This document discusses fertility preservation options for cancer patients. It begins by noting that advances in cancer treatment have led to improved survival rates but also increased risks of infertility. It then discusses the field of oncofertility, which aims to provide fertility preservation options for young cancer patients. The document reviews fertility preservation guidelines and options for both female and male patients, including embryo/oocyte cryopreservation, ovarian tissue cryopreservation, and sperm cryopreservation. It stresses the importance of discussing fertility preservation with patients before starting cancer treatment.

1. FERTILITY
PRESERVATION
IN
CANCER PATIENTS

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. • Advance in diagnosis & treatment of cancers
have lead to high cure rate & longer survival.
• Nearly 1 in 12 cases detected before 40 years
age.
• Survivors have to face infertility or early
menopause.
• More females delaying motherhood to 30s &
40s.

4. ONCOFERTILITY
Brings together Oncologists and fertility specialists
and hopes to provide real options to young
population who undergo life-preserving but fertility-
threatening treatment for cancers.

5. In 2006, the American Society of Clinical Oncology
(ASCO) published a clinical practice guideline on
fertility preservation for adults and children with
cancer
ASCO Guidelines are updated at intervals by Update
Committees of their original Expert Panels

6. • People with cancer are interested in
discussing fertility preservation so the doctor
MUST address the possibility of infertility
before the treatment starts.
• Direct them to fertility specialists.

7. • Give whole range of fertility preservation
options.
• Counsel patients along with spouse wherever
applicable.
• Refer patients to psychosocial providers if
distressed.
• Document the discussion on medical records.

8. TREATMENT OPTIONS FOR
FEMALES
1. Cryopreservation of unfertilized oocyte
2. Embryo cryopreservation
3. Ovarian transposition
4. Ovarian suppression
5. Ovarian tissue cryopreservation and
transplantation
6. Conservative medical therapy
7. Conservative gynecologic surgery

9. CANCER OVARY
Conservative surgery can be offered in
following:
1. Stage 1 invasive epithelial ovarian cancer
2. Malignant germ cell tumor (any stage)
3. Sex cord stromal tumor (any stage)
4. Borderline ovarian tumor (any stage)

10. • Ovaries are chemosensitive.
• Chemo leads to loss of primordial & growing
follicles.
• Radiation causes dose related germ cell
damage.
• 16.5 Gray causes immediate ovarian damage
in females under 20 years & 14 Gray in under
30 yrs.

12. CRYOPRESERVATION OF
UNFERTILIZED OOCYTES:
• For patients who do not have a male partner
• Do not wish to use donor sperm
• Have religious or ethical objections to
embryo freezing.

13. EMBRYO CRYOPRESERVATION
• An established ART
• Involves ovarian stimulation with gonadotrophins, surgical
oocyte retrieval, in vitro fertilization of oocyte & sperm in a
lab dish followed by freezing of all resulting embryos.
• Survival rate of thawed embryos upto 90%
• Implantation rate upto 30%
• Cumulative pregnancy rate upto 60%

14. EMBRYO CRYOPRESERVATION-
DISADVANTAGES
• Need of donor sperms
• Need for IVF
• Supraphysiological level 0f E2- unacceptable
in estrogen sensitive malignancy

16. OVARIAN TISSUE CRYOPRESERVATION AND
TRANSPLANTATION
• Does not require ovarian stimulation or
sexual maturity
• May be the only method available in children
• Considered experimental
• Should be performed only in centers with the
necessary expertise, under IRB-approved
protocols that include follow-up for recurrent
cancer

17. OVARIAN SUPPRESSION
• Done with GnRH analogues
• Insufficient evidence regarding the
effectiveness of gonadotropin releasing
hormone analogues
• Can be offered in Ca Breast & Hodgkin’s
lymphoma

18. OVARIAN TRANSPOSITION
(OOPHOROPEXY)
• Offered when pelvic radiation is performed
as cancer treatment
• Because of radiation scatter, ovaries are not
always protected
• Strongly recommended in young girls
needing radiotherapy

19. OVARIAN TRANSPOSITION
(OOPHOROPEXY)
erformed through laparoscopy or laparotomy
nvolves division of utero-ovarian ligament & fixing ovary
within the paracolic gutter
an be combined with cryopreservation of contralateral
ovary

22. CANCER ENDOMETRIUM
• Uncommon under 40 years
• British National Formulary recommends MPA
upto 200 – 400 mg daily or
• Megesterol Acetate 40 – 320 mg daily

24. CANCER CERVIX: RADICAL
TRACHELECTOMY
• Restricted to stage IA2-IB1 with <2 cm diameter,
<10 mm invasion
• Removal of cervix & adjacent parametrium while
preserving uterus
• Can be performed through vaginal, laparoscopic or
laparotomy routes

25. CANCER CERVIX: RADICAL
TRACHELECTOMY
• Disadvantages:
• Cervical stenosis
• Preterm labour, premature rupture of membranes
• 2nd
trimester loss
• Boss et al reported 70% conception with 49% term
delivery
• Plante et al reported 46% conception
with ¾ term deliveries

27. PATIENT AND CLINICIAN
COMMUNICATION
• Health care providers can use the following points
for a discussion of infertility and fertility
preservation with a patient (or parents or
guardians):
• Inform Patient of Individual Risk
• Some cancer treatments can cause
infertility or early menopause

28. INDIVIDUAL RISK ASSESSMENT
ndividual factors
• Cancer type
• Age
• Treatment plan
lassify risk
• High/Medium/Low/Non-existent
ertility status before cancer may also

29. FOR ADULT FEMALES
Both embryo and oocyte cryopreservation are
established fertility preservation methods
Discuss the option of ovarian transposition
(oophoropexy) when pelvic radiation is performed
as cancer treatment

30. FOR ADULT FEMALES
• Ovarian suppression (GnRH analogs)
• Insufficient evidence regarding their effectiveness as a
fertility preservation method
• Should not be relied on to preserve fertility
• Ovarian tissue cryopreservation
• Does not require sexual maturity for the purpose of
future transplantation)
• Experimental

31. TREATMENT OPTIONS FOR MALES
1. Sperm cryopreservation after masturbation
2. Sperm cryopreservation after alternate methods
of collection
3. Testicular transposition
4. Testicular suppression
5. Testicular tissue cryopreservation
6. Testicular transposition
7. Gonadal shielding during radiation
therapy

32. FOR ADULT MALES
Present sperm cryopreservation (sperm
banking) is the only established fertility
preservation method
Hormonal therapy is not recommended
• Not successful in preserving fertility

33. FOR ADULT MALES
Testicular tissue cryopreservation
• Does not require sexual maturity for the purpose of future re-
implantation or grafting of human testicular tissue
• Experimental
Potentially higher risk of genetic damage in sperm
collected after initiation of therapy

34. CONCLUSIONS
• Fertility preservation is often possible in people
undergoing cancer treatment
• Fertility preservation must be considered before
starting cancer treatment
• Broader application is limited by several factors
- Lack of knowledge
- Lack of insurance
- Failure to discuss options
- Investigational status of various fertility
preservation methods

35. CONCLUSIONS
• Fertility preservation methods are applied infrequently.
• Many methods are still in an experimental phase
• To be performed at recognized centers only
• Patients interested are encouraged to enroll in clinical
trials that will advance medical knowledge.
Informed consent cancer patients must include
Infertility
• Fertility preserving options
• Referral to appropriate specialists

36. Questionnaire
Fertility preservation in Cancer Patients
Prepared by Oncology Committee and Reproductive
Endocrinology and Infertility Committee of Asia-Oceana
Federation of Obstetrics and Gynecology
Prof. Kazunori Ochiai
Chair, Oncology Committee of AOFOG

37. Is fertility preservation a matter of your practice?
If Yes, Please proceed following questions.
1. What are the cancers for which fertility preservation is indicated?
2. Is a cancer specialist contacted to provide information when
fertility preservation will be offered to a cancer patient?
3. Is psychological support provided when fertility preservation is to
be provided for cancer patients? If yes, what kind of intervention
(e.g., a psychotherapist, a licensed special nurse, or the
department of neuropsychiatry) do you use?

38. Is fertility preservation a matter of your practice?
If Yes, Please proceed following questions.
4. Do you provide fertility preservation for cancer patients who
already have a child (or children) if they want it? If yes,
please give us the reasons, indications, and other
information.
5. Is there any patient-doctor network for fertility preservation
(such as the Oncofertility Consortium in the United States or
FertiPROTEKT in the German-speaking sphere) in your area
or country?

39. Is fertility preservation a matter of your practice?
If Yes, Please proceed following questions.
6. Is information about future loss of fertility given to patients
before the administration of chemotherapy (with alkylating
agents, etc.) that shows ovarian toxicity? (In such cases,
does the information include verbal information from a
doctor or nurse, written materials, and counselling.)
7. Is actual treatment only provided after fertility preservation
has been performed, in the case of a patient’s strong
request?

40. CERVICAL CANCER
1. Do you perform trachelectomy as a fertility preservation procedure in
cervical cancer patients?
2. What is the most advanced stage for which trachelectomy is indicated?
3. Is there any age limit for patients undergoing trachelectomy? If yes, what
is the age limit for trachelectomy?
4. Is trachelectomy indicated for adenocarcinoma? If yes, to what is the
most advanced stage for which trachelectomy is applicable?

41. CERVICAL CANCER
5. Is trachelectomy performed after the administration of NAC? In such
cases, what is the indication of trachelectomy?
6. How long is the time interval between trachelectomy and pregnancy
being allowed?
7. Is there any case where, pregnancy/delivery has occurred after
trachelectomy? If yes, please give the relevant information briefly (e.g.,
spontaneous pregnancy or ART and the delivery method).

42. CERVICAL CANCER
8. What do you pay attention to during pregnancy in patients who have had
trachelectomy (e.g., do you perform cervical circlage, do you admit the
patient to hospital, or do you administer a tocolytic agent)? If there are
any such cases, please give the relevant information briefly.
9. Is there any case where cervical cancer has recurred after trachelectomy?
If yes, please give the relevant information briefly.
10. What is the operative procedure used for trachelectomy (e.g.,
laparotomy or a laparoscopic, robot, or vaginal method)?

43. CERVICAL CANCER
11. Is the operation performed with the intention of preserving the uterine
artery as a general rule? Or is the artery cut at the start?
12. When a patient achieves pregnancy and gives birth to a baby after
fertility preservation, will radical surgery be performed on another
occasion?
13. Is surgical shifting of the ovary carried out in patients with cervical
cancer? If there has been any such case, please give us the relevant
information (concerning indications, site of shifting, etc.) briefly.
14. Can a surrogate mother be used by a patient with cervical Ca?

44. ENDOMETRIAL CANCER
1. Has high-dose hormone therapy been given as fertility
preservation to patients with endometrial cancer?
2. If yes, please identify the drug used for high-dose hormone
therapy, daily dose and the duration of administration.
3. Please let us know about the examinations conducted during
high-dose hormone therapy and the testing intervals.

45. ENDOMETRIAL CANCER
Examination
History and physical examination
Tumour markers
Endometrial sampling
Interval of examinations
• 3 monthly
• 6 monthly
• Yearly

46. OVARIAN CANCER
1. Is fertility preservation (ie; preservation of health looking ovary) is carried out
in ovarian cancer patient? If yes, answer following questions
2. What is your indication to preserve contralateral ovary?
1) Histopathology? ( Histology, Grade)
2) Stage?
3) Age?
3. Is adjuvant chemotherapy recommended?
4. Is total abdominal hysterectomy with contralateral adnexectomy is
recommended after completion of fertility?

47. OVARIAN CANCER
5. Please let us know about the modality and the interval of examinations
conducted during follow up or chemotherapy.
a. Modality
b. Tumour markers
c. Radiological examination
d. Second look surgery
e. Interval of examinations
- 3 monthly
- 6 monthly
- yearly

48. OVARIAN CANCER
6. How long is the time interval between primary
treatment (surgery or chemotherapy) and
pregnancy being allowed?
7. Can a surrogate mother and/or egg donation be
used by a patient with ovarian cancer?