Planning for tomorrow: Fertility preservation and childhood cancer
By Jessica Saenz
Medical science has significantly improved treatment for childhood cancer in recent decades. Today, most children diagnosed with cancer not only will survive their disease, but they will live into adulthood — possibly with hopes of starting a family of their own.
Unfortunately, children who undergo treatment for cancer, such as surgery, chemotherapy and radiation, are at risk for impaired fertility, or infertility, later in life.
It is now essential for families to consider fertility preservation and long-term quality of life when making treatment decisions. This International Childhood Cancer Day ― Tuesday, Feb. 15 ― learn about fertility preservation for children with cancer and what families should consider before children begin cancer treatment.
When should fertility preservation be considered?
Some cancer treatments are associated with an increased risk of infertility. "Regimens of chemotherapy that contain cyclophosphamide are very common and very good at treating cancer, but can impact fertility down the road," says Asma Chattha, M.B.B.S., a pediatric and adolescent reproductive health specialist and co-founder of the Pediatric Fertility Preservation Program at Mayo Clinic.
Though the risk of infertility should always be considered when discussing cancer treatment, Dr. Chattha says the risk is higher when cancer treatment targets certain areas of the body. "The two main areas where we think about radiation impacting fertility are the brain, which is where puberty signals come from, and the pelvis, where reproductive organs are located."
If you are a childhood cancer survivor, or the parent of a survivor, and your care team did not discuss fertility preservation, you are not alone. "Research shows that fertility preservation counseling, particularly in prepubertal children, is not occurring frequently enough, despite being a key quality of life indicator for survivors," says Dr. Chattha.
What fertility preservation options are available?
Many safe options are available for fertility preservation. The right option for your child depends on a few factors.
"For cancer treatments associated with a moderate to high risk of impacting fertility, we would offer fertility preservation to everyone. But options vary based on age and pubertal stage," says Dr. Chattha. Children who have not yet gone through puberty have fewer options, though more treatments are being explored in clinical trials.
Options for fertility preservation for prepubertal children involve storing ovarian and testicular tissue for later implantation. Ovarian tissue is collected through a small abdominal incision, known as laparoscopy, and testicular tissue is collected through a biopsy. Ovarian tissue storage became a clinically accepted method of fertility preservation in 2019.
"If you're an older male who has gone through puberty, it is relatively simple to store semen samples. Two or three of those samples are stored before the initiation of any chemotherapy or radiation therapy," says Dr. Chattha. "If you are an older female who has gone through puberty and has started having periods, you are also able to store eggs."
But there's more to consider for girls.
Harvesting eggs for freezing, also known as oocyte cryopreservation, is a possible option for girls who have gone through puberty. However, preparation for this procedure can delay treatment.
"This is where the patient and their family assess the option with fertility preservation physicians or counselors, and then the oncologists assess if it is feasible to delay treatment by two to three weeks," says Dr. Chattha.
Outside of storing eggs and sperm for later use in your child's life, measures can be taken to reduce the amount of radiation exposure to their reproductive organs. "A fertility preservation method that is talked about less often but is equally important is shielding," says Dr. Chattha. "We try to move the ovaries out of the field of radiation through a process called ovarian transposition. We also try to shield the testicles from radiation using small lead shields."
How is the tissue preserved until a childhood cancer survivor is ready to start a family?
As fertility preservation has become more common, the process of storage and access to tissue has been simplified for patients. "The storage banks are very familiar with transporting tissue safely. When they're ready to use the tissue, the treating facility can get in touch with the bank and have the tissue transported to the treating facility," says Dr. Chattha.
Until a child is ready to use this tissue, it is up to the child's family to pay storage fees and stay in contact with the storage facility and provide any address or phone number changes. "The payments are about $250 a year, so it's just over $20 a month. Typically, the storage cost does not end up being prohibitive for families. It's the initial procedure that's more expensive, so we do need to work with health insurance providers," says Dr. Chattha.
How and when should you talk to your child about fertility preservation?
When your child is old enough to understand, talk about how cancer treatment can affect the ability to start a family. Although your child may not understand some of the complexities, explaining the process and how it can help later in life is important.
You and your child might be required to sign a consent form before a procedure. If you need additional support talking with your child, take advantage of social workers and counselors you have access to through your child's treatment facility.
Discussing fertility preservation as your child prepares to receive cancer treatment can be difficult, and it might even feel inappropriate, considering your child's immediate needs. But learning about the options to preserve fertility can help you decide how to give your child the best quality of life now and in the future.
"We hope the Pediatric Fertility Preservation Program brings a lot of optimism for the future to these children. They're obviously fighting an uphill battle, and it's a very difficult time in their lives," says Dr. Chattha. "But I've always found the conversation surrounding fertility preservation to be a source of hope for families."
Watch Dr. Chattha discuss fertility preservation for children with cancer in this "Mayo Clinic Q&A" podcast video: