Treatments and investigations


To learn that you have a malignant condition requiring urgent treatment to save your life is devastating. Understandably the main concerns that you and your family will initially have will relate to your chances of survival. Subsequently, the quality of your future life and the effect that treatment may have on your fertility should be discussed. Whether you already have children or not, it can be very difficult to come to terms with the realisation that the cancer and treatment will make you infertile.

Your cancer specialist will be able to refer you to an assisted conception clinic for an immediate discussion about your fertility options. This referral in itself is encouraging. The implication you can read into it is that you are going to survive and come through your treatment successfully.

A particularly distressing situation for parents is the discovery of cancer threatening the life of their child. The major priority of course is survival and a cure. But now there is also the possibility of trying to protect the child's future fertility.

Cancer and fertility in men

Radiotherapy and chemotherapy treatments may permanently affect your fertility. The effects of these treatments on sperm production depend upon the length of the course of treatment, the total dosage of your treatment and (in the case of chemotherapy) the drugs used. Sperm production may return, although this can take several years. The choices you have are fairly straightforward. You can take a chance and hope that your fertility will return to normal, in the knowledge that if it does not do so, there are always the future options of using donor sperm to achieve a pregnancy or adoption. The alternative is to "bank" your sperm in an assisted conception unit before you start treatment.

The cryopreservation (freezing) of sperm involves storing sperm samples at very low temperatures (minus 196° C) in liquid nitrogen. If sperm samples are stored by cryopreservation before treatment commences, there is a realistic chance that your sperm could be used at some future date to obtain a pregnancy with your partner. It must be pointed out, that a significant proportion of men with newly diagnosed malignant disease have sperm of very poor quality. This means that it is less certain that cryopreservation will be successful. When it eventually comes to trying for a baby using your stored sperm, it may be necessary to consider using complex assisted conception techniques involving micro-assisted fertilisation in the form of ICSI (Intra-cytoplasmic sperm injection) on an IVF programme (see ICSI and IVF information).

Current legislation allows sperm to be stored from a named individual until he reaches 55 years of age. You will be required to sign a consent form to allow storage of your sperm. The clinic's counsellor will discuss the implications of storage and the future use of your sperm with you or with you and your partner.

It is essential that sperm samples are stored before you start treatment. The clinic might refuse to store your sperm if treatment has already commenced. This is because some chemotherapy treatments may damage sperm and cause future abnormalities in children. For this reason it is important that while you are receiving chemotherapy, contraceptive precautions must be taken.

You will be asked to provide an average of three samples. Each sample will be analysed to assess the quality and numbers of sperm present. The sperm sample is then frozen and stored for your future use only.

Cancer and fertility in women

To find out that you have a life threatening cancer is terrible enough. To be denied the possibility of having children is unbearable.

The effects on you of your treatment will depend upon the treatment itself. There are many combinations of chemotherapy drugs. Your treatment can be very complex combining chemotherapy or radiotherapy with surgery as well. Radiotherapy and chemotherapy treatments may leave you with a temporary or permanent menopause ("change of life"). If you have a hysterectomy (removal of the uterus) or bilateral oophorectomy (removal of both ovaries) a future pregnancy will be impossible.

Prompt referral to an assisted conception unit to discuss your options is essential.

This usually means a rapidly arranged consultation with the medical staff on the unit, as treatment of the cancer has already been planned and is generally poised to commence as soon as possible. All the options will be very fully discussed with you

These options will include:

  • await events and see if your fertility returns during the years after your treatment has been successful;
  • retrieval of your eggs for IVF and freezing of embryos;
  • removal and freezing of your eggs;
  • freezing of ovarian tissue;
  • future egg or embryo donation;
  • surrogacy
  • adoption.
IVF and freezing of embryos

If you decide to take up the egg retrieval options, it is usually possible to delay your cancer treatment for a few weeks. If you have a partner, IVF with his sperm can be carried out with cryopreservation of the embryos. Clinics are able to carry out "emergency" IVF treatment cycles using what is called a short protocol with pituitary antagonists (see IVF information) which means that once the IVF treatment cycle has started egg retrieval will take place about two weeks later. Your deferred cancer treatment can then commence.

Egg freezing

If you don't have a partner, it is possible to have your eggs frozen. The new technique of rapid freezing called vitrification is a fast freeze process where the egg undergoes instantaneous "glass-like" solidification without the damaging formation of ice crystals. Not all eggs will survive freezing and thawing when they come to be used at a later date and very occasionally none will survive. An alternative that you may wish to consider is to have your eggs fertilised with donor sperm as it is more successful to freeze embryos.

Freezing and storage of ovarian tissue

From birth, the ovaries contain in immature form all the eggs that will ever be produced. From this "egg bank" eggs develop to maturity during every natural menstrual cycle.

A biopsy sample of ovarian tissue will therefore contain dormant eggs that have not yet been stimulated to become mature. It is possible to freeze and store multiple tiny portions of ovary. While it is likely that some immature eggs in ovarian biopsies will survive the freezing and eventual thawing process, it remains to be seen whether or not they can then be stimulated to grow to maturity in the laboratory. The technology for "harvesting" the eggs from ovarian tissue is still in its infancy. Animal experiments are encouraging and suggest that there is every probability of future success.

The establishment of laboratory techniques to successfully mature and fertilise eggs from frozen ovarian tissue is likely to be 5 - 10 years down the line. In view of this it is essential to be realistic. You may find that the assisted conception unit have placed a ceiling age of 30 years for women undergoing storage of ovarian tissue. It must be stressed that this should not be regarded as a treatment option for the future. It is totally experimental at this stage.

There is an alternative to trying to mature eggs in the laboratory. There is already evidence that it is possible to transplant back into the body thawed ovarian tissue biopsies and stimulate the transplanted tissue to produce mature eggs, These eggs would then need to be retrieved for IVF in the laboratory. However, this technology would not be suitable for all women because of fears that tiny deposits of malignant cells from certain types of cancer may have spread to the ovaries before ovarian biopsy. These malignant cells might also survive freezing and thawing and be transplanted back into a woman who had been cured of her cancer! New regulations regarding tissue freezing and storage have come into force. This means that it will only be possible in the future to use cryopreserved tissue that has been prepared under the most stringent conditions, far greater than those that exist in the majority of assisted conception units (including our own). Arrangements can be made with a regional laboratory for biopsy and tissue storage. If you have had ovarian tissue stored in the past under less stringent conditions, there is a "grandfather" clause that will permit this tissue to be considered for future in-vitro egg maturation or transplant.

While the majority of the women decline cryopreservation of ovarian tissue, you will at least have the opportunity to discuss this option.

Surrogacy and adoption

If your cancer treatment involves having a hysterectomy you might still be able to have a baby resulting from your eggs by using a host or surrogate mother. Some couples will feel that adoption is the better option.

Storage of ovarian and testicular tissue from children before radiotherapy and chemotherapy

If there is uncertainty about the results of freezing adult ovarian tissue, even less is known about freezing ovarian and testicular tissue from children before they have reached puberty. The potential for future egg and sperm maturation is there but will it be possible? We simply do not know.

Assisted conception units have developed close links with their colleagues in haematology and radiotherapy / oncology. Rapid consultations can be set up and where it is appropriate, the child is also involved in the decision making process.

For girls it may be simpler to remove an entire ovary rather than perform a difficult ovarian biopsy, as the ovaries in children are quite tiny. Depending upon the medical circumstances, the ovary may be removed either at laparoscopy or by a small abdominal operation. For boys the testicular biopsy will involve a small incision under a short anaesthetic to remove tissue from the testicles.

The majority of parents will decline the storage of ovarian or testicular tissue from their children.

These issues can be extremely distressing for you and your family. But the very fact that you are discussing your future fertility treatment after cancer has been treated means that there is hope for that future. Your assisted conception unit will be able to offer you expert counselling which you will find very helpful.

March 2009