of the patient, baseline ovarian reserve, time available for fertility preservation and whether the patient is in a stable relationship with a partner who can offer sperm for the creation of embryos.
Fertility preservation options are:prepubertal girls: ovarian tissue cryopreservation;postpubertal girls: controlled ovarian stimulation (COS) and oocyte storage; ovarian tissue cryopreservation; GnRHa co‐treatment during chemotherapy;women: COS and embryo and/or oocyte storage; ovarian tissue cryopreservation; GnRHa co‐treatment during chemotherapy;prepubertal boys: no established options;postpubertal boys: sperm banking (sperm obtained from masturbation, electro‐ejaculation or SSR);men: sperm banking.
Ovarian tissue cryopreservation and transplantation: generally, no more than 50% of one ovary is removed for storage; storage and transplantation should be carried out in specialized centralized facilities.
COS: requires approximately 2 weeks to complete treatment to the oocyte retrieval stage. COS can start at any stage in the menstrual cycle. However, if starting in late follicular or luteal phase, use an FSH only preparation (and not HMG) and start GnRH antagonist at the same time as starting the FSH injections.
In women with estrogen receptor positive cancers, consider using antiestrogens (Letrozole or Tamoxifen) during ovarian stimulation. Consideration should also be given to gestational surrogacy to avoid high levels of circulating estrogens that can result from a pregnancy.
GnRH agonist appears to be effective in providing some protection to the ovaries during chemotherapy. Therefore, it would be reasonable to offer a woman GnRHa treatment during chemotherapy. However, the evidence for protection of fertility is insufficient and needs further investigation.
Answers to questions patients ask
1 Q1. How can I find out the effect cancer treatment had on my fertility and what would be my options if I don’t go for fertility preservation? A1. We can do fertility tests, at least 6 months after cancer treatment is completed to assess your ovarian store of eggs. It should be remembered that it can often take longer than 6 months for the ovaries to recover their function. The ovarian function will depend on age, ovarian reserve before cancer treatment and the cancer treatment received. Based on your fertility potential, options could be natural conception, ovulation induction, IVF, treatment with donor egg or embryo, or surrogacy.
2 Q2 How often does oocyte cryopreservation result in a pregnancy? A2. Based on the available evidence, an overall 4% live‐birth rate can be expected per oocyte thawed following vitrification. So, multiple eggs will need to be stored to give a patient a reasonable chance of pregnancy. However, older women will require more frozen oocytes to achieve a live birth compared to younger women [22,23,24].
3 Q3 How long can my embryos be stored for and does the storage duration affect success rate? A3. In the UK, the standard storage period for embryos is 10 years; however, this could be extended for up to 55 years in certain circumstances. Available data showed that duration of storage has no negative effects on success rate [25].
4 Q4 I’m having pelvic radiation; what can I do to reduce its effect on my fertility? A4. The ovaries can be protected from radiation injury by moving them out of the radiation field through key hold surgery (ovarian transposition/oophoropexy) [26]. Natural pregnancies as well as pregnancies following IVF treatment have been reported following oophoropexy [27,28]. However, due to the potential effects of radiation on the uterus, surrogacy might be needed for some women.
5 Q5 Does OTC affect the well‐being of children conceived from this procedure? A5. It does not seem likely from the available evidence that OTC affects the well‐being of children born from this procedure [8].
References
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2 2 Poorvu PD, Frazier AL, Feraco AM, Manley PE, Ginsburg ES, Laufer MR, LaCasce, AS, Diller LR, Partridge AH. Cancer treatment‐related infertility: a critical review of evidence. JNCI Cancer Spectrum. 2019;3(1).
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4 4 Andersen CY, Mamsen LS, Kristensen SG. Fertility preservation, freezing of ovarian tissue and clinical opportunities. Reproduction. 2019; 158:27–34.
5 5 Donnez J, Dolmans MM. Fertility preservation in women. N Engl J Med. 2017; 377(17):1657–65.
6 6 Beckmann MW et al. Concept paper on the technique of cryopreservation, removal and transplantation of ovarian tissue for fertility preservation. Geburtshilfe Frauenheilkd. 2019; 79(1):53–62.
7 7 Lotz L, Dittrich R, Hoffmann I, Beckmann MW. Ovarian tissue transplantation: experience from Germany and worldwide efficacy. Clin Med Insights: Reprod Health. 2019;( 13):1–8.
8 8 Gellert SE, Pors SE, Kristensen SG. Transplantation of frozen‐thawed ovarian tissue: an update on worldwide activity published in peer‐reviewed papers and on the Danish cohort. J Assist Reprod Genet. 2018; 35(4):561–70.
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10 10 Youssef M, Van Der Veen F, Al‐Inany Mochtar M, Griesinger G, Mohesen M, Aboulfoutouh I, van Wely M. Gonadotropin‐releasing hormone agonist versus hcg for oocyte triggering in antagonist‐assisted reproductive technology. Cochrane Database Syst Rev. 2014; 31(10).
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12 12 Rodgers RJ, Reid GD, Koch J, Deans R, Ledger WL, Friedlander M, Gilchrist RB, Walters KA, Abbott JA. The safety and efficacy of controlled ovarian hyperstimulation for fertility preservation in women with early breast cancer: a systematic review. Hum Reprod. 2017; 32(5):1033–45.
13 13 Jeruss JS, Woodruff TK. Preservation of fertility in patients with cancer. N Engl J Med. 2009; 360(9):902–11.
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16 16 Clowse ME, Behera MA, Anders CK, Copland S, Coffman CJ, Leppert PC, et al. Ovarian preservation by GnRH agonists during chemotherapy: a meta analysis. J Womens Health (Larchmt). 2009; 18(3):311–9.
17 17 Ben‐Aharon I, Gafter‐Gvili A, Leibovici L, Stemmer SM. Pharmacological interventions for fertility preservation during chemotherapy: a systematic review and meta‐analysis. Breast Cancer Res Treat. 2010; 122(3):803–11.
18 18 Blumenfeld Z, von Wolff M. GnRH‐analogues and oral contraceptives for fertility preservation in women during chemotherapy. Hum Reprod Update. 2008; 14(6):543–52.
19 19 Beck‐Fruchter R, Weiss A, Shalev E. GnRH agonist therapy as ovarian protectants in female patients undergoing chemotherapy: a review of the clinical data. Hum Reprod Update. 2008; 14(6):553–61.
20 20 Chen H, Xiao L, Li J, Cui L, Huang W. Adjuvant gonadotropin‐releasing hormone analogues for the prevention of chemotherapy‐induced premature ovarian failure in premenopausal women. Cochrane Database of Syst Rev. March 2019.
21 21 Dohle GR. Male infertility in cancer patients: review of the literature. Int J Urol. 2010; 17(4):327–31.
22 22 Oktay K, Cil AP, Bang H. Efficiency of oocyte cryopreservation: a meta‐analysis. Fertil Steril. 2006; 86:70–80.
23 23 The Practice Committee of the Society