Discuss fertility options carefully with your doctor before treatment. In some cases, you and your doctor may decide to try more than one option to preserve your fertility, especially if one of them has a low or unknown success rate. Be sure that you understand the risks and chances of success of any fertility option you are interested in, keeping in mind that no method works 100% of the time. Married women and others with long-term partners might want to include them in these discussions and decisions.
Embryo freezing
Embryo freezing, or embryo cryopreservation, is the most common and successful method of preserving fertility today. Mature eggs are removed from the woman’s ovaries and fertilized in the lab. This is called in vitro fertilization (IVF). The embryos are then frozen for future use after cancer treatment. This option works well for women who already have a partner, though single women can still have in vitro fertilization using donor sperm.
Eggs are collected during outpatient surgery, usually with a light anesthetic (drugs are given to make you sleepy while it is done). An ultrasound machine shows the ovaries and the fluid sacs (follicles) that contain ripe eggs. A needle is guided through the upper vagina, then into each follicle to collect the eggs. The eggs are fertilized, then frozen and stored.
Since each egg can most likely produce a single embryo at best, a woman will have a better chance of a successful pregnancy by storing several embryos. Hormones can be used to ripen several eggs at once. In most women, this means starting a cycle of hormone shots on day 3 of her menstrual cycle and continuing them for 2 to 3 weeks until many eggs are mature (often around 12 in a woman under age 35).
But some women who have fast-growing cancers cannot wait 2 to 3 weeks to begin treatment. And women with breast cancer may risk some growth of their tumors during IVF cycles because of the high levels of estrogen that result from the hormone shots. In cases like this, one option is “natural cycle IVF” in which ultrasounds are used to follow the progress of normal ovulation, and 1 or sometimes 2 eggs can be collected. Another option uses letrozole or tamoxifen during the hormone stimulation to keep the estrogen from encouraging cancer cells to grow. More studies are needed, but results so far do not show that this has any harmful effects on women’s breast cancer treatment or survival.
Successful pregnancy rates vary from center to center. Centers with the most experience usually have better success rates. Most states don’t make insurers cover IVF treatment, but a letter from your oncologist to your insurance company explaining the reason fertility preservation is needed can sometimes make a difference.
An important note about freezing
If you have frozen embryos, eggs, or ovarian tissue, it is important to stay in contact with the cryopreservation facility to be sure that any yearly storage fees are paid and your address is updated. Once a couple is ready to have a child, the frozen items are sent to their infertility doctor.
Ovarian transposition
Ovarian transposition means moving the ovaries away from the target zone of radiation treatment, usually during laparoscopy. Surgeons will usually move the ovaries above and to the side of the central pelvic area. This procedure typically does not require being in the hospital. It can be used either before or after puberty. The success rates have usually been measured by the percentage of women who regain their menstrual periods, not by being able to have a live birth. Typically, about half the women start menstruating again.
It is hard to estimate the costs of ovarian transposition, since this procedure may sometimes be done during another surgery that is covered by insurance. It is usually best to move the ovaries just before starting radiation therapy, since they tend to fall back into their old places over time.
Do not try to become pregnant during radiation therapy because radiation can harm the fetus.
Radical trachelectomy
Radical trachelectomy is an option for cervical cancer patients who have very small, localized tumors. The cervix is removed but the uterus and the ovaries are left. Trachelectomy appears to be just as successful as radical hysterectomy in removing cervical cancer in certain women. Women can become pregnant after the surgery, but are at risk for miscarriage and premature birth because the opening to the uterus may not close as strongly or tightly as before. These women will need specialized obstetrical care while pregnant.
Fertility-sparing surgical procedure
This surgical treatment can be used in some women with ovarian cancer in only one ovary. The cancer must be one of the less aggressive types, like borderline, low malignant potential, germ cell tumors, or stromal cell tumors. A surgeon will try to remove just the ovary with cancer, leaving the healthy ovary and uterus in place. If there is a risk of the cancer coming back, the surgeon may later remove the unaffected ovary after the woman has finished having children.
Experimental options
Egg freezing
Egg freezing (oocyte cryopreservation) means removing mature eggs with the same procedure described for embryo freezing, but the eggs are frozen before being fertilized with sperm. This process may also be called egg banking. The eggs are fertilized after thawing.
Egg freezing is experimental, and less is known about it than IVF. Fewer than 1,000 babies have been born as a result of egg freezing, but the methods are improving quickly. Doctors have learned how to freeze the eggs with little damage, and now are using a fast-freezing process called vitrification. Two European studies published in 2010 (one with 600 women) found that frozen eggs worked about as well as fresh ones when they were fertilized. Smaller studies in the United States have found similar success rates.
Egg freezing usually costs less than embryo freezing. It may be an option for women who have no partner when they are diagnosed with cancer. Because younger women have more eggs, and the eggs are likely to be healthier, some facilities cut off the age for egg freezing in the mid-thirties. This varies from one facility to another.
If you are looking at egg freezing, ask how many live births the facility has produced using frozen eggs. You may also want to ask how many eggs it takes, on average, to produce a single live birth. You will want to know the cost of the procedure (including all the medicines), annual storage costs of the frozen eggs, and the estimated costs of fertilizing and implanting later. And, of course, how much, if any, of these expenses might be covered by your insurance.
Ovarian tissue freezing
In ovarian tissue freezing, all or part of one ovary is removed by laparoscopy (a minor surgery where a thin, flexible tube is passed through a small cut near the navel to reach and look into the pelvis). The ovarian tissue is usually cut into small strips, frozen, and stored to be transplanted back into the woman’s body after treatment. The ovarian tissue can be placed close to the fallopian tubes or in another part of the body, like the abdomen (belly) or forearm. Usually the eggs produced by the tissue are collected and fertilized in the lab. In a few cases, the whole ovary has been frozen with the idea of putting it back in the woman’s body after treatment.
Ovarian tissue removal does not usually require being in the hospital. It can be done either before or after puberty. Still, it is experimental and has produced few live births so far. Doctors are studying it now to learn the best methods for success. For instance, some studies suggest that a quick freezing process (vitrification) of the tissue may have better outcomes than slow freezing.
The ovarian tissue does grow a new blood supply and produces hormones after it is transplanted, but some of the tissue usually dies and the grafts may only last for a few months to several years. Because they last such a short time, they are usually only transplanted when the woman is ready to try for a pregnancy. Ovarian tissue freezing costs vary a lot, so you will want to ask about the freezing and annual storage costs as well as removal and transplant expenses. In some patients, removal of the ovarian tissue can be done as part of another necessary surgery so that some of the cost is covered by insurance.
GnRH analog treatment
Gonadotropin-releasing hormones (GnRH) are long-acting hormones that can be used to cause a woman to go into menopause for a short time. These hormones are usually given as a monthly shot starting a couple of weeks before chemo or pelvic radiation therapy begins. GnRH treatment is given each month the whole time a woman is getting the cancer treatment. The hope is that reducing activity in the ovaries will reduce the number of eggs that are damaged. Studies suggest that it may help prolong fertility in some women, especially those aged 35 and younger, but more research is still needed to prove its usefulness.
This treatment costs a lot and can cause a woman’s bones to weaken if used for more than 6 months. Women who want to try this treatment may want to look into a clinical trial for their type of cancer. If this treatment is used, it is best done along with another method of preserving fertility like embryo freezing.
Oral contraceptive treatment
Some oncologists use birth control pills (oral contraceptives) during cancer treatment on the same basis as GnRH, hoping they will reduce activity in the ovary and save eggs. There is little scientific evidence for this, and some published studies suggest that it does not help reduce infertility.
Still, oral contraceptives can be useful during chemo, in that they may help control menstrual bleeding when a woman’s blood counts are low. They may also help reduce the risk of accidental pregnancy during treatment and exposing a fetus to chemo drugs.
Note that the hormones in birth control pills are not recommended for women with cancer that may be fuelled by hormones, such as breast cancer. Oral contraceptives can also increase the risk of blood clots, which may already be high because of the cancer and its treatment effects.
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