Preserving Fertility for Young Women with Cancer, with Karen Lisa Smith, MD, MPH

You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses. Many common cancer treatments can temporarily or permanently affect a woman’s fertility, which is the ability to have children. In today’s podcast, Dr. Karen Lisa Smith shares highlights from her article from the 2018 ASCO Educational Book, “Advances in Fertility Preservation for Young Women With Cancer.” Dr. Smith is a medical oncologist at the Kimmel Cancer Center at Sibley Memorial Hospital and assistant professor of oncology at Johns Hopkins University School of Medicine. Published annually, the Educational Book is a collection of articles written by ASCO Annual Meeting speakers and oncology experts. Each volume highlights the most compelling research and developments across the multidisciplinary fields of oncology. ASCO would like to thank Dr. Smith for discussing this topic.  Dr. Smith: Hello, my name is Dr. Karen Lisa Smith from the Johns Hopkins University School of Medicine. In this podcast, I will be sharing some key points from my 2018 ASCO Educational Book article titled, “Advances in Fertility Preservation for Young Women With Cancer.” Each year, over 30,000 young women are diagnosed with cancer in the United States. The most common types of cancers in young women are breast and gynecologic cancers, blood cancers, sarcomas, brain tumors, and colorectal cancer. Many women, especially in Western countries like the United States, are choosing to become pregnant later in life. As a result, young women diagnosed with cancer may not have completed their families at the time of diagnosis. Unfortunately, young women with cancer often require treatments that can make their future chances of childbearing low. For example, chemotherapy is toxic to the ovaries and radiation or surgery on reproductive organs carries a risk of future infertility. Additionally, some long-term treatments, such as hormonal therapy for breast cancer, require a woman to avoid becoming pregnant for years. How to address infertility in cancer survivors is an important clinical issue. The majority of young female cancer survivors report reproductive concerns and many desire children. Pregnancy after cancer treatment does not appear to increase the risk of cancer coming back.  However, young female cancer survivors become pregnant at lower rates than unaffected women in the general population. There is good news for young cancer survivors who wish to start a family. Recent advances in reproductive health care allow doctors to help their patients preserve fertility before cancer treatment begins. Fertility preservation is safe and can often be accomplished without a significant delay in cancer care, especially if fertility goals are addressed early and interested patients are referred to fertility specialists during the course of their cancer treatment planning. There are 2 main types of assisted reproductive the techniques that fertility specialists can use to preserve fertility in young women with cancer. The best established method of fertility preservation is embryo cryopreservation.  Women who use this method first receive hormonal medications for several days to stimulate the ovaries.  Next, they undergo a procedure to remove the eggs from the ovaries.  In the lab, the eggs are fertilized using sperm from a committed male partner or donor sperm.  The embryos are then frozen and stored for future use. Live birth rates using cryopreserved embryos in females with cancer are similar to those in infertile couples who undergo fertility treatments with fresh embryo transfers. For women who do not have a committed male partner or who do not wish to use donor sperm, oocyte cryopreservation has become a standard option for fertility preservation.  This method is similar to embryo cryopreservation in that women receive hormonal medications for several days to stimulate the ovaries and then undergo a procedure to remove the eggs from the ovaries.  However, in the case of oocyte cryopreservation, the eggs are frozen and stored for future use without being fertilized first.  Recent advances in laboratory techniques have allowed for successful oocyte freezing. We only know a little about pregnancy success in patients who freeze their eggs before cancer therapy, but what we do know shows that the success rates are comparable to those seen in the general population of women who freeze eggs in the absence of a cancer diagnosis. A potential benefit of freezing eggs or embryos is the opportunity to test for hereditary conditions. After fertilization and culture, several cells can be sent for genetic analysis to identify known genetic mutations such as a BRCA mutation, which increases the risk for breast and ovarian cancers. Genetic testing may allow couples to avoid passing a known mutation on to their children. Although many cancer survivors may be able to carry a pregnancy after treatment, some survivors will experience late effects of therapy or receive ongoing cancer therapies that make it unsafe or impossible to successfully carry a pregnancy. Cryopreserved embryos or embryos from cryopreserved oocytes may be transferred to a gestational carrier in the future if a patient is unable to carry a pregnancy herself. It is important to note that both embryo cryopreservation and oocyte cryopreservation require women to undergo ovarian stimulation, which helps a woman develop more eggs, followed by egg retrieval. This process takes about 2 to 3 weeks and, therefore, has the potential to briefly delay cancer therapy.  In most cases, this short delay is not significant. Some patients, however, may need to start cancer therapy quickly and cannot wait the 2-3 weeks needed for ovarian stimulation. There are some new techniques currently being investigated for these patients. One method harvests eggs without ovarian stimulation. Patients don’t need to delay treatment with this method and it may have a lower cost. However, implantation and pregnancy success rates with this approach are lower. Another investigational method is ovarian tissue cryopreservation, and this method is the only option for girls who have not yet hit puberty. It results in a minimal delay in treatment and can even be performed after exposure to some chemotherapy. It requires removal of all or part of the ovary, which is then frozen.  The ovarian tissue can then be transplanted back into the patient when she is ready to become pregnant.  Since the first time this technique was used in 2004, there have been over 130 live births reported after ovarian tissue transplantation. As with all procedures, there are risks involved with transplantation, including the possibility of reintroducing cancer cells in this tissue back into the patient. In addition to considering fertility preservation prior to cancer therapy using the assisted reproductive techniques we have reviewed so far, young women with cancer can talk to their oncologists about ovarian suppression during chemotherapy as a method for ovarian protection and fertility preservation.  Mediations called gonadotropin releasing hormone agonists (or GnRH agonists), help to reduce the toxicity of chemotherapy on the ovaries, and some studies have shown that this decreases the risk of infertility after cancer treatment. This treatment can also reduce the risk of early menopause resulting from chemotherapy. Although many young women with cancer report desiring children and options for fertility preservation are available, few young women pursue these options. For example, in 1 study of 1,041 young women with cancer, only 4% pursued fertility preservation. There are many reasons for this, but young women who are diagnosed with cancer and wish to start or grow their family should talk to their doctors about their fertility preservation options before starting treatment. To learn more, please view my article online at ASCO.org/edbook. Thank you. ASCO: Thank you Dr. Smith. Please visit ASCO.org/edbook to read the full article. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. Cancer.Net is supported by ASCO’s Conquer Cancer Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.