Fertility Preservation for Cancer Patients
Course Summary and a Framework on Decision Making
Video Lesson
Experts you'll learn from
Director, Reproductive Survivorship Program
University of California San Diego Health
Professor of Obstetrics and Gynecology, University of New South Wales
Director of Reproductive Medicine, The Royal Hospital for Women
Written Lesson
Considerations You Will Face
There are a number of criteria you may want to consider when deciding whether to freeze your eggs (or embryos). Below is a framework you may want to consider, as much of the decision will boil down to your personal family-building goals, your comfort level with risks of infertility, the resources at your disposal, and the odds that your eggs will work if you freeze them. This course will cover information that should inform each of these considerations but we’ll summarize a few key concepts here.
Consideration 1: Family-Building Goals
The degree to which you’re committed to having children (many are quite happy being “child free”), how many children, and whether those children are genetically related to you, are critical factors to consider. If one has trouble conceiving after cancer treatments, various paths to parenthood exist and they include fertility treatment, use of donor eggs, donor embryos or surrogacy, as well as adoption or fostering. Ferreting out the extent you’d be comfortable with these approaches will be useful in deciding whether to freeze your eggs or embryos. As you can see in the chart below, each approach carries trade-offs.
Consideration 2: The Risks of Infertility
A key consideration for a patient is whether they’ll have trouble conceiving later in life and need to use their frozen eggs. Embedded in this question are typically two questions we’ll touch on:
- Will I have greater risk of infertility as a function of the age at which I try to conceive
- Will the cancer itself or cancer treatment raise my risk of infertility
Infertility as a Function of Age: Whether a patient undergoes cancer treatment or not, conceiving becomes more difficult with age, as you can see below.
The above chart showcases averages, and so below, we take another, more conservative, look at the data to pinpoint the odds where investigators presume at least 95% will conceive after 12 months of trying.
Similarly, as you can see below, if you do encounter difficulty conceiving, the odds fertility treatment will work tend to diminish with age. In this case, having access to your younger frozen eggs may be of real help.
Infertility as a Function of Cancer: How one’s cancer diagnosis impacts fertility is often a function of many factors, as you’ll read. That said, often patients tend to be at higher risk if they’ve received more gonadotoxic treatment, or radiation focused on the abdomen, pelvis, or cranium. However, as you’ll see in the data, we need to be careful when quantifying risk (e.g. relative versus absolute).
Consideration 3: Risks to Delivering, Offspring, Cancer Prognosis, and More
Patients also tend to have a lot of questions beyond whether they’ll have trouble conceiving. For instance, patients tend to wonder whether it’s even safe to try to conceive after a cancer diagnosis, if they pass on risks to their child, and if they embark on fertility treatment, how will that impact their cancer prognosis or their offspring. Below, we highlight some useful data, but again, it’s critical to raise these questions with your doctor directly.
Consideration 4: Resources Available
Two key determinants in whether a patient decides to press forward are money and time. Fertility treatment and preservation costs vary by region. For instance, patients treated in France may pay little-to-nothing, while an uninsured American might pay upwards of $15,000 for care. In a later lesson, we cover ways to mitigate costs, which even still may make treatment unaffordable for many patients.
Time is also a factor here. More time may afford you the ability to weigh your options (this all may just be too much to process), find a better clinic (we’ll cover how to do that in a later section), gather funds, or undergo an additional egg retrieval to raise the odds of success.
Consideration 5: Will the Process Work
The odds that frozen eggs will lead to a delivery is really a function of two factors, as you can see in the chart below:
a) The age at which you freeze (younger is better) and
b) The number of eggs you’re likely to collect
As you can see below, blood tests to determine AMH levels or ultrasound tests to see antra follicle count foreshadow how many eggs a patient will have retrieved and provide a clue whether freezing your eggs will lead to a live birth.
Finally, the quality of the clinic’s laboratory will be a key determinant in the odds that frozen eggs will lead to a live birth. Egg freezing (and thawing) is a delicate, newer process (within the last 20 years), and a clinic with little proven experience represents a greater risk of a disappointing result.
Selecting a clinic experienced in treating cancer patients is also important. An experienced clinic can adjust the drugs a patient takes (e.g. adding in letrozole or tamoxifen) to allow them to maximize results while mitigating risk of cancer recurrence, as you can see in the data below.
Cancer patients often worry that they need to sacrifice safety for effectiveness. Below you can see that when cancer patients take no gonadotropin, they get few embryos and low estrogen levels and rates of recurrence. However, allowing them to take gonadotropin improves success rates and by pairing it with Letrozole, estrogen and recurrence rates stay as low as if they’d taken no gonadotropin at all.
The reality is that adding Letrozole or Tamoxifen to a regimen of Gonadotropin appears to give breast cancer patients as good rates of success as if they had taken Gonadotropin alone. This is borne out in this 2022 Dutch study below which showed no statistically significant difference in the number of cumulus-oocyte complexes retrieved across treatment types.