Fertility Preservation for Women

According to the National Cancer Institute, an estimated 1.9 million patients will be affected by cancer in 2022 alone. Over 60% survive their disease (for patients with breast cancer, survival rates are approaching 90%). This leaves over 1 million survivors annually, many of whom may not have started or completed their families.

One side effect of cancer therapy is premature ovarian failure and/or infertility. This can create a significant amount of stress and anxiety for a patient and affect her quality of life after recovery.

At the Center for Reproductive Medicine, we understand the urgency surrounding expected cancer treatments and other medical procedures that may complicate your efforts to start a family.

If you’re scheduled to undergo chemotherapy, radiation or a similar cancer therapy, now is the time to explore the fertility preservation services available at the Center for Reproductive Medicine. We will consult with you before and after you begin your cancer therapy to evaluate the effects of treatment on your reproductive health.

Our team is also currently leading a large multidisciplinary research initiative evaluating markers predicting ovarian failure; improved techniques for oocyte (egg) cryopreservation, in vitro maturation (IVM) and ovarian cortex cryopreservation; and medications to protect patients from the loss of gonadal function prior to chemo/radiation therapy. Please contact us if you would like to participate in one of our ongoing studies.

How do cancer therapies affect a woman’s fertility?

Every woman is born with a limited number of eggs which naturally declines over time until she reaches menopause. Prior to puberty, the gonads are relatively resistant to the effects of cancer therapy.

However, it is well-known that cancer and other gonadotoxic medical therapies can quickly and dramatically reduce a woman's supply of eggs, leading to premature menopause in up to 80% of patients. Risk factors include a women’s age, the type of chemotherapeutic agents used or the dosage of radiation given, and the cumulative dosage received. Women who are older (particularly those over 35 years) at the time of treatment and those with Hodgkin's Disease are particularly at risk.

There is currently no therapy to replenish a woman’s ovarian reserve once it has been depleted. Because it is difficult to predict whether a woman will be fertile after cancer therapy, it is important to consider fertility preservation options before starting treatment.

Fertility preservation options prior to cancer therapy

If you’re interested in fertility preservation, your options depend on how much time is available prior to the beginning of cancer therapy. Preservation options include:

In vitro fertilization and embryo freezing

*Requires two to six weeks and a source of sperm

For female patients who do not need to begin cancer treatment immediately, in vitro fertilization followed by cryopreservation (freezing) of the fertilized eggs can provide an opportunity to become pregnant after cancer treatment is completed. This procedure involves treatment with fertility drugs to trigger the development of multiple eggs. The eggs are retrieved transvaginally under light anesthesia and fertilized with sperm from the patient’s partner or a donor. The fertilized egg is then frozen. The whole procedure takes two to four weeks.

IVF with cryopreservation of embryos has been used extensively for infertility treatment since the early 1980s and is considered a safe and routine procedure, with pregnancy rates ranging between 30-50%. The embryos can be stored for a number of years until cancer treatment is completed. What’s more, even if the cancer treatment results in ovarian failure, the patient can be given hormones to mimic a normal ovulation cycle and the embryos can be transferred back to the uterus through a simple outpatient procedure.

Mature oocyte (egg) cryopreservation

*Requires two to six weeks for therapy

Because of the high water content in the human egg, the success of egg freezing is still considered investigational. Recent technological advances have resulted in dramatic improvements in egg survival and pregnancy rates, and a few centers have reported pregnancy rates comparable to in vitro fertilization in their donor egg programs.

These preliminary studies are encouraging and can be offered to patients at risk of losing their fertility as a result of gonadotoxic therapy. Like embryo freezing, this strategy typically requires a 10- to 14-day period of hormonal treatments to mature the eggs before they are frozen, making it a good option for patients who can safely delay their cancer therapy for two to six weeks.

The Center for Reproductive Medicine’s Fertility Preservation Center is the only program in Central Florida to offer egg freezing.

In vitro maturation

If cancer therapy cannot be delayed, patients can undergo a procedure where immature eggs are retrieved and matured in the laboratory. Recent reports of pregnancies and healthy live babies resulting from this technology hold promise for fertility preservation opportunities in female cancer patients. Similar to egg freezing, in vitro maturation is considered investigational and should be performed responsibly under ethics board-approved research protocols like the ones we follow at the Center for Reproductive Medicine.

Fertility-sparing surgery

If a patient requires abdominal or pelvic radiation as part of their cancer therapy, it can be helpful to surgically move or suspend the ovaries (a procedure called ovarian transposition) to minimize the amount of exposure to radiation.

For women with cervical or ovarian cancer, fertility-sparing surgery may be an option depending on the stage and type of cancer. These surgical methods can be technically difficult and should only be performed by gynecologic oncologists with extensive experience with such procedures.

Medical suppression of the ovaries

Girls who have not yet gone through puberty are relatively protected from the effects of chemotherapy. However, they can experience early menopause years after cancer treatment has been completed.

Prior to beginning treatment, these patients may wish to take a medication called Depo-Lupron (administered as a monthly injection) to inactivate or suppress the ovaries. For maximum effect, it should be given at least 10 days before the start of chemotherapy. This medication also has the effect of stopping menstrual periods. This can be useful because chemotherapy often lowers the platelet count, increasing the risk of heavy or prolonged bleeding during menstrual periods.

The evidence is controversial as to whether this treatment is clearly able to protect a female’s ovarian reserve, although an overall evaluation of the currently available studies does provide hope regarding its effectiveness.

Fertility preservation options following cancer therapy

For women seeking to build their families following cancer therapy, the first step should be an evaluation by a reproductive endocrinologist to assess their fertility potential.

Many women will resume regular menstrual periods after treatment. However, this does not necessarily indicate that their gametes (eggs) are not depleted or that they are fertile. Some women may experience the return of fertility but undergo ovarian failure earlier than expected, while others may present with infertility from ovulation disorders or intermittent ovarian function. The most reliable way to assess fertility after cancer therapy is by measuring hormone levels in the blood. An ultrasound of the ovaries can also be useful to assess a patient’s antral follicle count.

Following this fertility testing, treatment options include:

Fertility therapy and assisted reproductive technologies

Once testing has revealed that there is either ovulatory dysfunction or infertility, treatment options include in vitro fertilization, superovulation or ovulation induction with medications, and intrauterine insemination. These treatments’ success rates vary between approximately 10-12% for ovulation induction with oral medications to 15-20% for ovulation induction with gonadotropins.

Oocyte (egg) donation

For patients with no residual ovarian function after cancer therapy, the use of donated oocytes with in vitro fertilization is the most successful fertility protocol available today. Women who are infertile or in menopause can still carry a pregnancy using eggs from an anonymous or known donor. The donor undergoes the in vitro fertilization process, whereby multiple oocytes are retrieved, fertilized with sperm and then transferred into the recipient’s uterus. In female patients with male partners, donor eggs can be fertilized with the male partner's sperm to create embryos that are genetically related to the male partner. The entire process costs approximately $20,000 with a pregnancy rate of 60-70% per cycle.

Gestational carriers

For women with compromise to the uterus after radiation therapy or surgery, a gestational surrogate can be a successful option for pregnancy. Gestational surrogacy refers to a treatment process in which the patient undergoes in vitro fertilization. After the retrieval of multiple oocytes which are fertilized with sperm, the resulting embryos are transferred to another woman (the gestational surrogate) who carries the pregnancy to term. The intended parents are involved with the pregnancy, are typically present at the birth and take over parenting responsibilities immediately thereafter.

Pregnancy considerations after cancer

Thus far, research on the safety of pregnancy after cancer is reassuring, though further research is necessary to confirm these findings.

Gestational risks to the mother following cancer treatment

Among patients who have had breast cancer or cancers responsive to hormones, there can be a fear of recurrence with pregnancy. Although breast cancer is believed to be stimulated by estrogen and high levels of estrogen are present in pregnancy, there is currently no evidence that pregnancy after breast cancer increases the risk of recurrence or spread. This is still a controversial area, and women with breast cancer should consider their options very carefully.

Women with early uterine cancers may still be candidates for pregnancy if the cancer can be controlled without a hysterectomy. Uterine cancer is responsive to estrogen but is also inhibited by progesterone, and progesterone levels are extremely high during pregnancy.

Women who have had radiation to the pelvis or lower abdomen require special consideration when it comes to pregnancy. If the uterus has been exposed to high doses of radiation, the endometrium (the inner lining of the uterus) may have been destroyed. In this case, the woman’s periods will have stopped, and it will not be possible for her uterus to support a pregnancy. In addition, women who have had radiation to the uterus have a higher risk of miscarriage, early delivery and fetal growth restriction because the blood supply to the uterus has been compromised. If the uterus has not been irreversibly affected, expectant management for one year may decrease the risk of these adverse events.

Another situation that requires special consideration is a patient who has received high doses of adriamycin, bleomycin and/or radiation to the chest. In pregnancy, the woman’s lungs and heart have to work considerably harder to pump an increased volume of blood to the baby. Damage to the heart muscle or lungs may not be apparent until they come under increased stress (like during pregnancy); in these cases, heart failure can develop. Women who have had adriamycin or bleomycin treatment and/or radiation to the chest require careful evaluation by a cardiologist and diligent follow-up in pregnancy to avoid serious complications.

Risks to children born following cancer treatment

The risk of birth defects in children born to cancer survivors is reported to be similar to that of the general public: approximately 2-3%. Treatment of cancer during pregnancy would likely pose a serious risk to the developing fetus — but for men and women who have completed their treatment some time before pregnancy, there does not seem to be an increased risk of birth defects, miscarriages or stillbirths as a result of cancer treatment.

Furthermore, children born to cancer survivors do not appear to be at increased risk for getting cancer themselves (except in the case of true inheritable cancer syndromes).

Helpful resources

We encourage our patients who are considering fertility preservation options to explore the wide array of resources available, including:

• American Society For Reproductive Medicine (ASRM)
• American Cancer Society
• Lance Armstrong Foundation
• Fertile Hope