Female Fertility Preservation
The vast majority of pediatric cancer patients live full and vibrant lives after cure – lives that need not be limited by the side effects of life-saving treatments. Female patients may be at risk for infertility as a result of cancer treatment, including chemotherapy, radiation, or surgery. It is difficult to determine exactly when a patient may be left infertile due to treatment, but research in adult patients suggests that infertility may occur very early in treatment. Therefore, plans to preserve future fertility are ideally made at the time of diagnosis, not after treatment has begun.
There are several fertility preservation options available to females – some are experimental and some are not experimental. Determining which method is appropriate for a patient depends upon the age of the patient, the treatment she is scheduled to receive, how soon treatment must start, and the family’s wishes. Cost, insurance coverage, and proximity to a reproductive medicine clinic may impact the decision to pursue fertility preservation. Since the treatment for pediatric cancer must usually begin as soon as possible after diagnosis, time is short for a fertility preservation procedure.
Experimental Options for Pre-pubertal and Post-pubertal Females
Ovarian Tissue Cryopreservation (“freezing”)
This requires a surgical procedure to remove part or the entire ovary, which is then frozen. The ovary contains immature eggs called follicles. Research is ongoing to develop a method to mature the follicles into eggs, which could be fertilized for pregnancy. Another potential use of the ovarian tissue is to replant the tissue back into the woman once the treatment is completed. This may stimulate the body to make female hormones such as estrogen. Replanting tissue may not be appropriate for every woman, as there is the possibility of re-seeding cancer. Ideally, the procedure to remove ovarian tissue is performed prior to the patient receiving any cancer treatment. To minimize exposure to anesthesia, this surgery may be performed with another procedure such as central line placement or tumor resection.
This option is experimental and should only be performed at a hospital with Institutional Review Board approval. Families should consider this option if oocyte harvesting and freezing are not appropriate or if the patient needs to begin treatment emergently.
When Treatment is Completed
Because the cryopreservation procedure is relatively new, there is limited information regarding the use of ovarian tissue when treatment is completed. Research examining the use of replanted ovarian tissue is ongoing. To date, there is one report of a healthy baby born with ovarian tissue replanted in a pediatric patient, 13 years after her ovarian tissue was cryopreserved.
Live births following replanting cryopreserved ovarian tissue are reported in adult women. These are published reports of adult women resuming menses after tissue replanting, as well as a patient who used replanted ovarian tissue to start puberty development.
Research
Research is ongoing for the use of cryopreserved tissue for normal hormone health, as well as eventual pregnancy. The following hospitals are part of the Oncofertility Research Consortium and are fully prepared to enroll children in this study. The contact person at each hospital can be contacted by the treating oncologist, or directly by parents.
Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, IL
Contact: Laura Erickson, MSN, APN, CPNP — lerickson@luriechildrens.org — (312) 227-5535
Next Steps
PORF encourages parents to learn more about fertility preservation before making a final decision.
Parent to Medical Provider
The first set of questions is intended for parents to get fundamental information from their medical provider. PORF uses the term “medical provider,” because medical practices vary in how they interface with parents and patients. Sometimes the nurse practitioner, or physician assistant is a more comfortable source of information than the primary physician. Some practices have a special representative who addresses issues of fertility preservation. It is most important that parents speak to someone who is knowledgeable and a good listener.
Post-pubertal Questions:
- Will the treatment program that you recommend likely compromise fertility?
- What is the likelihood that cancer cells will be present in the ovary?
- What will be done to insure that cancer cells are not reintroduced into the body when the preserved tissue is replanted?
- Will this surgery cause additional pain, or delay the start of treatment?
- In the event of a pregnancy, is there any reason to believe the cancer, or the cancer treatment could endanger the fetus?
Pre-pubertal Questions:
- Will the treatment program that you recommend likely compromise fertility?
- What is the likelihood that cancer cells will be present in the ovarian tissue?
- What will be done to insure that cancer cells are not reintroduced into the body when the preserved tissue is replanted?
- Will this surgery cause additional pain, or delay the start of treatment?
- In the event of a pregnancy, is there any reason to believe the cancer, or the cancer treatment could endanger the fetus?
Parent to Parent
Answers to the questions above will give parents a good basis for their own discussion. Parents will be able to assess the value of the procedure for their own daughter. The age of their daughter and the promise of research bearing fruit are two important considerations for parents to discuss.
Post-pubertal Questions:
- Are we comfortable having a discussion about ovary removal and preservation with our daughter?
- If not, do we know of someone who would be comfortable having such a conversation?
- Does our religion or our culture take issue with this procedure?
- If so, should we consult with a religious consultant before we talk with our daughter?
- Will we be able to afford the cost of storing the tissue?
Pre-pubertal Questions:
- Since this research is relatively new, are we certain that it will not make our daughter more uncomfortable, or delay her treatment?
- Will our insurance pay for the research procedure?
- Will we be able to afford the cost of storing the tissue?
- Should we discuss this research with a religious consultant?
Parent to Religious Consultant
Post-pubertal Questions:
- How does our religion view cryo-preservation of ovarian tissue?
Pre-pubertal Questions:
- How does our religion view cryo-preservation of ovarian tissue?
To be hopeful in a time of tremendous stress is a demonstration of strength. Parents need support, encouragement, and courage to address the issue of fertility preservation. However, by its very nature, this is a discussion of hope for the future. We would not have this hope without the miracle of modern medicine. Since the vast majority of children with cancer live vibrant, productive lives, a parent’s gift of fertility may be well worth the struggle.