Fertility options before your cancer treatment

06 Aug 2021

Following a cancer diagnosis, you are usually thrust into the decision-making process and will be forced to plan the next few months of your life – what treatment path will you take? Which medical team will you select? What steps do you take to protect your fertility? And so on …

Making decisions about your fertility now, before treatment begins, could have a big impact on your future family down the line – even if the word ‘family’ wasn’t on your agenda.

Below are a few options to consider before commencing cancer treatment:

1. The ‘I’ll just wait and see’ approach

You may select to simply go ahead with cancer treatment, waiting it out to see if your fertility will be impacted. While there is no right or wrong choice here, this approach may lead to disappointment later if a family is something you’ve always dreamt of.

Different chemotherapies have a different impact on your ovaries, and some may trigger menopause. Choosing this option to manage your fertility means acknowledging the risk and accepting menopause may happen as a result of your treatment. If menopause does occur as a result of your treatment, it is highly unlikely that you will be able to achieve a natural pregnancy. However, there remain some options available should you still wish to consider becoming a parent including adoption or fostering or donation of an embryo from another couple, or an egg from another woman.

2. In vitro fertilisation (IVF)

IVF involves removing eggs from your ovary and fertilising them with sperm, all within the confines of a laboratory. The fertilised eggs, also known as ‘embryos’ are then either transferred back into the woman’s womb or are frozen and stored for future use.

The IVF process involves five stages:

1. Ovarian stimulation
During the menstrual cycle, up to 20 eggs develop but generally only one matures. For fertilisation to occur, an egg must be mature. The aim of IVF is to stimulate more eggs to grow and mature, and then to collect as many eggs as possible. To achieve this, women going through this process are given hormones to stimulate the ovaries, allowing them to develop more eggs to the mature stage.

2. Egg collection
The egg collection step involves a small surgical procedure performed under sedation or a light general anaesthetic. An ultrasound probe is inserted into the vagina to identify the fluid-filled cysts (or follicles) in the ovary which contain mature eggs. These eggs are collected using a specialised suction device.

3. Insemination and fertilisation
The removed eggs are examined in a laboratory under a microscope to determine the best quality eggs to select and these are then put into a special liquid that in turn prepares them for fertilisation. During this stage, the sperm quality is also tested before being put together with the egg to finalise the fertilisation. In some instances, where there are problems with the sperm, one sperm can be injected directly into the egg. This is known as Intracytoplasmic Sperm Injection (ICSI). Not all eggs need to be fertilised, and so you may choose to make some embryos to freeze and keep some eggs.

4. Embryo culture and freezing
The embryo will spend two to five days in a petri dish with a special solution designed to promote growth. Embryos can then be transferred back into the uterus to attempt to achieve pregnancy or can be frozen and then thawed to be used at a later date for pregnancy. This is the usual approach for women about to begin chemotherapy following a cancer diagnosis.

5. Embryo transfer following cancer treatment
When a couple decides to have the embryos put back into the uterus, it is likely the woman will again need to take additional hormones. Although it is easy to freeze embryos, not all of them survive during the freezing proves.

The success of an IVF process is generally linked to the age of a woman. For instance, a woman aged 40 years or younger, will generally have anywhere from five to 15 eggs collected. More than half of the eggs collected for IVF will be fertilised and subsequently frozen, of which approximately 65-70 per cent will survive thawing and then be reinserted into the womb. From here, it is expected that anywhere from 25-60 percent will result in a healthy pregnancy. The outcomes of IVF are also reliant upon the number of eggs initially collected and the quality of these eggs.

As previously discussed, IVF does include the use of hormones, and for some women, this can include large doses, which may stimulate certain cancer types. That said, there is no supporting research to suggest that IVF itself increases the chance of breast cancers growing or coming back. It is recommended that women do however avoid exposure to high levels of hormones. New ovarian stimulation regimens have been developed in an attempt to try and prevent high oestrogen levels during IVF, however, it is best to discuss this directly with your fertility specialist based on your own personal situation.

Common questions associated with IVF and cancer diagnosis:

1. Will IVF delay my cancer treatment?
IVF can delay the beginning of cancer treatment such as chemotherapy by at least two weeks. If IVF is an option you are considering, it is incredibly important to discuss the possible impact of delaying treatment with your oncologist and medical team. For most women, delaying cancer treatment by a few weeks is unlikely to impact your prognosis.

2. Where do I go to access IVF?
IVF is available in various clinics across Australia. For a full list of accredited clinics, visit the Fertility Society of Australia.

3. What are the costs involved?
Costs can vary and are dependent upon where in Australia you are located. Before starting this process it’s important to discuss with your nearest clinic what the cost estimates will be, and if you are available for any reimbursements available through Medicare or your private health fund. It is also worth exploring with your doctor if there are any grants or programs available that you may be eligible for to cover the cost of some or all of your treatments.

4. Are there any legal issues I need to be aware of?
The largest legal issue to be aware of is access to your embryos in the future. If you use donor sperm, you have full access to the embryo no matter what, however, if you and your partner develop the embryo, you are both legally entitled to the embryo. Therefore, permission from both you and your partner is required for the embryos to be used in the future. With this in mind, it is important to consider future possibilities, including a relationship breakdown, illness, natural conception etc., and what will then happen to the unused embryos. A way to navigate this issue is to use some of the eggs to create embryos and freezing some eggs without fertilization.

5. Are there any side effects from IVF treatments?
IVF can be a physically and emotionally draining process but serious side effects from treatment are uncommon. However, it is important to be aware that on the very rare occasion some complications may arise including:

a. Medication-related side effects
Fertility drugs are generally very safe, and side effects are minimal, however, these can include mood swings, headaches, nausea, hot flushes, bloating and stomach pain. In rare cases, some women may have a serious reaction to the drugs. Your fertility clinic should work closely with you to monitor for side effects and treat any problems. Your doctor can speak with you about more information about these side effects.

b. Complications during the egg collection process
This could include a very small risk of bleeding or infection.

c. Long-term effects on your baby
Though rare, children conceived by IVF are at a slightly increased risk of premature birth and birth abnormalities.

d. Your own health
Another long-term impact of IVF to consider is your own health. While research here remains unclear, it is well reported that IVF does not increase the likelihood of cancer recurring.

3. Egg freezing (cryopreservation)

The egg freezing process involves the harvesting of unfertilised, mature eggs for cryogenic freezing. This may be an option if you are not in a position to create embryos with a long-term partner or feel that donor sperm Is right for you.

Freezing of eggs allows you to use the use them at a later stage for fertilisation once you have established that you would like to use a future partner or sperm donor.

Similar to the IVF process, your ovaries are stimulated with hormones to form mature eggs, that are subsequently collected and frozen. When you are ready to use the eggs, they are thawed and fertilised before being implanted.

Pregnancy rates that use frozen eggs are improving slowly and are close to achieving the same success as traditional IVF. In a standard simulated cycle, between five and 15 eggs are generally collected, with approximately 80-90 per cent surviving the freeze and thawing process. From here, 70-80 per cent will be fertilised and transferred to the womb, with the hope that between 25-60 per cent result in a baby. However, the outcomes of this are dependent upon the quality and number of eggs collected in the initial phase.

As with IVF, there will be a delay in commencing treatment for cancer if you opt for the egg freezing route, as it again takes at least two weeks to stimulate the ovaries for egg collection.

Breast cancer is potentially impacted by ovarian stimulation so it is best to discuss this option with your fertility and oncological team to determine the impact this may have on your treatment. The side effects of egg freezing are similar to that of the IVF process.

4. Ovarian tissue freezing (Cryopreservation)

This is a relatively new technique that is still in the development phase and involves an operation to remove some ovarian tissue. In younger patients, this usually results in the removal of a large number of immature eggs.

Following the tissue removal, the tissue is frozen and stored until it can safely be returned to the patient. It is believed that new blood vessels will start to grow and establish once the transplanted tissue is returned, producing hormones that will help ripen the eggs.

If this happens, the IVF process may be used to help mature, collect and fertilise the eggs, or alternatively, it may be possible to mature the ovarian tissue itself in the laboratory to produce mature eggs for IVF.

Freezing ovarian tissue has similar implications to egg freezing with some tissue dying during the thawing process. It is also important to note that there may be an increased risk of transmitting cancer cells back into the body and that removing some of the ovaries may reduce fertility outcomes should it return naturally following cancer treatments.

5. Ovarian suppression during treatment

Ovarian suppression during chemotherapy for hormone receptor-negative breast cancer (HER negative) is thought to help protect the ovaries and improve the chances of protecting fertility during treatment.

It involves using a drug known as GnRHa – gonadotropin-releasing hormone analogs, such as Zoladex, or goserelin. This drug blocks the hormone signals to the ovaries telling them to develop and release the eggs.

Research indicates that in pre-menopausal women, this option in combination with chemotherapy can in fact protect fertility, while GnRHA used whilst on chemotherapy is thought to also reduce the chance of cancer returning and improve the survival of patients with this type of breast cancer.

Ovarian suppression does not impact the commencement of cancer treatments; however, it can be costly, and it is important to discuss the benefits and risks to you based on your personal situation.