Tuesday, April 22, 2008

Cancer Treatment and Fertility, Part 2: What Can Be Done?

On April 1st, I wrote about the impact of cancer treatments on fertility. I discussed the many ways in which the way we treat cancer can affect the patient’s ability to have kids in the future. Fortunately, there are many things we can do to try to preserve fertility.

Part 2: What can be done to preserve fertility?

Some fertility preservation techniques are well-known. One option for boys who are old enough is sperm banking (freezing and storing their sperm for possible future use). Ideally, this should begin prior to treatment and multiple samples should be preserved. Unfortunately, in some cases this is not possible, due to the urgency of beginning treatment, especially in leukemia patients who are often quite sick at the time of diagnosis. Despite the common use of sperm banking, the use of frozen sperm seems to be rare (for example, only 7% of testicular cancer patients used their stored sperm in one study).

What about children who are too young for standard sperm banking techniques? Although the testes of younger boys may be relatively spared from the effects of chemotherapy, this point is debated. In younger boys, sperm can be obtained by “electroejaculation” or by testicular sperm extraction (both under general anesthesia, of course).

These approaches work for boys whose infertility risk comes from systemic chemotherapy. As I discussed before, newer surgical techniques have made male infertility as a consequence of retroperitoneal lymph node dissection quite rare. What about radiation therapy? If the radiation must be directed at the testes, nothing can be done other than sperm banking. However, if only one testis must be irradiated, the other can be moved out of harm’s way surgically, and put back where it belongs when the radiation treatment has been completed.

A similar approach, called oophoropexy, can be used to move ovaries our of the radiation field in girls or women who need pelvic radiation. This can be done by a minimally invasive approach, using a scope. Unfortunately, damage to the uterus from radiation may still make pregnancy difficult or impossible.

Eggs (oocytes) can also be frozen and stored, just like sperm. Unfortunately, this is not as easily accomplished as it is in boys, and is not as successful. Oocytes can be retrieved directly (this requires drugs to stimulate their production and a minimally invasive procedure to harvest them), or ovarian tissue containing the oocytes can be extracted surgically and frozen. During cancer treatment, suppression of ovary function with medicines such as Lupron is probably also effective at preserving fertility, though this is not yet conclusively proven.

And what of the babies?

Given the number of options available to try to protect fertility, as well as the active research that will hopefully improve things in the future, we also have to give thought to the children who are born to survivors of childhood cancer. Chemotherapy and radiation therapy are mutagenic. Does that mean children born to people who receive these treatments are at increased risk of birth defects? Apparently not. A very large epidemiologic study published in 1995 failed to show a link between cancer therapy and developmental problems.

Hopefully, future therapies will have less impact on fertility than the treatments we have now, and we doctors will be able to look back on this time and be grateful our patients no longer have to add “Will I be able to have a baby?” to their list of worries when they are diagnosed.

Photo Credit


Related posts:
Cancer and Fertility: How Can Treatment Impact Fertility? (Part 1)

9 comments:

Jen said...

Thank you for doing this series, and especially for the great links. My daughter is a cancer survivor, so needless to say it's always been a concern for us. Her oncologist said that it's "likely" that she's not going to have any trouble with fertility, but I guess that we'll wait 20 years or so (hopefully!), and see.

rlbates said...

Another great post. Would you consider submitting it to SurgeXperiences?

Sue said...

This is information that I learned myself after my daughter had cranial/spinal radiation and chemotherapy which started in 2005. No one told us about this before her treatment started. Had I known before her treatment, would I have put an 8-year old through the procedure necessary.... I'll never know. What's done is done. We hear many people say "At least she's alive." Correct, except the treatment didn't work and the cancer is back... To the people that say this, my answer... "We thank God every day that she is still alive. Unfortunately, she has to deal with all of the horrible side affects of her treatment. Do you want to be holding her hand IF she reaches the age of child-bearing (all she wants is to be a Mom) when she hears that the radiation and chemo damaged her ovaries?" There are other options, and we are grateful for all of our blessings, but wanting to bare your own child... it's a woman's privilege that she will probably be denied, another issue because of that cancer she had when she was a child.....

Anonymous said...

Do all of these things apply for adults who are diagnosed with cancer?

Doctor David said...

Jen. I'm glad you found the series helpful and interesting. If you have other ideas for topics you'd like to hear about, please drop me a line and let me know.

Ramona, I'd be honored to submit this piece to SurgeXperiences!

Sue, I'm sorry to hear about your daughter's misfortune. It sounds like she's been through a lot... more than an 8 year old should have to deal with (and her mother!). I do hope she gets to childbearing age and becomes a mother. There IS hope. I have a patient, a woman with a disorder that should have made her super-sensitive to the side effects of the chemo she needed for her bone marrow transplant... and she's got 2 kids! So you never can tell what the future will bring.

Anonymous, yes, these things apply to adults with cancer as well.

Anonymous said...

Possible fertility problems are just one more worry for the parents and the patients. It never ends, and while we are grateful for all our options and the medical advancements, the truth is that it is never "over." (My daughter is 16 and 3 years off treatment for medulloblastoma.)

-- Grace

Susan said...

Hey Doctor David,

Recently found your blog and have really found your posts interesting.

This one really caught my attention.

My son had radiation to his brain, hypothalamus. He has a LGG.

Because of this he is panpit. I've never had the courage to ask a doctor if this will cause him to not have children.

He's 22, but learning disabled and really not interested now. But maybe one day he will be.

Just wondering...

Doctor David said...

Hi Susan,

Thanks for stopping by and reading my blog. It's tough to answer your question... but finding the answer is easy. Part of his long term follow up could include a sperm analysis (count and evaluation of motility), and then you would know.

Susan said...

Thanks Doctor Dave,

I appreciate this!!