UAB Synopsis, Vol. 28, No. 25, June 29, 2009

“Discussing options for fertility preservation with cancer patients improves their ability to successfully cope with their disease and treatment. This fact is surprising to many providers,” says G. Wright Bates Jr, MD, director of the Division of Reproductive Endocrinology and Infertility.

Dr. Bates directs UAB’s Fertility Preservation Program, which offers advanced treatments for fertility preservation and restoration for individuals and couples who have cancer or other serious medical conditions that may affect their chances of having children. Many reproductive-age men and women successfully undergo cancer treatment, but radiation and chemotherapy can affect fertility. Sperm production may recover, but egg loss is permanent, and premature menopause may occur.

Timely Treatment

The program’s goals include expanding awareness among physicians and patients that viable options exist for fertility preservation and ensuring treatment is as timely and trouble-free as possible.

“We are very responsive. We are available on short notice and go to the clinic where patients are being seen. We can treat men the same day and can schedule women within a day or two,” Dr. Bates says.

“Although the UAB Comprehensive Cancer Center does a nice job addressing reproductive issues, some oncologists don’t discuss fertility,” he says. Fewer than 1% of women are sent to fertility doctors and only about 10% of men are offered sperm banking. However, several options are available. For men, the UAB program offers sperm banking. Samples can be stored for several years and used for insemination, in vitro fertilization (IVF), or intracytoplasmic injection.

For women, the treatments available are:

• IVF and embryo freezing: This type of fertility preservation is the most established and successful. However, it requires time, expense, and sperm availability, and delays cancer treatment. “There also are concerns that the tumor may be responsive to the hormones used to induce ovarian hyperstimulation,” Dr. Bates says.
• Ovarian cryopreservation: For women who cannot undergo the hormonal treatments required for IVF or do not have time to undergo an IVF cycle, this investigational treatment involves retrieval of ovarian tissue, which is frozen and stored. The tissue is implanted in the remaining ovary once cancer treatment is completed, with the hope of restoring normal hormonal production and fertility.
• Cryopreservation of unfertilized oocytes: This experimental technique requires ovarian stimulation but does not require sperm. Unfertilized eggs are retrieved and frozen with the hope of later success with IVF. Immature eggs also can be retrieved without stimulation; however, maturation of these eggs in the lab is highly experimental.
• Ovarian transposition or relocation: If cancer treatment necessitates radiation of the pelvis, surgeons can reposition the ovaries out of the radiation’s path to minimize exposure.

Because of the overwhelming psychological, emotional, and ethical aspects of these decisions, patients undergo extensive counseling and discuss every scenario relevant to banking embryos and tissue. They then sign consent forms that dictate their wishes.

Many women and men can safely pursue pregnancy after chemotherapy or radiation. Dr. Bates and colleagues work with oncologists to determine patients’ fertility potential and treatment options. The full range of reproductive options is available.

The program also addresses early menopause with premature ovarian failure after cancer treatment. “Hormone supplementation in this younger population does not have the same risks as it does in older patients,” Dr. Bates says. UAB is participating in Fertile Hope, a national nonprofit organization dedicated to providing reproductive information, support, and hope to cancer patients and survivors whose medical treatments carry the risk of infertility.

UAB is one of the first institutions with IRB approval for tissue banking in conjunction with the Oncofertility Consortium, a national interdisciplinary initiative to explore reproductive options for patients diagnosed with cancer or other serious diseases. Researchers and clinicians within the Oncofertility Consortium are investigating new methods for improving fertility preservation options for young patients with cancer and other serious diseases and finding ways to communicate these options to patients at the time of diagnosis, before treatment begins. Consortium researchers are attempting to answer fundamental questions about success rates with fertility preservation and novel ways of preserving and developing eggs after freezing.

“This program has a potentially tremendous impact because the number of individuals facing cancer during their reproductive years is significant [about 800,000 men and women]. Patient awareness empowers them to make a decision about their own reproductive health,” he says.