A diagnosis of cancer brings up many important decisions. While chemotherapy, radiation, and surgery can often effectively treat cancer, these treatment options may also affect the ability for a woman in remission to conceive. When a Shady Grove Fertility physician meets with a patient who has recently been diagnosed with cancer, we understand that she is likely a young woman, in her 20s or 30s, who is in her most vulnerable time; often times, dealing with this alone. We recognize this is a challenging time; therefore we will provide compassionate and helpful counsel and expeditiously work in concert with her oncology team to identify the most effective treatment plan for preserving her fertility.
The majority of patients with cancer we see have breast cancer or lymphoma, which necessitates a decision about preserving their fertility very quickly. Usually, in order to preserve fertility, we need to freeze a woman’s eggs in between the diagnosis and whenever her oncologist is going to start chemotherapy, radiation, or potential surgery. Given that tight timeline, we need to complete her egg freezing in just a couple of weeks.
How does cancer treatment affect female fertility?
When it comes to treating cancer, some treatment regimens may impair future fertility.
Radiation: When radiation treatment is centered around the lower abdomen, there is a risk that the treatment could damage or destroy the ovaries, depending on the size and location of the tumor and the radiation dosage prescribed. This can damage or destroy eggs and ovarian function as well as affect hormone production and cause premature menopause.
Chemotherapy: Depending on the woman’s age, the type of chemotherapy prescribed, and the dosage, chemotherapy can damage the ovaries while also attacking the cancer, resulting in premature failure of the ovaries.
Surgery: When cancer exists in the reproductive organs, such as the uterus, the best treatment option may be surgery to remove the affected organs.
What does fertility preservation before cancer treatment involve?
Step 1: Determine If a Patient is the Right Candidate for Fertility Preservation
A woman will need to meet certain medical criteria in order to be eligible to preserve her fertility through egg freezing. We would not want to spend valuable time prior to initiating cancer treatment to go through the process and only end up with two eggs. It’s better than none, but for some patients, that may not be good enough. At times if we suspect a lower than desired yield of eggs we may recommend the patient pursue alternative options. If the patient wishes, and it is possible, we will try but if the ovarian response is too low we will stop.
Typically, women at a younger reproductive age, under 38, are going to make the best candidates for fertility preservation rather than women of advanced reproductive age. Because of the natural decline in egg quality and quantity as women age, fertility preservation may not be the answer. Instead, donor egg treatment can represent an alternative option for a woman in their early 40s.
Step 2: Test Ovarian Reserve
As a fertility specialist, one of our first steps is to determine realistic treatment outcomes based on the patient's specific fertility status. To do this we will look at the patient's ovarian reserve, which will give us a good idea as to how many eggs she has left. Given the short window of time between a cancer diagnosis and starting cancer therapies, it is important to start this step quickly.
We test a female's ovarian reserve through bloodwork and an ultrasound performed on days 2, 3, or 4 of the menstrual cycle. These tests include:
- Anti-Müllerian hormone (AMH)
- Follicle-stimulating hormone (FSH)
- Estradiol (E2)
- Luteinizing hormone (LH)
- Antral follicle count (AFC)
Step 3: Provide Medical and Financial Counsel
Once diagnosed, it is important to move quickly so as to not delay oncology treatment any longer than necessary; often, when time is of the essence, we gather the information and go right into cycle. Shady Grove Fertility has a dedicated cancer care team to help patients navigate their fertility preservation options. Their main goals are to help patients understand the available options, collaborate with the oncologist, and expedite fertility preservation treatment. Our fertility specialists see many patients within 24 to 48 hours of calling our office.
Schedule an Appointment: Please call 1.877.264.3311 to speak with a New Patient Liaison or submit a form on our website.
Financial Consultation: As soon as a patient schedules an appointment, she can expect to speak with a dedicated oncofertility financial counselor, often times prior to their actual physician consultation. During this time, the financial counselor will help to determine possible insurance coverage and discount programs or grants from local non-profit organizations to reduce or even completely cover the cost of treatment.
Physician-to-Physician Consultation: During this time, the Shady Grove Fertility physician will work in conjunction with the oncologist to provide a holistic approach to the patient's fertility treatment. An important aspect of our initial conversation with the patient's oncology team is reviewing the therapies planned in the oncology treatment. There are a few chemotherapeutics that can affect egg quality, but most of them are not used anymore. Should it be found that a therapy known to interfere with pregnancy is planned in treatment, it will make it more imperative to perform fertility preservation prior to initiating cancer treatment.
Physician Consultation with Patient: The patient will meet with a physician and nurse to determine an appropriate fertility treatment timeline before impending radiation, chemotherapy, or surgery.
Step 4: Preserve Fertility through Egg Freezing
Depending on where the patient is in her menstrual cycle, treatment can usually begin within 1 to 2 weeks of the initial visit. The process goes as follows:
Follicular stimulation for 10 to 12 days: Upon the start of the patient's menstrual cycle, she will start daily injectable medications to stimulate the follicular development in hopes to develop several eggs to freeze.
Trigger injection: At the end of the stimulation period, we will instruct the patient to take a “trigger” injection. The trigger injection helps the eggs mature and prepare for the egg retrieval.
Egg retrieval: Thirty-six hours following the trigger, the patient will have her eggs retrieved at one of our three ambulatory surgery centers. This intravaginal procedure takes a total of 5 to 10 minutes while she is under IV sedation.
Freezing of the retrieved eggs: Once retrieved, embryologists evaluate the eggs to determine the number of mature eggs before freezing them using vitrification, an ultra-rapid cooling process. We can store the mature eggs in liquid nitrogen indefinitely. We will contact the patient the following day to let her know how many eggs we were able to freeze.
Coming Back after Remission
Some women may ovulate on their own and get pregnant without assistance; they won’t necessarily need to use their frozen eggs to conceive. And, there is a chance a woman can still ovulate on her own and get pregnant without treatment. Chemotherapy can affect her ability to become pregnant, but for women who do not have difficulty getting pregnant, it’s important to know that the baby will not be affected by previous oncology treatment.
Medical Contribution by:
David S. Saffan, M.D.
Shady Grove Fertility | Annandale, VA