and surgery, and 60% for those treated with pelvic irradiation and vaginal brachytherapy.
Fertility preservation techniques (see chapter 10)
Other methods of fertility preservation include gonadal shielding, laparoscopic uterine fixation [11], embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation and autotransplantation of the ovary to the upper extremity with creation of vascular anastomosis [12].
Key points
Challenge: Fertility in a patient with previous pelvic irradiation.
Background:
With improved RT and chemotherapy techniques there is a significant increase in childhood cancer survival rates.
The impact of radiation therapy on fertility depends on radiation dosage, age at the time of radiation exposure and extent of radiation field treatment.
Ovarian dysfunction can manifest as premature ovarian failure or diminished ovarian reserve.
Uterine dysfunction can present as reduction in uterine volume, endometrial thickness, uterine blood flow or distensibility.
Pelvic irradiation increases the risk of pregnancy‐related complications, including spontaneous miscarriages, preterm labor and delivery, low birth weight infants and placental abnormalities (placenta accreta and percreta).
Prevention and management options:
Ovarian transposition and other fertility preservation techniques such as gonadal shielding, donor oocytes and gestational surrogacy, embryo, oocyte or ovarian tissue cryopreservation may be useful.
There have been no live births reported in patients with prepubertal pelvic irradiation. Postpubertal pelvic irradiation patients have had live births.
Answers to questions patients ask
1 Q1 As a cancer survivor, can I get pregnant?A1. In many cancer survivors, pregnancy is now possible, but it depends on a number of factors. You should speak to your cancer specialist regarding this and, generally, the cancer should be “cured” before you attempt pregnancy.
2 Q2 How does my radiation treatment affect my ovaries?A2. The radiation treatment causes direct damage to your eggs. This can result in a decrease in your ovaries’ ability to release female hormones and can lead to early menopause. The dose of radiation used, your age at time of radiation treatment and the area of your body that is radiated are some of the factors that determine the extent of damage to your eggs.
3 Q3 Can I get pregnant with my own eggs after radiation treatment?A3. If you are still getting regular periods, it may be possible for you to get pregnant with your own eggs. Your fertility specialist will do an ultrasound to measure your ovarian volume (at least 3 cc) and measure your antral follicle count (small follicles in your ovaries measuring 2–5 mm in diameter). Other tests include measuring your follicle stimulating hormone (FSH) level (should be less than 10 mIU/mL) and anti‐Müllerian hormone (AMH) level (should be more than 1 ng/mL). If you are not getting regular periods, you may be in premature menopause. In that case, you can get pregnant using an egg donor.
4 Q4 Will my pregnancy be complicated?A4. There is an increased chance of miscarriage in patients with a history of pelvic radiation. Other complications include preterm delivery, low birth weight babies, increased rate of C‐section and placental complications.
References
1 1 Rodriguez‐Wallberg KA, Olofsson JI. Future fertility in survivors of childhood cancer—examining the impact of cancer treatment on uterus function. Fertil Steril. 2019; 111(2):262–3.
2 2 Wo JY, Viswanathan AN. Impact of radiotherapy on fertility, pregnancy and neonatal outcomes in female cancer patients. Int J Radiat Oncol Biol Phys. 2009; 73(5):1304–12.
3 3 Schover LR, Rybicki LA, Martin BA, Bringelsen KA. Having children after cancer: a pilot survey of survivors’ attitudes and experiences. Cancer. 1999; 86(4):697–709.
4 4 Wallace WH, Thomson AB, Kelsey TW. The radiosensitivity of the human oocyte. Hum Reprod. 2003; 18:117–21.
5 5 Wallace WH, Thomson AB, Saran F, Kelsey TW. Predicting age of ovarian failure after radiation to a field that includes the ovaries. Int J Radiat Oncol Biol Phys. 2005; 62(3):738–44.
6 6 Larsen EC, Muller J, Schmieglow K, Rechnitzer C, Andersen AN. Reduced ovarian function in long‐term survivors of radiation‐ and chemotherapy‐treated child‐ hood cancer. J Clin Endocrinol Metab. 2003; 88:5307–14.
7 7 Bath LE, Wallace WH, Critchley HO. Late effects of the treatment of childhood cancer on the female reproductive system and the potential for fertility preservation. BJOG. 2002; 109(2):107–14.
8 8 Sanders JE, Hawley J, Levy W, Gooley T, Buckner CD, Deeg HJ, et al. Pregnancies following high‐dose cyclophosphamide with or without high‐dose busulfan or total‐body irradiation and bone marrow transplantation. Blood. 1996; 87(7):3045–52.
9 9 Van de Loo LE, Van den Berg MH, Overbeek A, Van Dijk M, Damen L, Lambalk CB, et al. Uterine function, pregnancy complications, and pregnancy outcomes among female childhood cancer survivors. Fertil Steril. 2019; 11(2):372–80.
10 10 Covens AL, van der Putten HW, Fyles AW, Leung PM, O’Brien PF, Murphy KJ, et al. Laparoscopic ovarian transposition. Eur J Gynaecol Oncol. 1996; 17(3):177–82.
11 11 Azais H, Canova C‐H, Vesale E, Simon J‐M, Canlorbe G, Usan C. Laparoscopic uterine fixation to spare fertility before pelvic radiation therapy. Fertil Steril. 2018; 110(5):974–5.
12 12 Schmidt KT, Larsen EC, Andersen CY, Andersen AN. Risk of ovarian failure and fertility preserving methods in girls and adolescents with a malignant disease. BJOG. 2010; 117:163–74.
18 Female fertility after chemotherapy
Nivedita Reddy
Assisted Conception Unit, Guy’s Hospital, London, UK
Case History 1: A 35‐year‐old woman presented with inability to conceive for 1 year. She had breast cancer diagnosed at the age of 28 and was treated with surgery followed by six cycles of chemotherapy and concomitant GnRH analogue, followed by tamoxifen for 5 years. Her menstrual cycles had been irregular but were now regular. She was seen prior to commencing chemotherapy when she had oocyte retrieval and embryos cryopreserved for fertility preservation.
Case History 2: A 31‐year‐old single woman presented with a history of one‐year subfertility and irregular menstrual cycles. She had a history of Hodgkin’s Lymphoma (HL) stage 2 at the age of 20, treated with three cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine), GnRH analogue and local radiotherapy to the chest. As the desired response was not achieved, the treatment was escalated to BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone). The anti‐Müllerian hormone (AMH) level was 12.3 pmol/L at diagnosis. She was offered oocyte freezing for fertility preservation prior to chemotherapy but declined it in order to avoid delay in commencing treatment. Concomitant GnRH analogues were administered during her chemotherapy.
Background
Breast cancer is the most frequently occurring cancer in women, with an incidence in the UK of 1 in 9 women, of which 15% occur in women under the age of 40 years. The survival rate is around 85%. [1]. Hodgkin’s lymphoma (HL), which demonstrates a peak incidence in the young adult population, is now associated