As cancer treatments improve, the problems faced by survivors of cancer and the complications of cancer therapies become more important. Many survivors are young and are diagnosed and treated before they have children. Malignancies and their treatment can significantly affect the chance of a patient having a child in the future. We therefore realise how important it is that all patients are able to discuss the effects of treatment with a fertility expert and explore whether they are able store eggs, sperm or embryos before their cancer treatment, which could be used to help them have their own biological child in the future.
Patients in this situation are faced with two devastating diagnoses simultaneously – malignancy and infertility. Having to face both diagnoses can cause huge distress and therefore all patients will be offered an appointment to see one of our counsellors if they wish.
At Saint Mary’s Hospital, we have stored sperm for men facing cancer treatment for many years. Our Fertility Preservation Service for women started in 2008. We appreciate that cancer treatment often has to start very quickly and in these cases we aim to see patients within one week.
Our service is led by Dr Cheryl Fitzgerald, Consultant in Reproductive Medicine and Della Gould, Clinical Nurse Specialist, who liaise closely with the rest of the Reproductive Medicine team and with the teams responsible for the patient’s cancer treatment.
Fertility preservation is not only an issue for cancer patients, but also other challenging patient groups at risk of fertility compromise because of medical treatments such as patients genetically predisposed to premature ovarian insufficiency or those undergoing chemotherapy or surgery for non-cancer diseases or wishing to store gametes before gender re-assignment treatment.
We offer NHS treatment to eligible patients and continue to work with health care purchasers to ensure that treatment is available to as many patients as possible. Whilst some patients may not be eligible for NHS funded treatment, we can still see these patients for a consultation within the NHS and give advice.
Testicular cancer is the most common malignancy seen in young men. Haematological malignancies (cancers of the blood) such as leukaemia and lymphomas are also seen frequently. Treatments may involve significant surgery (for testicular malignancies), chemotherapy and radiotherapy. Systemic chemotherapy and pelvic radiotherapy can lead to testicular failure, meaning that the testes are unable to produce sperm in the future.
Men facing potentially sterilising therapies can be offered the opportunity to bank semen before they start treatment. A semen sample is produced, the sperm extracted and frozen for the future. Samples can be legally stored for up to 55 years in the UK. When the patient returns to use the samples, they may be used within insemination treatment or, if there are additional female factors or the semen sample is of poorer quality, within IVF and/or ICSI. Not all men who have sperm stored will be eligible for NHS funded fertility treatment when they return to use the sperm, but we can continue to store the sperm until the patient decides whether he wishes to use the stored samples, either within NHS funded treatment or private fertility treatment.
Cancer treatments can have a number of different effects on female fertility:
Delay to conception
Most women will be advised to delay conceiving for a period of time following cancer treatment. Female fertility declines sharply in a woman’s mid to late thirties and delay can significantly reduce the chance of conception.
Oocytes (eggs) are highly susceptible to the effects of chemotherapy. Women treated with chemotherapy are therefore at risk of oocyte damage which may ultimately result in failure of the ovaries. The risk of ovarian failure is higher with increased dose and duration of chemotherapy and with particular types of chemotherapeutic agent. It is also more likely in women who already have a reduced reserve, ie, older women. Periods may stop during chemotherapy, but may come back up to nine months after chemotherapy treatment has finished. Although some patients will retain eggs in their ovaries after chemotherapy treatment, unfortunately many will suffer premature ovarian failure and would need to consider treatment with donated oocytes if they wish to conceive.
Whilst most chemotherapy treatments are administered systemically (throughout the body), most radiotherapy treatments are directed to a local area. Therefore toxicity from radiotherapy is usually limited to the area treated. Pelvic radiotherapy is highly toxic to oocytes and it is extremely rare for women to retain significant ovarian reserve after such treatment. Additionally, pelvic radiotherapy is associated with damage to the uterus (womb) caused by fibrosis and a reduction in blood flow. Following pelvic radiotherapy, it is likely that the woman would need to consider fertility treatment using donated oocytes and a surrogate host.
Surgery for gynaecological malignancies can impact on a woman’s chance of pregnancy in the future. Fertility options may therefore include the need for treatment with donated eggs or a surrogate host. It is important that a woman’s desire for future pregnancies is always considered and that fertility sparing treatment is performed whenever possible. This is always discussed with the woman and the surgeon responsible for the woman’s cancer treatment.
Fertility preservation options for women
We feel that all young women diagnosed with a malignancy should be seen by a fertility specialist to discuss the effect that their cancer treatment may have on their fertility and whether there is a possibility of storing eggs or embryos for future use:
Oocyte cryopreservation (egg freezing)
If a woman does not have a long term partner, she may attempt to store eggs. Following a cycle of ovarian stimulation and egg recovery (similar to that of an IVF cycle), all retrieved eggs are cryopreserved by the process of vitrification. Vitrification freezes eggs extremely rapidly and appears to be the optimal method. Mature eggs are very large cells and the chromosomes within them are not held within a nucleus. These properties make eggs very sensitive to disruption from the freezing process. In the UK, frozen eggs can be stored for up to 55 years. When a woman returns after completion of her cancer treatment, the frozen eggs are thawed and each surviving egg is injected with a single sperm using ICSI (intra-cytoplasmic sperm injection). More than 90% of eggs survive the freezing process and fertilisation rates are similar to those seen with ‘fresh’ eggs.
Embryo cryopreservation (embryo freezing)
If the woman is in a stable relationship, the couple may wish to freeze embryos instead of eggs. The woman undergoes a cycle of ovarian stimulation and egg retrieval as in conventional IVF. On the day of egg collection, an attempt to fertilise all mature oocytes is made. The following day, all fertilised oocytes are frozen at the ‘pronuclear’ one cell stage and, in the UK, may be stored for up to 55 years. Embryo freezing is a relatively successful procedure and follow up studies on babies born are reassuring. Approximately 1 in 3 couples will conceive following embryo freezing if the female partner is under 35 years of age. Although more successful than egg freezing, embryo storage should only be carried out for couples in a stable relationship as, if the couple separate, the male partner may withdraw his consent for continued storage and treatment. As a result, the embryos would have to perish.
After oncology treatment
Many patients present for fertility investigations after cancer treatment. Assessment can be carried out as for any couple. If a woman continues with a menstrual cycle after chemotherapy, we advise her to try to conceive as soon as possible (after discussion with the oncologists) as she has a higher risk of premature ovarian failure. However, it is important to wait at least nine months after the completion of treatment before assessing resultant ovarian reserve.
Risks of fertility preservation treatments
Throughout treatment, we work closely with the team planning cancer treatment, to minimise any risk to the patient or delay to their cancer treatment.
When the intention is to freeze eggs or embryos, ovarian stimulation can start at any time in the menstrual cycle as there is no need to ensure that the lining of the womb is at the same stage of the cycle as the ovaries. However, ovarian stimulation takes a minimum of just over two weeks. It is therefore crucial that patients are referred as early as possible in their treatment pathway to give them the opportunity to consider fertility treatment if they wish without delay to their oncology treatment. In some cases, such as acute leukaemia, any delay to the start of chemotherapy may be significantly detrimental and these patients are not able to freeze eggs or embryos although male patients would usually have time to freeze a semen sample.
2. Risk of high oestrogen levels during stimulation
High levels of oestrogen are seen during ovarian stimulation cycles. This could pose a risk to women diagnosed with an oestrogen sensitive breast cancer. Addition of the drug Letrozole is associated with significantly lower oestrogen levels and we use this routinely for oestrogen positive breast cancer patients. There are no large, long term follow studies, but early data has not demonstrated an increased risk of recurrence or disease progression in these patients.
3. Risk from egg retrieval
There is a potential risk for patients with ovarian malignancies that, following egg collection, there could be a spill of malignant cells from the ovary into the peritoneal cavity, although in practice this is rarely thought to be significant. We always discuss this with the oncologist to minimise risk.
4. Ovarian hyperstimulation syndrome (OHSS)
OHSS is a complication seen in approximately 1% of patients undergoing a cycle of ovarian hyperstimulation for egg recovery. The risk is no higher in fertility preservation patients, but we usually continue with drug therapy for one week after egg collection to try to reduce the risk further, so that the woman is in the best position to commence her oncology treatment.
How can I access this service?
Patients are usually referred by their GP or Cancer Specialist (Oncologist).