Fertility preservation in survivors of childhood cancer

1. Doctor, will I be able toDoctor, will I be able to
have a baby ?have a baby ?
Life after cancerLife after cancer
Dr Aniruddha Malpani
www.drmalpani.com

2. The child with cancerThe child with cancer
Early diagnosis, because of
better awareness and better
imaging techniques, means the
diagnosis is being made more
often
Newer treatment protocols
translates into more effective
treatment and better survival

3. OncofertilityOncofertility
The new specialty
Exploring and expanding
options for the
reproductive future of
cancer survivors

4. IVF specialists are seeingIVF specialists are seeing
two types of childhoodtwo types of childhood
cancer patients:cancer patients:
Newly diagnosed
patients ;
and
Long-term survivors.

5. Long term survivorsLong term survivors

6. Doctor, why didn’t you tell me toDoctor, why didn’t you tell me to
freeze my eggs / sperm ?freeze my eggs / sperm ?
This is a question your survivors
will ask you when their cancer is
treated and they come for a 5-
year followup
How will you answer ?
You will have wasted their
golden opportunity

7. Think of the future as well !Think of the future as well !
Many young cancer survivors
feel they received inadequate
information on their fertility
preservation options.
Fertility preservation gives
patients hope for a high
quality life after cancer
Please discuss this proactively

8. Newly diagnosed patientsNewly diagnosed patients
Need to cope with diagnosis of a
life-threatening disease.
Significant shock and emotional
distress
Shortened “window of
opportunity” for treatment. Time
is of the essence.
Please refer as soon as possible !

9. Newly diagnosed patientNewly diagnosed patient
Your major focus is to design
the best treatment plan. You
have lots of things to do
Establish a diagnosis
Stage the disease
Select the best protocol
Refer to a medical oncologist
Refer to a radiation therapist
Refer to a support groups
Discuss costs

10. Refer toRefer to
Specialty multi-disciplinary clinic for
a second opinion ?
Surgical oncologist for staging?
Medical oncologist for
chemotherapy ?
Radiation therapist ?
Please also refer to IVF specialist for
fertility preservation !

11. You have cancer !You have cancer !
You need to discuss many
emotionally-charged topics
Cancer-related infertility and
fertility preservation also need to
be discussed because you can
take proactive steps toward
preserving their fertility
Their future ability to have
children will significantly improve
their quality of life.

13. Having babies enhances qualityHaving babies enhances quality
of life for survivorsof life for survivors
Many cancer survivors
have a strong urge
to have a family.
Their brush with
death makes them
better parents

14. Cancer-related InfertilityCancer-related Infertility
Chemotherapy and pelvic radiation
compromise future fertility
More powerful drugs = better
survival and more infertility
Infertility is a source of long-term
distress in survivors –
especially if this
could have been
prevented !

15. Doctors as patient advocatesDoctors as patient advocates

16. The two things every pediatricThe two things every pediatric
oncologist needs to knowoncologist needs to know
about fertilityabout fertility
Chemotherapy and pelvic
radiotherapy damages gonadal
reserve and can cause
infertility
Fertility preservation
techniques can help to
mitigate this damage

17. Dramatic improvements inDramatic improvements in
preserving fertilitypreserving fertility
Take proactive steps to preserve
fertility before initiating cytotoxic
therapy. Decisions should be made
as early as possible. Even one dose of
chemo can impair fertility
We can freeze
◦ Eggs
◦ Sperm
◦ Ovarian tissue
◦ Testicular tissue

18. Sperm preservationSperm preservation
Should be routine for all
postpubertal boys
Touchy topic. Needs to be discussed
proactively
Easy to freeze sperm
Major expense is the storage cost
( over many years)
Sperm can only be used for ICSI –
they are worth their weight in gold !

19. Testicular tissue preservationTesticular tissue preservation
Option for prepubertal boys
Still experimental
In vitro sperm maturation –
hope for the future
Technology will evolve and
improve over time

20. Egg preservationEgg preservation
Option for postpubertal girls
Complex and expensive
Need to do egg collection to
collect eggs

21. Ovarian tissue preservationOvarian tissue preservation
Ovarian tissue freezing for
prepubertal girls
Much more complex and
expensive
Still experimental
Refer to specialty center

22. Following hormonal stimulation, oocytes are aspirated
directly from the ovaries, using ultrasound guidance.
About 10-15 oocytes are retrieved (which typically
produces 5-6 high quality embryos)

23. In Vitro FertilizationIn Vitro Fertilization

24. VitrificationVitrification
New technology- fast freezing of
vitrification. Much better results
• Fast freezing prevents ice crystal
formation that can damage DNA
No increase in congenital
anomalies compared with
naturally conceived infants.

30. Cryopreservation of OvarianCryopreservation of Ovarian
Cortical TissueCortical Tissue
Experimental. May be only
option for prepubertal patients
Summary of procedure:
◦ Retrieve ovarian tissue by
laproscopy
◦ Freeze strips of ovarian cortical
tissue ( contains primordial
follicles)
◦ Later, reimplant tissue; hip, arm
◦ Or graft ovarian tissue onto
the remaining ovary

31. Cryopreservation of OvarianCryopreservation of Ovarian
Cortical TissueCortical Tissue
Advantages: no hormonal
stimulation, no time delay
Disadvantages:
◦ Experimental procedure; few live
births
◦ 25% follicles die because of initial
ischemia
◦ Concern for reimplantation of
cancer cells with ovarian tissue
implantation (not suitable if there
may be metastases in the ovaries)

33. Retrieval and In Vitro MaturationRetrieval and In Vitro Maturation
( IVM) of Immature Oocytes( IVM) of Immature Oocytes
Another option might include
aspiration of immature oocytes from
the small “antral” follicles of the
ovary with maturation of these
oocytes in a laboratory setting in the
future.

34. Using Frozen Embryos andUsing Frozen Embryos and
OocytesOocytes

35. Referrals to IVF specialistReferrals to IVF specialist
Oncologists should refer interested
patients to reproductive specialists as
soon as possible
Pretreatment fertility counseling and
fertility preservation improves quality of
life.
“ Losing my hair would be temporary,
but losing my ability to have children
would be permanent and devastating.”

36. Hope for the futureHope for the future
In vitro gametogenesis
Using stem cells for
generating gametes in vitro

38. Additional online educationalAdditional online educational
resourcesresources
www.savemyfertility.org
www.fertilehope.org
www.myoncofertility.org

39. FAQsFAQs
Should survivors be tested for their
fertility once they become adults ?
Should they tell their prospective
spouses about the possibility of their
fertility being reduced ?
Does pregnancy increase the risk of
cancer recurrence?

40. FAQsFAQs
Is it safe to delay the chemo ?
Does egg/tissue freezing really work?
What are the success rates of each
treatment? How many babies have
been born?
What is the safety of fertility
treatments (especially for hormone
sensitive cancers)?

41. FAQsFAQs
How long can the eggs/ sperm be
stored ?
What happens if the patient dies?
How much do the treatments cost?
Insurance coverage? Financial
assistance?
What is the birth defect rate of
children born to cancer survivors?

43. Please protect your patient’sPlease protect your patient’s
fertility !fertility !