When it comes to treating cancer, we rush into it as early as possible, and rightly so, you want to get rid of it, but it’s easy to miss something crucial and that’s where we need to talk about fertility. You want to make sure you’re clear about your options, even if you’re not thinking about having kids right now! To help you navigate the world of fertility and cancer, you’re going hear from Mahmoud, here is the expert in the field of oncofertility and is a representative of the Oncofertility Consortium. Here is what we cover in this conversation:
- How awareness about cancer treatment can drive our choices
- Saving your fertility before treatment
- Breakthroughs in fertility preservation
- Fertility tourism: new global phenomenon
- and much, much more!
Joe: Mahmoud, there are so many treatments for cancer that they all affect people in a different way. When it comes to understanding the impact on fertility, it’s really important to be prepared, right?
Mahmoud: Yes, that’s right. I recommend that each patient who will receive chemotherapy and radiotherapy should know adequate information about the effect of the anti-cancer treatment on his/her fertility. The main issue in this topic is that the anti-cancer treatments have some side effects. Sometimes these side effects are very strong and dangerous regarding the fertility. That’s why some famous scientific organisations will classify the anti-cancer treatments regarding the risk on fertility into different categories.
To speak to patients, I always say that a cancer patient should at least have the awareness about the type of anti-cancer treatment she/he will get. I can just say, for example, as a start, the high-risk anti-cancer treatments should be known very well to the patients. This category contains total body irradiation, so the patient will receive radiation all over his/her body. Cranial irradiation, so radiation to the head. Or ionizing radiation to the pelvis that contains, in females, of course, the ovaries, or for the males, the testes. Or another type of chemotherapy, it’s called alkalating chemotherapy. These chemotherapies are very strong. They cause damage to the gonads. The gonads means ovaries in females or testes in male. This alkalating agents like cyclophosphamide or busulfan are also used in many cancers.
Or if the patient were to receive surgery including the removal or ovary in females or testes in males. These conditions are really important that the patient be aware of and he/she should know that in these conditions, there is a high risk of losing fertility, up to 80 percent. That’s why another measure should be provided to preserve fertility. From the other point of view, okay, this is the highly toxic, or highly gonadotoxic group of anti-cancer treatments, but when they are used, in females, the most common cancer that require aggressive anti-cancer treatment in females are breast or cervical cancers, or leukaemia, lymphoma, and central nervous system.
Any female patient that will suffer from breast cancer, cervical cancer, leukaemia, lymphoma, central nervous system, most probably will receive these aggressive anti-cancer treatments, and will be at risk for losing fertility. For males, the most common cancers are: testicular cancer, germ cell tumour, leukaemia, lymphoma, and central nervous system. Any male patient that will be diagnosed with these types of cancer, most probably will receive aggressive chemotherapy and radiotherapy.
Then should receive also fertility preservation measures. This is just a summary or short account on the effect of anti-cancer treatments on fertility regarding female and male patients.
Joe: Yes, that’s fantastic, Mahmoud. Thank you for sharing that. In terms of preserving fertility, what are the main options for women?
Mahmoud: Regarding this, we classify the options that we can give to women into three major categories. Established options that are recognised by most of the scientific organizations world-wide and non-established options or debatable options and experimental options. The established options are embryo freezing and egg freezing or oocyte freezing. The debatable options include using of GnRH analog or surgical transposition of ovaries away from the field of irradiation, using of shields to protect the ovaries during radiotherapy.
Or fractionation, so we fractionate the doses of chemotherapy and radiotherapy in order to make this less gonadal toxic. The experimental options include ovarian tissue freezing and later transplantation. In vitro maturation of eggs and freezing by vitrification. Very new option called artificial ovary. It’s something very experimental but we think it will have a major impact in the future when research results improve. This is just a summary for the options that we can offer to ladies and young girls, also. This is also very important.
The preservations options are provided to adult or young adult women. Also, to girls, the young girls before puberty. Any young girl diagnosed recently with cancer at the age of younger than 12 or something can also use some of these fertile preservation options. This is very important because the young girls with cancer, maybe they are not offered these options, as many doctors are not aware of the availability of some preservation options to the young girls. Fertility preservation options can be provided to young adult women and to young girls before puberty. This is also very important.
Joe: Yes, that’s crucial that you’re sharing that, Mahmoud. In terms of the time window before commencing irradiation treatment or chemotherapy, so how much time do you need for these kinds of options to put that into play?
Mahmoud: This is a very good question because time is one of the most important factors for success in fertility preservation strategies. As long as we have time before initiation of anti-cancer therapy, we can provide more options. That means early diagnosis of cancer is a very important factor, or very important success factor. That the patient diagnosed very early and then referred from the oncologist to the gynecologist or to the reproductive biologist centre team, or oncofertility team very early.
Then the oncofertility team can assess the situation and discuss with the oncologist and also discuss with the patient the number of fertility preservation options that can be offered, and then fix the fertility preservation strategy. In emergency cases, so, for example, if the patient is diagnosed just today and she has to start chemotherapy tomorrow, for example, in this case, we have a small number of options because we don’t have time. Time is very important and according to the time we have, we can provide some fertility preservation options before initiation of anti-cancer therapy.
We can also provide some options during the period of anti-cancer therapy and we can later, after, of course, giving the anti-cancer therapy, we can do also some measures to restore fertility. It is basically two-step strategy. Step one is to preserve fertility and we can do that before initiation of anti-cancer therapy, or during the period of anti-cancer therapy. Step two is to restore fertility. We preserve first and then after preserve, we restore. This is how we think about time and about the options that we can provide then to the patient.
Joe: Yes, Mahmoud, that’s fantastic to know that there are definitely options. What about men, what about men and younger boys? What are the options for them when it comes to preserving fertility?
Mahmoud: That’s also a good question that you mentioned boys, or young boys, because it is the same. We can provide options to young boys and also to young adult men. The same concept, we have three categories, established options, like sperm freezing or debatable options like GnRH analogs, shielding also to the area of the scrotum, or fractionation of chemotherapy and radiotherapy, and experimental options like freezing of the testicular tissue or using stem cells and some other new techniques.
I want to emphasize that the adult patients either women or men have big numbers of options. While the younger patients, due to the biology and because they are before puberty, either boys or girls, have small number of options. That’s why the younger patients, or young cancer patients, for us, are difficult cases a little bit, because we don’t have enough options for them. In practice, we observe some sort of lack of awareness among doctors and among patients, or their legal guardians about their available fertility preservation options that can be provided in these cases.
Maybe I take this chance, dialogue with you, to say that young cancer patients, either girls or boys, can benefit from fertility preservation options and should be informed or well-informed about this by their oncologist and should be referred as early as possible to the oncofertility team in order to design the suitable fertility preservation strategy for them.
Joe: You make such a crucial point, Mahmoud. I know that, for example, my oncologist was great in telling me about my options and suggested sperm freezing before treatment. Not everyone is so lucky. I guess if you are going through this process, what are some of the questions you should be asking for and what should you do if you’re not getting the answers you’re looking for when it comes to fertility preservation and perhaps talking to your specialist?
Mahmoud: This is a very good question because this is how we deal in reality. I can say that for each cancer patient, that once diagnosed with cancer, he has to ask his oncologist, or her oncologist, the following question: What is the risk of gonadal toxicity of the anti-cancer therapies that I will receive? What is the probability of losing my fertility after receiving this anti-cancer therapy? This is very important because if the risk of losing fertility as a result of the anti-cancer therapy is greater than 50 percent, then a fertility preservation strategy should be provided as soon as possible, before initiation of anti-cancer therapy.
The first question, what is the risk of losing my fertility with this anti-cancer therapy? The second question, if the risk is greater than 50 percent, what are the possible fertility preservation options that I can receive, and where I can receive them? It’s very important, sometimes patients don’t know where they can receive these services. Also, these services are not present in each hospital. These services, fertility preservation services are relatively new medical treatments and complex. You can find them only in University hospitals, for example, or specialised hospitals.
The oncologist has to inform the patient where he can, or she can get this fertility preservation treatments. Also, it’s better to tell the patients how much these fertility preservation options or treatments cost? In many situations, or many countries, the coverage of the insurance is not universal and some fertility treatments, even, and fertility preservation treatments are not covered by insurance. Then they are very expensive services. Many patients cannot afford this. It is a complex process but very crucial, very crucial and very important to make information available to the patient and to give them a guide to where they can go and how much and if they need financial help, where also they can ask and get financial help.
Of course, the awareness of the community is very important. There are many universities and centres worldwide that are exerting good efforts to spread awareness about fertility preservation options and care for cancer patients. In case the patient didn’t get enough information or no information from his oncologist, he has to search at least on the internet about the major places or sites that provide enough information for this. Of course, in the United States, there is Oncofertility Consortium at the North-western University, and they have a very good online service.
One of these services is the website: Savemyfertility.org. Through this website, there are enough information about all steps in fertility preservation for cancer patients and good answers to most of the questions that can be asked in such situations.
Joe: That’s fantastic, Mahmoud. You also mentioned that there are some experimental treatments, such as freezing testicular tissue, are these experimental methods, are they workable in practice right now?
Mahmoud: Yes. In cancer patients, the experimental options are new options, many scientific groups are trying very hard since a long time to provide options that can help preserve fertility in wider groups of patients. For example, we have established options, but these established options are not suitable for all patients. That’s why we have to develop new methods to cover more or to benefit more patient groups. This is the concept. Regarding the experimental options in case of female cancer patients, here comes ovarian tissue freezing or transplantations.
This technique actually is in practice for more than 15 years. It is successful and until now, the number of babies born and reported worldwide following this technique is more than 120. That means that a female cancer patient before initiation of anti-cancer therapy, she can receive small surgery to remove one ovary or part of her ovary. Then we freeze this ovarian tissue for years until the patient starts chemotherapy and finishes the chemotherapy and radiotherapy and become fit again and willing to become pregnant. At that time, if she suffered from problems to get pregnant in a natural way, then she can use her stored or frozen ovarian tissue.
We thaw out or defreeze her ovarian tissue and transplant this tissue back to the same patient again. Then with some medications, we stimulate the ovulation again and help the patient to get pregnant. This process was successful and produced more than 120 babies, reported worldwide. For ovarian tissue freezing and/or transplantation, it is in practice and success rate is about 25 percent. This is, as an experimental option, very acceptable and good success rate. With improvement of the technique of freezing, transplantation, the success rate of tissue freezing and re-transplantation will increase dramatically in the near future.
Regarding the male patients, the testicular tissue freezing is relatively something new than the ovarian tissue freezing. It is not widely used in practice for one reason, because the established option of sperm-freezing is very successful and very easy option. It is satisfactory for many doctors to depend on sperm freezing. The problem comes in the young boys. Young boys before puberty don’t produce sperm. In this case, we have only one option left, just to take part of the testes or testicular tissue and freeze it and then think how we can then use this tissue to produce sperm in the lab. Many scientific works have been done in this area and they have promising results.
Until now, there are no babies born from testicular tissue freezing and transplantation, for example. For women, ovarian tissue is in practice since more than 15 years and produced babies. This is the difference between them. In general, the future comes from these experimental options. The options that are experimental now will be established within the next five to ten years or so. We are progressing in this direction.
Joe: That’s fantastic, Mahmoud, to know that we are moving forward as a society in this area because there are many challenges around fertility. They are not only medical but, of course, there are financial, legal, and even religious reasons that can get in the way. Sometimes people can look outside of their country to get what they want, to get this sorted. What do people need to know about that?
Mahmoud: This is a very important question and situation and phenomenon. Now, fertility treatments are more internationalised. Many patients travel abroad to seek fertility treatment. Actually, this is a global phenomenon, and it has a definition in science. The big organisations in reproductive medicine in the United States, the American Society for Reproductive Medicine and also, in Europe, the European Society for human reproduction and embryology detected these phenomena, that many patients travel from their home country to another country to receive fertility treatments for different reasons.
This phenomenon now has a scientific term, it’s called cross-border reproduction care or fertility tourism in some cases. Cross-border care or CBRC is a global phenomenon growing and it is a reality. The reasons for these phenomena is that some fertility treatments are not available in some countries, or some fertility treatments are expensive in some countries, or some fertility treatments are not allowed by law in some countries due to a religious or cultural reason, as you said. That’s why some patients don’t find these treatments or don’t find access to these treatments in their home countries, that’s why they travel to another country to receive these treatments.
For example, third-party reproduction in general and surrogacy, so sperm donation, egg donation, embryo donation and surrogacy are not legally allowed in many countries. Patients who seek such type of treatment don’t have other options, rather than travelling to another country that allows such type of treatment. For cancer patients, as we speak about cancer patients, this issue is very important because sometimes cancer patients don’t receive fertility preservation treatment or services before cancer treatment, for many reasons, maybe time, lack of time, or lack of awareness or whatever.
If they receive the cancer treatments and they suffered later from infertility or fertility loss, the only option for them at that time is to seek family building options, or third-party reproduction or adoption. Some cannot have children after losing their fertility. In such cases, the only option available for them now is to go for third-party reproduction or adoption. I can see many countries don’t allow such type of options and then the only way for patients in this case is to go to another country that’s allowing such types of treatment.
At any case, these patients also should receive good information about where they can go. If they will travel abroad, their doctors or their treating doctors should tell them where they go, and which type of treatments should be the best options for them. This is very important because countries are not universal in their legal systems, or pricing, regarding the medical service.
To avoid any kind of exploitation, or harm to the patients, good information should be provided by the treating doctor and also selection of destination, of a good destination that can provide good health services according to the international guidelines. In this case, I guess it’s very beneficial, this cross-border reproductive care phenomenon can be very beneficial to many patients, as long as there are some control and guidance. Some guidance and control regarding such type of treatments.
Joe: Yes, fantastic, Mahmoud. I thank you so much, that was enlightening.
Mahmoud: Thank you.