Oncofertility Program at FFI
The physicians and staff at The Florida Fertility Institute are dedicated to helping you preserve your fertility when you’ve been diagnosed with cancer. As the only private practice in the state of Florida to carry the prestigious Northwestern Oncofertility Consortium designation, we are honored to serve you. The American Society of Clinical Oncologist Guidelines state, as part of education and informed consent before cancer therapy, health care providers (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, and surgeons) should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Although patients may be focused initially on their cancer diagnosis, the Update Panel encourages providers to advise patients regarding potential threats to fertility as early as possible in the treatment process so as to allow for the widest array of options for fertility preservation. The discussion should be documented. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard practice and are widely available. Other fertility preservation methods should be considered investigational and should be performed by providers with the necessary expertise.
Understanding of the risks of permanent amenorrhea in women treated with modern chemotherapy and radiotherapy has changed little over the years. However, there have been outstanding advances in the science of fertility preservation that may affect patient decision-making. The Panel reviewed the new techniques exist to allow embryo and oocyte cryopreservation (with hormonal stimulation), ovarian transposition, surgical options other than radical trachelectomy, ovarian suppression, ovarian tissue cryopreservation and transplantation, and other considerations. Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries. The physicians and staff at The Florida Fertility Institute understand that because of requirements for scheduling and performing procedures, some (but not all) interventions may entail a delay in cancer treatment and wishes to emphasize that early referral to a subspecialist can minimize this delay.
New data indicate that although it is ideal to stimulate ovaries within 3 days of the start of the menstrual cycle, random stimulation can be successful as well. This is an important and recent advance in the field of reproductive endocrinology. Furthermore, newer hormonal stimulation regimens (eg, letrozole and tamoxifen) may be effective as traditional methods, and their use may be preferred in women with hormone-sensitive cancers. Although aromatase inhibitors are primarily used as adjuvant treatment of hormone-positive breast cancers (in premenopausal women), they can act as ovarian stimulants yet suppress estrogen levels. As a result, letrozole has been used for ovulation induction in infertility patients and, in the last 10 years, for the purpose of ovarian stimulation for fertility preservation via oocyte or embryo cryopreservation in women with estrogen-sensitive cancer. When combined with standard fertility drugs, letrozole enhances ovarian stimulation while keeping estrogen levels near physiologic levels. Studies suggest that this approach results in similar numbers of eggs and embryos and similar pregnancy outcomes. Short-term follow-up indicated no impact on cancer-free survival.
Success rates for this procedure have improved significantly, and it is no longer considered experimental by the American Society of Reproductive Medicine. Some reproductive specialty centers have reported success rates comparable to those obtained using unfrozen eggs, especially in younger women. Like embryo cryopreservation, this technique also requires ovarian stimulation and ultrasound-guided oocyte retrieval. Oocyte cryopreservation is of particular importance for women who do not have a male partner or prefer not to use donor sperm.
The new evidence continues to support the conclusion that sperm cryopreservation is an effective method of fertility preservation in males treated for cancer. In contrast, gonado protection through hormonal manipulation is ineffective. Testicular tissue or spermatogonial cryopreservation and transplantation or testis xenografting are still experimental and have not yet been successfully tested in humans. However, such approaches may be the only methods of fertility preservation potentially available to prepubertal boys. There are case reports and small case series of successful collection of sperm from a postmasturbation urine sample, rectal electroejaculation under anesthesia, and testicular sperm aspiration, but these remain uncommon and/or investigational. It also seems that testicular cryopreservation procedures can be combined with other medically indicated procedures to increase the feasibility and acceptability of these procedures. In general cryopreservation of sperm will cause little to no significant delay in the initiation of cancer treatment.