Oncofertility

 

oncofert (1)

“Oncofertility is a subfield that bridges oncology and reproductive research to  explore and expand options for the reproductive future of cancer survivors. The name was coined in 2006 by Teresa K. Woodruff at the Oncofertility Consortium.” – Wikipedia

“1.16  People with cancer who wish to preserve fertility

1.16.1   Cryopreservation of semen, oocytes and embryos

1.16.1.1   When considering and using cryopreservation for people before starting chemotherapy or radiotherapy that is likely to affect their fertility, follow recommendations in ‘The effects of cancer treatment on reproductive functions’ (2007)[10][2013]

1.16.1.2   At diagnosis, the impact of the cancer and its treatment on future fertility should be discussed between the person diagnosed with cancer and their cancer team. [new 2013]

1.16.1.3   When deciding to offer fertility preservation to people diagnosed with cancer, take into account the following factors:

  • diagnosis
  • treatment plan
  • expected outcome of subsequent fertility treatment
  • prognosis of the cancer treatment
  • viability of stored/post-thawed material. [new 2013]

1.16.1.4   For cancer-related fertility preservation, do not apply the eligibility criteria used for conventional infertility treatment. [new 2013]

1.16.1.5   Do not use a lower age limit for cryopreservation for fertility preservation in people diagnosed with cancer. [new 2013]

1.16.1.6   Inform people diagnosed with cancer that the eligibility criteria used in conventional infertility treatment do not apply in the case of fertility cryopreservation provided by the NHS. However, those criteria will apply when it comes to using stored material for assisted conception in an NHS setting. [new 2013]

1.16.1.7   When using cryopreservation to preserve fertility in people diagnosed with cancer, use sperm, embryos or oocytes. [new 2013]

1.16.1.8   Offer sperm cryopreservation to men and adolescent boys who are preparing for medical treatment for cancer that is likely to make them infertile. [new 2013]

1.16.1.9   Use freezing in liquid nitrogen vapour as the preferred cryopreservation technique for sperm. [new 2013]

1.16.1.10   Offer oocyte or embryo cryopreservation as appropriate to women of reproductive age (including adolescent girls) who are preparing for medical treatment for cancer that is likely to make them infertile if:

  • they are well enough to undergo ovarian stimulation and egg collection and
  • this will not worsen their condition and
  • enough time is available before the start of their cancer treatment. [new 2013]

1.16.1.11   In cryopreservation of oocytes and embryos, use vitrification instead of controlled-rate freezing if the necessary equipment and expertise is available. [new 2013]

1.16.1.12   Store cryopreserved material for an initial period of 10 years. [new 2013]

1.16.1.13   Offer continued storage of cryopreserved sperm, beyond 10 years, to men who remain at risk of significant infertility. [new 2013] –  Recommendations: People with cancer who wish to preserve fertility. (NICE guidelines)

 

Sperm, eggs or embryos can be frozen and stored for possible use in the future. This is known as cryopreservation. Cryopreservation of sperm, eggs or embryos may be a possible option for people who have been diagnosed with cancer, if the cancer treatment is likely to cause infertility.

If you are diagnosed with cancer, you should be given the opportunity to discuss your diagnosis and the effect of cancer treatment on your fertility, both with your cancer team and with a fertility specialist.

The decision to freeze some sperm, eggs or embryos depends on several things, including the type of cancer you have, your treatment plan and how quickly your treatment needs to start. Your healthcare team should also take into account whether future fertility treatment is likely to be successful, and whether the stored sample will still be usable when you are likely to need it. You should be able to have your frozen sample stored for at least 10 years.

The criteria for having fertility treatment that have been described throughout this information do not apply to people who have been diagnosed with cancer and wish to use cryopreservation to preserve their fertility. However, if you need to use your frozen sample in the future, these criteria will apply if you are having your treatment in the NHS.

Sperm –   If you are a man or adolescent boy you should be able to have a sperm sample frozen before your cancer treatment begins. Storage of your sperm should continue beyond 10 years if you are still at risk of fertility problems after this time.

Eggs and embryos –  Women (and adolescent girls, if appropriate) who are well enough to have ovarian stimulation and egg collection should be offered either egg or embryo storage, depending on which is most suitable, before cancer treatment begins.You and your healthcare team should discuss whether there is enough time to have this procedure before your cancer treatment needs to start (the egg collection process can take several weeks), taking into account whether it may worsen your condition or outlook.” – NICE Guidelines

 

CancerFert1

“Sperm freezing should be offered to all men.

Sperm banking –  freezing a sperm samples produced by the patient, at really cold temperatures (-180oC) until they are needed for fertility treatment.
Sperm and eggs can be collected and frozen after puberty.

Egg freezing should be discussed sometimes it is not possible to wait long enough to take the injections needed to collect the eggs. In such patients, ovarian tissue freezing may offer hope, although it is still a really new therapy, so we do not really know how well it works.

Egg freezing – freezing eggs until they are needed for fertility treatment. Hormonal injections need to be taken, and the eggs need to be removed from the ovaries using a small needle under anaesthetic. This is like having IVF treatment.

Ovarian tissue and freezing – eggs come from the ovaries. When egg freezing is not possible, ovarian tissue (a bit of the ovary) can be removed during an operation, and frozen. It is still a really new therapy, so we do not really know how well it works.

CANCERFERT2

Testicular tissue and freezing In boys who have not gone through puberty, there are still no sperm being made in the testicles. In this case, some doctors are trying testicular tissue freezing, where an operation is used to remove a piece of testicular tissue and freeze it. At the moment, this treatment is still experimental, since no one has ever had a successful pregnancy from thawed testicular tissue. Further research could make this a reality.  When egg freezing is not possible, ovarian tissue (a bit of the ovary) can be removed during an operation, and frozen. It is still a really new therapy, so we do not really know how well it works.

cancerfert3

Egg donation – when a woman is infertile without any eggs, they and their partner can use eggs from a donor, during IVF therapy to have a baby.
Sperm donors – when a man is infertile without any sperm, they and their partner can use sperm from a donor, during IVF therapy to have a baby.

cancerfert4

Surgical sperm retrieval – sperm are made in the testicles. When sperm freezing is not possible (no sperm can be produced by ejaculation), it is possible to do an operation called surgical sperm retrieval, to find and collect sperm from the testicles, which can then be frozen.

cancerfert5

IVF and difference with mild IVF  Mild IVF uses lower doses of hormones than other forms of IVF. This makes it cheaper, and possibly with fewer health complications, But this might also give it lower pregnancy rates than other forms of IVF.

Embryo Glue in couples having IVF treatment, it is used to try helping the embryo stick to the womb wall of the woman, and help the pregnancy.  

Pre-implantation Genetic Screening (PGS) –  PGS is a way of telling if an embryo has the correct number of chromosomes (i.e. bits of DNA in our cells we need to be healthy). Babies without the correct number of chromosomes can have illnesses like Down syndrome.

Where can cancer patients find places regarding fertility as an NHS patient or private?

This is really difficult since it varies from place to place. In London, we (Andrology Department, Hammersmith Hospital) and UCL Hospital are just about the only NHS providers. Hammersmith also do private.

cancerfert6

Do you know which chemo drugs cause infertility?        

They all do to some extent.

Things like total hysterectomy, the removal of both cancerous testicles, certain chemo drugs, radiotherapy especially to pelvic area, ( those on hormone treatment?) etc leads to infertility?

Yes, any major surgery or radiotherapy in the pelvic region is likely to cause infertility.

Cancer treatment can damage the ovaries, but this damage can sometimes get repaired and fertility / periods return after 2-5 years. In contrast, menopause is usually because the ovaries have come to the end of their ‘life’, so there is very little chance of recovery.

Definition of the medical term if not natural menopause?

I would call it ‘cancer-induced infertility.’ If this persisted for a while (e.g. 5 years,), I would call it menopause.

What is a AMH blood test?

AMH (Anti-Mullerian Hormone) – women with very low levels have a lower chance of responding to hormonal injections to stimulate egg growth. So it can be used to help women who may be going through the menopause, decide how likely IVF treatment would work in them.

How does it affect the LGBT community, rules etc and single women/men when it comes to preserving fertility or NHS IVF services etc?

I firmly believe we should not discriminate the LBGT community when it comes to fertility preservation. So, anyone biologically female should be offered egg freezing, and anyone biologically male should be offered sperm freezing. They have the same rights as anyone else when it comes to NHS freezing. There might be additional costs for IVF since they might need donor sperm or a surrogate etc.”

Credit for Medical Definitions: Dr Channa Jayasena Consultant in Reproductive Endocrinology and Andrology at Imperial College London and Hammersmith Hospital, London.

Credit for illustrations above:  Sarah Smizz

 

Becki Illus-14

“Wednesday February 20 2013
IVF provision is to be extended to women up to the age of 42.
New standards set out for treating fertility problems dominate the health news.
The coverage is based on updated infertility guidance from the National Institute for Health and Clinical Excellence (NICE).
While these guidelines are wide-ranging, the media’s coverage focuses largely on recommendations that:

NHS-funded IVF should now be offered up to the age of 42 (in certain circumstances)
– the current IVF age limit is 39, couples having difficulty conceiving should be offered treatment after two years of regular unprotected intercourse, instead of the current three.

– same sex couples should be offered NHS fertility treatment.

NICE says there is a need for new guidelines to reflect the medical advances which mean fertility problems (particularly in older women) can be treated more effectively.
 

Other recommendations say that women under the age of 37 should only have one embryo transferred in their first cycle of IVF. This is intended to reduce the number of multiple pregnancies arising from IVF, which can result in complications for both mother and child.

Most couples would no longer be offered intrauterine insemination, as NICE says the results are no better than those for sexual intercourse. An exception to this is if there are circumstances where vaginal intercourse would not be appropriate or possible.

NICE guidelines are considered best practice and are based on the best available evidence. Local NHS organisations should follow the recommendations.

What are the new NICE recommendations on infertility?
The updated NICE guidelines have been published following an extensive consultation on draft guidelines issued in May 2012. The new guidelines set out many recommendations, the most high profile of which are outlined below.

IVF

NICE now recommends that women aged under 40 who have been unable to conceive after two years of regular unprotected intercourse (or 12 cycles of artificial insemination (IUI), in which semen is introduced into the woman’s vagina), should be offered three full cycles of IVF.
These IVF cycles can be either with or without intra-cytoplasmic sperm injection (ICSI), a technique in which a single sperm is injected into the egg.
If the woman reaches the age of 40 during treatment, the current full cycle should be completed, but no further cycles offered. This is one year earlier than was previously recommended.

Women aged 40-42 years who have been unable to conceive after two years of regular unprotected intercourse (or 12 cycles of artificial insemination) should now be offered one full cycle of IVF, with or without ICSI.
However, NICE recommends they must also:
  • have never previously had IVF treatment
  • show no evidence of low ovarian reserve (this is when eggs in the ovary are impaired or low in number)
  • have been informed of the additional implications of IVF and pregnancy at this age
Previously, NICE did not recommend IVF for women over 39.
 
 
 

Ovarian stimulation

Women with unexplained infertility (where the cause of the problem is not known) should not be offered drugs which stimulate the ovaries (such as clomifene citrate, anastrozole or letrozole), as these drugs are now thought to be an ineffective treatment for the problem.

Intrauterine insemination:

Couples with unexplained infertility, women with mild endometriosis, or men who have ‘mild male infertility’, should normally attempt to conceive through regular vaginal intercourse for two years rather than receive intrauterine insemination.
NICE says this is because new evidence shows that it is no better at achieving a live birth than people attempting to conceive through regular vaginal intercourse.

However, intrauterine insemination may still be suitable in certain circumstances where vaginal intercourse would not be suitable or appropriate, for example:
 
  • people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem, who are using partner or donor sperm
  • people with conditions requiring specific consideration in relation to methods of conception (for example, where the man is HIV positive)
  • people in same-sex relationships
 
Embryo transfers

The NICE guidelines also include new recommendations on the number of fresh or frozen embryos that should be transferred to a woman’s womb, these are designed to reduce the risk of multiple births following IVF.
 
The recommendations state that:

Women under 37 in their first IVF cycle should have only a single embryo transfer.
In their second IVF cycle they should have a single embryo transfer if one or more top-quality embryos are available (embryo quality is assessed using a number of factors that point to the likelihood of an embryo leading to a successful pregnancy, such as the amount of cells in the embryo).
Doctors should only consider using two embryos if no top-quality embryos are available. In the third IVF cycle, no more than two embryos should be transferred.

Women aged 37–39 years in the first and second full IVF cycles should also have single embryo transfer if there are one or more top-quality embryos, and double embryo transfer should only be considered if there are no top-quality embryos. In the third cycle, no more than two embryos should be transferred.

For women aged 40-42 years, double embryo transfer can be considered.
How have these fertility guidelines been received in the media?
 
The new guidelines were widely reported in the papers, although not always in a fair and balanced way. The Daily Mail’s headline inaccurately claims that, “lesbians will get IVF on the taxpayer”. The guidelines actually recommend that intrauterine insemination should be offered to women in same-sex relationships.
Intrauterine insemination is an entirely different fertility treatment to IVF. After six unsuccessful cycles of IUI, the NICE guidance says that all women (regardless of sexual orientation and relationship status) should be eligible for IVF.

The Daily Mail also conflates its reporting of the new guidelines with a claim that “Five thousand fatherless children have been born to lesbian couples and single mothers following fertility treatment in the past decade”. This appears to be based on figures from the Human Fertilisation and Embryology Authority. The paper did not report on any other recommendations by NICE.

The BBC and The Guardian concentrate on the new recommendations that IVF be given sooner and to older women, while The Independent reports that women under 37 will not be permitted to try for twins at their first attempt at IVF. This is a slightly flippant response, as the main reason why double embryo transfer is sometimes used is to try to increase the chance of a having a single successful pregnancy (reducing risk to mother and unborn baby), not to ‘try for twins’.

However, as multiple pregnancy is also a possibility when more than one embryo is transferred – and multiple pregnancies carry higher health risks than single pregnancies – that is why single transfer is preferred when possible.

Independent experts have welcomed the new guidelines, but have argued that current provision of NHS-funded fertility treatments varies widely between areas, depending on budgetary pressures and the advice of medical experts in each local NHS organisation.
There is the risk that local restrictions on NHS spending – in spite of NICE guidelines – may mean that they remain something of a ‘wish list’ for many.


Analysis by Bazian. Edited by NHS Choices.” – NHS Choices

IMG_1266

 

“This guidance has been written for same-sex female couples who are planning to conceive a child through artificial insemination:

What is donor insemination? –  Donor insemination involves using donor sperm. This can be obtained by using an anonymous sperm donor (from a sperm bank), or using a known donor or a friend. All information below is for babies that are conceived, through donor insemination, after 6 April 2009 when laws changed affecting the rights of same-sex female couples.In the UK, women can inseminate through a licensed fertility clinic or at home. Depending on which method you use there are implications with regards to legal parenthood.

For couples in a civil partnership or marriage –  If a baby is conceived in a UK licensed fertility clinic or at home and the couple are in a civil partnership or married, then the non-birth mother will automatically be the second legal parent and will be named as such on the birth certificate. The donor will have no legal parenthood status.

For couples not in a civil partnership or marriage –   If a baby is conceived in a UK licensed fertility clinic and the couple are not in a civil partnership or married, they will need to complete a simple form at the clinic for the non-birth mother to be the legal parent, and to appear on the birth certificate. The donor will have no legal parenthood status.If the baby is conceived outside of a UK licensed fertility clinic and the couple are not in a civil partnership or married, the non-birth mother must apply to adopt the child to gain legal rights.

Fertility treatment
For many, the first place to go for information about fertility treatment is their GP. They can give you advice on the services available, help with health checks, and advise you whether you’ll be eligible for NHS fertility funding.

NHS funding for fertility treatment is limited for everyone, and what is available varies from place to place, with criteria set by each area’s Clinical Commissioning Group (CCG).Until February 2013, there was no official guidance on what NHS funding should be offered to same-sex female couples seeking fertility treatment.

Now CCG’s can refer to guidelines published by the National Institute of Clinical Excellence (NICE). This guidance offers NHS trusts best practice for the assessment and treatment of people with fertility problems.

For the first time, these guidelines set out what same-sex female couples can expect when looking for fertility treatment.

What does the NICE guidance say? –  NICE’s new guidance says that couples must attempt to conceive before being considered for NHS treatment. Opposite-sex couples are expected to try and conceive through sexual intercourse for two years before being considered. This is obviously not an option for female same-sex couples.

The NICE guidance therefore expects female same-sex couples to have tried to conceive six times using artificial insemination (funded themselves, not by the NHS) before they would be considered for NHS-funded fertility treatment.

The guidance does not stipulate whether couples need to try to conceive using a fertility clinic, or whether attempts to conceive at home with donor sperm makes you eligible for NHS treatment. This is a decision for your local NHS trust to make. Many NHS trusts will require same-sex couples to use fertility clinics to conceive before considering funding treatment, meaning many same-sex couples will need to pay fees before being eligible for NHS funded treatment.

Why might I be expected to pay for fertility treatment?
Your NHS trust will make its own decision about whether they expect you to try to conceive six times at a clinic (for a fee) or at home (for free). Stonewall expects many trusts to say you have to try to do so at a clinic, as they will want you to try to conceive using a safe and clinically effective method of conception, using approved and tested sperm.

Other criteria –    Even if you have tried to conceive six times, you still may not be eligible for NHS funded treatment in your local area. Your local NHS trust will have a number of other criteria that you may also need to meet before they will fund treatment.

These can include things like your age, whether you smoke, and other lifestyle factors such as alcohol consumption and levels of fitness.It is therefore important to find out what your local NHS trust’s criteria on funding fertility treatment before beginning the process of conceiving.

The law is clear, however, that these criteria should apply equally to opposite-sex and same-sex couples – it would be unlawful for a trust to deny you fertility treatment simply because you are a same-sex couple.
The laws on parenting rights when a child is conceived through artificial insemination place a focus on biological sex rather than gender identity.

Legal parents for children conceived through donor insemination
The Human Fertilisation and Embryology Act (2008) sets out who a child’s legal parents will be when conceived through donor insemination. This legislation was particularly significant for same-sex couples as it allowed, for the first time, a child to have two mums or two dads named as legal parents.Under UK law, a child can only have two legal parents although a number of people can hold parental responsibility. For children conceived through donor insemination, who the legal parents are will depend on the circumstances at the time a child is conceived.” From: Donor insemination and fertility treatment – Stonewall

“FERTILITY LAW EXPERTS NATALIE GAMBLE ASSOCIATES PROVIDE USEFUL INFORMATION ON HOW THESE RULES APPLY TO TRANS PEOPLE ON THEIR WEBSITE;

Source: NATALIE GAMBLE ASSOCIATES

“Total hysterectomy – the womb and cervix (neck of the womb) are removed; this is the most commonly performed operation.
Subtotal hysterectomy – the main body of the womb is removed, leaving the cervix in place.
Total hysterectomy with bilateral salpingo-oophorectomy –  the womb, cervix, fallopian tubes (salpingectomy) and the ovaries (oophorectomy) are removed
radical hysterectomy – the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue.” – NHS Choices

“Vaginal hysterectomy – where the womb is removed through a cut in the top of the vagina.
Abdominal hysterectomy – where the womb is removed through a cut in the lower abdomen.
Laparoscopic hysterectomy (keyhole surgery) – where the womb is removed through several small cuts in the abdomen.” – NHS Choices

Testicular Cancer –  treatment almost always includes the surgical removal of the affected testicle – called orchidectomy or orchiectomy – which doesn’t usually affect fertility or the ability to have sex.” – NHS Choices

Surgery to remove the testes is called an orchidectomy. It is the main treatment for testicular cancer. Usually you only need one testicle removed and the other testicle compensates and makes enough testosterone.

Very rarely both testicles might be removed if there is cancer in both testicles. You will have testosterone replacement treatment to prevent hormone symptoms.

In prostate cancer, stopping testosterone production can slow down or stop cancer cell growth. Most men have medicines to switch off testosterone production rather than having their testicles removed. – NHS Choices

Other options:

“UK Fostering is an independent fostering agency and was set up by a team of dedicated professionals who are passionate about changing the lives of children. Our aim is to provide children and local authorities with fully trained, compassionate and competent foster care, when they need it most.”

CRUK

World Health Organisation (WHO) definition on infertility

Infertility definition by Wikipedia

Understanding reproductive loss

Infertility – NHS

Children with cancer given chance to be mums and dads by having eggs and sperm frozen

 

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