Reviewed by: Sarah Felderhoff, MSN, APRN and Winifred Mak, MD, PhD
Written by: Abbi Havens
When a person receives a cancer diagnosis, a million questions may run through their head. Has it spread? What is my prognosis? How can I fight this? How can I tell my family? When a person’s life is turned upside down by the diagnosis of cancer, their fertility is often the last thing on their mind.
In fact, according to Sarah Felderhoff, advanced practice provider and oncofertility navigator for Cancer Fertility Preservation at UT Health Austin, most people diagnosed with cancer may not even be aware of the threat to their fertility that certain cancers and common treatments present.
“Often before beginning chemotherapy, patients will receive a ‘chemo teach’ which is essentially a crash course in chemotherapy,” says Felderhoff. “The bottom of one page in a massive packet might say, ‘Can cause infertility.’ It’s often not pointed out and many patients aren’t aware of it.”
According to Felderhoff, oncologists often have a window of two weeks or less to begin treatment following a cancer diagnosis, so it’s critical that fertility preservation is part of the conversation from the very beginning. Felderhoff and Winifred Mak, MD, PhD, a reproductive endocrinology and infertility specialist who is also a part of a part UT Health Austin’s Reproductive Endocrinology and Infertility care team, are dedicated to educating patients on every possible option to preserve their fertility throughout chemotherapy, radiation treatment and more.
Oncofertility combines reproductive endocrinology and oncology to preserve the reproductive potential of cancer patients and survivors. But to our patients, it’s so much more than that. Oncofertility is your future family, and we meet every patient where they are. Whether they’ve dreamed of a family since childhood or haven’t, whether they are too young to consider a family or nearing menopause, whether they’ve just begun their fight against cancer or have already won, we empower patients with the choice to build their future family as they see fit, without a diagnosis standing in their way.
The Effects of Cancer and Cancer Treatment on Fertility
For both men and women, many common cancer treatments can have a lasting impact on your future ability to reproduce:
- Chemotherapy for Women: Chemotherapy can cause primary ovarian insufficiency (POI) in which your ovaries stop releasing eggs and estrogen. POI can be temporary or permanent. This treatment can also lower the number of healthy eggs stored in the ovaries.
- Chemotherapy for Men: Because chemotherapy works by killing cells in the body that divide quickly, sperm are an easy target for the treatment. If all cells that divide in the testicles to produce new sperm (spermatogonial stem cells) are damaged, then the body can no longer produce sperm.
- Radiation Therapy for Women: Radiation to the abdomen, pelvis or spine can damage your reproductive organs. The ovaries can often be protected during radiation treatment by oophoropexy, a procedure that moves the ovaries away from the area receiving radiation. Radiation to the brain may damage the pituitary gland which signals the ovaries to produce estrogen needed for ovulation.
- Radiation Therapy for Men: A high enough dosage of radiation directly to the testicles, groin area, pelvis, abdomen or spine can kill the spermatogonial stem cells that produce sperm. Radiation to the brain may damage the pituitary gland that signals the testicles to produce testosterone and sperm.
- Surgery for women: Surgery for cancers of the reproductive organs and for cancers in the pelvic region can cause scarring of the reproductive tissue, negatively impacting fertility. The size and location of tumors greatly affect whether or not fertility is compromised during surgery.
- Surgery for Men: Most often it is only necessary to remove one testicle in the event of testicular cancer. If one healthy testicle remains, a man can continue to produce sperm after surgery. If the remaining testicle is damaged or both testicles are removed, a man cannot traditionally reproduce. Additional cancer-related surgeries may interfere with ejaculation.
- Hormone Therapy for Women: Hormone therapy can disrupt the menstrual cycle, leading to complications in fertility.
- Hormone Therapy for Men: Hormone therapy can affect sperm production and have sexual side effects including a lower libido and difficulty getting an erection.
Options for Preserving Fertility as a Cancer Fighter or Cancer Survivor
Fertility is extremely personal. Whether you are male or female, battling cancer or in survivorship, one patient’s fertility needs and goals are never the same as the next. The options available to help you achieve your desired outcome depend on your circumstances.
“It boils down to your age and sex,” says Felderhoff. “As a post-pubertal female, you have several options. For women without a partner, there is egg freezing, which requires stimulating medication to help your body grow more eggs than you normally would in a cycle because you’re trying to get as many eggs as you can to freeze. For many women with a partner, freezing embryos prior to treatment is possible and often preferable.”
Additional measures can be taken to preserve fertility throughout the course of cancer treatment, including:
- Ovarian Shielding: Special shields are placed over the ovaries during radiation treatment.
- Ovarian Transposition: The ovaries are surgically moved higher in the abdomen and away from the radiation field to minimize damage.
- Ovarian Suppression: Hormone treatments are used to temporarily halt ovarian function
Post-pubertal men have several options to preserve their reproductive function as well. Most commonly men, can undergo sperm banking (freezing semen specimen for future use) prior to chemotherapy or radiation therapy. If men cannot provide a semen sample, testicular sperm extraction (TESE), a procedure in which sperm are collected directly from the testes, can be performed and frozen for future use. Radiation shielding, which shields one or both of the testicles during radiation treatment, is also an option.
For pre-pubescent females and males, options are limited. Although still widely considered experimental, patients may freeze their ovarian or testicular tissue to be placed back in the body post-treatment and hormonally stimulated to produce eggs or sperm.*
For those in cancer survivorship, the process of fertility preservation may look different.
“For cancer survivors, we really meet them where they are. We can’t change the past, so we focus on the state of their fertility now to get them where they want to be,” Felderhoff says. “We do a full evaluation of their fertility and what their ovarian or sperm reserve looks like. If it’s very poor, there are still so many options. There is adoption, there are egg and sperm donors, there are gestational carriers and more. We walk patients through all of this so that every last option is laid out on the table. And often, cancer survivors are able to have children in a traditional fashion.”
Our cancer fertility preservation program does not end with surgical procedures, egg and sperm freezing, embryo freezing and radiation shielding. If adoption, utilizing egg or sperm banks, or gestational carriers is the right choice for you and your future family, our care team will walk you through it every step of the way.
A New Approach to Oncofertility
Preserving fertility for cancer patients and survivors is a complicated process that requires a team of top-notch specialists to think on their feet and problem solve under extreme pressure and a strict timeline. Felderhoff and Dr. Mak combine their expertise to lay every possible option for patients out on the table and act fast.
“Oncologists will refer a patient to me as the oncofertility navigator,” explains Felderhoff. “I will do the initial workup including lab work, ultrasounds and patient education. If they want to move forward with any of the options presented to them, I refer them to Dr. Mak and she will be their reproductive endocrinologist. I will continue to work with the patient to be their point of contact from the beginning to the end of the fertility preservation process.”
Walking a cancer patient through the process of preserving their fertility throughout the cancer journey requires more than skills and experience. It requires compassion and extreme emotional intelligence to make a patient feel safe, both for themselves and their future family.
“I find it’s best to let the patient lead the conversation. This is about them, their feelings and their hopes,” says Felderhoff. “I plan to leave no stone unturned so patients know the full extent of their options. It’s a sensitive subject, but the important thing is to let the patient lead the conversation however they feel comfortable. Often patients may feel uncomfortable with the conversation, but they’ll call back and say ‘Actually, I did some more research on my own and I’m ready.’ Myself and my team will be there.”
No matter the circumstances, a cancer diagnosis is never easy. We’ll walk beside you every step of the way so that in the face of a major setback, you can have hope for the future family you’ve always dreamed of.
Cancer Fertility Preservation welcomes patients beginning on August 26, 2019. If you or a loved one are undergoing cancer treatment or have survived cancer and wish to explore your reproductive options, call 1-833-UT-CARES to schedule an appointment.
*We do not yet offer this service at UT Health Austin, but our care team can connect you to the proper resources to have a conversation about tissue banking.