Oncofertility Preservation Clinic:

Cancer treatment planning is especially important because a patient’s survival and future health can hinge on making the correct treatments, but these treatments may unfortunately cause damage to the reproductive system, organs and glands that control fertility. Actually, Cancer treatment like chemotherapy (especially alkylating agents) can affect the ovaries, causing them to stop releasing eggs and estrogen called primary ovarian insufficiency (POI). Sometimes POI is temporary and your menstrual periods and fertility return after treatment. Oncologists must be aware of situations where their treatment will affect fertility in patients who are being treated for cancer and they must also be aware of the pathways available for procedures such as cryopreservation of gonad tissue. It is now imperative for fertility preservation to be considered as part of the care offered to patients with cancer.

There are still obvious challenges remain to be resolved, especially in the area of fertility preservation in prepubertal patients. These include ethical issues, such as valid consent and research in the area of tissue retrieval, cryopreservation, and transplantation.

Fertility Preservation for Female Cancer Patients (options for Fertility Conservation):

  1. Ovarian Suppression with GnRH analogues:

GnRH analogues is utilized during chemotherapy to suppress ovarian cycling and induce a temporary medical menopause. The action of GnRH analogues is not clearly understood as primordial and primary follicles do not have GnRH receptors and it is possible that GnRH analogues preserve those follicles that have already initiated growth

Ovarian Transposition (Oophoropexy)

The aim is to surgically remove the ovaries from the direct field of radiation. It is found useful during the treatment of gynaecological cases and haematogical cancers such as Hodgkin’s lymphomas. Most ovarian transpositions are carried out laparoscopically and there have been suggestions that lateral transposition may be more protective than median transposition of the ovaries.

  1. Embryo, Oocyte, and Ovarian Tissue Cryopreservation

The choice of what tissue type should be preserved depends on the type of cancer, the patient’s age, and whether she has a partner. Often it is time that is the limiting factor in this choice.

  1. Embryo Cryopreservation

Embryo storage is ideal for an adult woman in a stable relationship as it is an established technique which has been available since the mid-1980s. IVF offers a success rate of approximately 30% per cycle (dependent on age) and this is similar to the natural conception rate achievable by healthy couples without assisted reproductive techniques. It involves stimulating the ovaries using gonadotrophins which results in high estrogen levels, and certainly this raises concerns for some tumors such as breast cancers with estrogen receptor positivity. It is still unclear what the risks of such techniques in terms of tumor progression or relapse in a hormone dependent cancer are. Some groups have attempted to address this by using tamoxifen or letrozole alone or in combination with standard IVF stimulation for women with breast cancer or endometrial cancer. IVF stimulation takes a minimum of two weeks. After stimulation of follicles to maturation, an egg collection procedure is undertaken usually under a heavy sedation anesthetic. The eggs are collected transvaginally using an ultrasound probe to guide a fine needle into the ovary.

IVF is then undertaken to fertilize the patient’s eggs with the partner’s sperm before freezing the embryo. At present there is limited availability donor sperm for adult women trying to preserve reproductive potential whilst undertaking chemotherapy.

  1. Oocyte Cryopreservation

This technique is suitable for adults and for older teenagers who do not have a current partner. Stored eggs can later be thawed and IVF techniques with ICSI can be used. Oocytes are much more sensitive to damage from cryopreservation techniques than embryos (probably secondary to spindle damage from ice crystal formation). The formation of ice crystal and the attendant cellular damage during freezing can potentially be avoided by vitrification. For younger patients, oocyte storage may be an option, as harvest techniques can include transabdominal ultrasound and laparoscopy for retrieval of eggs rather than subjecting the patient to the transvaginal technique.

  1. Ovarian Tissue Cryopreservation

This is a technique that can be used for adults and for children. This method is the best option for preserving fertility in prepuberty and single girls. Optimal treatment benefit can only be expected in the presence of a healthy ovarian reserve, as such it less likely to be beneficial to the older patient above 40 years. Laparoscopy is required to undertake a biopsy of two thirds of ovarian tissue for preservation.

At first, the tissue is cut into thin sections and then cryopreserved in a relatively straightforward fashion. Following ovarian transplantation, normal ovarian function was restored leading to conception and delivery of a live infant at 38 weeks. The risk of re-implanting tissue with occult cancer remains significant. Only patients with cancer cases associated with low risk of ovarian metastasis such as squamous cell carcinoma of the cervix, Wilms’ tumor, Hodgkin and non-Hodgkin’s lymphoma should be considered for future auto transplantation. Patients with moderate and in particular high risk of ovarian involvement should not be considered for future auto transplantation. In 2010, Royan Institute established the Human Ovarian Tissue Bank as a subgroup of the Embryology Department with the intent to provide fertility preservation services to cancer patients eligible for preservation of reproductive ability. This bank passed an audit and received a certificate of international quality standard ISO 9001:2015 in 2016. This bank has about 180 patients between the ages of 7- 35 years.

Fertility Preservation in the Male Cancer Patient

Practical Laboratory Issues for Sperm Banking:

A critical factor for male patients requiring sperm banking is the timing of the sample as it is essential that this occurs before chemo- or radiotherapy. Prescreening is required and the patients are checked for Hepatitis B and C, Syphilis, HIV and CMV.

Frequently Asked Questions:

  • Who have the indications for freezing and preserving ovarian tissue?

Ovarian tissue cryopreservation (OTC) is the latest option recommended for fertility preservation in pre-pubertal and adult patients with premature ovarian insufficiency (POI) or in whom taking IVF hormones may have adverse effects on their cancer.

  • Can we use follicle and ovarian tissue freezing for all cancer patients?

Tissue pieces and ovarian follicles will be stored if they don’t have any cancer cells.

  • How long can follicles and pieces of ovarian tissue be stored for?

According to World Bank standards, we can store samples in our bank for up to 20 years.

  • Is it possible to freeze and preserve ovarian tissue at any time?

No, it is not, patients’ samples should be stored before starting the courses of radiotherapy and chemotherapy.

  • Do patients have to stop the caner-cured drugs when they set an appointment for the ovarian bank?

To get your answer, please contact your doctor.