Fertility after Cancer Treatment: New Hope from New Research

Cancer is often thought of as a disease of the elderly, but it affects people of all ages, including infants, children, and young adults. With new therapies providing remission or cure for more and more patients, more and more cancer survivors are living with the side effects of treatment. One concern unique to younger cancer patients is the effect that treatment may have on their ability to have a family later in life. All of the standard therapies for cancer - surgery, radiation therapy, and chemotherapy - can negatively affect fertility under certain circumstances.

Most obvious is the effect of surgery on fertility. Removal of reproductive organs, such as the testicles, ovaries, or uterus, makes parenthood through normal means difficult to impossible. Even if the reproductive organs are not the primary target, radiation therapy to the pelvis or abdomen can permanently damage parts of the reproductive system. Chemotherapy drugs target rapidly dividing cells in the body, which include sperm cells and the protective layer of cells around a woman's eggs. The extent of the damage to the reproductive system depends on the type of drugs used, the dose received, and the patient's age at the time of treatment.

Recently, there has been a push from many fronts for greater awareness of the issues facing cancer survivors, including loss of fertility. Fertility preservation has become an active area of research, and new solutions are joining more mainstream techniques to provide new hope to patients.

For women, several surgical procedures for gynecologic cancer provide the option of preserved fertility. For example, some women with early-stage ovarian cancer can have surgery that only removes one ovary instead of both ovaries and the uterus. A new technique called abdominal radical trachelectomy can preserve the uterus for some women with cervical cancer.

But concerns remain about the rates of recurrence after fertility-sparing surgery for gynecologic cancer, and these techniques cannot prevent damage caused by radiation therapy and chemotherapy. For these reasons, work on the preservation and reintroduction of a woman's viable ovarian tissue has generated excitement in the cancer community. In 2004, the first healthy baby conceived using this technology was born. Autotransplantation is currently considered experimental, but may play a larger role in preserving women's fertility in the future.

Sperm banking has been a mainstay for men undergoing cancer therapy that might damage their ability to father children. But this technique is not useful for men with very low sperm count or sperm motility. Testicular sperm extraction is a new technique that removes sperm cells directly from testicular tissue. Some experimental assisted reproductive technologies such as intracytoplasmic sperm injection - the in vitro injection of a single sperm into an egg - can use surgically extracted sperm.

Along with technological innovation in the field comes a greater awareness that these issues need to be thoroughly discussed with young patients before treatment.

"We have to improve the technology, to figure out how to protect gonadal function during treatment, but we also have to heighten people's awareness, particularly in the medical community," says Dr. Ted Trimble of NCI's Gynecologic Cancer Therapeutics Program.

"Reproductive issues need to be considered and discussed with patients or, in the case of minors, with their parents," he continues. "In addition, after treatment, the issues of reproduction and sexuality need to be part of the standard things that you talk to people about."

In light of this new awareness, the Health Services Committee of the American Society of Clinical Oncology (ASCO) is developing practice guidelines on fertility preservation in cancer patients, which they hope to complete in the next few months.

"It came to the committee's attention that there was growing activity around fertility preservation in patients with cancer," explains Dr. Stephanie Lee of the Fred Hutchinson Cancer Research Center and a member of the ASCO committee, "and that this would be a good opportunity for ASCO to look at the available data and to produce some guidance for practicing oncologists."

The new guidelines will be available to physicians as well as members of the public who are interested in this quality-of-life issue.