In a nutshell
This review looked at options to preserve future fertility for young people diagnosed with blood cancer.
For teens and young adults, blood and bone marrow cancers are one of the most common types of cancer. These include Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), and acute leukemia. Fortunately, blood cancers generally have good outcomes for young people. However, there can be long-term health concerns including infertility. People who survived cancer as children, teens, or young adults are 48% more likely to develop infertility than their siblings. Fertility preservation may improve young cancer patients’ ability to have children in the future.
Methods & findings
This review outlined fertility options for young men and women (age 14 – 24) with blood cancer.
For women, chemotherapy can reduce the ovarian reserve. This means the body has less ability to produce mature eggs. However, some types of blood cancer have more impact on fertility than others.
Initial chemotherapy for leukemia and HL has a low- to medium-impact on fertility. Additionally, radiation therapy to the pelvic region has a high risk. Chemotherapy for blood cancers which have returned after previous treatment is also high risk. When possible, fertility preservation is recommended before treatments with a high risk to fertility.
The most common fertility preservation technique for women is freeze oocytes (eggs). Hormonal medication is used to stimulate the ovaries to produce multiple oocytes. Then the eggs are collected and frozen. An oocyte freezing cycle takes two to three weeks and requires delaying cancer treatment. Ovarian stimulation can be started at any time of the menstrual cycle with equal success. Storing at least 10 oocytes allows for a 60% chance of later having a baby using the frozen eggs.
For patients before puberty or who cannot delay cancer treatment, freezing ovarian tissue is an option. This technique involves laparoscopic surgery, using a small robotic arm. Part of one of the ovaries is removed and frozen. When the woman is ready to become pregnant, the ovarian tissue can be surgically put back in place. There is a 97% chance the ovary will function correctly.
Freezing ovarian tissue is an established practice for patients with lymphoma. There have no reports of lymphoma returning after ovarian tissue is returned to the body. However, there is concern that ovarian tissue could contain cancer for patients with leukemia.
Some blood cancer patients require radiation to the pelvis, but do not need high-risk chemotherapy. For these patients, it is possible to surgically move the ovaries within the abdomen. Being away from the area exposed to radiation can preserve the ovaries’ function.
For young men, chemotherapy can damage the cells in the testes which produce sperm. The best fertility preservation option is sperm banking, or cryopreserving (freezing) sperm. Sperm banking is simple, has no health risks, and does not delay cancer treatment. Sperm banking is recommended before treatment for all young men who can provide semen samples through ejaculation.
Some young men have gone through puberty but cannot provide semen samples, or there are no live sperm. There are several options in this case. Electro-ejaculation involves using an electric shock to cause ejaculation. Testicular extraction of sperm (TESE) involves surgically collecting immature sperm from the testes. Both techniques can have a risk of infection for patients with low white blood cells and platelet levels. They also require the use of anesthesia. Electro-ejaculation or TESE are recommended prior to cancer treatments with a high risk to fertility.
For young men newly diagnosed with blood cancer, the risk to fertility depends on the type of cancer and the treatment used. Initial chemotherapy for leukemia or HL is low- to medium-risk to fertility. In addition to chemotherapy, some patients have radiation therapy to areas where the cancer is concentrated. Radiation therapy to the pelvis is high risk to fertility.
For some patients, blood cancer relapses (returns) after it is initially treated. In this case, stronger chemotherapy is required. Treatment for relapsed blood cancer always carries a high risk to fertility. Sperm banking, electro-ejaculation, or TESE are recommended if the young man has not already banked sperm. However, sperm banking should not be done if he has received chemotherapy within the past six months, as the sperm could be damaged.
For boys before puberty, the only technique available is cryopreserving a sample of the testicles. This technique is also an option for young men who have already started chemotherapy, because tissue is less sensitive than sperm to chemotherapy. However, freezing testicular tissue is still experimental. Most of the boys who used it have not yet attempted to father children.
The bottom line
This review highlighted current options to preserve future fertility for young people diagnosed with blood cancers.
The fine print
This review gives general guidelines. Speak to your oncologist or fertility specialist for information about your treatment.
Published By :
The Lancet. Haematology
Feb 01, 2021