fertile hope

7/31/2019 Fertile Hope

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&Cancer FertilityFertility Options to Consider Before Treatment Begins

& Parenthood Options AfterCancer


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If you or someone you care about

is faced with a cancer diagnosis,

preserving fertility may be one of

the last things on your mind. But

if youre a woman of childbearing

age or a man who is concerned

about his future ability to become

a father, it is important to

understand that the treatments

that help fight cancer may also

affect your ability to have children.


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Fortunately, there are more options to preserve your fertility than ever

before. If you want to be a parent after treatment, you may still be able

to fulfill your dream. Whether you are a newly diagnosed patient or a

long-term survivor, several parenting options may be available for youto consider.

This booklet offers some up-to-date information about infertility

risks, fertility preservation options and parenting options after cancer.

It is hoped that this information will help you and your doctor make

decisions that are right for you.

Fertility Risks

Different cancer treatments affect the body in different ways.

Chemotherapy, radiation and surgery can all affect your reproductive

system. In general, the higher the dose and the longer the treatment,

the higher the chance for reproductive problems. Your age, the type

of drugs, the area of radiation and other factors can influence your

risk. Ask your doctor how your treatments might affect you.

CancerCancer itself can cause infertility. For example, some men with testicular

cancer and Hodgkins disease have low sperm counts before treatment

even starts.

Chemotherapy

Chemotherapy can damage both sperm and eggs. Chemotherapy

drugs in the alkylating class are the most detrimental but others, like

platinum-based drugs, are also damaging. Individual treatment factorssuch as patient age, drug type(s), and total drug dosage may affect the

chance of becoming infertile.

Radiation

Radiation therapy can also impair the reproductive system. If the radi-

ation field includes the brain, it may affect fertility by damaging areas

that control hormone production. Radiation therapy aimed close to, or

at the pelvic area of the body, can cause infertility by directly affecting

the testicles or ovaries.


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Surgery

Surgery that removes part or all of your reproductive system can

impair or even eradicate your fertility potential. If the cancer involves

your testicles, ovaries, uterus, cervix or the nerves and lymph nodes in

the abdomen and pelvis, talk to your doctor about the effects of the

surgery on your fertility and/or your ability to establish a pregnancy or

if you are a woman, to maintain a pregnancy.

Other treatments that may be deemed necessary for you may also

damage fertility. Ask your doctor to help determine the fertility risks

associated with your individual treatment regimen.

Definitions

InfertilityFor men, infertility may occur when you no longer make sperm, the

sperm are few in number or they have been damaged by cancer treat-

ment. Infertility is not the same as impotence, which is the inability to

have an erection sufficient for intercourse.

For women, infertility occurs when you no longer produce mature

eggs or have some other condition that prevents you from becoming

pregnant or maintaining the pregnancy. Women are born with a cer-

tain amount of eggs in their ovaries. Some or all of these eggs can be

damaged and destroyed from cancer treatments. Because you do not

grow new eggs, this loss of eggs can cause infertility and premature

ovarian failure.

Premature Ovarian Failure (Women Only)

Premature ovarian failure (or early menopause) is the loss of fertility

before age 40. Some women go into menopause immediately aftertreatment. This also means that they are infertile. Others will be fortu-

nate to regain their fertility after treatment. Still others will have

menstrual periods again but the egg supply may have been damaged so

they enter menopause early.

If you go into menopause early, you may need to take calcium sup-

plements and hormone replacements, like the birth control pill. Talk to

your doctor to learn how to treat premature ovarian failure.


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Men Fertility Preservation Options

Before Treatment

Sperm Freezing

Sperm banking is a simple, proven way to try topreserve your fertility. Sperm may be frozen and

banked for future use. Sperm samples can be

collected as frequently as daily or every other

day to be cryopreserved (frozen). Even if your

sperm count is low or you only have time to make one deposit, sperm

banking may still be worthwhile. There are new technologies that

require few sperm to achieve pregnancy. Once sperm is frozen, there is

no set time limit as to how long it can remain frozen until it is used.Testicular tissue freezingis an option for some men who cannot

bank sperm because of the inability to ejaculate. When sperm are present

in the testicle but not in the semen, it is a relatively straight forward

outpatient surgical procedure to remove sperm-bearing tissue from the

testicles and freeze it for future use.

Radiation shieldingshould be requested when appropriate. The

doctor places special lead-lined shields over one or both testicles. If you

are having radiation to the lower abdomen or pelvic area, this may help

reduce the risk of damage to your fertility.

After Treatment Diagnosing Infertility

A semen analysis is a simple test that can be performed by a doctor

after you finish treatment to see if you are producing sperm. The results

of the test will help you decide the best options for becoming a parent.

Sometimes sperm production will restart after cancer treatment. Thismay take a couple of years of it can occur sooner, but you could

become fertile again. Since you do not know when or if it will return,

you should consider using some form of birth control if you are not

ready to become a father.

Parenthood Options After Cancer

Natural conception can occur if your semen analysis is in the normal

or near normal range. Many cancer survivors have children after treat-

ment. Before you decide to try to have children, you should talk to your

doctor about how long you should wait after radiation or chemotherapy

because these treatments may affect the genetic material in the sperm

producing cells and repair of the damage that is caused may take a year

or so depending on the type of treatment.

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Assisted reproduction may be an option if your sperm count or

quality is low or if there is no sperm in your semen. Male infertility

specialists should be consulted to determine if they can help you. If

you banked sperm, a doctor can use that sperm in a process called in

vitro fertilization (IVF) to impregnate your wife or partner. If you didnt

bank sperm, a doctor may be able to find and extract sufficient numbers

of sperm in your testicular tissue. A single sperm can now be injected

into an egg to establish a pregnancy.

Donor sperm from another man can be used if no sperm is found

in either your semen or testicular tissue. Sperm donation programs

allow you to select an anonymous donor whose traits and characteris-

tics closely match your own.

Adoption is an excellent choice for many couples wanting tobecome parents. Adoption agencies may look at your medical history

or require a letter from your doctor about your health. It is a good idea

to select an agency that is open to working with cancer survivors.

WomenFertility Preservation Options Before Treatment

Embryo Freezing

Embryo freezing is a proven, successful way to try to preserve

your fertility. It requires sperm, so it is a good option to consider

if you are married, have a committed partner or are willing to

use donor sperm. The process requires hormonal stimulation to

retrieve your eggs and takes two to six weeks.

Egg Freezing

Egg freezing is an experimental option for women who do not want tofertilize their eggs to freeze embryos. Pregnancy rates are lower than

embryo freezing (unfertilized eggs are more delicate and can easily be

damaged during cryopreservation), but the techniques are improving.

The process requires hormonal stimulation to retrieve your eggs. It,

like embryo freezing, also takes two to six weeks.

Ovarian Tissue Freezing

Ovarian tissue freezing may be a good option if you do not have a lotof time before treatment or if you cannot have the hormonal stimula-

tion needed for egg retrieval and either embryo or egg freezing. This

approach, which also is considered experimental, involves the surgical

removal and freezing of ovarian tissue.

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After chemotherapy and/or radiation therapy is completed, the

ovarian tissue can be thawed and transplanted to the pelvis or arm. If

the ovarian tissue is transplanted to the pelvis, the hope is that the tissue

will begin to function normally and that an egg will be picked up by the

fallopian tube, thus allowing normal conception. If the ovarian tissue

is transplanted to the arm and begins to function, eggs can be removed

and used for in vitro fertilization.

In the future, ovarian tissue freezing might also be able to restore

hormonal function. This would be a benefit if you go into early

menopause.

Ovarian Shielding & Ovarian Transposition

These are methods of minimizing radiation to your ovaries. By decreas-ing the amount of radiation, you can decrease the amount of damage

to your ovaries and your eggs. If you are receiving radiation treatment

to your abdominal area, these options should be discussed with your

doctor. These methods do not protect the ovaries from chemotherapy.

Fertility Sparing Surgery

There are now many surgical options for gynecologic cancers that

may help preserve your fertility. If you have a gynecological cancer,

ask your oncologist what fertility-sparing surgical options may be

available for you.

Suppression of Ovarian Activity During Chemotherapy

While controversial, there is some data to indicate that suppressing the

activity of the ovary with medications called gonadotropin releasing

hormone agonists (GnRHa) may lessen the negative impact ofchemotherapy on future ovarian function. Studies are now being done

to try to determine if this medication is of benefit. You should discuss

this option with your oncologist and reproductive endocrinologist.

Assessing Fertility After Treatment

If you are having periods without the aid of hormonal supplements

like birth control pills, you may still be fertile. A reproductive endocri-

nologist can use simple hormone tests and ultrasound to measure theapproximate number of eggs you have in your ovaries.


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Parenthood Options After Cancer

Natural Conception

Natural conception may be possible if you remain fertile after treat-

ment. Many women are able to get pregnant naturally after cancer

treatments.

Assisted Reproduction

Assisted reproduction methods like embryo freezing, egg freezing and

ovarian tissue freezing, are usually thought of as pre-treatment options.

They can also be done after cancer treatment. If you are fertile, but

worried that you might go into early menopause before you are ready

to start a family, you may want to preserve your fertility after treatment.

Donor Eggs & Embryos

Donor eggs and embryos can be used if you do not have any healthy

eggs after treatment. Egg donation allows you to select an anonymous

donor whose traits and characteristics closely match your own. The

donor eggs can be fertilized with your partners sperm to create

embryos. Embryo donation allows you to use embryos from couples

who have extra embryos and have completed their own families. In

either case, the embryos are transferred to your uterus. This means

that even if you are in early menopause, you may be able to carry a

pregnancy and give birth.

Gestational Surrogacy

Gestational surrogacy is the term used when another woman carries a

baby for you. This may be an option if your doctor feels that pregnancy

is unsafe or if you are unable to carry a child. If you are not in earlymenopause, your eggs can be fertilized with your partners sperm and

the resulting embryo implanted into a surrogate. The surrogate would

then carry your biological child. If you cannot use your own eggs,

donor eggs or embryos can be used. Surrogacy laws vary from state

to state, so it is important to understand the surrogacy laws where

you live.

AdoptionAdoption is an excellent choice for anyone wanting to become a parent.

Adoption agencies may look at your medical history or require a letter

from your doctor about your health. It is a good idea to select an

agency that is open to working with cancer survivors.


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Safety of Pregnancy & Children After Cancer

Current available studies suggest the following:

Pregnancy after cancer does not reduce chances of the patients

survival (i.e. trigger cancer recurrence), even after breast cancer.

Radiation to the uterus can increase the risk of miscarriage or pre-

mature births.

The stress of pregnancy can sometimes worsen undetected damage

from cancer treatment to a womans heart or lungs.

Sperm cells exposed to chemotherapy or radiation may suffer

genetic damage. This damage appears to be repaired one to two

years after treatment.

Growing eggs exposed to chemotherapy or radiation may suffer

genetic damage. This damage appears to be repaired within sixmonths.

Rates of birth defects in the general population are 2% to 3%.

Rates of birth defects in children born after one parents cancer

treatment appear similar; no higher than 6% and probably less.

No unusual cancer risk has been identified in the offspring of can-

cer survivors (except in families identified with true genetic cancer

syndromes, for example, inherited retinoblastoma).syndromes, for

example, inherited retinoblastoma).

Research thus far is reassuring, but the number of pregnancies and

births studied after cancer treatment is still small; larger studies could

reveal additional health risks. Please consult your medical team when

considering conception and pregnancy after cancer treatment


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Conclusion

Many options exist for you to become a parent. Thinking about fertility

now can help assure you have choices when you are ready to become a

parent. Talk to your medical team about your treatment and its effects

on your fertility. Your oncologist can refer you to a reproductive spe-cialist. Social workers, religious advisors, psychologists and other sur-

vivors can also help you understand your fertility choices.

The following are some sample questions you may want to ask:

Will my treatment have any short or long term side effects on my

reproductive system?

Is infertility a possible side effect of my treatment?

Are there alternative ways to treat my cancer that will result in lessdamage to my reproductive system?

What are my fertility preservation options before, during and after

treatment?

Would using any of these options possibly make my cancer treat-

ment less effective?

After treatment, how will I know if I am infertile or fertile?

After treatment, will I enter into menopause prematurely?

(women only)

If I become menopausal after this treatment, is the change more

likely to be temporary or permanent? (women only)

If I become infertile after treatment, what are my options for

becoming a parent?

How long after treatment should I wait before trying to conceive?

Fertile Hope: Fertility Resource for Cancer Patients

Founded in 2001, Fertile Hope is a national nonprofit organization dedicated to provid-

ing reproductive information, support and hope to cancer patients whose medical treat-

ments present the risk of infertility. For more information, please call (888) 994-HOPEor visit www.fertilehope.org.


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The Cleveland Clinic and Fertile Hope 2/2005

1 Male Health Issues after Treatment for Childhood Cancer, Childrens Oncology Group, 2003.

2 Maria Hewitt, et al., eds. Childhood Cancer Survivorship: Improving Care and Quality of Life,The National Academy of Sciences, 2003.

3 Loredana Gandini, et al., Testicular cancer and Hodgkins disease: evaluation of semen quality,

Human Reproduction, Vol. 18 No. 4, April 2003, pp. 796-801.

4 Ibid.

5 Female Health Issues after Treatment for Childhood Cancer, Childrens Oncology Group, 2003.

6 S. Postovsky, et al., Sperm cryopreservation in adolescents with newly diagnosed cancer,

Medical and Pediatric Oncology, Vol. 40, 2003, pp. 355-359.

7 Angela B. Thomson, et al., Late reproductive sequalae following treatment of childhood cancerand options for fertility preservation, Best Practice & Research Clinical Endocrinology and

Metabolism, Vol. 16, No. 2, 2002, pp. 311-334.

8 Recommendation for the use of specific area gonad shielding on the patient, FDA Center forDevices and Radiological Health, Sec. 1000.50,

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1000&showFR=1.

9 What tests are used to diagnose male infertility? UC Davis Health System,http://www.ucdmc.ucdavis.edu/ucdhs/health/a-z/67Infertilitymen/doc67diagnosis.html.

10 Samantha M. Pfeifer and Christos Coutifaris, Reproductive Technologies 1998: Options Available

for the Cancer Patient,Medical and Pediatric Oncology, Vol. 33, pp. 34-40.

11 Angela B. Thomson, et al., Late reproductive sequalae following treatment of childhood cancer and

options for fertility preservation, Best Practice & Research Clinical Endocrinology and Metabolism,Vol. 16, No. 2, 2002, pp. 311-334.

12 Mark F. H. Brougham, et al., Male fertility following childhood cancer: current concepts and future

therapies,Asian Journal of Andrology, Vol. 5, Dec. 2003, pp. 325-337.

13 Fertility After CancerOptions for Starting a Family, Virtual Hospital, The University of IowaHospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html.

14 Ibid.

15 Fady I. Sharara, Healthology Press,

http://imagecaredrugs.healthology.com/focus_article.asp?f=fertility&b=healthology&c=ovarianreserve_article.

16 Fertility After CancerOptions for Starting a Family, Virtual Hospital, The University of Iowa

Hospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html.

17 Find out an average rate


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THE CLEVELAND CLINIC

FOUNDATION

9500 Euclid Avenue, Cleveland, OH 44195

The Cleveland Clinic is an independent,not-for-profit, multispecialty academic medical

center. It is dedicated to providing qualityspecialized care and includes an outpatient clinic,

a hospital with more than 1,000 staffed beds,an education division and a research institute.

The Cleveland Clinic Foundation 8/2005

Next Steps

For more information, or to schedule a consultation:

Women:

The Cleveland Clinic Fertility Center at Beachwood

(216) 839-3150

http://www.clevelandclinic.org/obgyn/

The Cleveland Clinic Department of Obstetrics & Gynecology

at the Main Campus

(216) 444 1758

http://www.clevelandclinic.org/obgyn/

Men:

If you want to sperm bank, a doctor needs to give you a prescription to

do this. If you have a prescription, you may start the process by calling

the Cleveland Clinic Andrology Laboratory and Sperm Bank

(216-444-8182 or 1800 223-2273, ext. 48182) to set up a convenient

appointment for you to go to the bank. The laboratory is located on

the main campus on first floor of the Crile Building at East 100 and

Carnegie Ave. It will be open weekdays and weekends if needed for

banking.

If you have questions regarding your fertility preservation, you may

call the Director of the Laboratory (216-444-9485) or the physician

who is head of the section of male infertility at 216-444-6340. They

will be happy to work with you and your doctor to assist you in pre-

serving your fertility potential.

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