Cancer and Fertility: What Are Preservation Options for Women?

Jamie Forward:

So, let’s talk a little bit about preserving fertility. So, now that we understand more about the issues that may occur, what are the potential approaches for fertility preservation? 

Dr. Terri Woodard: 

So, there are a lot of different approaches.   

And some of it really depends on the type of cancer diagnosis. So, as I was talking about before, there are women that are diagnosed with gynecologic cancers, for instance. And historically, the way that we’ve treated those cancers is to remove reproductive organs, which obviously is not compatible with fertility. But over the years, we’ve learned that especially if someone has early-stage disease, we can be more conservative in our surgical methods. Or sometimes, instead of doing surgery, treat people hormonally, like in the instance of endometrial cancer, and still give that patient an opportunity to try to conceive after cancer treatment.  

For other things, like if a patient is getting radiation to the pelvis, there are ways to surgically move the ovaries as well as the uterus now, up higher into the abdominal cavity, so that the radiation doesn’t have as strong as an effect.  

Really, the standard of care, especially here in the United States, has been to utilize assisted reproductive technology. So, that’s referring to things like IVF, which would include embryo freezing, or the first part of it would be egg freezing. And then finally, for our young, young patients who may not have gone through puberty yet, or who may not have the time to do ART, we can sometimes offer ovarian tissue freezing. 

Jamie Forward: 

Okay, great. So, what is the ovarian tissue preservation? What is that exactly? 

Dr. Terri Woodard: 

So, essentially the idea of ovarian tissue freezing is that we can remove a portion of the ovary or an entire ovary and basically freeze it. And that tissue contains lots of immature follicles in it. Sometimes, they actually contain some mature follicles, and we can get those eggs when we remove that tissue.  

But the idea is that we can freeze this tissue, and if the woman develops ovarian failure, this tissue can then be transplanted back into the body after cancer and start to work again. And there have been hundreds of births using this technique. I will say it’s not widely available in the United States. There are specialized centers who are doing this. But essentially, this tissue can work, and patients can conceive naturally or via IVF. 

Jamie Forward: 

Fascinating. So, related to egg freezing, as you were talking about earlier, so imagine the timing of that can potentially affect, how does that – you work that in if you’re thinking about treatment in the future? How do you go about coordinating that? 

Dr. Terri Woodard: 

Yeah. So, to do egg freezing or embryo freezing, you do need the services of a reproductive endocrinologist. And so, one important thing is being able to find a reproductive endocrinologist. We certainly encourage oncologists to establish those relationships so that they can quickly refer a patient for fertility preservation if need be.  

But typically, it takes about two weeks for a patient to freeze her eggs or get the eggs to freeze embryos. And there have been some misconceptions on the length of time it takes and how much it might delay the start of therapy. But now, we have something called random start protocols that make this process a lot quicker than it used to be historically. Historically, we always had to wait for her to start her period. So, if she just had her period, then you’re waiting a whole other month before you can do a cycle. But these days, she can come in at whatever part of her cycle, and we can get her started right away. 

Jamie Forward: 

That’s great information. I was under the assumption that it would take much longer than that. So, thank you for clarifying. So, you’ve mentioned ways to protect the ovaries, egg freezing, tissue preservation.  

So, how do you determine which approach is best for which patient type? 

Dr. Terri Woodard: 

So, all of these are going to be highly individualized. And I think that’s why it’s so important to have that initial fertility consultation because part of that consultation is going to be discussing the risk. So, if the risk is relatively low, we probably don’t want to go and remove someone’s entire ovary if chances are she’s most likely going to be okay, but she might want to freeze eggs. I think the other part of this is what aligns with the patient. So, sometimes people have ethical, or moral, or religious reasons that they might not want to do one versus the other, so sometimes that plays a role.  

And, unfortunately, the other thing that often dictates what people choose to do is finances. Most of this is not covered by insurance. So, that often limits people’s choices.  

Jamie Forward: 

Are you hopeful about the future of fertility for cancer survivors? 

Dr. Terri Woodard: 

I am hopeful. So many really cool things are happening in the world of reproductive medicine.  

I alluded to it earlier, but now people are doing uterine transposition, so actually moving the uterus out of the pelvic cavity. People are doing uterine transplants, which have not been done in women with cancer yet, but it’s probably on the horizon. People are developing artificial ovaries. So, I think there’s going to be a lot of other options that are available to women in the future that are not available now. And I’m also hopeful that access will improve, as well.  

I’ve been involved with the Alliance for Fertility Preservation. They helped us get some legislation passed in the state of Texas that provides some coverage for patients with cancer. But every year, when I look at their map of who’s developed legislation to provide access to patients, it gets larger. So, I’m hopeful that eventually we’ll get to a point where every person who wants fertility preservation can get it and that the finances aren’t the issue.