Fertility Preservation: A Comprehensive Approach to the Young Woman With Cancer

Abstract

Modern treatments for cancers of the reproductive age are yielding ever-higher cure rates, but more often than not, the price paid for survival is the loss of reproductive function from gonadal toxicity. Alkylating agents and ionizing radiation have well-recognized deleterious effects within the testes and ovary and cause sterility in a high proportion of patients exposed to these treatments. Preservation of fertility for men simply involves the banking of sperm before treatment, but for women, the storage of gametes is technically very complex and has limited success. Even when faced with the diagnosis of cancer, many reproductive-aged women are burdened by the possibility of never conceiving a child with their own eggs. Fertility preservation for the reproductive-age women with cancer is emerging as a challenging, but rewarding, application of assisted reproductive technologies such as in vitro fertilization. With recent advances in cryopreservation techniques, oocytes, embryos, and ovarian tissue can be banked from these patients before exposure to sterilizing chemotherapy and radiotherapy, providing future fertility options without compromising survival.

Preservation of Fertility in Pediatric and Adolescent Patients With Cancer

“…[53][54][55][56][57] Currently, this technique is available only in certain parts of the United States as an experimental protocol until more can be learned about its safety and efficacy. 45 Within this context, it is the only method that can be offered to prepubertal girls.…”

“…61,62 Embryo cryopreservation is an established technique with acceptable pregnancy rates, but its use is limited to females who are either involved in a stable relationship or willing to identify a known or anonymous donor because of the need for sperm. 54 The need for ovarian stimulation theoretically precludes this option for women with estrogen-sensitive tumors, although the use of aromatase inhibitors during stimulation has been proposed as a way of mitigating this concern. 57 …”

Sexuality and Fertility after Cancer

“…Women who do not require urgent treatment may undergo a cycle of in vitro fertilization before cancer treatment and cryopreserve embryos, but the chance of a pregnancy with future use is still limited, and patients without a male partner have to use donor sperm to take advantage of this option. 41 Women with breast cancer can utilize new protocols that may limit exposure of cancer cells to high estrogen levels by adding aromatase inhibitors or tamoxifen to the ovarian stimulating drugs. 42 Cryopreservation of mature, unfertilized oocytes is another experimental choice, but only around 100 children have been born worldwide from this technique, and concerns remain about the genetic integrity of the spindle and the optimal freezing technique.…”

“…42 Cryopreservation of mature, unfertilized oocytes is another experimental choice, but only around 100 children have been born worldwide from this technique, and concerns remain about the genetic integrity of the spindle and the optimal freezing technique. 41,43 Centers around the world have begun harvesting ovarian tissue for cryopreservation, in the hopes that autotransplantation or even xenotransplantation of the tissue will result in the development of healthy, mature oocytes. 41,43 For some malignancies, cancer cells could theoretically be harbored in the ovarian tissue.…”

“…41,43 Centers around the world have begun harvesting ovarian tissue for cryopreservation, in the hopes that autotransplantation or even xenotransplantation of the tissue will result in the development of healthy, mature oocytes. 41,43 For some malignancies, cancer cells could theoretically be harbored in the ovarian tissue. The one published birth from autotransplanted, cryopreserved ovarian tissue has been questioned since the patient had signs of recovered activity in her remaining ovary on the other side.…”