Breaking Down Fertility Preservation for Patients With Cancer

For many patients with cancer, it is never too soon to begin discussing fertility preservation options as they begin their cancer journeys, as an expert explained in an interview with CURE.

CURE spoke with Dr. Emeline Aviki, a gynecologic oncologist and physician lead of the onco-fertility program at NYU Langone’s Perlmutter Cancer Center, about novel fertility preservation techniques, current shortcomings and misconceptions related to this issue and more.

CURE: How have fertility preservation options for patients expanded or evolved in recent years?

Aviki: They've expanded in a number of ways. First is, why have they expanded? And what's the need for them expanding? Women and men are being diagnosed with cancers at younger and younger ages, and so the opportunity to preserve fertility outside of GYN cancers has increased tremendously, so that that has thrown into sharp relief how important it is for us to have novel procedures that we didn't have in the past to try to preserve their fertility.

Now, the specific procedures that have been developed in recent years are ovarian tissue preservation — so when a woman is diagnosed with a cancer, if she has at least two weeks before she needs to start treatment, and she's already gone through puberty, she will have her eggs frozen. Her eggs are retrieved, the cycle takes about two weeks, the eggs come out, and then she can start treatment. If a woman is pre-pubertal, meaning hasn't gone through puberty yet, or she doesn't have the the luxury of two weeks to have the eggs retrieved, then our only option is to actually go in and take an ovary so that we can then use that tissue to reimplant it after she's been cured of her cancer, so the new, reimplanted tissue can then create eggs, reverse her menopausal status, and allow her to have the reproductive future that she always wanted. So, ovarian tissue cryopreservation is one of the novel procedures, a second is uterine transposition.

For young for women with colorectal and pelvic sarcomas that are not GYN related, not ones I would usually treat, we have the option now of taking the uterus and the cervix, detaching it from the pelvis, and reimplanting it in the upper abdomen, so that the woman can receive radiation to her pelvis without destroying the uterus ability to carry a child down the road. Once she's cured of her cancer, and radiation is done, we then reimplant the uterus back into its normal location, along with the ovaries, and she can then go on to having pregnancies. She would require a c-section, but otherwise, everything's the same.

The last more novel procedure is pre-pubertal testicular tissue cryopreservation. So, this is a similar concept to the ovarian tissue cryopreservation, but in young boys. For these boys, it's still under clinical trial, which means it's not yet established as a standard of care. It's still being investigated in terms of its efficacy, unlike ovarian tissue, which has already been studied and proven. But a young kid, even a six month old, can then have their testicular tissue removed before they start treatment for, for example, a leukemia which would completely ablate or ruin their testicles’ ability to produce sperm in the future. They have that tissue preserved, and then later on, the tissue could be reimplanted and produce sperm in the same way. So those are the more novel fertility preservation techniques.

When is the right time for patients to start having these conversations about fertility preservation with their care team?

The second you have the diagnosis and know what your treatment is, it's important to discuss fertility. If someone is of reproductive age, that conversation has a number of components. One is, what is the patient's desire? Do they want to have children in the future? Do they know if they want to have children? If they don't know but they're inclined to maybe yes, then they should pursue any options that are available. If they do know that they want to, then, of course, they should pursue any options that are available. What's important is that before they start treatment, they undergo whatever fertility preservation technique they're going to have because that would increase its likelihood of actually being successful.

And in some cases, like I said, you have days before you have to start treatment. So if you don't start the conversation and bring up the topic at the very initial diagnosis, then you could miss your window, or you could delay treatment that could compromise your cancer outcomes down the road.

Can you tell me a bit about some of the non-GYN cancers where these procedures are potentially necessary?

So any cancer, if we think about the ovaries being ablated, or the ovaries no longer being able to produce eggs that will then make a child, there are specific types of chemotherapy that you can be exposed to or radiation that you can be exposed to that eliminate your ovaries’ ability to function normally in the future. These are very common in breast cancer, for example, in leukemias, lymphomas, in colon or rectal cancers, in pancreatic cancers, there are several, and the list goes on, even sarcomas, brain tumors, in many cases, the list is very long. It's all about knowing what the treatment is going to be, and having someone who is an onco-fertility specialist who can tell you this chemotherapy is likely to eliminate your ability to make eggs in the future. So, we need to get the eggs out, or if we don't have time, we need to get the ovarian tissue out.

What are some shortcomings in the field of oncology in terms of our approach to fertility preservation?

So, it is highly variable whether or not a fertility preserving conversation is had with a patient, and that should not be the case. So, if you are diagnosed with a breast cancer where you're going to need chemotherapy at one location versus another, if you don't have the onco-fertility services set up at one versus the other, then the conversation may never occur, and someone may never be aware that options exist. That, I think, is our biggest shortcoming right now, having the conversation for the low-hanging fruit cases like getting the eggs out. That's one thing.

The other is, these more novel treatments do not exist everywhere. They only exist at specialized centers. We are so proud at NYU Langone Perlmutter Cancer Center to offer all of them to our patients. For centers to offer all of these techniques is incredibly rare, and when you're choosing a cancer center, that's not something that's on your radar, even if you are a young person. And so, I would say our biggest shortcoming now, where we fail patients, is not consistently across the country offering fertility-preservation services when the patients would be candidates for them.

What are some persistent misconceptions for patients regarding fertility preservation?

I think their misconception is that they're not candidates when they just don't know about the techniques, and their doctors don't know about the techniques, or don't know where to send them. Navigation is a concept for onco-fertility that is so important. You have to realize when someone's diagnosed with cancer and they're a young, fertility preserving age, they have to sometimes navigate getting their diagnostic tests done, getting their imaging studies done, seeing their medical oncologist, seeing a radiation oncologist, seeing a surgical oncologist, and then tack on to that fertility, but they then have to go to a reproductive endocrinologist, have monitoring every single day, other injections or treatments, or go under another surgery. It is a tremendous amount for a young person to navigate on their own, or for a parent to navigate for their child. And so having onco-fertility navigation is so valuable in allowing patients to actually complete their fertility preservation journey, so that they can then have the family that they dream of in the future after they're cured.

Transcript has been edited for clarity and conciseness.

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