Fertility Preservation for Women Diagnosed with Cancer

Starting the Conversation
Fertility Preservation for Women Diagnosed with Cancer
Introduction
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Many women who have been diagnosed with cancer think preserving their fertility is important and want information about their options. However, patients may not feel comfortable bringing up fertility issues.

  • Patients may not be aware of their options for preserving fertility.
  • Patients may be focused on their cancer diagnosis and unable to think about fertility or the possibility of having a future family.
  • Women may later regret not considering fertility issues prior to starting cancer treatment.
  • Even women with a poor prognosis may want to consider fertility preservation.

Understanding there are fertility preservation options available and referring at-risk patients in a timely manner to specialists can improve patients’ emotional outlook and future quality of life.

Fertility Preservation - Where Does It Fit?

a) See table below
b) See figure below

Options for Fertility Preservation
  • The following table gives a brief description of options available to women who wish to preserve their fertility.
  • The American Society of Clinical Oncology and American Society for Reproductive Medicine recommend, when possible, at-risk patients be referred to a fertility preservation specialist prior to starting cancer treatment.
  • Several resources are listed on the reverse that can help you and your patients locate a fertility preservation specialist.
  • Remember there are other ways to build a family after cancer if we are unable to preserve your fertility now. Talking with a specialist can help you explore other options that might be right for you.
OptionDefinitionTimingTime RequirementOther Considerations
Embryo BankingOvarian stimulation; Harvesting eggs, IVF and freezing of embryosBefore or after treatment10–15 days outpatient surgical procedureNeed partner or donor sperm
Egg BankingOvarian stimulation; Harvesting and freezing of unfertilized eggsBefore or after treatment10–15 days outpatient surgical procedure 
Ovarian Tissue Banking (Experimental)Surgical removal of ovarian tissue and processing of tissue for freezingBefore or after treatmentOutpatient surgical procedureAutotransplantation of tissue has produced live births; studies ongoing for IVFM
Radiation ShieldingUse of shielding to reduce scatter radiation to the ovariesDuring treatmentIn conjunction with radiation treatmentsDoes not protect against effects of chemotherapy
Ovarian TranspositionSurgical reposition of ovaries out of radiation fieldBefore treatmentOutpatient procedure 
Radical TrachelectomySurgical removal of the cervix with preservation of the uterusBefore treatmentInpatient surgical procedureLimited to early stage cervical cancer
Ovarian Suppression (Experimental)GnRH analogs used to suppress ovariesDuring treatmentIn conjunction with chemotherapyData are mixed on the effectiveness of this option.
Starting the Conversation

Discussing fertility preservation is important. These key points can help start the conversation:

  • Cancer and cancer treatment may affect your fertility.
  • Based on your treatment plan, your risk of infertility is [high, moderate, low] (see table below).
  • Although it may not be on your mind now, it is important to discuss fertility before you begin treatment.
  • You may have options for fertility preservation before you begin cancer treatment (see table above).
  • Not all women experience infertility after cancer treatment, however it is still important to explore your fertility preservation options before treatment. 
  • I can refer you to a fertility preservation specialist if you would like to discuss your options further.
Cancer Therapy and the Risk of Infertility

The following table classifies various cancer therapies and regimens based on their known infertility risk in women (defined as permanent amenorrhea).

While this table provides general guidelines, each patient is different and treatment may impair their fertility differently.

 

Infertility risk associated with specific cancer treatments and regimens

High Risk
  • Whole abdominal or pelvic radiation doses >6 Gy in adult women
  • Total body irradiation (TBI)
  • Cranial/brain irradiation >40 Gy
  • CMF, CEF, or CAF x 6 cycles in women >40 years
  • Total cyclophosphadmide 5 g/m2 in women >40 years
  • Total cyclophosphadmidey  > 7.5 g/m2 <20 years
  • Alkylating chemotherapy (e.g., cyclophosphamide, busulfan, melaphan) conditioning for transplant
  • Any alkylating agent (e.g., cyclophosphamide, ifosfamide, busulfan, BCNU [carmustine], CCNU [lomustine]) + TBI or pelvic radiation
  • Protocols containing procarbazine: MOPP, MVPP, COPP, ChlVPP, ChlVPP/EVA, BEACOPP, MOPP/ABVD, COPP/ABVD
Intermediate Risk
  • Abdominal/pelvic radiation
  • CMF, CEF, or CAF x 6 cycles in women 30-40 year
  • Spinal radiation doses >25 Gy CMF, CEF, or CAF x 6 cycles in women 30–40 years
  • Bevacizumab (Avastin)
  • Protocols containing cisplatin
  • FOLFOX4
  • Total cyclophos-phamide 5 g /m2 in women age 30- 40
Low Risk
  • CMF, CEF, or CAF x 6 cycles in women <30 years
  • Nonalkylating chemotherapy: ABVD
  • Anthracycline + cytarabine
No Risk
  • Radioactive iodine
  • MF
  • Multi-agent therapies using vincristine
Unknown Risk
  • Monoclonal antibodies, e.g., cetuximab (Erbitux)
  • Tyrosine  kinase inhibitors, e.g., erlotinib (Tarceva), imatinib (Gleevec)

Table adapted from Fertile Hope, an initiative of LIVESTRONG; Cancer and Fertility: Fast Facts for Reproductive Professionals (2008); and Meirow D, et al. Clin Obstet Gynecol. 2010;53:727-739.

CMF=cyclophosphamide/methotrexate/fluorouracil • CEF=cyclophosphamide/epirubicin/fluorouracill • CAF=cyclophosphamide/adriamycin (doxorubicin)/ fluorouracill • MOPP=mechlorethamine/oncovin (vincristine)/procarbazine/prednisonel • MVPP=mechlorethamine/vinblastine/procarbazine/prednisolonel • COPP=cyclophosphamide/oncovin/procarbazine/prednisonel • ChlVPP=chlorambucil/vinblastine/procarbazine/prednisolonel • EVA=etoposide/vinblastine/\ adriamycinl • BEACOPP=bleomycin/etoposide/adriamycin/cyclophosphamide/oncovin/procarbazine/prednisonel • ABVD=adriamycin/bleomycin/vinblastine/ dacarbazinel • AC=adriamycin/cyclophosphamidel • CHOP= cyclophosphamide/hydroxydaunomycin/oncovin/prednisonel • COP= cyclophosphamide/oncovin/ prednisonel • MF=methotrexate/5-fluorouracil

Resources

For more information about infertility risk, fertility preservation options for women diagnosed with cancer, and how to locate and refer your patients to a fertility preservation specialist:

References
  • The Ethics Committee of the American Society for Reproductive Medicine. Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion. Fertil Steril. 2013; 100:1224-31.
  • De Vos M, Smitz J, Woodruff TK. Fertility preservation in women with cancer. Lancet. 2014;384:1302-10.
  • Jeruss JS, Woodruff TK. Preservation of fertility in patients with cancer. N Engl J Med. 2009;360:902-911.
  • Loren AW, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013; 31: 2500-10. 
  • Meirow D, Biederman H, Anderson RA, Wallace WH. Toxicity of chemotherapy and radiation on female reproduction. Clin Obstet Gynecol. 2010;53:727-739.
  • JM Letourneau, EE Ebbel, PP Katz, et al. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer. 2012; 118:1710–1717.
  • Levine JM, Kelvin JF, Quinn GP, Gracia CR. Infertility in reproductive-age female cancer survivors. Cancer. 2015;121(10):1532-9.
  • Tschudin S, Bitzer J. Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases. Hum Reprod Update. 2009;15:587-597.
  • Woodruff TK. The Oncofertility Consortium—addressing fertility in young people with cancer. Nat Rev Clin Oncol. 2010;7:466-475.

The Oncofertility Consortium® is an international, interdisciplinary initiative designed to explore the reproductive future of cancer survivors.

To learn more about fertility preservation, please visit SaveMyFertility.org for additional resources.

To learn more about the Oncofertility Consortium, visit oncofertility.northwestern.edu.

© 2017 The Oncofertility Consortium®