Maintaining open and honest communication with your doctor is an important part of your care. In fact, research has shown that people who have a good relationship with their doctor tend to be more satisfied with the care they receive. However, starting some conversations can be difficult. So to get the ball rolling, the Cancer.Net Blog is asking doctors to share their tips and insights for discussing a number of potentially sensitive or difficult subjects that might come up during diagnosis, treatment, and follow-up care.
When you are first told you have cancer, it may be difficult to think beyond your diagnosis. However, discussing life after treatment, even before treatment begins, is very important, especially when it comes to fertility. Although not everyone wants to have children, most people would like to have the option. Unfortunately, infertility can be a temporary or permanent side effect of some cancer treatments.
To learn more about how cancer affects fertility and ways to preserve it, I talked with Kutluk Oktay, MD, Director of the Innovation Institute for Fertility Preservation and IVF and the Division of Reproductive Medicine at New York Medical College.
Q: Why is it important to talk with your doctor about fertility before treatment begins?
Dr. Oktay: Cancer drugs have DNA-damaging effects. Once treatment begins, your eggs or sperm will have already been damaged, making it impossible or more difficult to preserve them. Not only will you have fewer eggs or sperm left to preserve, but DNA-damaged eggs and sperm may not be viable or may have genetic disturbances. That is another reason why fertility preservation specialists, typically an infertility specialist with further training/expertise, prefer that you consider fertility preservation prior to starting chemotherapy.
Q: Why do some people hesitate to talk about their fertility? What can be done to address this?
Dr. Oktay: Some people may think that there is no time to consider their fertility. They may think that fertility preservation could affect their chance of a cure or that having fertility preservation treatments may be risky. Others may be unaware that there are things that can be done to preserve fertility before cancer treatment. To prevent this from happening, we need to educate both patients and cancer care specialists. Recent fertility preservation guidelines from the American Society of Clinical Oncology (ASCO) have attempted to do that and have provided valuable information and documents to educate both professionals and patients.
Q: How can people start this conversation with their health care team?
Dr. Oktay: As soon as cancer has been diagnosed and treatment is being planned, a person should ask about the impact of these treatments on his or her fertility, even if he or she is ambiguous about future fertility. Younger patients may not have immediate plans or desire to have children, but this may change in future years. Unfortunately, once egg reserve or sperm production is lost, it is not medically possible to reverse that process. Hence, fertility preservation should be planned ahead of time.
Q: What questions should people ask during this conversation?
- Will my treatment plan affect my future fertility?
- Are there methods to preserve my fertility before these treatments?
- Do I have sufficient time to do this?
- Will I be able to carry a pregnancy in the future, will it be safe for me?
- Is this an area that you are comfortable discussing? If not, can you refer me to an expert who can discuss this with me?
- Can you refer me to a fertility preservation expert?
Q: Does this conversation change if the person is single rather than in a relationship or married?
Dr. Oktay: The conversation should not be halted based on a person’s partner status. There are fertility preservation techniques both for people who are single and those who are adults with a partner. They all require immediate action without delay, as for example, the more established techniques for females, such as embryo or egg freezing, may take two weeks to complete. In men who are single or with a partner, semen freezing will not need much time to prepare but will still need to be brought up.
Q: When should a person with cancer ask to be referred to a fertility specialist?
Dr. Oktay: The ASCO fertility preservation guidelines conclude that this should happen as early as possible. Even those who are ambiguous about future fertility should be referred to a fertility preservation specialist for counseling and possible fertility preservation treatment.
Q: How effective are fertility preservation methods?
Dr. Oktay: In general, fertility preservation methods are very effective, though none guarantees future fertility, as this is influenced by individual factors. Embryo, egg, and sperm freezing are established methods and are routinely used. Success rates with egg and embryo freezing depend on the age that they were frozen. Younger patients have a higher chance of success. You can use this online calculator to get an idea of age-based success for egg freezing.
Ovarian cryopreservation and later transplantation is considered experimental, but this procedure has resulted in over 40 live births despite the fact it is only 15 years in development. Because of this, the current success rates are unknown. Ovarian suppression, which involves taking hormones that suppress ovarian function during treatment, is considered ineffective for preserving fertility. It may temporarily delay menopause, but some studies have shown conflicting results. At the present time, you should not rely on ovarian suppression as a reliable method of fertility preservation.
Q: Is fertility preservation usually covered by insurance?
Dr. Oktay: Some insurance plans may cover all or parts of fertility preservation procedures. In general, procedures involving assisted reproduction technologies bring a cost with them. You should discuss the costs with the institution and ask if insurance will cover all or some of the treatment. You can also consider financial support from certain patient organizations.
Q: Could taking steps to preserve your fertility affect how well cancer treatment works?
Dr. Oktay: In general, no, but this should be discussed with your oncologist and fertility preservation specialist. For example, women may be concerned about the hormonal effects of fertility preservation treatments. Hormonal suppression with GnRH analogs, in theory, may affect the way cancer cells respond to chemo, especially if you have an estrogen-sensitive cancer. If undergoing ovarian stimulation to freeze eggs or embryos, estrogen levels may be of concern if you have an estrogen-sensitive cancer, such as breast or endometrial cancer. However, there have been protocols developed with aromatase inhibitors that are shown to keep estrogen levels lower and result in good success rates while freezing eggs or embryos.
Another potential issue is the delay to start chemotherapy so that a fertility preservation treatment can be completed. If your medical oncologist thinks this delay could be harmful, the fertility preservation specialist could shorten the treatment by collecting eggs without full stimulation and maturing them in a laboratory, for example. In short, there are always options, but they should be discussed and agreed on jointly with your fertility preservation specialist and cancer doctor.
Q: If a person’s fertility has already been affected by cancer treatment, is there anything that can be done?
Dr. Oktay: For women, you would first need to have an ovarian reserve assessment. If there is still some egg reserve remaining, you may still be able to have children with assisted reproduction techniques, but the chances would be lower compared to doing this before chemotherapy. However, you must act as soon as possible because with age you will lose any remaining eggs and will experience early menopause.
If the ovarian reserve is totally lost and you are in menopause, then you may consider egg donation. If you cannot carry a pregnancy because of continuing treatments and/or because the uterus was removed, you may utilize a gestational carrier. There is no medical treatment that can bring back the eggs that were lost.
For men, if you produce some sperm, insemination or in vitro fertilization (IVF) with intracytoplasmic sperm injection can be sufficient. If there is no sperm in the ejaculate, sometimes sperm can be recovered directly from the testes. If that does not yield any sperm, the last option is to use donor sperm.