Preserving fertility before cancer treatment

Dr Yossi Unterslak offers ways to preserve fertility before cancer treatment.

Damaged caused

Chemotherapies and radiation therapies can damage women’s ovaries and induce premature menopause, significantly harming fertility. Cancer patients who are set to undergo chemotherapy or radiotherapy need to consider preserving their fertility.

Options are available to secure patients’ future families, but this requires immediate action after diagnosis. The entire fertility preservation process can be completed before patients start therapy; in the time they’re waiting for medical aids to authorise treatment and while they finish off work.

Freezing of eggs

For single women, who don’t have partners, egg freezing is best. Every month, women grow a family of eggs   in their ovaries. One dominant egg is selected for ovulation and the others would normally die.

Stimulation of the eggs that would normally die takes places, making them  mature dominant eggs. The importance of this is that the future production of eggs is not affected by stimulation in anyway.

Generally, stimulation is started on day two of women’s periods, but in cases of cancer patients, it can be started at any point in their cycle. Stimulation takes up to 12 days. Two days after that, the eggs are retrieved.

The eggs are retrieved through a 20-minute procedure that doesn’t involve any cuts or stitches. A very    thin needle is used, in a transvaginal procedure, to retrieve the eggs from the ovaries while the patient is under conscious sedation.

The retrieved mature eggs are frozen and can be stored for long periods of time, until patients have completed therapy and are ready to have children.

Egg freezing and stimulation concerns

Certain cancers require consideration prior to egg stimulation, as the increase in certain hormones, such as oestrogen and progesterone, may be considered harmful. These cancers are certain breast tumours, which have receptors that are sensitive to oestrogen and progesterone. The very short-lived rise in hormones is unlikely to make a long-term difference to the survival and prognosis of the patient. Certain drugs, such as oestrogen receptor antagonists, are protective and can be used to prevent any tumour growth.

Egg collection requires transvaginal aspiration of the ovary. If a person has an ovarian tumour, putting a needle into the ovary in a patient may cause the ovarian cancer to spread to nearby or even distant organs. In these cases transvaginal egg aspiration would not  be recommended. In all other cases of malignancy this is not a worry.

Freezing of embryos

The best option for couples is to freeze their embryos. The women’s   eggs are collected in the same way as egg freezing. The men’s sperm is collected and used to fertilise the eggs  to become embryos. The embryos are frozen and stored.

What freezing embryos does is give the couple a chance of still having a family, even if cancer therapy induces menopause.

Freezing embryos is a better option than freezing eggs, as the potential of the eggs is known so there is no concern if the egg quality is good enough to yield embryos.

There is the possibility of performing biopsies on embryos to search for and eliminate embryos with certain cancer forming genes, such as the BRCA gene.

IVF

In vitro fertilisation (IVF) is the process of fertilising an egg with sperm outside the human body. This is made possible by facilitating embryo development in a laboratory, instead of in the fallopian tube. The better embryo(s) are placed back inside the uterus for further development and, hopefully, the start of a successful pregnancy.

With IVF treatment, female cancer survivors will be able to carry their own pregnancy, unless they had a gynaecological cancer where they had radiotherapy in areas, such as the uterus, ovaries, vagina or pelvic area.   In this case, they may need to use a surrogate to carry the pregnancy.

Physically, patients do experience some pain during IVF treatment, but the best is done to manage this.

Pregnancy success rates

Pregnancy success rates depend on the age of patients freezing their eggs or embryos, as age is a continuous factor that effects fertility in women. Women under the age of 35 have a higher chance of getting pregnant than those over 35, but the fact that they’re cancer survivors doesn’t affect their chances at all.

Cancer survivors have the same pregnancy success rates with IVF treatment as any other patient undergoing fertility treatment have. The advanced technology used, at Vitalab – a fertility clinic – to freeze eggs, embryos and sperm allows for 97% of the tissue to survive the thawing process, which gives the patient a 40% to 60% chance of getting pregnant.

Action plan

Before starting oncology therapy, patients need to contact a fertility clinic. At Vitalab, cancer patients are prioritised and specialists re-organise their schedules to ensure they’re seen within the first two days after contact. No matter which option patients opt for, the process takes 14 days.

When patients freeze their embryos or eggs, they have their own DNA and genetics available to have a biological child. So often, patients have already had treatment, and as a result had to use donor eggs or sperm.

Patients need to be guided by their oncologists as to when it’s safe to use frozen embryos or eggs. Certain cancers will require longer periods of remission prior to pregnancies as compared with others.

Encouraged for men 

Men of any age after puberty, who have been diagnosed with cancer, can preserve their fertility by freezing their sperm before getting therapy.

As men don’t need any medication to create sperm, they can provide and freeze sperm samples within three days after seeing a fertility specialist.

Costs 

Although Vitalab tries to keep the cost as low as possible for cancer patients, fertility preservation can still be costly. Especially since medical aids in SA don’t tend to cover fertility treatments. Vitalab generally work with First Health Finance, a registered financial provider that provides affordable payment plans to patients who are unable to afford fertility treatments.

Ask your oncologist

Oncologists don’t generally refer patients for fertility treatment. So, patients must ask about their future fertility to find out if their case will allow for two weeks (before starting therapy) to get their eggs or embryos frozen.

Even if the therapy a patient is undergoing may not affect the ovaries, patients should still preserve their fertility. In the time needed to treat the disease and the time needed post-remission before pregnancy may mean the patient misses the crucial time during which they can conceive.

Support offered

Vitalab links patients with social workers and psychologists that specialise in fertility and oncology to support them throughout their fertility treatment as it can be an emotional time.

Cancer patients can become demotivated, wondering why they need to push through the therapy if they can’t have a family and become parents. My patients who have survived cancer and frozen their eggs or embryos have said knowing that they have the ability to have children got them through treatment. With their family dreams secured, they took on the gruelling illness knowing that one day they could be a parent.

MEET OUR EXPERT  – Dr Yossi Unterslak

Dr Yossi Unterslak is a reproductive assistant at Vitalab, based in Sandton, Gauteng. He received an undergraduate degree from the University of Pretoria before specialising in obstetrics and gynaecology at the University of the Witwatersrand, and completing his Masters of Medicine.