FERTILITY PRESERVATION (FP)

Fertility preservation (FP) refers to the extension of the reproductive window through preservation of gametes, embryos and gonadal tissue (oocyte, sperm, embryo, ovarian and testicular tissue). Contemporary advances in assisted reproductive technology allow for safe long-term storage of gametes, permitting their use to achieve pregnancy at a later more convenient time. Initially used in oncofertility, use of FP has now been extended to women at risk of infertility due to decreasing ovarian reserve associated with age, medical disorders or genetic conditions.

The effect of chemotherapy  and radiotherapy on fertility is seen both in women and men and depends on age, medication used and dose of chemo and radio therapy. In men it can result in  oligospermia or  azoospermia and in the women it can result in irregular menstrual cycle, premature ovarian failure or infertility.

Fertility preservation both in the men and women is an interdisciplinary team approach involving the medical , radiation and surgical oncologist, fertility specialist or reproductive medicine expert and a counsellor.

Indication for FP

1. Oncofertility - Patients in reproductive age planned for

a) Gonadotoxic Chemotherapy -  in cancer and non-cancer conditions

b) Radiotherapy  leading to gonadal damage.

2. To prevent age related decline in fertility in women, where women wants to postpone her child bearing. One can freeze the oocytes or eggs

3. Decline in fertility in autoimmune-disease

• Rheumatoid arthritis

• SLE

• Inflammatory Bowel diseases

• Steroid resistant glomerulonephritis

• Bechet’s disease,

• Pemphigus vulgaris

4. Genetic disorders and ovarian pathology leading premature ovarian insufficiency 

   • Turner mosaic

   • Beta-thalassemia

   • ·Galactosaemia. 

5.      Ovarian pathology leading to premature ovarian insufficiency 

·     Endometriosis?

·     Chronic pelvic inflammatory disease (e.g., Genital tuberculosis)

6. Patients undergoing hematopoietic stem cell transplantation 

7. Hematological diseases 

-        Sickle cell anemia

-        Thalassemia major

-        Aplastic anemia

8.    Transgender

Fertility preservation and method used depends on age, type of disease, spread of the disease, type and dose of adjuvant therapy, time available before chemotherapy/radiotherapy, whether has a partner or not. usually, pregnancy is recommended only 2 years after  stopping, Chemotherapy.

Fertility preservation options in the men include sperm and testicular tissue preservation. The fertility preservation option  in the adult male with normal sperm count is easy and several samples can be frozen in a short time. In children and adolescent only testicular tissue cryopreservation is an option.

In  the female it  is  important to determine the ovarian reserve before and after treatment,  to determine effect of cancer on the ovarian function and  to detect metastasis in the frozen ovarian cortex. The options in the female include, oocyte cryopreservation, embryo cryopreservation if partner available, ovarian tissue cryopreservation, ovarian transposition, ovarian suppression using GnRH agonist injections and specific methods of performing surgery and giving radiation therapy that can help in protecting a women’s fertility as shown in the figure below. Risk of ovarian metastasis differs with cancer types and therefore ovarian tissue cryopreservation should be done only in those cancers with low risk of ovarian involvement. 

If done in patients with moderate or severe risk of ovarian involvement , before transplantation it is important to check presence of cancer cells in the ovarian tissue by immunohistochemistry.  Ovarian tissue cryopreservation is the only option in children and pre-pubertal girls due to limited by the sexual immaturity.

Safety after fertility preservation for mother and child

• No detectable increased risk of disease recurrence with most FP methods and pregnancy, even in hormonally sensitive tumors

• Cancer treatment has mutagenic effects on the oocyte present in growing follicles and risk is related to the stage of oocyte development during exposure and the drug regime used

• Cancer therapy or FP does not increase the risk of cancer, chromosomal abnormalities, congenital abnormalities or fetal malformations in the offspring if conception after 1 year after cessation of the treatment

Therefore, all patient at risk for treatment induced infertility and those  interested in fertility preservation options should be referred to the reproductive medicine expert as soon as possible to avoid delay in start of cancer treatment.