Knowing the Options: When Cancer Treatment May Impact Your Fertility

A cancer diagnosis is devastating news on its own. But when a woman also hears that the treatment meant to save her life may threaten her ability to have children, it’s likely she’ll have new questions and concerns. Fertility preservation is especially important today because of a noted increase in cancer diagnosis in younger adults, particularly those in their 30s.

Thanks to special Oncofertility programs such as the one at Miami Cancer Institute, part of Baptist Health ― and the Institute’s innovative approach, including the first successful uterine transposition surgery on a cancer patient in the Southeast in April ― patients have help attaining their dream of becoming parents.

The program provides one-on-one fertility education and counseling to describe the risks cancer treatments can cause to fertility, explain fertility preservation options and quickly connects patients to services provided by reproductive endocrinologists in the community. Together, the teams can best coordinate care to both preserve fertility and begin cancer treatment as soon as possible.

Institute patients are seen by the Oncofertility program staff after the care team has determined their interest in having a family one day. “While many of our patients already have families or are pastchild-bearing age, the rise in cancer diagnoses in younger adults means that this is becoming a more common discussion,” said Elina Melik-Levine, ARNP, a nurse practitioner and educator at the Institute who meets via telehealth or in person with patients exploring fertility options.

Elina Melik-Levine, ARNP, a nurse practitioner and educator at Baptist Health Miami Cancer Institute 

“Ideally we meet right after their initial diagnosis, when the treatment plan is developed, but sometimes we meet even before we know the exact treatment plan,” Ms. Melik-Levine said. “It’s very rare that cancer care doesn’t impact fertility in some way, so the sooner we talk, the sooner they can understand their options and make decisions.”

Care that impacts fertility

Chemotherapy, surgery and radiation therapy can all diminish fertility. Certain medications can impact hormone levels or damage gametes directly, leading to temporary or permanent infertility.

Surgery to remove reproductive organs can also cause a loss of fertility. In addition, radiation can harm reproductive organs, particularly if radiation occurs in the pelvis, abdomen or in certain parts of the brain that control hormones that trigger puberty and the production/maturation of the egg and sperm. In addition, some cancer survivors, particularly those with certain types of breast cancer, are placed on medications they must take for five to 10 years to inhibit recurrence.

“With these medications, there is a risk of injury to a developing fetus and miscarriage, so women are advised to avoid pregnancy while taking these drugs,” Ms. Melik-Levine said. “As females age, their reproduction potential declines with each year that passes. In the case that any anti-cancer treatment is prescribed for a course of several years, it becomes especially important to educate patients about the female reproductive function and the impact of that treatment on fertility.”

Fertility preservation options

Moving forward with a pregnancy plan means becoming familiar with a variety of options. Among them are:

·      Egg cryopreservation ― the collection and freezing of eggs.

·      Embryo cryopreservation ― the freezing of embryos.

·      Ovarian tissue freezing ― taking tissue from an ovary and freezing it to later be thawed and placed in the body to produce eggs again. (Often for pre-pubescent girls.)

·      Ovarian transposition ― a surgical procedure to move the ovaries away from the path of radiation. Typically, the ovaries are relocated higher in the abdomen and gradually return on their own to their original position.

·      Uterine transposition ― a surgical procedure to move the uterus and ovaries out of the path of radiation. The Institute’s first uterine transposition occurred in a 29-year-old woman with rectal cancer. During surgery to remove the cancer, which follows radiation and chemotherapy, the patient’s uterus and ovaries will be moved back to their original position.

·      Testicular tissue freezing ― a surgical procedure to remove testicular tissue, including the cells that produce sperm. (Often the only option for prepubescent boys. Still experimental.)

·      Sperm banking ― also known as sperm cryopreservation. This involves the collection and freezing of sperm before treatment begins.

·      Ovarian or testicular shielding ― protecting the ovaries or testicles during pelvic radiation with special shields.

Other options for cancer patients or cancer survivors include donor eggs, donor embryos, surrogacy and adoption.

While more insurance companies are beginning to cover the cost of fertility treatment, which can range from a few hundred dollars for sperm banking to many thousands of dollars for egg and embryo freezing, many patients find themselves without coverage.

“There are many steps in the process,” Ms. Melik-Levine explained. “Freezing eggs, for example, involves hormone treatment to stimulate the ovaries to produce as many mature eggs as possible. Then there is a procedure to extract the eggs, which are sent to a long-term third-party facility for storage. When the woman is ready to start a family, the cost of IVF is additional.” Fertility experts who work with Miami Cancer Institute are familiar with available programs that may help cover some of the costs, when needed.

Some concerns for survivors

A study published in the Journal of the National Cancer Institute found that childhood cancer survivors who became pregnant as adults were as likely to have healthy babies as women with no history of cancer. However, the odds of developing a heart problem during pregnancy or having a severe complication during labor, while rare, were twice as high for female childhood cancer survivors.

And, as previously mentioned, because of the continued maintenance therapy some patients must be on for up to 10 years following treatment, their more advanced age may make it difficult to become pregnant naturally.

“Fertility preservation is optional but extremely important to many of our patients, so our greatest focus is to get them to the fertility experts as quickly as we can to increase their chances of being able to start a family one day and to move forward with treatment,” Ms. Melik-Levine said.