There are many reasons as to why people who are diagnosed with cancer are not presented fertility preservation options by their medical team. Some of the reasons that medical teams give for not having these discussions include, but are not limited to: the fact that they feel the person may not be able to afford it; that they do not believe there is time to do it before treatment must start; or that they feel the person will not be able to handle that conversation on top of the many other things they are emotionally processing.

Cancer type and site

Cancers affecting the male and female reproductive organs or neuroendocrine axis (brain tumours or metastatic deposits) are likely to cause infertility by direct damage8–17. Patients may have reduced fertility potential at diagnosis due to compromised general health factors.

Chemotherapy drugs and dose

Alkylating agents have an intermediate to high chance of causing infertility 6 Platinum agents, anthracyclines and taxanes have an intermediate risk of infertility6 and 6 mercapturine, methotrexate, 5 fluorouracil, vincristine, bleomycin and actinomycin have a low or no risk6. High dose chemotherapy associated with haematopoietic stem cell transplantation causes severe and often permanent infertility in most cases.

Radiation therapy

Total body irradiation and cranio-spinal irradiation have a high risk of damage to the hypothalamic pituitary gonadal axis.17 Whole abdominal and pelvic radiation in females (> 15Gy in pre pubertal females, > 10 Gy in post pubertal females and > 6 Gy in adults) is associated with a high risk of infertility.6 The testis is highly sensitive to irradiation; a dose as low as 0.15 Gy causes reduced sperm production and doses of 0.5 Gy or above can cause azoospermia. Partial recovery from irradiation-induced azoospermia may occur; however, the time to recovery is proportional to the testicular dose.

Surgery

Surgical procedures to male or female reproductive organs or the neuro-endocrine axis can result in infertility.

Combination treatment

The combination of chemotherapy with another treatment modality will also impact on patients overall reproductive risk.

What Types of Fertility Preservation Are Available?

FP options depend on the patient’s age, cancer type and available time before treatment.

Fertility Preservation Options:

Egg Banking to cryopreserve (freeze) a women egg

Embryo Banking to freeze embryos for future implantation. Hormonal stimulation of the ovaries result in the maturation of multiple eggs that can be harvested and fertilized immediately with her partner’s sperm to create embryos, which are then frozen for future use. This process may require 2-6 weeks to complete.

In Vitro Maturation (IVM) of oocytes, where multiple immature eggs are harvested by ultrasound guided aspiration without prior hormone stimulation. These eggs will then be matured in the laboratory either before or after freezing. The main advantage is the relatively short time period required to obtain immature eggs, which minimizes any delay before cancer treatment.

• Sperm Banking to freeze sperm for future use. Multiple semen samples can be collected and frozen over a period of several days.
• Testicular Sperm Aspiration or Extraction is a minor surgical procedure where sperm is retrieved directly from the epididymis or testes, which can frozen for future use. This is only required when no sperm can be produced through ejaculation.
• Tissue banking where ovarian cortex or testicular tissue is surgically removed and frozen. This tissue can later be transplanted back into the body and hormonally stimulated to produce eggs and sperm with so
• Shielding of the genital and pelvic region with a lead
• Ovarian Transposition to physically move the ovaries out of the pelvis
• Gonadotropin Agonist

Conclusion

oncofertility has evolved from a new word to a recognized field that has strong pre-clinical and clinical research outputs. Improved stimulatory protocols,101 laboratory and freezing techniques have been important factors in this success. The ongoing challenge for researchers has been to find a solution that provides patients with normal reproductive hormones, as well as a permanent fertility solution.