Fertility preservation for young cancer patients wherever they live

WITH more than 170 babies globally now born to women who have had ovarian tissue grafting following cryopreservation before cancer treatment, experts say it’s important to raise the awareness of this fertility preservation option for young cancer patients.

Associate Professor Catharyn Stern, Head of Clinical Research at Melbourne IVF, said young cancer patients now had a survival rate of more than 80%, and it was vital to address fertility preservation, so these patients did not face the “double whammy” of cancer treatment and then infertility.

Associate Professor Stern is co-author of a Perspective in the MJA highlighting the role of the National Ovarian and Testicular Transport and Cryopreservation Service in providing another option for fertility preservation in young cancer patients.

The service, which was launched in September 2019 and is partly funded by Sony Foundation Australia, aims to provide equitable access to the best available fertility preservation options for young cancer patients, regardless of where they live, with collaboration between local centres and the Fertility Preservation Service at Melbourne’s Royal Women’s Hospital.

Associate Professor Stern said international guidelines now recognised the importance of preserving fertility for young people receiving cancer treatment.

“We know that it’s a really important part of early cancer management,” Associate Professor Stern told InSight+. “There is a suite of fertility preservation options – it’s not a one-size-fits all – and so some patients will benefit from egg freezing, tissue freezing or sperm freezing, or more than one option, but we have to be able to provide all options to patients.”

Associate Professor Stern said ovarian tissue cryopreservation for women was now considered non-experimental.

“While gonadal tissue cryopreservation is still considered experimental for young boys and young girls, it is recognised as the only option they have,” she said. “So, we need to be able to make this accessible and offer it.”

Associate Professor Stern said there had now been more than 170 births around the world following ovarian tissue grafting.

“When we started storing ovarian tissue for women 25 years ago, there were no pregnancies around the world from putting the tissue back, but we had good [laboratory] evidence in animals that this worked,” she said. “There are now women who are having babies and wouldn’t have had the opportunity otherwise.”

Professor Michael Chapman, senior fertility specialist with IVF Australia, said the freezing of eggs, sperm, and embryos had been available to young cancer patients for many years, and gonadal tissue preservation was a newer option.

“Until recently, this has been – and some people say probably still is – an experimental option because while there have been pregnancies, the odds of a pregnancy are quite low compared to those achieved with the freezing of eggs or embryos.”

Professor Chapman said the Melbourne team offering this service were “world leaders in the area”.

“For them to be able to offer it Australia-wide is excellent,” he said.

Professor Chapman said a key advantage in gonadal tissue cryopreservation was its immediacy.

“If a patient came to me today and was referred by an oncologist saying we need to start chemotherapy tomorrow, we could do a laparoscopy this afternoon and take the tissue and send it off, “ he said. “Whereas for egg freezing and freezing of embryos, we have at least a 10–12 day waiting time while we stimulate the ovaries to produce the eggs.”

The MJA authors also noted that tissue cryopreservation provided a fertility preservation option for pre-pubertal boys at significant risk of azoospermia from gonadotoxic treatments.

“As boys do not produce mature sperm that can be frozen, a treatment involving testicular biopsy and cryopreservation of spermatogonial stem cells, followed by transplantation into the testis after treatment, is proposed to allow restoration of fertility,” they wrote, noting that the procedure remains experimental.

Associate Professor Stern said tissue freezing was more complex than egg and sperm freezing.

“Tissue requires different [laboratory] conditions and so it’s not as easy to freeze tissue successfully [as] it is to freeze eggs or sperm,” she said.

She said gonadal tissue cryopreservation was offered by several facilities around Australia, and the national transport and cryopreservation service helped to ensure equitable access, including to patients in regional and rural areas.

“We have had multiple referrals from all over Australia, including Darwin and Western Australia,” she said. “For people who can’t get this specialised service locally, this is the way to go.”

Associate Professor Stern said the program was available for children, adolescents and young adults, and storage was currently provided free to people aged under 21 years.

As with all procedures, Associate Professor Stern said there were small risks associated with gonadal tissue harvesting and grafting. Tissue is harvested via a laparoscopy for girls and women and by testicular biopsy for boys and men.

“The procedure has an operative risk; it’s very small. There is also the potential for false hope, but we talk about this so patients and essential parties are well counselled,” she said. “And when you graft tissue, there is a theoretical risk that for a patient who has had leukaemia, you could reinvigorate the tumour.”

Associate Professor Stern said there was a lot of research investigating this risk, with some very promising solutions likely to be available within the next few years.

Professor Chapman said the MJA article reinforced the need for patients of reproductive age, who required cancer therapy that may damage their ovarian or testicular tissue, to be offered the opportunity to preserve their fertility.

“That’s still not fully accepted by the oncological world, it’s not necessarily seen as a vital part [of cancer management]. The emphasis obviously is on curing the cancer, and in fact, when patients are referred to me by their oncologist, only about 50% decide to have any sort of fertility preservation done because their focus at that acute point in time is being cured, not worrying about the future,” Professor Chapman said. “But the opportunity must be there.”

Associate Professor Stern said it was also important to raise awareness of fertility preservation among GPs who often diagnose the cancer.

“It is important that everybody supporting patients who have cancer treatment should ask about fertility preservation,” she said.