Not all female cancer patients opt for fertility preservation, however. For example, the initial treatment for Hodgkin’s lymphoma, ABVD (doxorubicin hydrochloride [Adriamycin], bleomycin, vinblastine, and dacarbazine), is a chemotherapeutic regimen with low toxicity that usually does not cause infertility.
"Many of those patients do not end up doing fertility preservation, because ultimately 90% of women with Hodgkin’s lymphoma get cured and will be able to get pregnant without a problem, as long as they try before the age of 35," Dr. Gracia said.
The problem is that "10% of women who relapse will then require a bone marrow transplant as the subsequent therapy," she continued, and no one knows who they will be. "That treatment causes infertility in over 95% of patients."
Many oncologists do not refer Hodgkin’s lymphoma patients on the assumption that all will be fine after ABVD therapy. "But if the chemotherapy regimen fails and [the patients] come back to see me, at that point the options are more limited in terms of what you can offer them. ... Their ovaries may not respond as well to treatment in order to stimulate the ovaries with injections of gonadotropin, and then retrieve eggs in order to freeze eggs or embryos."
Providing fertility preservation for patients with leukemia can be challenging, Dr. Gracia added, because they sometimes are so sick "that it’s not really safe to put them through procedures like ovarian stimulation, or egg or embryo freezing. Those are patients we are often not able to help."
Dr. Nicole Noyes
Cancer prognosis also can be a factor in deciding whether a patient is a good candidate for fertility preservation, although Dr. Noyes urged caution on that issue. "Even if a patient has stage III cancer and the survival rate is 20%, I don’t think it’s my place to judge that. ... If she is in the 20% who survive, she will not be happy if you say, ‘I didn’t do oocyte retrieval because I didn’t figure you would make it,’ " she explained.
In a survey answered by 516 oncologists, slightly less than half of respondents took "a neutral stance" on the advisability of poor-prognosis patients pursuing fertility preservation. While 23% agreed that these patients should not pursue fertility preservation, 32% disagreed; data were missing for 1%. Similarly, 51% had no opinion on posthumous parenting, only 16% expressed support, and 32% were opposed. Again, data were missing for 1%.
"Oncologists’ personal attitudes regarding posthumous reproduction were related to referral of patients with a poor prognosis," the authors wrote, noting that religious beliefs can influence physician attitudes (J. Support. Oncol. 2011 [doi: 10.1016/j.suponc.2011.09.006]).
How Old, How Young, and With Whom?
Age cutoffs for fertility preservation vary from practice to practice, but most physicians won’t perform the practice in patients older than age 46. When providing counseling about fertility preservation options, Dr. Noyes makes it a point to ask the patient if she is in a committed relationship with someone with whom she can rear a child.
"Oftentimes rather than just freezing all embryos, I’ll freeze half as unfertilized eggs and half as embryos, even if the woman is in a committed relationship," Dr. Noyes said. "This creates less pressure on the couple, and there is some reproductive autonomy if things don’t work out. The woman could still use those eggs with someone else."
Dr. Gracia once had a 49-year-old cancer patient seek her assistance with fertility preservation. "I told her, ‘You’re close to menopause and unfortunately, fertility preservation technologies will not work at your age.’ Even in situations where a woman’s fertility is already compromised, a cancer diagnosis often makes individuals even more aware of their future fertility, since treatments may take away their ability to have children."
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A patient undergoing the egg retrieval procedure.
With IVF, the efficiency is about a 6%-7% live birth rate per egg. With egg freezing, the efficiency stands at about 5% per egg, "so it’s similar to IVF, which is good," Dr. Noyes said. "We know from years and years of IVF that every egg isn’t meant to be a baby. Otherwise, the pregnancy success rate would have gone from about 30%, which it was in 1990, to almost 100% now. It improved from about 30% in 1990 to 50%-60% now."
To date, Dr. Noyes has performed fertility preservation in about 125 cancer patients, and 6 of them have returned to use the frozen eggs or embryos. "On average, they are using their preserved eggs or embryos about 3 years after preserving them," she said. "It depends on their age when they freeze the eggs or embryos. The very young girls aren’t going to be back for a decade or more."