Fertility Preservation Before Cancer Treatment

Fertility preservation is the one cancer decision with a hard clock on it. Most options must happen before treatment starts. A few can be arranged during a pause. Almost none can be arranged afterward.

NCI makes one finding worth reading twice. Survivors were less regretful if they had met with a fertility specialist. That held whether or not they went on to preserve their fertility. The meeting itself is what lowered regret.

NCI also notes something uncomfortable. Sometimes you may need to start this conversation. Oncology teams are focused on the cancer. Nobody will be offended if you raise this first.

Ask for a referral to a fertility specialist. The two titles to use are oncofertility specialist and reproductive endocrinologist.

Whether treatment affects fertility depends on several things at once. NCI lists them:

• The type of treatment.
• The dose.
• How long it lasts.
• Your age at the time of treatment.
• How much time has passed since treatment.
• The cancer type, and whether the tumor is near reproductive organs.
• Your baseline fertility, including any earlier problems.
• Other health conditions.

That list is why a general risk figure means little. The question to ask is about your regimen, your dose, and your age.

Chemotherapy can harm ovarian follicles. Those are the sacs that hold immature eggs. NCI singles out one class of drug. Alkylating agents carry a high risk. They can stop the ovaries from ripening eggs and making estrogen. That leads to primary ovarian insufficiency. Risk is greater with high doses, and with several drugs at once.

Radiation depends on where the beam goes. Radiation to the pelvis can harm the ovaries or destroy eggs. Radiation near the uterus can cut blood flow or leave scarring. That raises the risk of problems in a later pregnancy. Radiation to the brain can affect the glands that signal the ovaries. Those glands drive estrogen and progesterone.

The technique matters too. NCI notes proton beam radiation and intensity-modulated radiation therapy may have less effect on fertility than standard radiation.

A stem cell transplant usually follows high-dose chemotherapy, radiation, or both. Those conditioning treatments can harm the ovaries. Researchers are testing reduced-intensity conditioning to see if it lowers that risk.

Surgery depends on the tumor. Cervical, ovarian and uterine cancers may need a hysterectomy, which removes the uterus. An oophorectomy removes one or both ovaries. Surgery for anal, bladder, colon or rectal cancer can cause adhesions. Those are scar-like bands between organs. They can block an egg's path from the tube to the uterus.

Hormone therapy can cause primary ovarian insufficiency. Targeted therapy is less well mapped. NCI notes some studies find that tyrosine kinase inhibitors may affect fertility. Targeted drugs can also affect hormone organs such as the thyroid. The effects of immunotherapy on fertility are still being studied.

These are the two best-known methods, and they follow the same first steps.

Embryo freezing usually starts with hormone tests and an ultrasound. You then take fertility drugs. Those push the ovaries to ripen several eggs at once. The eggs are collected. They are fertilized with sperm in the lab to make embryos, then frozen. Later the embryos are thawed and placed in the uterus. That step is in vitro fertilization, or IVF. It is the most common form of assisted reproduction.

Egg freezing follows the same stimulation and collection, then freezes the unfertilized eggs. They are fertilized later, when you are ready.

The practical difference is not medical. Embryos require a sperm source and a decision about who controls them later. Frozen eggs leave that decision open.

Several methods exist precisely because stimulation is not always possible or safe.

Ovarian tissue freezing takes ovarian tissue out by surgery and freezes it. Later it is thawed and put back in the body. Hormone production and egg release can then resume. Women who have had this done have conceived, both with and without help. NCI names three groups for whom this is the option:

• Girls who have not yet reached puberty.
• Those advised not to delay cancer treatment for another procedure.
• Those advised not to receive the hormone treatments other methods require.

Ovarian transposition is an operation that moves the ovaries out of the radiation field. It is also called oophoropexy. Sometimes the tubes are moved too. It can be done during cancer surgery.

Ovarian shielding, also called gonadal shielding, places lead shields over the ovaries and other reproductive organs during radiation to reduce scatter.

Gonadotropin-releasing hormone agonists are drugs that shut the ovaries down. They are shortened to GnRHa. They stop the ovaries making estradiol, a form of estrogen. They are sometimes used as hormone therapy for breast cancer before menopause.

Radical trachelectomy is a surgery for early-stage cervical cancer. It is for women who want to become pregnant later. It removes the cervix, nearby tissue, the upper vagina, and sometimes lymph nodes. The uterus, tubes and ovaries stay. The uterus is then joined to the lower vagina. A special band helps keep it closed during pregnancy.

Hormone therapy for breast cancer often runs for years. That collides with the years someone might want a child.

NCI reports first results from the POSITIVE clinical trial. Some women treated for breast cancer can pause hormone therapy while trying to conceive. In the short term, that did not raise the risk of the cancer coming back.

The word "short-term" is doing real work in that sentence. If this applies to you, ask what the follow-up period was and what is still unknown.

NCI states this plainly. Success rate, cost and availability all vary. Some states require insurers to cover fertility preservation for people with cancer.

Three organizations NCI points to are worth contacting early:

• The Oncofertility Consortium runs a clinic finder. It also connects patients with navigators.
• The Alliance for Fertility Preservation publishes information on state laws requiring insurance coverage.
• Livestrong Fertility runs a discount program for qualifying cancer patients. It also helps locate clinics.

Ask whether the hospital has a patient navigator who handles fertility referrals. That role exists at a growing number of centers. It can turn weeks of phone calls into days.

This surprises people, and it belongs in the same talk. Even when treatment lowers fertility, pregnancy stays possible. Some cancer treatments can harm a pregnancy or cause a miscarriage. NCI notes your doctor may advise birth control during treatment. Ask which method is safe with your regimen.

• Could this treatment make it harder to become pregnant or to carry a pregnancy?
• Is there an alternative treatment with a lower fertility cost?
• Which preservation method do you advise for me, and is it available here or at a fertility clinic?
• How long would the procedure delay the start of cancer treatment, and is that delay safe?
• Can I speak to a social worker about insurance coverage and cost?
• What birth control should I use during treatment?

For what happens once treatment ends, see our page on fertility in women after cancer treatment. For the wider picture of long-term follow-up, see survivorship.

The fertility drugs used before egg or embryo freezing push the ovaries hard. A small number of people react too strongly. That reaction is called ovarian hyperstimulation syndrome. Mild bloating and a sore belly are common and settle. The signs below are not.

• Call 911 or go to an emergency department if you are short of breath or cannot lie flat, or one leg becomes swollen, hot and painful, which can point to a clot.
• Call the fertility clinic the same day if you gain more than 2 lb (1 kg) in a single day, you are passing much less urine than usual, your belly pain is severe, or vomiting is stopping you keeping fluids down.
• Call the fertility clinic within a day or two if bloating is getting steadily worse after egg collection, or you feel dizzy when you stand up.

Clinics running stimulation cycles expect these calls and have an after-hours number. Ask for it before your first injection.

• MedlinePlus: ovarian hyperstimulation syndrome
• NCI: female fertility and cancer treatment