Of the estimated 1.5 million people diagnosed with cancer each year in the United States, more than 126,000 are between the ages of 20 and 45. Many young cancer patients want to have children after their treatment is completed, and many will be able to have children naturally at that time. However, some patients will lose their ability to conceive a child without the help of procedures designed to assist with reproduction. Unfortunately, many young patients are not adequately informed of and prepared for the risks to fertility that may accompany cancer and some cancer treatments.
Fertility Preservation Program at Memorial Sloan-Kettering
As part of its Survivorship Initiative, Memorial Sloan-Kettering Cancer Center has established a program called Fertility Preservation and Parenthood After Cancer Treatment, led by Clinical Nurse Specialist Joanne Frankel Kelvin, RN, MSN, AOCN. As described by Ms. Kelvin, the program is designed to accomplish two major goals. The first is to provide our clinicians with the information, resources, and assistance they need to initiate these discussions with their patients. The second is to ensure that our patients receive this information in a timely manner. This allows them to make informed decisions about either preserving fertility before treatment or pursuing other options to start or complete their families after treatment.
An advisory group, led by Ms. Kelvin and including two former cancer patients, was convened to identify how best to achieve the goals of the program. It was agreed that four elements were needed. The first involves creating resources for patients, including written education materials and a Web site offering information about preserving one's ability to have children after cancer treatment. The second involves creating resources for clinicians, including an internal Web site with detailed information on fertility issues and guidance in making referrals. The third focuses on ongoing education for clinicians, including nurses, and a continuing education program planned for next year targeted to doctors and nurses at Memorial Sloan-Kettering, as well as those in the tri-state area. The fourth element is the availability of the clinical nurse specialist, Ms. Kelvin, to provide education and counseling to our patients, to answer clinicians' fertility questions, and to be a liaison with reproductive centers in the New York area.
Cancer and Fertility
Cancer and cancer treatments vary in their likelihood of causing infertility, depending on individual factors such as disease, age, treatment type and dosages, and pretreatment fertility. Patients who are interested in fertility preservation should consider their options as soon as possible to maximize the likelihood of success.
Certain surgical procedures require the removal of organs involved with reproduction. Surgery or radiation therapy may alter the structure of these organs, potentially affecting their function. For example, some men may develop an inability to ejaculate normally as a result of their treatment, which may prevent them from naturally delivering sperm into the vagina. Women may develop changes in their uterus that would prevent implantation of an embryo or that might make them unable to carry a pregnancy to term. Chemotherapy — particularly drugs known as alkylating agents — and radiation therapy delivered to the pelvis can be toxic to a man's testicles or a woman's ovaries, destroying sperm and eggs. Additionally, women may experience early menopause. And surgery or radiation therapy delivered to the brain may affect hormonal regulation of a woman's monthly menstrual cycle and egg development, or a man's sperm production.
“We can't make assumptions about what is important to our patients, and consequently, we must provide them with information about all their options.”
Joanne Frankel Kelvin, RN, MSN, AOCN
Although clinicians cannot always prevent fertility problems in their patients, they can frequently provide options for many patients who wish to preserve their fertility and parent their own biologic child after cancer treatment.
Fertility Preservation and Parenting Options for Men
For men, the simplest method of doing so is sperm banking, in which a man manually stimulates ejaculation at a sperm bank before receiving treatment. In the best-case scenario, patients collect three separate specimens, two to four days apart. However, if there is not adequate time before treatment must begin, a single sperm collection may be adequate. The specimen is analyzed and the sperm are then frozen and stored. If the man is unable to father a child naturally after treatment, his sperm are thawed and used to fertilize the egg of his partner or of a donor.
For men who cannot ejaculate normally, a procedure known as electroejaculation may be an option. In electroejaculation, controlled electrical stimulation is used to induce ejaculation. For men who do not have an adequate amount of sperm in their ejaculate, testicular sperm extraction may be an option. In this procedure, a small piece of testicular tissue is surgically removed to attain sperm.
Fertility Preservation and Parenting Options for Women
For women, the standard method of fertility preservation is a procedure known as embryo freezing, which is performed by a reproductive endocrinologist. The procedure starts with ovarian stimulation with hormone injections that will be given over the course of about two weeks, followed by retrieval of eggs, fertilization, and then freezing of the resulting embryos for later use.
Some women do not have a partner at the time of diagnosis and are unwilling to use donor sperm. And other women may have religious or ethical objections to freezing an embryo. For both these groups of women, there is another, experimental approach called egg freezing, in which the eggs, after ovarian stimulation and retrieval, are frozen and stored to be fertilized at a later time, when a woman is ready to use them. It is important to note that both embryo and egg freezing require that a woman delay her cancer treatment for at least two weeks.
Not all patients will have the opportunity to preserve their fertility before treatment nor will all patients want to undergo such procedures. There are other options for patients who wish to become a parent after treatment. Patients can use donor sperm or donor eggs if they don't have enough healthy sperm or eggs of their own. Patients can contract with a surrogate mother or gestational carrier if they are unable to carry a pregnancy. And of course adoption is also an option.
Not all cancer treatments cause fertility problems. Countless individuals go on to have children naturally after successful cancer treatment. However, some young cancer patients planning to have children may have their fertility affected by the treatments required to save their lives. If you have concerns about the effects of your treatment on your fertility, discuss these issues with your doctor.
“We at Memorial Sloan-Kettering recognize that many young patients want to have children after treatment, regardless of their age, their disease, or whether they have children already,” Ms. Kelvin explains. “We can't make assumptions about what is important to our patients, and consequently, we must provide them with information about all their options. At the same time, not everyone will be able to collect sperm or eggs before treatment. It is equally important to talk about the other ways of becoming a parent.”