Eggs are collected during outpatient surgery, usually with a light anesthetic (drugs are given to make you sleepy while it is done). An ultrasound machine shows the ovaries and the fluid sacs (follicles) that contain mature eggs. A needle is guided through the upper vagina, then into each follicle to collect the eggs. The eggs are fertilized, then frozen and stored.

Since each egg will most likely produce a single embryo, a woman will have a better chance of a successful pregnancy by storing several embryos. Hormones can be used to produce several eggs at once. In most women, this means starting a cycle of hormone shots during her menstrual cycle and continuing them for 2 to 3 weeks until many eggs are mature (often around 12 in a woman under age 35). Some women who have fast-growing cancers cannot wait 2 to 3 weeks to begin treatment. Women with breast cancer may risk some growth of their tumors during IVF cycles because of the high levels of estrogen that result from the hormone shots. In cases like this, one option is "natural cycle IVF" in which ultrasounds are used to follow the progress of normal ovulation, and 1 or sometimes 2 eggs can be collected. Another option uses letrozole or tamoxifen during the hormone stimulation to keep the estrogen from encouraging cancer cells to grow. More studies are needed, but results so far do not show that this has any harmful effects on women's breast cancer treatment or survival.

Successful pregnancy rates vary from center to center. Centers with the most experience usually have better success rates. Most states don’t make insurers cover IVF treatment, but a letter from your oncologist to your insurance company explaining the reason fertility preservation is needed can sometimes make a difference.

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Egg Freezing (This is an experimental option)

Egg freezing means removing mature eggs with the same procedure described above for embryo freezing, but the eggs are frozen before being fertilized with sperm. This process may also be called egg banking. The eggs are fertilized after thawing.

Egg freezing is experimental, and less is known about it than IVF. Fewer than 1,000 babies have been born as a result of egg freezing, but the methods are improving quickly. Doctors have learned how to freeze the eggs with little damage, and now are using a fast freezing process called vitrification. Two European studies published in 2010 (one with 600 women) found that frozen eggs worked about as well as fresh ones when they were fertilized. Smaller studies in the United States have found similar success rates.

Egg freezing usually costs less than embryo freezing initially. It may be an option for women who have no partner at the time of cancer diagnosis. Because younger women have more eggs, and the eggs are likely to be healthier, some facilities cut off the age for egg freezing in the mid-30s. This varies from one facility to another.

If you are looking at egg freezing, ask how many live births the facility has produced using frozen eggs. You may also want to ask how many eggs it takes, on average, to produce a single live birth. You will want to know about the cost of the procedure (including all the medicines), annual storage costs of the frozen eggs, and the estimated costs of fertilizing and implanting later, and, how much, if any, of these expenses might be covered by your insurance.

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Ovarian Tissue Freezing (This is an experimental option)

In ovarian tissue freezing, all or part of one ovary is removed by laparoscopy (a minor surgery where a thin tube is passed through a small incision near the navel to reach and look into the pelvis). The ovarian tissue is usually cut into small strips, frozen, and stored to be transplanted back into the woman's body after treatment. The ovarian tissue can be placed close to the fallopian tubes or in another part of the body, like the abdomen (belly) or forearm. Usually the eggs produced by the tissue would need to be collected and fertilized in the lab. In a few cases, the whole ovary has been frozen with the idea of putting it back in the woman's body after treatment.

Ovarian tissue removal does not usually require being in the hospital. It can be done either before or after puberty. Still, it is experimental and has produced few live births so far. Doctors are studying it now to learn the best methods for success. For instance, some studies suggest that a quick freezing process (vitrification) of the tissue may have better outcomes than slow freezing.

The ovarian tissue does grow a new blood supply and produces hormones after it is transplanted, but some of the tissue usually dies and the grafts may only last for a few months to several years. Because they last such a short time, they are usually only transplanted when the woman is ready to try for a pregnancy. Ovarian tissue freezing costs vary a lot, so you will want to ask about the freezing and annual storage costs as well as removal and transplant expenses. In some patients, removal of the ovarian tissue can be done as part of another necessary surgery so that some of the cost is covered by insurance.

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A Note on Freezing

If you have frozen embryos, eggs, or ovarian tissue, it is important to stay in contact with the cryopreservation facility to be sure that any yearly storage fees are paid and your address is updated. Once a couple is ready to have a child, the frozen items are sent to their infertility doctor.
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Ovarian Transposition

Ovarian transposition means moving the ovaries away from the target zone of radiation treatment, usually during laparoscopy. Surgeons will usually move the ovaries above and to the side of the central pelvic area. This procedure typically does not require being in the hospital. It can be used either before or after puberty. The success rates have usually been measured in terms of the percentage of women who regain their menstrual periods, not in terms of being able to have a live birth. Typically, about half the women start menstruating again.

It is hard to estimate the costs of ovarian transposition, since this procedure may sometimes be done during another surgery that is covered by insurance. It is usually best to move the ovaries just before starting radiation therapy, since they tend to fall back into their old places over time.
Do not try to become pregnant during radiation therapy because radiation can harm the fetus.

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Radical Trachelectomy

Radical trachelectomy is an option for cervical cancer patients who have very small, localized tumors. The cervix is removed but the uterus and the ovaries are left. Trachelectomy appears to be just as successful as radical hysterectomy in removing cervical cancer in certain women. Women can become pregnant after the surgery, but are at risk for miscarriage and premature birth because the opening to the uterus may not close as strongly or tightly as before. These women will need specialized obstetrical care while pregnant.

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Fertility-Sparing Surgical Procedure

This surgical treatment can be used in some women with ovarian cancer in only one ovary. The cancer must be one of the less aggressive types, like borderline, low malignant potential, germ cell tumors, or stromal cell tumors. A surgeon will try to remove just the ovary with cancer, leaving the healthy ovary and uterus in place. If there is a risk of the cancer coming back, the surgeon may later remove the unaffected ovary after the woman has finished having children.

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Ovarian Shielding

Ovarian shielding is when your doctor places external shields over the site of your ovaries to minimize damage from radiation. The success rates are unknown, but most doctors agree that the amount of radiation and resulting damage to your ovaries is dramatically decreased. The costs are usually included in radiation treatment procedure. Ovarian shielding does not protect the ovaries against the effects of chemotherapy.

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Resources

Livestrong: http://www.livestrong.org/Get-Help/Learn-About-Cancer/Cancer-Support-Topics/Physical-Effects-of-Cancer/Female-Infertility    

American Cancer Society: www.cancer.org 

Boston IVF - The Maine Center
778 Main St. South Portland, ME 04106                  
1-877-858-2483 http://www.bostonivf.com/ 

American Fertility Association:  www.theafa.org/ 

Advanced Reproductive Care:  www.arcfertility.com/ 

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Adapted from Boston IVF/Livestrong/ACS

Men & Fertility Issues

During puberty (usually around age 13 to 14), a boy's testicles start making sperm, and they normally will keep doing so for the rest of his life. Since sperm cells divide quickly, they are an easy target for damage by chemotherapy. The higher the dose of chemo, the longer it takes for sperm production to get back to normal, and the more likely it is to stop. Permanent infertility results if all the stem cells in the testes are damaged to the point that they can no longer produce maturing sperm cells. The most damage is done when men are treated with both chemotherapy and radiation to the abdomen (belly) or pelvis.

The risk of the chemotherapy causing infertility varies depending on drugs and the doses used. After chemo treatment, sperm production slows down or may stop altogether. Some sperm production usually returns in 1 to 4 years, but can even take up to 10 years. If sperm production has not recovered within 4 years, it is less likely to ever recover. Men, older than 40, may also be less likely to recover their fertility but age seems to be a less important factor in men than in women.

Chemotherapy drugs that are linked to the highest risk of infertility in men include:

  • Chlorambucil (Leukeran®)
  • Cyclophosphamide (Cytoxan®)
  • Procarbazine
  • Melphalan (Alkeran®)
  • Cisplatin

It is important that you speak with your healthcare provider about the medications recommended as part of your chemotherapy and their effects on your future fertility.

A man's fertility canals are affected if he gets radiation to the testicles. Radiation at high doses kills the stem cells that produce sperm. Radiation is aimed directly at the testicles to treat some types of childhood leukemia. Young men with seminoma, a type of cancer of the testicle, may have radiation to the groin area, very close to their remaining testicle. Even when a man has another type of cancer in the abdomen (belly) or pelvis, his testicles may still get enough radiation to harm sperm production.

Radiation to the brain sometimes affects the pituitary gland. The pituitary gland signals the testicles to make hormones. Interfering with these signals can affect sperm production and cause problems with fertility.
Discuss your fertility options carefully with your health care provider before treatment. In some cases, you and your doctor may decide to try more than one method to preserve your fertility -- keeping in mind that no method is perfect. Be sure that you understand the risks and chances of success of any fertility option you wish to try. You may want to include your partner in these discussions and the decision-making.

Scroll through these topics or click on one to go directly to that content. 

Radiation Shielding

Radiation shielding is when special shields are placed over one or both of the testicles during radiation treatments, which helps reduce the risk of damage to your fertility. Scatter radiation may cause some damage, but overall shielding significantly reduces the amount of radiation to the area. Radiation shielding does not protect against chemotherapy.

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Sperm Banking

Sperm banking is an effective way for men who have gone through puberty to store sperm for future use. Many men can store sperm even if they have reduced sperm quality or quantity. This option can also work for boys as young as 12 or 13, as long as they have gone through puberty.

In sperm banking, a man provides one or more samples of his semen. This is usually done in a private collection room at a sperm bank facility or hospital. The man ejaculates (has a climax) through masturbation or with the help of a partner. The semen is collected in a sterile cup and given to the sperm bank.

Once the sperm bank gets the sample, they test it to see how many sperm cells it contains (this is the sperm count), what percentage of them are able to swim (which is called motility), and how many have a normal shape (called morphology). The sperm cells are then frozen and stored.

Sperm banking is an option for men who want to have children after completing cancer treatment. It is also a good option for a man who thinks he may want children in the future, but isn't sure. By storing the sperm, you can decide later. If the sample is not used, it can be discarded or donated for research.

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Intra-Cytoplasmic Sperm Injection:  ICSI

ICSI is a recently developed technique that involves the direct injection of one sperm into a mature egg.  It has revolutionized the treatment of male infertility, achieving highly successful fertilization rates with very limited numbers of sperm.  Even if only a few sperm are available before or after chemotherapy, they can be frozen and used for future attempts at conception.

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A Note on Freezing

It is important to stay in contact with the sperm bank so that yearly storage fees are paid and your address is updated. Once you are ready to have a child, the frozen sperm is sent to your infertility doctor.

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Testicular Sperm Extraction

Testicular sperm extraction (TESE) is possible for males who do not have mature sperm present in their semen, before or after cancer treatments. This means, that if you did not bank your sperm prior to starting cancer treatments and currently have no sperm in your ejaculate, there may still be sperm in your testicular tissue that can be used with in vitro fertilization (IVF) to try to achieve pregnancy.

Testicular sperm extraction is an outpatient surgical procedure available for males after puberty. Testicular tissue is obtained, usually by open biopsy and then examined for sperm cells. If sperm cells are found, they are removed and used immediately or frozen for future use with in vitro fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI) to achieve pregnancy.

Success rates vary depending on the exact technique of the biopsy used, but range from 30-70%. Studies have shown the presence of live sperm up to 45% of the time in men who had no sperm in their ejaculate after cancer treatment.

The average cost of testicular sperm extraction is $6,000-$16,000. Some insurance companies pay for the procedure if it is performed in conjunction with other treatments. There is such a wide range in cost because many factors are involved: hospital fees, anesthesia, staff time and equipment. If TESE is done at the same time as IVF to achieve pregnancy, there are additional costs.

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Testicular Tissue Freezing

Testicular tissue freezing is an outpatient surgical procedure that can be done before or after cancer treatments. Testicular tissue, including the cells that produce sperm, are surgically removed, frozen, analyzed and stored.

It is available for men, before or after puberty. In many cases it is the only option for prepubescent boys. The procedure is experimental with no live births to date, but shows promise for the future.
The average cost of testicular tissue freezing is unknown and the technique is only offered at a handful of centers across the country.

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Donor Sperm

Using donor sperm is the most simple and inexpensive way to become a parent for men who are infertile after cancer.

Major sperm banks in the United States collect sperm from young men who go through a detailed screening of their physical health, educational and emotional history, family health history, and even some genetic testing. Couples can choose a donor who matches their physical traits, educational record or talents. Couples can choose a donor who will remain anonymous or who is willing to have contact with a child later in life.

For the woman in the couple, it involves IUI (intrauterine insemination), usually without any hormone treatments. Sperm donors are chosen for their high sperm counts and motility. Success rates range from 50-80% and are highest in women with no infertility problems. Most women become pregnant within 3 to 6 attempts.

Donor sperm costs vary and average $3,000 - $5,000, which is usually enough sperm for several attempts. Additional fees will apply for any procedures necessary for the female partner to conceive.

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Resources

Fertile Hope through the LiveStrong Foundation: www.fertilehope.org/learn-more/cancer-and-fertility-info/parenthood-options-men.cfm 

American Cancer Society: www.cancer.org 

Boston IVF - The Maine Center
778 Main St. South Portland, ME 04106
1-877-858-2483
http://www.bostonivf.com/ 

American Fertility Association:  www.theafa.org/ 

Advanced Reproductive Care:  www.arcfertility.com/ 

Livestrong: http://www.livestrong.org/Get-Help/Learn-About-Cancer/Cancer-Support-Topics/Physical-Effects-of-Cancer/Male-Infertility 


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