JANI JENSEN: My name is Jani Jensen,
and I'm an assistant professor in the Department
of Reproductive Endocrinology and Infertility
at Mayo Clinic in Rochester, Minnesota.
And I'm the author of "Fertility Preservation" which
is appearing in the January 2011 issue of Mayo Clinic
Proceedings.
Fertility preservation is a new discipline,
and it refers to strategies used to promote or retain
fertility for patients that are undergoing treatment
for life-threatening illnesses.
Now, we usually think of this in context of cancer therapy,
but it can apply to other serious illnesses,
including things like lupus, or treatment
of other myeloproliferative disorders.
In this year alone, nearly 1.5 million Americans
are going to be diagnosed with cancer.
Now, of this group, approximately 10% of them
are in the reproductive age.
When you speak to reproductive age patients who
have a new diagnosis of cancer, you'll
find that a high number of them are
very concerned about their ability
to have children in the future.
If you ask adolescent females, for example,
about their desire for fertility, over 80% of them
will say that they want to try any strategy
to preserve fertility, and 93% of them
said they would do it even if they're
told that it's experimental.
Recognizing this, in 2006, the American Society
for Clinical Oncology issued guidelines
recommending that all oncologists
tell reproductive age cancer patients of risks
to their future fertility of cancer treatment
and refer patients who are interested in fertility
preservation to a reproductive endocrinologist for fertility
preservation counseling.
Now, despite the fact that these guidelines have been in place
for over four years, nearly half of all oncologists
at one large academic medical center reported
that they had never referred a patient to a reproductive
endocrinologist for a fertility preservation consult. Risks
to future fertility vary depending on cancer treatment.
One of the particular concerns we have is
the use of alkylating agents--
for example, Cyclophosphamide-- for cancer treatment.
Now, alkylating agents aren't cell-cycle specific,
so they can affect the very primitive sperm and egg cells.
And in the case of primordial stem cells-- for sperm--
once they're gone, they can't be regenerated.
Women are born with a finite number of eggs.
And once all the eggs are depleted,
we never have an opportunity to make any more.
So protecting the ovarian reserve and oocytes we already
have is of critical importance.
For post-pubertal men, the most successful strategy
is sperm banking.
Now, sperm banking has a long history in both human use,
as well as in agriculture.
And the samples are relatively simple to collect and store.
Frozen sperm can subsequently be thawed and used
either for insemination into a female partner's uterus
or with a high-tech procedure, such as in vitro fertilization,
where sperm are thawed and then directly injected in an egg
to make an embryo that's placed in a woman's uterus.
So for post-pubertal women, there are also a few options.
The most mature technology is embryo cryopreservation.
Now, embryo cryopreservation relies heavily
on strategies from in vitro fertilization, which has been
around, now, for over 30 years.
One of the concerns that women have
is the length of time that's required to either undergo
embryo or egg freezing.
Typically, we recommend that women undergo treatments
between the time they maybe have surgery
and then begin chemotherapy.
For women who do not have two to three weeks needed
to undergo these procedures, we have other options.
One of them is ovarian tissue cryopreservation.
Ovarian tissue cryopreservation, though,
is still considered more experimental
than the mature technologies of embryo or egg cryopreservation,
and so patients need to be cautioned about this.
But for women who don't have sufficient time
to undergo the other two procedures,
this can be a very valuable option.
The last option that we have for reproductive age women
is to try to suppress the ovaries.
Now, the data on ovarian suppression and return
to fertility are mixed, but the theory
is that shutting down communication
between the hypothalamus, pituitary, and ovaries--
even temporarily-- can put the eggs in a state of quiescence,
and thereby protect them from chemotherapeutic agents,
which are designed to attack dividing cells.
Patients can have some side effects
that are menopausal from them from getting these agents.
But in general, they're tolerated very well.
Since this is a new discipline, there
are many unanswered questions and a lot
of areas of controversy.
One of them, for example, is that--
are there some patients who are just to ill to even offer
fertility preservation?
In my experience, sometimes I find
that patients who have the worst prognosis
are often those who desire fertility
preservation the most.
Another are of controversy is in care of adolescents.
So parents need to authorize or give consent
to fertility preservation treatments
to patients who are less than 18 years old.
Another area of controversy is who should pay?
So not all insurance companies will cover fertility
preservation procedures.
Recognizing this, many large academic medical centers
have developed programs to give discounted prices
to cancer patients who are undergoing
this type of treatment, and there are also
several good programs that offer discounted or even free
medications for the patients, which
can be a significant cost.
Another area of concern is whether or not
the treatments may worsen outcomes for patients.
And this is particularly true for cancers
like breast cancer, which can be hormonally responsive.
Data that have been published to this point
are relatively short-time, with outcomes ranging
between two and five years.
But what some of the larger studies of women with breast
cancer who have undergone fertility preservation
have shown is that women who have done this
seem to be at no increased risk of cancer recurrence
or mortality.
Women often ask when the best time to attempt pregnancy
would be after cancer treatment.
Now, there's not a consensus opinion,
but most experts recommend that women
delay trying to conceive for at least one,
and ideally two or more years after cancer treatment is
completed, because the risk of recurrence
is highest in that window.
One question that patients always ask
is if there is a risk to the offspring that
are born from cancer survivors.
We now have reassuring data from large studies
that have looked at several thousand children born
to cancer survivors that have shown that there's no increased
risk of having birth defects or any type of childhood
malignancies.
Patients are often very reassured to hear this.
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