Cancer

&

Fertility

Fertility Options to Consider Before Treatment Begins & Parenthood Options After Cancer

If you or someone you care about is faced with a cancer diagnosis, preserving fertility may be one of the last things on your mind. But if youre a woman of childbearing age or a man who is concerned about his future ability to become a father, it is important to understand that the treatments that help fight cancer may also affect your ability to have children.

Fortunately, there are more options to preserve your fertility than ever before. If you want to be a parent after treatment, you may still be able to fulfill your dream. Whether you are a newly diagnosed patient or a long-term survivor, several parenting options may be available for you to consider. This booklet offers some up-to-date information about infertility risks, fertility preservation options and parenting options after cancer. It is hoped that this information will help you and your doctor make decisions that are right for you. Fertility Risks Different cancer treatments affect the body in different ways. Chemotherapy, radiation and surgery can all affect your reproductive system. In general, the higher the dose and the longer the treatment, the higher the chance for reproductive problems. Your age, the type of drugs, the area of radiation and other factors can influence your risk. Ask your doctor how your treatments might affect you. Cancer Cancer itself can cause infertility. For example, some men with testicular cancer and Hodgkins disease have low sperm counts before treatment even starts. Chemotherapy Chemotherapy can damage both sperm and eggs. Chemotherapy drugs in the alkylating class are the most detrimental but others, like platinum-based drugs, are also damaging. Individual treatment factors such as patient age, drug type(s), and total drug dosage may affect the chance of becoming infertile. Radiation Radiation therapy can also impair the reproductive system. If the radiation field includes the brain, it may affect fertility by damaging areas that control hormone production. Radiation therapy aimed close to, or at the pelvic area of the body, can cause infertility by directly affecting the testicles or ovaries.

Surgery Surgery that removes part or all of your reproductive system can impair or even eradicate your fertility potential. If the cancer involves your testicles, ovaries, uterus, cervix or the nerves and lymph nodes in the abdomen and pelvis, talk to your doctor about the effects of the surgery on your fertility and/or your ability to establish a pregnancy or if you are a woman, to maintain a pregnancy. Other treatments that may be deemed necessary for you may also damage fertility. Ask your doctor to help determine the fertility risks associated with your individual treatment regimen. Definitions Infertility For men, infertility may occur when you no longer make sperm, the sperm are few in number or they have been damaged by cancer treatment. Infertility is not the same as impotence, which is the inability to have an erection sufficient for intercourse. For women, infertility occurs when you no longer produce mature eggs or have some other condition that prevents you from becoming pregnant or maintaining the pregnancy. Women are born with a certain amount of eggs in their ovaries. Some or all of these eggs can be damaged and destroyed from cancer treatments. Because you do not grow new eggs, this loss of eggs can cause infertility and premature ovarian failure. Premature Ovarian Failure (Women Only) Premature ovarian failure (or early menopause) is the loss of fertility before age 40. Some women go into menopause immediately after treatment. This also means that they are infertile. Others will be fortunate to regain their fertility after treatment. Still others will have menstrual periods again but the egg supply may have been damaged so they enter menopause early. If you go into menopause early, you may need to take calcium supplements and hormone replacements, like the birth control pill. Talk to your doctor to learn how to treat premature ovarian failure.

Men
Fertility Preservation Options Before Treatment Sperm Freezing Sperm banking is a simple, proven way to try to preserve your fertility. Sperm may be frozen and banked for future use. Sperm samples can be collected as frequently as daily or every other day to be cryopreserved (frozen). Even if your sperm count is low or you only have time to make one deposit, sperm banking may still be worthwhile. There are new technologies that require few sperm to achieve pregnancy. Once sperm is frozen, there is no set time limit as to how long it can remain frozen until it is used. Testicular tissue freezing is an option for some men who cannot bank sperm because of the inability to ejaculate. When sperm are present in the testicle but not in the semen, it is a relatively straight forward outpatient surgical procedure to remove sperm-bearing tissue from the testicles and freeze it for future use. Radiation shielding should be requested when appropriate. The doctor places special lead-lined shields over one or both testicles. If you are having radiation to the lower abdomen or pelvic area, this may help reduce the risk of damage to your fertility. After Treatment Diagnosing Infertility A semen analysis is a simple test that can be performed by a doctor after you finish treatment to see if you are producing sperm. The results of the test will help you decide the best options for becoming a parent. Sometimes sperm production will restart after cancer treatment. This may take a couple of years of it can occur sooner, but you could become fertile again. Since you do not know when or if it will return, you should consider using some form of birth control if you are not ready to become a father. Parenthood Options After Cancer Natural conception can occur if your semen analysis is in the normal or near normal range. Many cancer survivors have children after treatment. Before you decide to try to have children, you should talk to your doctor about how long you should wait after radiation or chemotherapy because these treatments may affect the genetic material in the sperm producing cells and repair of the damage that is caused may take a year or so depending on the type of treatment.
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Assisted reproduction may be an option if your sperm count or quality is low or if there is no sperm in your semen. Male infertility specialists should be consulted to determine if they can help you. If you banked sperm, a doctor can use that sperm in a process called in vitro fertilization (IVF) to impregnate your wife or partner. If you didnt bank sperm, a doctor may be able to find and extract sufficient numbers of sperm in your testicular tissue. A single sperm can now be injected into an egg to establish a pregnancy. Donor sperm from another man can be used if no sperm is found in either your semen or testicular tissue. Sperm donation programs allow you to select an anonymous donor whose traits and characteristics closely match your own. Adoption is an excellent choice for many couples wanting to become parents. Adoption agencies may look at your medical history or require a letter from your doctor about your health. It is a good idea to select an agency that is open to working with cancer survivors.

Women
Fertility Preservation Options Before Treatment Embryo Freezing Embryo freezing is a proven, successful way to try to preserve your fertility. It requires sperm, so it is a good option to consider if you are married, have a committed partner or are willing to use donor sperm. The process requires hormonal stimulation to retrieve your eggs and takes two to six weeks. Egg Freezing Egg freezing is an experimental option for women who do not want to fertilize their eggs to freeze embryos. Pregnancy rates are lower than embryo freezing (unfertilized eggs are more delicate and can easily be damaged during cryopreservation), but the techniques are improving. The process requires hormonal stimulation to retrieve your eggs. It, like embryo freezing, also takes two to six weeks. Ovarian Tissue Freezing Ovarian tissue freezing may be a good option if you do not have a lot of time before treatment or if you cannot have the hormonal stimulation needed for egg retrieval and either embryo or egg freezing. This approach, which also is considered experimental, involves the surgical removal and freezing of ovarian tissue.

After chemotherapy and/or radiation therapy is completed, the ovarian tissue can be thawed and transplanted to the pelvis or arm. If the ovarian tissue is transplanted to the pelvis, the hope is that the tissue will begin to function normally and that an egg will be picked up by the fallopian tube, thus allowing normal conception. If the ovarian tissue is transplanted to the arm and begins to function, eggs can be removed and used for in vitro fertilization. In the future, ovarian tissue freezing might also be able to restore hormonal function. This would be a benefit if you go into early menopause. Ovarian Shielding & Ovarian Transposition These are methods of minimizing radiation to your ovaries. By decreasing the amount of radiation, you can decrease the amount of damage to your ovaries and your eggs. If you are receiving radiation treatment to your abdominal area, these options should be discussed with your doctor. These methods do not protect the ovaries from chemotherapy. Fertility Sparing Surgery There are now many surgical options for gynecologic cancers that may help preserve your fertility. If you have a gynecological cancer, ask your oncologist what fertility-sparing surgical options may be available for you. Suppression of Ovarian Activity During Chemotherapy While controversial, there is some data to indicate that suppressing the activity of the ovary with medications called gonadotropin releasing hormone agonists (GnRHa) may lessen the negative impact of chemotherapy on future ovarian function. Studies are now being done to try to determine if this medication is of benefit. You should discuss this option with your oncologist and reproductive endocrinologist. Assessing Fertility After Treatment If you are having periods without the aid of hormonal supplements like birth control pills, you may still be fertile. A reproductive endocrinologist can use simple hormone tests and ultrasound to measure the approximate number of eggs you have in your ovaries.

Parenthood Options After Cancer Natural Conception Natural conception may be possible if you remain fertile after treatment. Many women are able to get pregnant naturally after cancer treatments. Assisted Reproduction Assisted reproduction methods like embryo freezing, egg freezing and ovarian tissue freezing, are usually thought of as pre-treatment options. They can also be done after cancer treatment. If you are fertile, but worried that you might go into early menopause before you are ready to start a family, you may want to preserve your fertility after treatment. Donor Eggs & Embryos Donor eggs and embryos can be used if you do not have any healthy eggs after treatment. Egg donation allows you to select an anonymous donor whose traits and characteristics closely match your own. The donor eggs can be fertilized with your partners sperm to create embryos. Embryo donation allows you to use embryos from couples who have extra embryos and have completed their own families. In either case, the embryos are transferred to your uterus. This means that even if you are in early menopause, you may be able to carry a pregnancy and give birth. Gestational Surrogacy Gestational surrogacy is the term used when another woman carries a baby for you. This may be an option if your doctor feels that pregnancy is unsafe or if you are unable to carry a child. If you are not in early menopause, your eggs can be fertilized with your partners sperm and the resulting embryo implanted into a surrogate. The surrogate would then carry your biological child. If you cannot use your own eggs, donor eggs or embryos can be used. Surrogacy laws vary from state to state, so it is important to understand the surrogacy laws where you live. Adoption Adoption is an excellent choice for anyone wanting to become a parent. Adoption agencies may look at your medical history or require a letter from your doctor about your health. It is a good idea to select an agency that is open to working with cancer survivors.

Safety of Pregnancy & Children After Cancer Current available studies suggest the following: Pregnancy after cancer does not reduce chances of the patients survival (i.e. trigger cancer recurrence), even after breast cancer. Radiation to the uterus can increase the risk of miscarriage or premature births. The stress of pregnancy can sometimes worsen undetected damage from cancer treatment to a womans heart or lungs. Sperm cells exposed to chemotherapy or radiation may suffer genetic damage. This damage appears to be repaired one to two years after treatment. Growing eggs exposed to chemotherapy or radiation may suffer genetic damage. This damage appears to be repaired within six months. Rates of birth defects in the general population are 2% to 3%. Rates of birth defects in children born after one parents cancer treatment appear similar; no higher than 6% and probably less. No unusual cancer risk has been identified in the offspring of cancer survivors (except in families identified with true genetic cancer syndromes, for example, inherited retinoblastoma).syndromes, for example, inherited retinoblastoma). Research thus far is reassuring, but the number of pregnancies and births studied after cancer treatment is still small; larger studies could reveal additional health risks. Please consult your medical team when considering conception and pregnancy after cancer treatment

Conclusion Many options exist for you to become a parent. Thinking about fertility now can help assure you have choices when you are ready to become a parent. Talk to your medical team about your treatment and its effects on your fertility. Your oncologist can refer you to a reproductive specialist. Social workers, religious advisors, psychologists and other survivors can also help you understand your fertility choices. The following are some sample questions you may want to ask: Will my treatment have any short or long term side effects on my reproductive system? Is infertility a possible side effect of my treatment? Are there alternative ways to treat my cancer that will result in less damage to my reproductive system? What are my fertility preservation options before, during and after treatment? Would using any of these options possibly make my cancer treatment less effective? After treatment, how will I know if I am infertile or fertile? After treatment, will I enter into menopause prematurely? (women only) If I become menopausal after this treatment, is the change more likely to be temporary or permanent? (women only) If I become infertile after treatment, what are my options for becoming a parent? How long after treatment should I wait before trying to conceive?

Fertile Hope: Fertility Resource for Cancer Patients Founded in 2001, Fertile Hope is a national nonprofit organization dedicated to providing reproductive information, support and hope to cancer patients whose medical treatments present the risk of infertility. For more information, please call (888) 994-HOPE or visit www.fertilehope.org.

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Male Health Issues after Treatment for Childhood Cancer, Childrens Oncology Group, 2003. Maria Hewitt, et al., eds. Childhood Cancer Survivorship: Improving Care and Quality of Life, The National Academy of Sciences, 2003. Loredana Gandini, et al., Testicular cancer and Hodgkins disease: evaluation of semen quality, Human Reproduction, Vol. 18 No. 4, April 2003, pp. 796-801. Ibid. Female Health Issues after Treatment for Childhood Cancer, Childrens Oncology Group, 2003. S. Postovsky, et al., Sperm cryopreservation in adolescents with newly diagnosed cancer, Medical and Pediatric Oncology, Vol. 40, 2003, pp. 355-359. Angela B. Thomson, et al., Late reproductive sequalae following treatment of childhood cancer and options for fertility preservation, Best Practice & Research Clinical Endocrinology and Metabolism, Vol. 16, No. 2, 2002, pp. 311-334. Recommendation for the use of specific area gonad shielding on the patient, FDA Center for Devices and Radiological Health, Sec. 1000.50, http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1000&showFR=1. What tests are used to diagnose male infertility? UC Davis Health System, http://www.ucdmc.ucdavis.edu/ucdhs/health/a-z/67Infertilitymen/doc67diagnosis.html.

10 Samantha M. Pfeifer and Christos Coutifaris, Reproductive Technologies 1998: Options Available for the Cancer Patient, Medical and Pediatric Oncology, Vol. 33, pp. 34-40. 11 Angela B. Thomson, et al., Late reproductive sequalae following treatment of childhood cancer and options for fertility preservation, Best Practice & Research Clinical Endocrinology and Metabolism, Vol. 16, No. 2, 2002, pp. 311-334. 12 Mark F. H. Brougham, et al., Male fertility following childhood cancer: current concepts and future therapies, Asian Journal of Andrology, Vol. 5, Dec. 2003, pp. 325-337. 13 Fertility After CancerOptions for Starting a Family, Virtual Hospital, The University of Iowa Hospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html. 14 Ibid. 15 Fady I. Sharara, Healthology Press, http://imagecaredrugs.healthology.com/focus_article.asp?f=fertility&b=healthology&c= ovarianreserve_article. 16 Fertility After CancerOptions for Starting a Family, Virtual Hospital, The University of Iowa Hospitals and Clinics, http://www.vh.org/adult/patient/cancercenter/fertility/fertilitytext.html. 17 Find out an average rate

The Cleveland Clinic and Fertile Hope 2/2005

Next Steps For more information, or to schedule a consultation: Women: The Cleveland Clinic Fertility Center at Beachwood (216) 839-3150 http://www.clevelandclinic.org/obgyn/ The Cleveland Clinic Department of Obstetrics & Gynecology at the Main Campus (216) 444 1758 http://www.clevelandclinic.org/obgyn/ Men: If you want to sperm bank, a doctor needs to give you a prescription to do this. If you have a prescription, you may start the process by calling the Cleveland Clinic Andrology Laboratory and Sperm Bank (216-444-8182 or 1800 223-2273, ext. 48182) to set up a convenient appointment for you to go to the bank. The laboratory is located on the main campus on first floor of the Crile Building at East 100 and Carnegie Ave. It will be open weekdays and weekends if needed for banking. If you have questions regarding your fertility preservation, you may call the Director of the Laboratory (216-444-9485) or the physician who is head of the section of male infertility at 216-444-6340. They will be happy to work with you and your doctor to assist you in preserving your fertility potential.

THE CLEVELAND CLINIC FOUNDATION

9500 Euclid Avenue, Cleveland, OH 44195 The Cleveland Clinic is an independent, not-for-profit, multispecialty academic medical center. It is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education division and a research institute. The Cleveland Clinic Foundation 8/2005