Fertility Preservation

Created by:
Sanidya Fasya Hardiansyah - 2265050071
Mentor :dr. Batara Imanuel Sirait, Sp.OG, (K) FER
KEPANITRAAN KLINIK ILMU OBSTETRI DAN GINEKOLOGI RUMAH SAKIT UMUM UNIVERSITAS KRISTEN INDONESIA
FAKULTAS KEDOKTERAN UNIVERSITAS KRISTEN INDONESIA
PERIODE 30 Mei – 06 Agustus 2022
 Table of contents
introduction
01

discussion
02

conclusion
03
 Why to preserve fertility ?

● Increase rate of unmarried females age > 30 years

● Increase incidence of malignancy / cancer among children
during productive age period
● Survival and cure rate of cancer are improving
● Technology for early detection & treatment
 Malignancy encountered in reproductive
age group

● Breast cancer
● Ovarian tumors
● Lymphomas
● Pediatrics solid tumors
● Testicular cancer
● Bone tumors
 Cancer burden in reproductive age group population

● Every year 250,000 children all over the

world get diagnose with cancer
● In india, it is estimated that nearly 40-50.000
new childhood cancer cases occur each year.
● In 2020, every 250 adult was survivor of
childhood cancer
● Approximately, 40-80% of females face
possible infertility as a result of their cancer
treatment
● Multy modality treatment is current standart of care in treating
malignancy
● Both chemotherapy and radiotherapy have a major impaction
reproductive potential
● Infertility cause being
1. Disruption of the hypothalamic pituitary gonadal axis
2. Direct immunological or cytotoxic injury to the germinal
epithelium within the testis
3. Anorexia- cachecxia syndrome
4. Psychological issues such as anxiety and depressions
 chemotheraphy

● The effects depend upon the type of the chemotherapeutic agent used, dose ,
age, and baseline ovarian reserve. The most damage is caused by drugs called
alkylating agents and the drug cisplatin. Younger women who receive
chemotherapy are less likely to become infertile than are older women.
● MOA-apoptosis of the growing follicles and activation of the resting follicle with
subsequent apoptosis, leading to a burn out effect & fibrosis of stromal blood
vessels
● Clinical manifestation range from a complete amenorrhea to premature
menopause and varying degree of infertility
 Radiation theraphy
● Radiation can be more damaging to fertility than chemotherapy, depending on the location
and size of the radiation field and the dose given. For example, high doses of radiation can
destroy some or all of the eggs in the ovaries.
● Radiotherapy affects both teh ovarium and the uterus
● Effects Radiation on uterus → leads to reduce vascularity, damage to myometrium leading to
fibrosis and hormone dependent endometrial insufficiency, resulting in advers reproductive
outcome
● Increased rates of infertility, miscarriage, preterm labor, IUGR, LBW.
● Radiotherapy effects to testis → has a detrimental and irreversible effects on the testis
- Very small dose lead to histological changes in sprematogonia number nd shape
- Exposure to 2-3 gy of radiation leads to significant sprematocyte damage
- 4-6 gy range lead to significant sprematid injury
- > dose of radiation the more preciitous the decline in sperm concentration and the longer the
period of time required for recovery of sprematogenesis
The preservation of fertility potential is an important issue for young people at risk of
becoming infertile due to clinical conditions, diseases, or treatments. The best-
characterized target group for fertility preservation is the patient population diagnosed
with cancer at a young age since the bulk of the data indicates that the gonadotoxicity
inherent to most cancer treatments induces iatrogenic infertility.Additionally, the
indications for fertility preservation beyond cancer are also increasing since a number
of benign diseases and chronic conditions either require gonadotoxic treatments or are
associated with premature follicle depletion.
 ti o n s :
a
Indic

1. Malignant disease
2. Benign disease
3. Age related fertility declined
 Options of fertility preservation

Envolves: Oncologist, pediatricians,

Gynaecologist and urology

women men

● Embryo cryopreservation ● Sperm cryopreservation

● Oosyte cryopreservation
● Ovarian tissue cryopreservation
Embryo cryopreservation
● Ovarian hyperstimulating → surgical retrieval→ IVF an essential
component
● Embryo bangking is the most succsesful form of fertility preservation and
should be offered to all women who are married or who are open to the
idea of using donor sprem
● Limitation :
- High estradiol levels during stimulation may have a negative effect on
estrogen- sensitive tumors
- Delay cancer treatment
- Non appplicability in prepubertal patients
Oocyte cryopreservation
● With appropriate counseling, is recommended for patients facing
infertility due to chemotherapy or other gonadotoxic therapies
● When a woman is unmarried or does not have a partner mature oocyte
cryopreservation is preferred
● Cryopreservation ( slow freezing) or vitrification (rapid freezing) is an
option
Ovarian tissue cryopreservation
● Entails the surgical removal of ovarian tissue containing numerous
primordial follicles or whole ovary → cryopreservation of tissue slices →
subsecquent grafting back to the site of the ovary
● Excellent emerging methode suitable for menarchal girls → large number
of immature oocyte in ovarian cortex
● Reported success with ovarian tissue transplantation that has resulted in at
least 12 patients with 28 subsequent live births in humans
● Concern for reintroduction of malignant cell back into the host,
particularly for patients treated for leukemia
Sprem cryopreservation
● Strongly advisable to complete serm bangking before starting therapy to
avoid increased genetic damaged in sperm collected after the start of
theraphy
● Collection of three of four samples with approximately 48 h periods of
abstinence between sampling is ideal
● If sprem count or motility is impaired or sample amount limited, IVF is
necessary eles IUI is feasible
● Conception rates of IUI are lower than with IVF
GnRH agonist &
antagonist
● Pituitary desensitization that ensues after 7 to 14 days later → reduce the
number of primordial folliccles destroyed by toxic agents
● May reduce the blood flow to the ovary and reduce delivery of
chemotherapeutic agent
● GnRH antagonist rapid inhibition of gonadotropin and sex steroids secretion
leasing to immediate down regulation
● Insufficient evidence to definitively recommend this therapy.
 ASCO clinical practice guideline on fertility
preservation
● To preserve the full range of options, fertility preservation approaches should be
discuss as early as possible, before treatment starts
● Refer patients who express an interest in infertily preservation (and patients who are
ambivalent) to reproductive specialist
● Document fertility preservation discussions in medical chart
● No patient should be excluded from consideration for discussion of fertility
preservation for any reasons, including age, prognosis , socioeconomic status or
parity
● Concern such as need to initiate chemotherapy quickly should not dissuade from
bangking sperm
Conclusions
● Fertility preservation has become an established branch of reproductive medicine
● Multidisciplinary team approach and individualisation of case are key to its success
● Fertility preservation should be discussed with men and women the fertile age
group who are about to embark in cancer treatment
● Fertility preservation gives hope in future reproduction and hope a life after cancer
● Embryo freezing is most successful method to date
● For pubertal men and women gonadal tissue freezing is the only available method
• Dolmans M, Donnez J,Fertility preservation in women for medical and social reasons: Oocytes
vs ovarian tissue,Best Practice & Research Clinical Obstetrics & Gynaecology,Volume
70,2021,Pages 63-80,ISSN 1521-6934,https://doi.org/10.1016/j.bpobgyn.2020.06.011
https://www.sciencedirect.com/science/article/abs/pii/S152169342030122X?via%3Dihub
• Fred F. Ferri MD,Fertility Preservation in Women, FACP, in Ferri's Clinical Advisor 2022
https://www.sciencedirect.com/topics/medicine-and-dentistry/fertility-preservation
• https://www.researchgate.net/publication/26242981_Fertility_preservation_for_women_with_malig
nancies_Current_developments_of_cryopreservation
• Rodriguez-Wallberg,K.A.; Hao, X.; Marklund, A.; Johansen, G.; Borgström, B.; Lundberg, F.E. Hot
Topics on Fertility Preservation for Women and Girls—Current Research, Knowledge Gaps, and
Future Possibilities. J. Clin. Med. 2021, 10, 1650. https://doi.org/10.3390/ jcm10081650
Thank you