Fertility preservation for young cancer patients

Recent advances in cryopreservation are providing effective fertility preservation options for young Canadians requiring chemotherapy for cancer. Both female and male patients can opt to freeze gametes before undergoing treatment. Embryo, oocyte, and ovarian tissue freezing are possible for females, and sperm freezing is possible for males. The decision to proceed with fertility preservation is made by taking into account the patient’s age, diagnosis, oncology treatment plan, fertility status, and personal/social situation. Management should include surveillance of ovarian reserve, counseling on fertility and sexual health, and provision of egg and embryo banking in cases where the patient’s reproductive lifespan is likely to be significantly reduced. Barriers to fertility preservation include a lack of awareness and the high cost of these services. A multidisciplinary approach to care, education of oncology professionals and patients on issues related to reproduction, and better funding can help ensure that cancer patients receive timely counseling and appropriate fertility preservation services. M odern chemotherapeutic protocols are highly effective at destroying malignant cells, but also damage ovaries and testicles in the process, leading to infertility in a sizable percentage of patients. This is a challenging survivorship issue faced by fertility specialists and cancer specialists alike. Most young cancer survivors desire future pregnancy, and the psychological impact of infertility can be greater than the effects of the cancer itself, with overt PTSD seen in some cases. Fertility preservation treatments can increase the likelihood of future pregnancy. More importantly, they can also provide patients with hope and a positive distraction during a very negative time in their lives. Young patients often have a limited understanding of their own reproduction and what options exist through modern assisted reproductive technology (ART), and are unlikely to seek advice on fertility preservation; therefore, referral to a fertility specialist with the ability to discuss and deliver these services is critical. Ovarian reserve testing Ovarian reserve (the pool of primordial follicles) and reproductive potential both decline as women age. The reduction in natural fertility with age is mirrored by the lower pregnancy rates with medical fertility treatments such as in vitro fertilization (IVF). Chemotherapeutic agents accelerate the age-related loss of primordial follicles through an increase in recruitment of ovarian follicles (burnout theory), apoptosis of supporting granulosa cells, and disappearance of eggs. The toxicity of chemotherapeutic treatments varies according to the specific agents administered, dose, and protocol, and the reproductive potential of the patient at the time of treatment. Primordial follicles are not mitotically active, so they are still sensitive to alkylating agents (a mainstay of most combination chemotherapy), which are cell cycleindependent drugs that can cause direct DNA damage. Dr Roberts is a co-director of the Pacific Centre for Reproductive Medicine and a clinical assistant professor in the Division of Reproductive Endocrinology and Infertility at the University of British Columbia. He is past-president of the Canadian Fertility and Andrology Society. He also serves as president of the board for Fertile Future, a charitable organization dedicated to reducing costs for fertility preservation services for those with cancer. This article has been peer reviewed.