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Perth Haematology :: Dr Steven Ward

Fertility Issues

 

FERTILITY ISSUES

Chemotherapy and radiotherapy interfere with growing and dividing cells. This includes eggs and sperm. Cancer treatment and the cancer itself can lead to infertility. The effects and potential preventative measures are outlined for males and females.

 

Fertility preservation in Males

The methods for retaining fertility in males is much simpler and well established than in females.

 

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Sperm Banking: sperm cryopreservation after masturbation

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Standard method, most established and proven technique; relatively simple

 

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Gonadal shielding during radiotherapy

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Lead shields are used to reduce radiation dose to testicles

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Only applicable in selected cases due to radiation field and anatomy

 

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Testicular tissue cryopreservation

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Freezing testicular tissue and re-implantation

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Requires biopsy/operation; investigational; not been tested in humans

 

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Testicular suppression with hormones (gonadotrophin releasing hormone analogs or antagonists)

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Use of hormones to make testes dormant and protect testes during chemotherapy or radiotherapy; investigational;; not proven to be effective

 

Cytotoxic drug effects of male fertility

 

Agents

Effect on Males

Radiation (2.5Gy to testes)

Chlorambucil (1.4mg/m2)

Cyclophosphamide (19g/m2) v high dose

Procarbazine (4g/m2) high dose

Melphalan (140mg/m2) transplant dose

Cisplatin (500mg/m2)

Prolonged azoospermia

BCNU (1g/m2)

CCNU (500mg/m2)

Azoospermia in adults after treatment before puberty

Busulfan (600mg/kg)

Ifosfamide (42g/m2) v high dose

BCNU (300mg/m2)

Actinomycin D

Azoospermia likely (but always given with other highly sterilising agents)

Carboplatin (2g/m2)

Azoospermia not often seen

Doxorubicin (770mg/m2)

Thiotepa (400mg/m2)

Cytarabine (1g/m2)

Vincristine (8g/m2)

Temporary effect alone; can be additive to other agents above

Amsacrine; Bleomycin; dacarbazine; Daunorubicin; Epirubicin; Etoposide; Fludarabine; 5FU; Mercaptopurine; Methotrexate; mitoxantrone; thioguanine

Temporary reduction in sperm count; additive effects are possible

Prednisolone

Unlikely to affect sperm count

Interferon

No effects on sperm production

New agents: Imatinib; taxanes

Unknown effects

 

 

Fertility preservation in Females

 

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Embryo cryopreservation

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Harvest eggs, in vitro fertilisation (IVF); freeze embryos for later implantation

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The most established method in females; requires 10-14 days of ovarian stimulation (hormones) from the start of menstrual cycle; surgical procedure; may not have enough time; requires sperm from partner or donor

 

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Oocyte Cryopreservation

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Harvest and freeze unfertilised eggs

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 Investigational; small numbers performed; 2% live births per thawed oocyte (3-4x lower than standard IVF); requires 10-14 days of ovarian stimulation from start of menstrual cycle

 

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Ovarian Cryopreservation and Transplantation

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Freeze ovarian tissue and re-implant after cancer treatment; Few cases so far; live births have occurred; surgical procedure; not suitable if ovary involved by tumour

 

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Gonadal shielding during radiotherapy

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 Shields reduce dose of radiation to reproductive organs

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 Only possible in certain situations

 

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Ovarian transposition (oopheropexy)

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 Surgical repositioning of ovaries away from radiatherapy field

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50% chance of success; surgical procedure; may need IVF too

 

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Ovarian suppression with hormones

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Use of hormones to make ovaries dormant during therapy

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Small studies; investigational

 

Cytotoxic drug effects of female fertility

Degree of risk

Cancer treatment

High risk (>80%)

Haematopoietic stem cell transplantation with Cy/TBI or Bu/Cy

External beam radiation to a field that includes the ovaries

Lower risk (<20%)

ABVD

CHOP x 4-6 cycles

CVP

AML therapy (anthracycline/cytarabine)

ALL therapy (multi agent)

Very low or no risk

Vincristine

Methotrexate

Fluorouracil

Unknown risk (examples)

Taxanes

Monoclonal antibodies (trastuzumab, bevacizumab, cetuximab)

Tyrosine kinase inhibitors (erlotinib, imatinib)

These are general guidelines based on best available literature. Additional factors, particularly pre-treatment ovarian reserve, specific treatment regimen, and age determine individual risk for immediate fertility or for premature ovarian failure after resumption of menses.

(Lee et al,2006) Journal References Lee SJ, Schover LR, Partridge AH et al. (2006). American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients. J Clin Oncol .24(18)