What is oncofertility? Fertility preservation options before chemotherapy or radiotherapy, whom to talk to and when, and the ESHRE and ASCO approach.
Oncofertility is an area in which the possibility that chemotherapy, radiotherapy and other cancer-related treatments may affect your fertility is addressed before treatment, and in which, when needed, options such as storing eggs, embryos, ovarian tissue or sperm are assessed together with oncology and reproductive medicine specialists. Current recommendations ask that this conversation take place as early as possible, before cancer treatment starts, and that interested patients be referred to reproductive specialists. In the intense period that a cancer diagnosis brings, it can be hard to think about fertility. Below you can find how treatments can affect fertility, the options that are discussed and the questions you can ask before deciding; your oncologist and a reproductive specialist decide together which option is suitable for you.
How do cancer treatments affect fertility?
The effect varies with the treatment and the person
Chemotherapy, radiotherapy and some surgical procedures can affect fertility. Whether an effect occurs, and at what level, varies with the type and dose of the treatment, the person's age and individual characteristics. The same result is not expected in everyone; for this reason it is important to ask your oncologist what the planned treatment means for you.
The limit of reserve indicators in this context
Your reproductive specialist may use the AMH measurement or the antral follicle count by ultrasound to predict the response of your ovary to stimulation before treatment; the use of one of the two for this purpose is recommended. The AMH value before treatment should not be used as an indicator of your fertility after treatment.
When and with whom should you talk?
Together with oncology and reproductive medicine specialists
A multidisciplinary team approach and a direct link between the oncology clinic and the fertility preservation team are recommended. In practice this means raising your questions about fertility with your oncologist while your treatment plan is becoming clear and, if necessary, asking to be referred to a reproductive specialist.
Time pressure and the decision process
Decisions after a diagnosis may have to be made in a short time. In this period, noting down your questions beforehand and having someone close accompany you to the consultation can make the decision process easier. Preserving fertility or not preserving it are both among the informed decisions you can make.
What fertility preservation options exist for women?
The information here covers post-pubertal women. The options vary with your age, your treatment, your type of cancer and how much time allows.
Egg freezing and embryo freezing
Egg freezing is strongly recommended as an established option; embryo freezing is also an established option. In embryo freezing, it is also emphasised that subjects such as who will decide and to whom the embryo will be considered to belong should be discussed beforehand. Both methods involve stimulating the ovaries with hormone medicines and collecting eggs.
Ovarian tissue freezing
Freezing ovarian tissue is an option that is considered in some situations, and the oncology and reproductive medicine team assess its suitability together. This option can be offered for treatments with a moderate or high risk of harming the ovary and where egg or embryo freezing is not possible or is not preferred.
GnRH analogues and moving the ovaries out of the radiation field (transposition)
In women who have not reached menopause, GnRH agonist medicines can be offered during chemotherapy for breast cancer; but these should not be regarded as equivalent to egg freezing or as an option that takes its place for fertility preservation. That is, these medicines do not on their own take the place of egg or embryo freezing. Moving the ovaries out of the radiation field (transposition) can be offered only if radiotherapy to the pelvic region alone is planned; this method is not suitable for those whose ovarian reserve has fallen or those at risk of spread to the ovary.
What fertility preservation options exist for men?
The focus of fertility preservation in men is freezing and storing a sperm sample before treatment. Other options may exist for those who have difficulty giving a sample; a specialist in reproductive medicine or urology assesses this.
How is the decision on fertility preservation made for children and adolescents?
In this age group the decision is made through an assessment that the child and the family carry out together, receiving information from paediatric oncology and reproductive medicine specialists.
What do follow-up after treatment and the use of stored material look like?
Menstrual pattern and ovarian function
After treatment, the menstrual pattern and ovarian function can be monitored by the doctor. How and how often this is done varies with the person and the treatment received.
Use of stored material
When and how stored eggs, embryos, tissue or sperm will be used is addressed together by the oncologist and the reproductive specialist, with an assessment of the pregnancy in terms of the type of cancer. There is no assurance that the stored material will be usable or will result in a pregnancy.
Can you get emotional support when making a fertility decision?
Alongside the decisions on diagnosis and treatment, making a decision about fertility too can be a heavy burden. It is recommended that psychological support be offered to you in the decision process; it is also stated that the clinical benefit of this support has not yet been well researched. Information and support about fertility can reduce your distress and the feeling of regret after the decision. Cost is one of the known barriers; you can also talk about financial matters with your healthcare team.
What questions can you ask your doctor?
- To what extent can my planned treatment affect my fertility?
- Which storage options could be considered for my situation?
- Does fertility preservation affect when my cancer treatment starts, and if so how?
- Are hormone medicines suitable for my type of cancer?
- What conditions and consents are needed for the use of stored material?
- From whom can I get information about costs and payment?
Frequently Asked Questions
What is oncofertility, and when should this conversation take place?
Oncofertility is an area in which the possibility that chemotherapy, radiotherapy and other cancer-related treatments may affect your fertility is addressed before treatment, and in which, when needed, options such as storing eggs, embryos, ovarian tissue or sperm are assessed together with oncology and reproductive medicine specialists. Current recommendations ask that this conversation take place as early as possible, before cancer treatment starts, and that interested patients be referred to reproductive specialists.
Do cancer treatments affect fertility in the same way in everyone?
No. Chemotherapy, radiotherapy and some surgical procedures can affect fertility; but whether an effect occurs, and at what level, varies with the type and dose of the treatment, your age and your individual characteristics. The same result is not expected in everyone; for this reason it is important that you ask your oncologist what the planned treatment means for you.
Is AMH or the antral follicle count an indicator of my fertility after treatment?
No. Your reproductive specialist may use the AMH measurement or the antral follicle count by ultrasound to predict the response of your ovary to stimulation before treatment; but the AMH value before treatment should not be used as an indicator of your fertility after treatment.
What is the difference between egg freezing and embryo freezing?
Egg freezing is strongly recommended as an established option; embryo freezing is also an established option. Both methods involve stimulating the ovaries with hormone medicines and collecting eggs. In embryo freezing, it is also separately emphasised that subjects such as who will decide and to whom the embryo will be considered to belong should be discussed beforehand.
For whom is ovarian tissue freezing considered?
Freezing ovarian tissue can be considered for treatments with a moderate or high risk of harming the ovary, and where egg or embryo freezing is not possible or is not preferred. The oncology and reproductive medicine team assess the suitability of this option together.
Do GnRH analogues take the place of egg freezing?
No. In women who have not reached menopause, GnRH agonist medicines can be offered during chemotherapy for breast cancer; but these should not be regarded as equivalent to egg freezing or as an option that takes its place for fertility preservation.
Can the ovaries be protected before pelvic radiotherapy?
Moving the ovaries out of the radiation field (transposition) can be offered only if radiotherapy to the pelvic region alone is planned. This method is not suitable for those whose ovarian reserve has fallen or those at risk of spread to the ovary.
What are the fertility preservation options in men?
The focus of fertility preservation in men is freezing and storing a sperm sample before treatment. Other options may exist for those who have difficulty giving a sample; a specialist in reproductive medicine or urology assesses this.
How is the decision on fertility preservation made in children and adolescents?
In this age group the decision is made through an assessment that the child and the family carry out together, receiving information from paediatric oncology and reproductive medicine specialists.
Is it guaranteed that stored eggs, embryos or sperm will be used or will result in a pregnancy?
No. When and how stored eggs, embryos, tissue or sperm will be used is addressed together by the oncologist and the reproductive specialist, with an assessment of the pregnancy in terms of the type of cancer. There is no assurance that the stored material will be usable or will result in a pregnancy.
Do I have to wait for the day of my period for ovarian stimulation?
No, it is not necessary. In situations where the start of treatment cannot be delayed, starting stimulation without waiting for a period day (random start) can be offered as an option; in some situations dual stimulation may also be considered. Your reproductive specialist determines which protocol is suitable for you and the time to start.
Could this conversation be unnecessary for me because of my type of cancer or my age?
No. It is recommended that the conversation about fertility be held with all patients who have reproductive potential, whatever their treatment plan and their demographic and socioeconomic situation. Do not hesitate to raise the subject yourself; bringing it up is not a responsibility that belongs only to you.
Can fertility be discussed again after cancer treatment is over?
Yes. It is recommended that fertility-related follow-up continue after cancer treatment is over; for women, a second opportunity for fertility preservation may also arise after treatment. Whether there is such an opportunity for you varies with your treatment and your situation.
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