The Ulman Foundation is a nonprofit organization focused on providing support and education to young adults diagnosed with cancer. Many young patients don’t realize the ways in which cancer treatment could affect their ability to have biological children in the future. Therefore, we provide important information to young patients to help them make the best decisions before they begin treatment. I’m glad to share some of this information with readers of CONQUER magazine.
Fertility Preservation 101
First, we need to understand that fertility preservation is not the same as infertility. Fertility preservation is an involved process that ensures the patient’s ability to have children in the future. The process involves collecting and storing a patient’s sperm, eggs (or oocytes, which are immature eggs), or embryos (fertilized eggs). These different cells are collected in different ways, depending on the patient’s gender. The semen, eggs, and embryos are then tested, and if they are viable, they are frozen through a process called “cryopreservation,” so that they can be available for future use.
These specimens allow patients to have a biological child in the future even if they are not able to carry a pregnancy or conceive a child through sex, because of infertility caused by cancer treatment or by the cancer itself.
Patients with cancer need to know that their disease and subsequent treatments may render them infertile, either temporarily or permanently. The one caveat to this is that in almost all cases, patients do not know their fertility potential before a cancer diagnosis. For our fertility preservation conservation, we have to assume that the patient is fertile, and we consider the patient’s unique diagnosis and treatment to predict his or her risk of infertility.
Patients may become infertile because of cancer treatment, including surgery, chemotherapy (and other toxic therapies), and radiation. This means that infertility is being forced on the patient to help save his or her life. For young patients, this is one more unknown and a harsh reality of the cancer journey.
Male Fertility Preservation Options
Men have the physiological advantage in that they continue to produce new sperm throughout their entire life. This allows their bodies to remove any sperm exposed to harmful therapies, and potentially reproduce new sperm that is free from exposure to toxic therapies. However, if the treatment causes harm to their testes (the hormone- and sperm-producing glands) or other reproductive-related body structures (such as the pituitary gland), men may no longer be able to produce viable sperm that can produce children.
The ideal time to collect the sperm sample is after a few days of abstinence and while the male is an inpatient in the hospital, at home as an outpatient, or in a clinic. Once the sample is collected and makes it to an andrology lab, the sperm will be analyzed to ensure its motility (movement), morphology (shape), and sperm count. This information will then be relayed back to the patient.
These factors will determine whether the sample is good enough to be stored for future use. The lab will analyze and determine the number of vials (with sperm) that can be stored, in the hope for multiple attempts of insemination in the future. The quality of the sperm does not decline over time; therefore, samples can be preserved indefinitely, or until the patient is ready to use it for impregnation with the help of advanced reproductive technologies.
This means that a physician or a healthcare provider specializing in reproductive endocrinology and infertility would work with the patient and his partner to coordinate the use of the sample, which will be used to fertilize an egg (an oocyte), and then implanted into the woman’s uterus.
Research shows that a male’s fertility should return to normal, or close to normal, no later than 4 years after cancer treatment. At that time, if his fertility is not restored, it will most likely not return. Male patients should have semen analysis done at a fertility clinic after their cancer treatment, to assess their fertility potential as part of their survivorship plan.
Males Before Puberty
As far as fertility preservation options go, the standard-of-care options are only for men who have gone through puberty. If the male patient has not hit puberty yet, all fertility preservation options are experimental. These options could include testicular tissue cryopreservation; sperm extraction or aspiration may be a potential option for some patients, and requires the expertise of an infertility specialist and a medical team.
Female Fertility Preservation Options
Exposure to chemotherapy and/or radiation radically reduces a woman’s ovarian reserve, which constitutes the woman’s reproductive potential. This is why fertility preservation is presented as an option to young women before starting chemotherapy or radiation or before undergoing surgery that may remove or affect reproductive organs.
Female fertility preservation is similar to in vitro fertilization, better known as IVF, but instead of the reimplantation process done as the final step in IVF, in fertility preservation cryopreservation is used to keep the eggs (or embryos) until the time of implantation (to become pregnant either personally or by using a surrogate).
In IVF, the male sperm fertilizes the woman’s egg in a laboratory setting to create an embryo, and then the infertility specialist implants this embryo into the woman’s uterus, to begin the pregnancy. The IVF process is invasive for women, because it requires daily self-injections of hormones, which are done at home, as well as frequent blood draws to monitor the levels of the hormones. These hormone injections are stimulating the woman’s eggs to mature, so they could be harvested and analyzed, potentially fertilized before freezing, cryopreserved, and safely stored for the future to facilitate a pregnancy.
At the time of egg retrieval, the woman can decide to store her eggs, or with a partner or a sperm donor, she can store embryos. Both options are now standards of care.
Unlike men, women are born with all the eggs in our ovaries that we will ever have. Over time, we lose eggs, most notably when we start menstruating, because our bodies release an egg each month during ovulation.
The IVF process is meant to expedite the maturation of the eggs, with the hope of having several, or many, mature eggs at the time of egg retrieval (for impregnation with the sperm). It takes about 2 to 4 weeks to complete 1 cycle of egg retrieval, which is often done in an outpatient setting.
Like men, these options are only available for women after puberty. However, several experimental options are now available at various institutions that are conducting clinical studies.
There is a significant cost associated with the use of sperm and advanced reproductive technologies to be able to attempt a pregnancy in the future.
The initial cost of fertility preservation for a male is about $500 to $1,000, plus the fees of $150 or more per year for storing the semen. There are also fees associated with the coordination and release of the sample, which can cost roughly $800.
The cost for 1 cycle of egg retrieval for a woman is roughly $10,000 upfront, plus additional expenses for annual storage of the eggs.
And then there are future fees for finalizing the process of getting pregnant with the help of advanced reproductive technologies, such as IVF.
Why Fertility Preservation?
I consider fertility preservation to be an insurance policy for patients. It allows patients to have hope that despite their cancer diagnosis and treatment, they may have biological children in the future. Preserving this piece of hope is a quality-of-life issue for many adolescent and young adults with cancer.
All hope is not lost if the patient is unable to pursue fertility preservation before treatment thanks to advances over time, as well as other family planning options, such as egg, sperm, or embryo donation, surrogates, and adoption. Furthermore, fertility preservation and infertility issues are not only relevant during a cancer diagnosis. It can also be considered at a later point, along the cancer continuum and into survivorship, as circumstances and wishes change.
- Fertility preservation involves collecting and storing a patient’s sperm, eggs, or embryos
- If the semen, eggs, or embryos are viable, they are frozen through a process called “cryopreservation,” so that they can be available for future use
- Patients with cancer need to know that their disease and subsequent treatments may render them infertile, either temporarily or permanently
- Research shows that a male’s fertility should return to normal, or close to normal, no later than 4 years after cancer treatment
- Exposure to chemotherapy and/or radiation radically reduces a woman’s ovarian reserve, which constitutes the woman’s reproductive potential
- The initial cost of fertility preservation for a male is about $500 to $1,000; the cost for 1 cycle of egg retrieval for a woman is roughly $10,000 upfront
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