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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 38-40

Role of fertility preservation in young cancer survivors: A case series


FNB Reproductive Medicine Trainee; Head of the Department, Institute of Reproductive Medicine, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Dr. Aishwarya Parthasarathy
No. 33/95, Vanniar Street, F3 TNR Villa, Choolaimedu, Chennai - 600 094, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tofj.tofj_2_19

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  Abstract 


There is still a huge lacunae in the fertility preservation services being offered to young cancer survivors. The future fertility prospects should be discussed before the treatment to decrease the psychological trauma when they are expected to have a long-term survival. There has been growing awareness in India with the establishment of focused societies. The strategies are still experimental worldwide barring a few. Here, we present four cases of fertility preservation in varying scenarios in young cancer survivors who attended the Institute of Reproductive Medicine, Madras Medical Mission, Chennai, Tamil Nadu, India.

Keywords: Embryo, fertility, oocyte, preservation, random start


How to cite this article:
Parthasarathy A, Shankar K. Role of fertility preservation in young cancer survivors: A case series. Onco Fertil J 2019;2:38-40

How to cite this URL:
Parthasarathy A, Shankar K. Role of fertility preservation in young cancer survivors: A case series. Onco Fertil J [serial online] 2019 [cited 2019 Dec 12];2:38-40. Available from: http://www.tofjonline.org/text.asp?2019/2/1/38/261251




  Introduction Top


There is 2.7 times more chances of cancer incidence in the age group of 15–30 years when compared to adults.[1] The advances in oncology have promised longer lifespan for the young survivors[2] and with that there arises the question of quality of life and reproductive potential. Currently, embryo and oocyte cryopreservation in females and sperm cryopreservation in males are the only established techniques as per the American Society for Reproductive Medicine.[3] A multidisciplinary setting with effective communication between surgical oncologists, radiation oncologists, medical oncologists, and reproductive health specialists during the development of a treatment plan will maximize the chance of future fertility while minimizing the delay in treatment. The four complex scenarios in which fertility preservation was offered at our center highlight the importance.


  Case Reports Top


Case 1: Oocyte cryopreservation in breast cancer

A 27-year-old unmarried female noticed a lump in her right breast 3 weeks before her visit to the breast clinic. She underwent a core biopsy, which revealed estrogen-sensitive grade 3 invasive ductal carcinoma (P6, U6, M6, and B5). She was referred to us for fertility preservation before chemotherapy.

The option of oocyte cryopreservation was discussed after extensive counseling. She underwent controlled ovarian stimulation (COS) using random start protocol starting on the 26th day of her menstrual cycle to avoid delay in the initiation of chemotherapy, with a combination of letrozole for 5 days and gonadotropins using antagonist protocol for downregulation. Follicular monitoring was done along with serum estradiol levels at regular intervals. After 10 days of stimulation, when adequate follicular growth was achieved, ovulation was triggered with injection triptorelin 0.4 mg at a peak estradiol value of 888 pg/mL and oocyte retrieval was done after 35 h. Thirteen eggs were retrieved and 10 metaphase II oocytes were cryopreserved. Postretrieval, three cycles of leuprolide depot injection (3.75 mg) were given for 3 months to decrease the effects of chemotherapy on ovarian reserve as an additional measure. Neoadjuvant chemotherapy was started 5 days after retrieval and was followed by surgery.

Case 2: Embryo cryopreservation and surrogacy posthysterectomy

A 34-year-old female married for 4 years came to us after laparoscopic hysterectomy done in view of Stage 1B endometrial carcinoma, wherein ovaries were conserved. She was planned for radiotherapy and hence wanted embryo cryopreservation followed by surrogacy. Before starting the program, she was evaluated and found to have normal pelvic and breast screening. Ovarian reserve test showed diminished reserve (Antral Follicle Count-5; Anti Mullerian Hormone-0.76 ng/ml). Semen analysis of the partner was normal.

She was planned for COS with random-start antagonist protocol, i.e., as not to delay the radiotherapy. After 10 days of gonadotropins, injection triptorelin 0.4 mg was used for ovulation at a peak serum estradiol of 1658 pg/ml. Five eggs were collected, intracytoplasmic sperm injection (ICSI) was done, and two embryos were frozen on day 3. Postoocyte retrieval, she was given in. Cetrorelix 0.5 mg for two days for luteolysis and was planned for embryo transfer by surrogacy. Two blastocysts were transferred on day 5 in the surrogate which resulted in a biochemical pregnancy.

Case 3: Embryo cryopreservation in ovarian malignancy

A 25-year-old married lady was referred to us by an oncologist with bilateral borderline ovarian tumor diagnosed after ovarian cystectomy done for bilateral ovarian cysts. She was counseled for embryo cryopreservation in view of future completion surgery involving oophorectomy. At our center, she underwent COH using random-start antagonist protocol, and embryos were cryopreserved. When she was referred back to the oncologist, staging laparotomy, bilateral oophorectomy, infracolic omentectomy, and pelvic lymphadenectomy were performed and histopathology revealed bilateral atypical proliferative serous tumor. Omentum and lymph nodes were free of the disease. She was referred for embryo transfer 4 months after the surgery, and 3 × 8 celled Grade A embryos were transferred on day 3. She had twin pregnancy, and the pregnancy is ongoing at 20 weeks of gestation.

Case 4: Intracytoplasmic sperm injection pregnancy following sperm cryopreservation

A 31-year-old male had semen frozen 5 years back with us before chemotherapy when he had been diagnosed with testicular teratoma. Currently, he is on remission and came to us for discussing options as his current semen analysis showed azoospermia. ICSI with the cryopreserved sperms was planned. On the day of egg collection, frozen semen was thawed, ICSI was performed on 9 M2 oocytes, and 7 fertilized. Elective cryopreservation was done, and frozen embryo replacement was done a month later using hormone replacement protocol on day 3. Dydrogesterone was given as luteal phase support. She conceived with twins and currently 21 weeks pregnant.


  Discussion Top


Five-year survival rates with testicular cancer, hematologic malignancies, breast cancer, and other cancers that strike young people maybe 90% or greater.[3] The most important aspect is the involvement of a multidisciplinary team, counseling, and consenting. Female fertility preservation is more complicated. The available techniques are embryo and oocyte cryopreservation, of which the latter has achieved popularity because the pregnancy rates are now similar to those achieved with fresh oocytes.[4] Recently, there are reports of healthy pregnancies following ovarian tissue transplantation.[5] The latest systematic review on the use of gonadotropin-releasing hormone agonist before chemotherapy reiterates the efficacy and safety and as an available option to reduce chemotherapy-induced premature ovarian insufficiency patients with early breast cancer.[6]

To overcome the delay in start of treatment, in three of our cases, we had used the random-start protocol in the luteal phase for COS.[7] In estrogen-sensitive breast cancers as in the first case, a combination of letrozole and gonadotropins decrease the peak estradiol values and avoids excessive estrogen exposure. One needs expertise for using transabdominal route for oocyte retrieval and excellent laboratory conditions for oocyte cryopreservation.

Embryo cryopreservation is the best possible solution for women who have partners. The use of surrogacy, although might be questioned in the future due to the National ART bill, 2016, is a big boon for women who have undergone hysterectomy. The oocyte retrieval was a challenge in both case 2 and case 3 due to altered anatomy posthysterectomy and with residual cancer, respectively. The third case needed expertise to avoid multiple puncture through ovarian stroma to avoid spillage of tumor cells. Involving the oncologist was essential in both these cases, as embryo transfer was planned after their approval.

Male adult fertility preservation is well established through sperm cryopreservation. As most testicular cancers occur in young men and have >90% 5-year survival rate, the oncologists should discuss sperm cryopreservation. At our center, 2–3 ejaculates are stored within a few days of referral from the oncologist. Sexual maturity is essential to provide a semen sample. If the children cannot ejaculate or are too young, then an epididymal sperm aspiration and testicular sperm extraction can be done with their assent and parental consent. Testicular cryopreservation in adolescents is still experimental.[3]


  Conclusion Top


This case series aims to provide an insight into the various scenarios one might face in routine clinical practice. Counseling and informed consenting form the cornerstone of fertility preservation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bleyer A, Viny A, Barr R. Cancer in 15- to 29-year-olds by primary site. Oncologist 2006;11:590-601.  Back to cited text no. 1
    
2.
Revel A, Revel-Vilk S. Fertility preservation in young cancer patients. J Hum Reprod Sci 2010;3:2-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ethics Committee of the American Society for Reproductive Medicine. Electronic address: ASRM@asrm.org. Fertility preservation and reproduction in patients facing gonadotoxic therapies: An ethics committee opinion. Fertil Steril 2018;110:380-6.  Back to cited text no. 3
    
4.
Argyle CE, Harper JC, Davies MC. Oocyte cryopreservation: Where are we now? Hum Reprod Update 2016;22:440-9.  Back to cited text no. 4
    
5.
Anderson RA, Wallace WH, Telfer EE. Ovarian tissue cryopreservation for fertility preservation: Clinical and research perspectives. Hum Reprod Open 2017;2017:hox001.  Back to cited text no. 5
    
6.
Lambertini M, Moore HC, Leonard RC, Loibl S, Munster P, Bruzzone M, et al. Gonadotropin-releasing hormone agonists during chemotherapy for preservation of ovarian function and fertility in premenopausal patients with early breast cancer: A systematic review and meta-analysis of individual patient-level data. J Clin Oncol 2018;36:1981-90.  Back to cited text no. 6
    
7.
Cakmak H, Rosen MP. Random-start ovarian stimulation in patients with cancer. Curr Opin Obstet Gynecol 2015;27:215-21.  Back to cited text no. 7
    




 

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Abstract
Introduction
Case Reports
Discussion
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