Fertility and Cancer Rachel Fyfe - PowerPoint Presentation

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Fertility and Cancer

Rachel Fyfe

Adolescent and Young Adult Cancer Coordinator

John Stoddard Cancer Center and Blank Children’s Hospital

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Objectives

Discuss how cancer can affect fertility

Describe the process of fertility preservation options available

Address the need to have the discussion about fertility with patients

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Fertility

Patients of reproductive age often find prospect of infertility one of the most difficult components of their disease and treatment

Oncology providers focus on survival

Can be difficult to assess who is interested in future fertility

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Fertility

Surveys of cancer survivors have identified an increased risk of emotional distress in those who become infertile because of their treatment

Long-term quality of life is affected by unresolved grief and depression

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Males and fertility

Surgery

of reproductive structures may result in erectile dysfunction or retrograde ejaculation, leading to the inability to release sperm naturally into the vagina.

Radiation to the testes and some chemotherapy drugs can impair your ability to produce healthy sperm. You may recover from this after treatment; however, this may take months or even years. Predicting who will regain sperm production and who will not is difficult.

Radiation or surgery to certain areas of the brain may reduce development of the pituitary gland hormones that stimulate sperm production

.

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Livestrong Fertility tool

https://www.teamlivestrong.org/we-can-help/fertility-services/risks

/

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Cancer Drugs with high risk for males

Actinomycin

D

Busulfan

Carboplatin

Carmustine

Chlorambucil

Cisplatin

Cyclophosphamide (Cytoxan

®

)

Cytarabine

Ifosfamide

Lomustine

Melphalan

Nitrogen mustard (

mechlorethamine

)

Procarbazine

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Cancer Drugs Cont.

Higher doses of these drugs are more likely to cause permanent fertility changes , and combinations of drugs can have greater effects

.

The risks of permanent infertility are even higher when males are treated with both chemo and radiation therapy to the belly (abdomen) or pelvis.

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Cancer Drugs with lower risk for males

5-fluorouracil (5-FU)

6-Mercaptopurine (6-MP)

Bleomycin

Cytarabine

(

Cytosar

®

)

Dacarbazine

Daunorubicin

(

Daunomycin

®

)

Doxorubicin (Adriamycin

®

)

Epirubicin

Etoposide (VP-16)

Fludarabine

Methotrexate

Mitoxantrone

Thioguanine

(6-TG)

Thiotepa

Vinblastine (

Velban

®

)

Vincristine (

Oncovin

®

)

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Radiation and males

Radiation to the pelvic area can affect sperm production.

Even when a man gets radiation to treat a tumor in his abdomen (belly) or pelvis, his testicles may still end up getting enough radiation to harm sperm production

.

Sometimes radiation to the brain affects the hypothalamus and pituitary gland.

These work together to produce

LH and FSH.  These hormones are released into the bloodstream and signal the testicles to make testosterone and also to produce sperm. 

When cancer

or cancer treatments interfere with these signals, sperm production can be decreased and infertility can occur. 

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Radiation Cont.

Sperm may

be damaged by exposure to

radiation

. 

Current

recommendations

for trying for a baby range

from 6 months to 2 years after

radiation treatment

is

completed.

The doctor

will be able to consider

the

circumstances

to give

more specific information about how long

a person

should wait.

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A little background on sperm

How much sperm a male has to begin with will affect how much can be stored.

A healthy amount

is at least 15 million sperm per

milliliter of ejaculation.

Motility is also important. You want at least 40% of these to be moving.

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Sperm Banking Process

For best results the patient will not have ejaculated within the last 72 hours.

The semen sample must be collected in a sterile cup by masturbation.

The sample may be given at the fertility clinic or at home. There is a one hour window to get the sample from home to the clinic before the sperm is compromised.

No lubricants may be used in the collection of the sperm.

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Sperm Banking Cont.

After the sample has been given, it will go in 1,2,3, or 4 vials to be cryopreserved. This would be 1,2,3, or 4 CHANCES of future pregnancies.

The amount of vials depends on how much sperm is present as well as their motility in the ejaculation.

If a patient is only able to get 1 or 2 vials, they may want to try again. This would mean another 72 hours before they have the optimal amount of sperm.

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Sperm Banking Cont.

Each sample (1,2,3, or 4 vials) costs 100 dollars. This pays for the sperm analysis as well as the cryopreservation process.

There is also a 250 dollar yearly storage fee.

Insurance rarely pays for this.

Once sperm is cryopreserved a person can wait until they are ready for children to unfreeze it.

Sperm stored for over 20 years have produced live births.

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Emergency Sperm Banking at Methodist

We do have the ability to collect sperm on sight. However, this is not recommended and should be used only on the weekends or night time after the fertility clinic has closed.

Instructions for that are on the S or T drive in the AYA folder as well as in the med room for blank/ Shelley’s office.

Mid Iowa Fertility is who we utilize in Des Moines.

www.midiowafertility.com

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Male Fertility after Cancer

Cancer can take away a males ability to produce sperm completely, temporarily or not at all.

Some people may have a lower sperm count after cancer or the mobility may be affected (temporarily or permanently).

Typically you want to wait at least a year after treatment is completed to check on any fertility issues.

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Females and Fertility

Studies have suggested that women with cancer are less likely to be given information about preserving their fertility than men

.

Women who already have at least one child or those who are not married also are less likely to receive information.

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Females and fertility

Surgery may require removal of organs needed to become pregnant or maintain a pregnancy (for example, hysterectomy, removal of ovaries).

Radiation to the pelvis and some chemotherapy drugs may destroy eggs in the ovary, making it more difficult or impossible to become pregnant. In addition, monthly menstrual periods may stop. Menstruation may start again after some months, but some women develop premature (early) menopause. These women stop ovulating and are not able to become pregnant. Again, predicting who will be affected is difficult.

Radiation to the pelvis may cause changes in the uterus. As a result, an embryo may not be able to implant, or the uterus may not be able to expand to hold a growing fetus. This can result in complications during pregnancy such as miscarriage, preterm (early) birth, or low birth weight babies.

Radiation or surgery to certain areas of the brain may reduce development of pituitary gland hormones that stimulate the ovaries each month, disrupting the monthly menstrual cycle and interfering with ovulation.

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Cancer Drugs with high risks for females

Busulfan

Carboplatin

Carmustine

(BCNU)

Chlorambucil

Cisplatin

Cyclophosphamide (Cytoxan 

®

)

Dacarbazine

Doxorubicin (Adriamycin

®

)

Ifosfamide

Lomustine

(CCNU)

Mechlorethamine

Melphalan

Procarbazine

Temozolomide

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Cancer Drugs with lower risk for females

5-fluorouracil (5-FU)

Bleomycin

Cytarabine

Dactinomycin

Daunorubicin

Fludarabine

Gemcitabine

Idarubicin

Methotrexate

Vinblastine

Vincristine

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Radiation and females

Radiation treatments use high-energy rays to kill cancer cells. These rays can also damage a woman’s ovaries.

High doses can destroy some or all of the eggs in the ovaries and might cause infertility or early

menopause.

Radiation to the uterus can cause scarring, which decreases the flow of blood to the uterus and also makes the uterus unable to stretch to full size during pregnancy. Women who have had radiation to the uterus have an increased risk of miscarriage, low-birth weight infants, and premature births

.

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Fertility Preservation for females

E

mbryo cryopreservation is

the most established and successful method of preserving a woman’s

fertility.

Mature

eggs are removed from a woman’s ovaries and fertilized in the lab. This is called in vitro fertilization (IVF).

Collecting the eggs typically takes 10 to 14 days, depending on where a woman is in her menstrual cycle. 

During

the process, a woman takes injectable hormone medications

to

allow several eggs to develop in the ovaries at

once.

 

The eggs are then collected during outpatient surgery, usually with a light

anesthetic.

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Fertility Preservation Cont.

An ultrasound is used to guide a needle through the upper part of the vagina and into the ovary to collect the eggs.

Sometimes thousands of sperm are put in a sterile dish with each egg. Sometimes one sperm is injected into each egg using a special lab equipment under a microscope. The embryos are then frozen to be used after cancer treatment.

This option works well for women who already have a partner, though single women can still freeze embryos using donor sperm.

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Egg preservation

For egg freezing, mature eggs are removed and frozen before being fertilized with sperm.

When

the woman is ready to become pregnant, the eggs can then be thawed, fertilized, and implanted in her uterus.

The efficacy of this is lower than embryo freezing, but is becoming more common and less risky.

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Cost

One cycle of egg freezing is $7,800 plus the cost of medication.

Medication costs vary depending on the person and situation

The annual storage fee for egg freezing is $750.

Cost can vary and insurance does not necessarily cover the options.

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Success Rates

IVF with frozen eggs result in lower live births than with fresh eggs

Age matters. The younger a patient is the more success

For those under 35 there is on average a 43% success rate

35-37

yrs

old it goes down to about 40%

38-40

yrs

old it is about 34%

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Lupron treatment (ovarian suppression)

The goal of this treatment is to shut down the ovaries during cancer treatment to help protect them from damaging effects

.

The hope is that reducing activity in the ovaries during treatment will reduce the number of eggs that are damaged, so women will resume normal menstrual cycles after treatment.

These shots are given monthly throughout the time that treatment is given.

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Lupron Cont.

Studies on Lupron for fertility preservation have shown inconsistent results.

A recent study did show that there may be more success rates for early breast cancer patients than others.

This treatment is considered experimental.

Shots are expensive and insurance usually does not cover them.

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Fertility after cancer

Women with menstrual periods after cancer treatment may become pregnant. However, menstruation is not proof that you are fertile.

In some women, cancer treatments stop menstrual periods. This is called early menopause. It causes permanent infertility.

Other women’s menstrual periods stop during treatment but return later. Women who have periods after chemotherapy may still have lowered fertility. Even a woman who menstruates during treatment and remains fertile afterward might have lowered fertility or early-onset menopause.

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Talking about it

NCCN Guidelines for patients in the reproductive age range include discussing fertility every time no matter the risk factor.

Be open and honest about time frames, treatment risks and what the options are.

These patients have a right to know about this.

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Talking about it Cont.

Assess who is in the room. Ask to talk privately with the patient. NEVER ASSUME!

Ask the patient who they want to be present for this conversation before allowing anyone back.

Ask what the patient already knows about their treatment and how it relates to fertility.

Fill in any gaps about how their fertility can be affected.

Give opportunities for questions and check in with them that they are understanding everything.

Emphasize the time frame

Be empathetic

Give referral information for a reproductive endocrinologist

Use teach back!

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Concluding thoughts

Patients deserve to know their fertility risks

Preservation may or may not be an option due to finance, time, treatment and cancer type.

Even though some treatments are more or less likely to affect fertility, there are no guarantees.

Get comfortable talking about it!

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Good resources

www.midiowafertility.com

https://

www.livestrong.org/we-can-help/livestrong-fertility

https

://

www.cancer.gov/about-cancer/treatment/side-effects

https://oncofertility.northwestern.edu

/

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Reference

Zarnegar

, S,

Gosiengfiao

, Y,

Rademaker

, A, Casey, R,

Albritton

K.

Recall of Fertility Discussion by Adolescent Female Cancer Patients: A Survey-Based Pilot

Study. Journal of Adolescent and Young Adult Oncology. Oct. 2017

Fernbach

, A, Lockhart, B,

Armus

, C,

Bashore

, L, Levine, J, Kroon, L, Sylvain, G, Rodgers, C. Evidence-Based Recommendations for Fertility Preservation Options for Pediatric and Adolescent Patients Diagnosed with Cancer. J of

Pediatitc

Oncology Nursing 2014;31 (4) :21 1-222

LorenAW

,

ManguPB

,

BeckLN

, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J

Clin

Oncol

. 2013;31(19):

2500–510.

KohlerTS

,

KondapalliLA

,

ShahA

, et al. Results from the survey for preservation of adolescent reproduction (SPARE) study: gender disparity in delivery of fertility preservation message to adolescents with cancer. J Assist

Reprod

Genet

2011;28:269–77

PeddieVL

,

PorterMA

,

BarbourR

, et al. Factors affecting decision making about fertility preservation after cancer diagnosis: a qualitative study. BJOG

2012;119:1049–57

Ann

Oncol

.

 2017 Aug 1;28(8):1811-1816.

doi

: 10.1093/

annonc

/mdx184.

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Questions?

Rachel.fyfe@unitypoint.org