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Fertility Guidelines Aim to Jumpstart Conversations

Young cancer patients and their doctors sometimes overlook a fairly common side effect of cancer treatment: infertility. Recognizing this, the American Society of Clinical Oncology (ASCO) recently released guidelines for addressing the issue.

Doctors should talk to patients about the possibility of infertility early on when discussing treatment, according to the new ASCO guidelines, and be prepared to refer patients to specialists who can help them choose a method of preserving their fertility when appropriate.

The guidelines mark a shift in thinking about cancer treatment and survivorship -- one that many doctors and patients say is overdue.

"We're at this amazing crossroads where survival rates are higher than they've ever been, and at the same time there are more reproductive options than there were before," said Lindsay Beck, co-author of the new guidelines and founder of the patient group Fertile Hope. "If you don't have that discussion early on, patients will miss their opportunity."

Beck began Fertile Hope in 2001 after her own struggles to find a way to preserve her fertility in the face of cancer treatment. The group provides information and financial assistance to young cancer patients who need fertility preservation procedures. She says oncologists haven't been doing enough to inform patients of the treatment risks or fertility preservation options.

"I don't think they're maliciously not doing it," she emphasized. "Oncologists aren't reproductive specialists, so this [guideline] gives them information on what's available today."

Other experts agree there's room for improvement in the way doctors address the issue with young patients.

"Historically, many of the cancers we cure today were not cured in the past," said gynecological oncologist Carolyn Runowicz, MD, national volunteer president of the American Cancer Society and director of the Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center. She was not involved in creating the guidelines.

"Now with earlier detection and better treatment, we are increasing the number of cancer survivors," she said. "For many, issues of fertility arise."

That was certainly the case for Antoinette Ramos of California, who was diagnosed with Hodgkin disease last year at age 25. Her doctor mentioned the possibility of infertility after treatment only in passing, she said.

"He said, 'Don't worry, I've had lots of patients who've gone on to have children,' " Ramos recalled.

Ramos was single, and still is, but had always planned to have children someday. The possibility of infertility came as a shock to her.

"The fact that that choice might be taken away from me really rocked my whole existence," she said. "I didn't cry when I found out I had cancer -- I cried when I found out it could affect my fertility."

With the help of Fertile Hope, Ramos froze 19 of her eggs before beginning chemotherapy.

The new ASCO guidelines are informative for oncologists who may not know very much about modern methods of fertility preservation, according to Runowicz. They list the various cancer treatments that can cause infertility, and detail both proven and experimental methods of fertility preservation.

For men, sperm freezing is both effective and well-established, the guideline says, noting that sperm should be collected before cancer therapy begins because even one course of treatment can cause damage. Hormonal therapy, on the other hand, has not been shown to be successful. Shielding the testicles from radiation is another possibility, but one that requires considerable expertise to be done properly.

For women, embryo freezing is the most established technique, but it may not be an option if a woman has no partner or cannot delay treatment long enough for egg harvesting. Freezing eggs alone presents the same timing problems and is still a relatively new and unstudied technique. Shielding the ovaries from radiation, or moving them out of the field of radiation, may be feasible for some women. Likewise, new surgical techniques may help women with certain cancers preserve their fertility.

Few options exist to preserve fertility in children who have not yet reached puberty, the guidelines note. Experimental techniques include freezing sections of tissue from the ovaries or testicles, in hopes that implanting them into the body later will restore fertility. But it is not certain how well these strategies might work.

Deciding which fertility preservation treatment to use depends on each person's particular situation, said reproductive endocrinologist Kutluk Oktay, MD, co-chair of the committee that wrote the new guidelines. He is director of the fertility preservation program and associate professor at Weill Medical College of Cornell University in New York.

"So far the most established method is embryo freezing, but even there, there are areas that need further research," he said.

For instance, Oktay is studying ways to help women with breast cancer safely stimulate egg production without increasing estrogen levels, which can fuel breast cancer growth. Other methods, like ovarian tissue freezing, are still so new there simply isn't any long-term data to show if they are effective or safe.

"The downside is most of the technologies we use have not been around for too long and don't have a long track record," he said, "but whatever we have is promising."

Oncologists aren't the only ones who will find the new guidelines useful, Oktay stressed. Other diseases can also cause infertility.

"These technologies are good for anyone whose fertility is threatened for any reason," he said.

Citation: "American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients." Published online May 1, 2006 in the Journal of Clinical Oncology. First author: Stephanie J. Lee, MD, MPH, Dana-Farber Cancer Institute, Boston.