Fertility Preservation Silvina Bocca, MD, PhD, HCLD What is Fertility Preservation? Fertility preservation is a subspecialty within the field of Reproductive Endocrinology and Infertility. Specifically, it focuses on helping reproductive-age men and women who are about to undergo cancer treatment understand their risks of infertility and possible treatment options. It can also apply to healthy women who wish to delay child-bearing. Who Needs Fertility Preservation? Why is Fertility Preservation Needed? We know that when patients are about to start a chemotherapy or radiation regimen, survival is the most important consideration. However, the Jones Institute Fertility Preservation Program is designed to provide information tailored to each individual patient regarding his or her options of treatment due to the potential for decreased fertility after cancer treatment. Chemotherapy or radiation can damage sperm and eggs, but the degree of damage can be hard to predict. For women, one marker of decreased fertility potential after cancer treatment is the loss of menstrual cycles, or premature menopause. However, some women who still have menstrual cycles after their cancer treatments may have “diminished ovarian reserve”, which means that the ovaries were damaged by treatment, but there is some ovarian function remaining. However, patients with “diminished ovarian reserve” may have difficulty conceiving, either on their own, or with Assisted Reproductive Therapies (ART). For men, either the cancer itself or the cancer treatments can cause infertility. Specific cancers that can damage the testis include testicular cancer and Hodgkin’s Lymphoma. Post-treatment sperm counts can be considered either normal, low, or completely absent. Treatment of malignancy, as well as some precancerous and benign conditions, may necessitate surgical resection of reproductive organs or administration of chemotherapy or radiation therapy. This often leads to infertility, which is a major quality of life concern. With appropriate pretreatment planning and intervention, biologic parenthood is possible for many of these men and women who will lose reproductive function. Because the age-related decline in fertility is primarily related to the oocyte, strategies to preserve oocytes are likely to afford effective means of avoiding infertility in women who wish to delay childbearing. For women who are approaching advanced reproductive age, but are not ready to become pregnant or are not in the position to have a child, options to preserve fertility, including embryo and oocyte cryopreservation, may be considered. Factors that may play a role in future infertility include: gender, age, chemotherapy medications, dose and number of cycles, radiation dose and location, prior difficulty conceiving, prior surgeries. PRETREATMENT COUNSELING — Physicians should discuss with patients the risk of infertility and possible interventions to preserve fertility prior to initiating potentially gonadotoxic therapy. This discussion should occur soon after diagnosis since some interventions to preserve fertility take time and could delay the start of treatment. Early referral to a reproductive endocrinologist can be useful. Advances in chemotherapy have led to development of less gonadotoxic treatment regimens for many cancers, such as Hodgkin lymphoma. Fertility preservation requires individualization. The optimal approach depends upon the type of gonadotoxic treatment (radiation versus chemotherapy), time available, patient age, the specific disease, and whether the patient has a partner. WHAT ARE THE OPTIONS FOR FERTILITY PRESERVATION IN WOMEN? Options for women prior to chemotherapy or radiation: • Emergency in vitro fertilization (IVF) with embryo freezing • Emergency ovarian stimulation with oocyte (egg) freezing 2 • IVF using a protocol specific for women with hormone-sensitive cancers: • Ovarian tissue freezing • Laparoscopic ovarian transposition Options for protecting ovarian function during chemotherapy or radiation: For radiation: Medical treatments to reduce radiation induced ovarian damage have not been successful in humans. • Ovarian transposition (oophoropexy) • Shielding For chemotherapy: *Gonadal suppression Options for women after chemotherapy or radiation • natural conception • transfer of frozen embryos into the uterus • IVF with one’s own eggs • IVF with donor eggs or embryos • IVF using a surrogate to carry the pregnancy • adoption LOGISTICS AND COST Depending on your type of cancer and treatment plans, several options for fertility preservation may be available to you at the Jones Institute at EVMS. A brief description of these choices is listed below. Note that often, fertility treatments are not covered by insurance—you can learn more about the costs when you meet with the Reproductive Endocrinologist. Women who are considering fertility preservation should first have a detailed consultation with a reproductive endocrinologist to address the issues discussed above. Potential candidates will generally undergo baseline ovarian reserve testing (day 3 serum FSH and estradiol levels and antral follicle count) prior to initiating treatment. The 3 processes of embryo and oocyte cryopreservation are identical to that of in vitro fertilization up until the time of the oocyte retrieval. Controlled ovarian hyperstimulation with daily injectable gonadotropins is initiated in the early follicular phase or after an interval on the birth control pills, and continues for approximately 10 to 14 days to achieve multiple periovulatory follicles. During this time, frequent monitoring of serum estradiol levels and follicle diameters is standard practice, often requiring office visits every two to three days. The oocyte retrieval is performed via needle aspiration utilizing transvaginal ultrasound guidance, typically under conscious sedation. For embryo cryopreservation, oocytes are inseminated with sperm and frozen the following day. For oocyte cryopreservation, mature oocytes are frozen on the day of the oocyte retrieval. In the United States, the cost of embryo and oocyte cryopreservation procedures is comparable to that of in vitro fertilization. You can contact our business office at 757446-8944 to inquire specific costs and insurance coverage. WHAT ARE THE METHODS TO PRESERVE FERTILITY IN MEN? Options for men prior to chemotherapy or radiation: • sperm freezing • testicular sperm extraction or testicular tissue freezing Options for men after chemotherapy or radiation • IVF with fresh or frozen sperm • Donor sperm insemination: Donor sperm insemination is an option if autologous cryopreserved sperm are not available. • Adoption Cost: You can contact the CryoLaboratory directly at (757) 446-5029 or www.JonesInstitute.org to schedule sperm banking. The cost of sperm freezing and storage is significantly lower than freezing eggs or embryos. 4 REFERRAL INFORMATION At the Jones Institute for Reproductive Medicine we provide a full range of evaluation and treatment options for men and women who are about to begin treatments that may threaten their chance for future child-bearing or who may like to preserve fertility. For more information about our general infertility clinic, please see our website (www.JonesInstitute.org). We work with your oncologist and primary care provider. We provide 24 hr/7d per week consultation and services. To refer a patient to the Jones Institute Fertility Preservation Program, please contact us at (757) 446-7100. We will do our best to see the patient as soon as possible. Please be prepared to fax any pertinent medical records to (757) 446-7455 so that our consultation with the patient can be as informative as possible. Also, feel free to contact us at www.JonesInstitute.org. Fertility Preservation Guidelines Several Oncology and Reproductive Medicine professional societies have practice guidelines with recommendations about referrals, consultations, and treatments for fertility preservation. American Society for Reproductive Medicine American Society of Clinical Oncology www.asco.org/guidelines/fertility) British Fertility Society Children’s Oncology Group 5