Doctor, will I be able to Doctor, will I be able to have a baby ?have a baby ?

Life after cancerLife after cancer

Dr Aniruddha Malpaniwww.drmalpani.com

The child with cancerThe child with cancer

Early diagnosis, because of better awareness and better imaging techniques, means the diagnosis is being made more often

Newer treatment protocols translates into more effective treatment and better survival rates

OncofertilityOncofertility

The new specialtyExploring and expanding options for the reproductive future of cancer survivors

IVF specialists are seeing IVF specialists are seeing two types of childhood two types of childhood cancer patients:cancer patients:

Newly diagnosed patients ;

and Long-term survivors.

Long term survivorsLong term survivors

Doctor, why didn’t you tell me to Doctor, why didn’t you tell me to freeze my eggs / sperm ?freeze my eggs / sperm ?This is a question your survivors

will ask you when their cancer is treated and they come for a 5-year followup

How will you answer ?You will have wasted their

golden opportunity

Think of the future as well !Think of the future as well !Many young cancer survivors feel they received inadequate information on their fertility preservation options.

Fertility preservation gives patients hope for a high quality life after cancer

Please discuss this proactively

Newly diagnosed patientsNewly diagnosed patientsNeed to cope with diagnosis of a

life-threatening disease. Significant shock and emotional

distressShortened “window of

opportunity” for treatment. Time is of the essence.

Please refer as soon as possible !

Newly diagnosed patientNewly diagnosed patientYour major focus is to design

the best treatment plan. You have lots of things to do

Establish a diagnosisStage the diseaseSelect the best protocolRefer to a medical oncologistRefer to a radiation therapistRefer to a support groupsDiscuss costs

Refer to Refer to Specialty multi-disciplinary clinic for

a second opinion ?Surgical oncologist for staging?Medical oncologist for

chemotherapy ?Radiation therapist ?Please also refer to IVF specialist for

fertility preservation !

You have cancer !You have cancer !You need to discuss many

emotionally-charged topicsCancer-related infertility and

fertility preservation also need to be discussed because you can take proactive steps toward preserving their fertility

Their future ability to have children will significantly improve their quality of life.

Having babies enhances quality Having babies enhances quality of life for survivorsof life for survivors

Many cancer survivors have a strong urge to have a family.

Their brush with death makes them better parents

Cancer-related InfertilityCancer-related InfertilityChemotherapy and pelvic radiation

compromise future fertilityMore powerful drugs = better

survival and more infertilityInfertility is a source of long-term

distress in survivors – especially if this could have been prevented !

Doctors as patient advocatesDoctors as patient advocates

The two things every pediatric The two things every pediatric oncologist needs to know oncologist needs to know

about fertility about fertility Chemotherapy and pelvic radiotherapy damages gonadal reserve and can cause infertility

Fertility preservation techniques can help to mitigate this damage

Dramatic improvements in Dramatic improvements in preserving fertilitypreserving fertilityTake proactive steps to preserve

fertility before initiating cytotoxic therapy. Decisions should be made as early as possible. Even one dose of chemo can impair fertility

We can freeze◦ Eggs◦ Sperm◦Ovarian tissue◦Testicular tissue

Sperm preservationSperm preservationShould be routine for all

postpubertal boysTouchy topic. Needs to be discussed

proactivelyEasy to freeze spermMajor expense is the storage cost

( over many years)Sperm can only be used for ICSI –

they are worth their weight in gold !

Testicular tissue preservationTesticular tissue preservation

Option for prepubertal boysStill experimentalIn vitro sperm maturation –

hope for the futureTechnology will evolve and

improve over time

Egg preservationEgg preservation

Option for postpubertal girlsComplex and expensiveNeed to do egg collection to collect eggs

Ovarian tissue preservationOvarian tissue preservation

Ovarian tissue freezing for prepubertal girls

Much more complex and expensive

Still experimentalRefer to specialty center

Following hormonal stimulation, oocytes are aspirated directly from the ovaries, using ultrasound guidance.

About 10-15 oocytes are retrieved (which typically produces 5-6 high quality embryos)

In Vitro FertilizationIn Vitro Fertilization

VitrificationVitrification

New technology- fast freezing of vitrification. Much better results

• Fast freezing prevents ice crystal formation that can damage DNA

No increase in congenital anomalies compared with naturally conceived infants.

Cryopreservation of Ovarian Cryopreservation of Ovarian Cortical TissueCortical Tissue

Experimental. May be only option for prepubertal patients

Summary of procedure:◦ Retrieve ovarian tissue by

laproscopy◦ Freeze strips of ovarian cortical

tissue ( contains primordial follicles)◦ Later, reimplant tissue; hip, arm◦ Or graft ovarian tissue onto

the remaining ovary

Cryopreservation of Ovarian Cryopreservation of Ovarian Cortical TissueCortical Tissue

Advantages: no hormonal stimulation, no time delay

Disadvantages: ◦ Experimental procedure; few live births◦ 25% follicles die because of initial ischemia◦Concern for reimplantation of cancer cells with ovarian tissue implantation (not suitable if there may be metastases in the ovaries)

Retrieval and In Vitro Maturation Retrieval and In Vitro Maturation ( IVM) of Immature Oocytes( IVM) of Immature Oocytes

Another option might include aspiration of immature oocytes from the small “antral” follicles of the ovary with maturation of these oocytes in a laboratory setting in the future.

Using Frozen Embryos and Using Frozen Embryos and OocytesOocytes

Referrals to IVF specialistReferrals to IVF specialistOncologists should refer interested

patients to reproductive specialists as soon as possible

Pretreatment fertility counseling and fertility preservation improves quality of life.

“ Losing my hair would be temporary, but losing my ability to have children would be permanent and devastating.”

Hope for the futureHope for the future

In vitro gametogenesisUsing stem cells for generating gametes in vitro

Additional online educational Additional online educational resourcesresources

www.savemyfertility.orgwww.fertilehope.orgwww.myoncofertility.org

FAQsFAQsShould survivors be tested for their

fertility once they become adults ?Should they tell their prospective

spouses about the possibility of their fertility being reduced ?

Does pregnancy increase the risk of cancer recurrence?

FAQs FAQs Is it safe to delay the chemo ? Does egg/tissue freezing really work?

What are the success rates of each treatment? How many babies have been born?

What is the safety of fertility treatments (especially for hormone sensitive cancers)?

FAQsFAQsHow long can the eggs/ sperm be

stored ? What happens if the patient dies? How much do the treatments cost?

Insurance coverage? Financial assistance?

What is the birth defect rate of children born to cancer survivors?

Please protect your patient’s Please protect your patient’s fertility ! fertility !