Patients diagnosed with cancer are typically planned to undergo surgery, chemotherapy or radiation depending on the location and the type of the cancer. In some cases, a combination of these treatment options may be applicable during a time period and in most cases urgent treatment is necessary. Therefore, an immediate consultation with a fertility specialist is important in determining the type of fertility preservation method for each individual case. The most common options include sperm, egg and embryo freezing. In couples, embryo freezing has been the most utilized option and in single or married men sperm freezing has been available for many years.
Most recently, egg freezing has become an option for women due to improved freezing techniques and the option of testing each egg for chromosomal abnormalities at the time of the freezing process. The procedure has to be expedited in cancer patients or those that require radiation or chemotherapy for non-cancerous diseases.
Typically, a baseline ultrasound and blood work is done immediately to determine the dose of the FSH medication and the type of protocol that will be used in ovarian stimulation. In most cases, ovarian stimulation requires 8-10 days of FSH stimulation to mature eggs followed by egg retrieval. During this time either Lupron is used to prevent spontaneous egg development and premature ovulation or other alternatives such as Ganirelix or Cetrorelix.
The duration of the treatment is generally two weeks after starting the injections, but is also dependent on the last menstrual period. If the patient is in the first few days of her period, treatment can be started immediately and completed within two weeks. If the period is expected within the next 1-3 weeks, then the treatment will be completed within the two weeks after the initiation of the menstrual cycle. In women with irregular cycles, blood work and an ultrasound can be done to determine the timing of their cycle and depending on the evaluation, treatment can be started immediately or within 1-2 weeks.
Lupron can be started one week after ovulation or overlapped with birth control pills to prevent its flare effects. In cancer patients, birth control pills are generally not utilized in order to expedite treatment and therefore Lupron is started in the luteal phase. Lupron flare effects can result in an initial increase in the FSH and LH activity which may result in ovarian cysts potentially delay treatment, but starting in the luteal phase or with birth control pills prevents such problems. Alternatively and more commonly Ganirelix or Cetrorelix type of medications are used once the period starts for immediate response, without the flare effect and more recently in egg freezing protocols.
In women with “estrogen dependent” or estrogen receptor positive tumors such as some breast cancers in the reproductive years, specific protocols are tailored to maintain low estrogen levels during ovarian stimulation. These include low dose FSH stimulation along with Tamoxifen and Ganirelix or Cetrorelix in addition to an aromatase inhibitor drug called Femara. Femara is an aromatase inhibitor that keeps the estrogen levels low during treatment. Treatment lasts for two weeks and all drugs are initiated around the same time and terminated at the time of egg retrieval, except Femara which is continued until estrogen levels drop to very low levels.
Egg retrieval involves a procedure where under direct ultrasound guidance, a needle is passed along the side of a vaginal ultrasound probe through the top of the vagina into follicles (small fluid filled spaces that contain the eggs) within the ovary(s). The follicular fluid and the egg are aspirated and collected in a test tube, which is promptly delivered to the embryologist for analysis and processing. The procedure itself is painless because it is done under anesthesia, however patients commonly experience some residual postoperative abdominal discomfort and/or cramping that rarely persists for more than a few hours. Anesthesia used for the egg retrieval procedure is administered through the IV and result in loss of consciousness preventing patients from feeling the pain and discomfort during the procedure. This type of anesthesia does not require intubation (placement of tube in the mouth/throat) but rather a deep sleep. Postoperatively, all patients are given detailed instructions and are discharged within an hour with a prescription for analgesics (pain killers) and other medications as indicated.
Once the eggs are retrieved, they are frozen (vitrified – ultrarapid freezing) the same day for long term storage. Eggs can be tested for chromosomal abnormalities using the CGH test that is done on the polar body adjacent to the egg. Polar bodies can be removed just prior to freezing the egg and tested for chromosomal abnormalities. If the polar body is chromosomally normal, the egg is also considered to be normal because they are the mirror images of each other chromosomally.
Patients can then start cancer treatment as scheduled with their hematologist – oncologist. In some cases, patients may prefer to freeze additional eggs in between treatment cycles or during remission, although the chances may be lower because of losing their egg reserve due cancer treatment. These options need to be discussed with patients prior to initiating treatment.