Jarett L. Feldman and Matthew J. Matasar
Patient Population (Cancer Stat 2012)
• ∼271000 men & ∼402000 women CA survivors <39 y old; fertility preservation is an important focus in the tx of CA pts
• doctor–pt communication is vital
Factors That Affect Fertility in Cancer Patients: (Adv Radiat Biol 1990;14:227, Cancer J 2009;15:27)
Factors That Affect Different Options Used in Fertility Preservation:
• Type of CA & age of the pt
• Time available before initiating tx
• Type of tx planned (surgery only vs. combination chemotherapy & radiation)
• Whether or not the pt has a partner & resources available
Evaluation of Ovarian Reserve in Woman With Cancer Previously Treated With Chemotherapy: (N Eng J Med 2009;360:902)
• U/s-directed follicle count, recommend referral to reproductive specialist
Preservation Options in Women: (DeVita, et al. Principles & Practice of Oncology, 9th ed. 2011. ASCO Educational Article. 2006)
Embryo cryopreservation
• Definition: Requires the harvesting of eggs, in vitro fertilization & freezing of embryo for later implantation
• Timing: Before or after tx
• Comment: Standard & most established technique. Requires a partner or donor sperm. Expensive. Of note, letrozole-FSH stimulation does not lead to elevated estradiol level w/c is a concern of breast CA pts
Cryopreservation of Mature & Immature Oocytes:
• Definition: Requires harvesting & freezing of unfertilized eggs
• Timing: Before or after tx
• Comment: Does not require a sperm donor at the time of extraction. Lower overall fertilization & birth rates (meta-analysis showed that the fertilization & live-birth rates per sperm-injected oocytes were 62.5% for fresh oocytes compared to 3.1% for the slow-freeze protocol (Fertil Steril 2005;84:S37))
Oophoropexy:
• Definition: Surgical repositioning of the ovaries away from the radiation field commonly in the upper abd. Case reports in upper extremities.
• Timing: Before tx
• Comment: Success rates vary dramatically (Hum Reprod Update. 2004;10:251). Can lead to chronic ovarian pain, infarction of the fallopian tube, formation of ovarian cyst & difficulty w/spontaneous pregnancies in the future.
Ovarian tissue cryopreservation:
• Definition: Requires the removal of ovarian tissue that is frozen & re-implanted at the completion of Rx
• Timing: Before & after tx
• Comment: Investigational use only & a theoretical concern regarding reseeding CA cells during the autotransplantation procedure in certain CAs
Gonadal shielding:
• Definition: The use of a shield to reduce the radiation exposure to the reproductive organs
• Timing: During tx
• Comment: Can only be used in certain situations. Expertise is required.
Trachelectomy:
• Definition: Surgical removal of the cervix while preserving the uterus
• Timing: During tx
• Comment: Limited to early stage cervical CA
Hormonal suppression through pharmacologic techniques:
• Definition: The use of GnRH analogs or antagonists to suppress ovarian function
• Timing: During tx
• Comment: Controversial regarding efficacy
Preservation Options in Men: (DeVita, et al. Principles & Practice of Oncology, 9th ed. 2011. ASCO Educational Article. 2006)
Sperm cryopreservation
• Definition: Freezing sperm obtained through masturbation, penile vibratory stimulation, electroejaculation
• Timing: Before tx
• Comment: Recommend 3–4 collections w/∼48h of abstinence prior to each collection (not relevant for testicular sperm extraction). Limiting factors include cost. Damage to sperm DNA can last up to 2 y after the completion of Rx & thus sperm collection should be performed prior to tx.
Gonadal shielding
• Definition: Use of a shield (ie, clamshell, lead blocks) to reduce the dose of radiation delivered to the testes
• Timing: During tx
• Comment: Expertise is required & does not protect against systemic Rx
Testicular sperm extraction
• Definition: Removing individual sperm from testicular bx
• Timing: Before & after tx
• Comment: Can only be performed in males after puberty & can be used in pts who are unable to ejaculate &/or unable to obtain an erection
Testicular tissue preservation:
• Definition: Testicular tissue surgical removal & frozen for future use
• Timing: Before tx
• Comment: Experimental
Improved surgical techniques such as: Nerve spearing RPLND & prostatectomy
Resources
Fertile Hope, Susan K. Komen Foundation, Lance Armstrong Foundation