The F-Word Everybody Should Be Talking About

Adolescents and young adults undergoing certain chemotherapy regimens, radiation, and various surgeries may struggle with fertility and pregnancy issues following their cancer treatments.

The American Society of Clinical Oncology has developed specific risk guidelines and indicates that the greatest risk of treatment-related infertility involves the use of alkylating agents (in particular, cyclophosphamide, ifosfamide, chlorambucil, melphalan, busulfan, and procarbazine); hematopoietic stem cell transplantation (with total body irradiation); and surgical removal of necessary organs (oophorectomy, hysterectomy, orchiectomy). All of these treatment modalities yield a greater than 80 percent chance of treatment-related infertility.

Is infertility a necessary price to pay for cancer survival?
Hardly! Historically, men with cancer have had more effective options in terms of safeguarding their future fertility. In post-pubescent adolescent and young adult males, sperm cryopreservation prior to cancer therapy has become an established and efficacious modality of fertility preservation. As the most established technique for preservation, it is also the most economical choice, with the procedure costing approximately $1,500 for storage up to three years.

For young women, fertility preservation has proven to be a more difficult feat with larger economic and feasibility barriers. Women have had far less successful fertility preservation options prior to initiation of cancer treatment. Embryo cryopreservation is considered an established method of fertility preservation but requires a partner or sperm donor, a delay in cancer treatment by about 4 to 6 weeks due to time required for ovarian stimulation (with daily injections of follicle-stimulating hormone), and out-of-pocket costs ranging from $8,000 to $10,000.

Live birth rates following embryo cryopreservation are lower than that of fresh embryos, and for women with hormone-sensitive tumors, there is an additional risk of exacerbation of the malignancy due to the high levels of estrogen exposure to induce oocyte collection.

For those women not in a partnered relationship and who are averse to a random donor, cryopreservation of unfertilized oocytes is another option, but research indicates that these unfertilized eggs are more prone to damage during the freezing procedure, and the overall pregnancy rates are extremely low. To date, there have been approximately 120 deliveries with this approach with the same financial, timing, and hormonal barriers as embryo cryopreservation.

Currently, most insurance companies do not offer assisted reproductive techniques as benefits financially covered for cancer patients at risk for treatment-induced infertility. Often these very high out-of-pocket costs are solely paid by the patients and their families. If the patient is under- or un-insured, many of these adjuvant preservation modalities are unattainable by patients who are also balancing the finances associated with their primary cancer treatment.

There have also been structural and organizational access barriers identified that can hinder the patient from receiving this specialized care. Often many ancillary fertility services are associated with larger academic medical centers, and geographic location can be a barrier to receiving services if the patient lives too far away from a specialized center, especially given the time-sensitive nature of completing this procedure.

What can nurses do about it?
Available evidence suggests that fertility preservation and counseling is of great importance to adolescents and young adults diagnosed with cancer. Even so, recent surveys of cancer survivors suggest that this information and counseling is not always presented.

As clinicians, we must incorporate proper fertility counseling at the time of diagnosis, prior to treatment decision plans, so patients can be informed of potential risk and options. Even though the time following diagnosis is often overwhelming for the patient, we need to remember that fertility-specific counseling is something that must be done systematically and with care.

My favorite resource is Fertile Hope, a partner of LiveStrong that provides financial assistance, support, and accurate information for both healthcare professionals and patients.

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