Pocket Oncology (Pocket Notebook Series), 1st Ed.

FERTILITY PRESERVATION

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