Though a relatively new field, oncofertility has been life-changing for cancer survivors and their loved ones. A cancer diagnosis can raise a lot of questions for adults and adolescents, including unforeseen questions about fertility.
In this article, we'll look at how Oncofertility care helps patients make more informed, confident decisions about family-building before starting cancer treatment.
What is oncofertility?
Oncofertility is a medical discipline that brings together oncology and reproductive medicine to help cancer patients understand fertility risks and access fertility preservation options.
Coined in 2006 by Teresa K. Woodruff, Ph.D., “oncofertility” refers to a field of medicine that addresses the interconnecting challenges of cancer and reproductive health.
As cancer survival rates for adolescents and young adults increase, the question of reproductive health has grown more relevant. How will cancer treatment affect fertility? What are the options for reproductive preservation? When should patients seek fertility treatment?
Woodruff and other experts realized that it was difficult for patients to bridge conversations between cancer care with fertility care providers, despite a clear need.
Importance of oncofertility
Oncofertility is especially important because it has historically been a challenge for patients to discuss fertility treatment with oncologists and their cancer treatments with fertility specialists. However, oncologists and fertility doctors must collaborate to provide the best long-term and short-term care for patients that consider reproductive health.
For example, a cancer patient may decide to pursue in vitro fertilization (IVF) before undergoing chemotherapy. When they try to schedule an appointment, they may end up on a months-long waitlist. An oncofertility specialist would recognize that this patient has an urgent case and help build a care plan and navigate interventions between cancer care and fertility care. This is why it's critical for oncology and fertility specialists to work together for a more holistic approach to caring for patients.
Statistics on cancer and infertility
- Overall incidents of cancer cases in adolescents and young adults (aged 15-39) increased from 1990-2019. In 2019, the global rate was 44.99 cases per 100,00 people.
- Individuals diagnosed with cancer are 38% less likely to get pregnant.
- Adolescent girls and women with breast cancer are 46% more likely to be at risk of an infertility diagnosis compared to women without cancer.
- In the US, 90,000 people between the ages of 15 to 39 are diagnosed with cancer each year. Nearly 1 million cancer survivors are currently of reproductive age.
- 70-75% of cancer survivors are interested in parenthood, but as low as 51% of these survivors receive correct information about oncofertility.
Oncofertility vs fertility preservation
What’s the difference between oncofertility and fertility preservation? These two practices are closely related, but distinct in one major way.
Fertility preservation is an umbrella term for medical interventions people undergo to protect their ability to conceive in the future. Individuals may choose to pursue fertility preservation treatments for several reasons, including age, medical conditions, or a desire to delay having children.
Oncofertility – or oncofertility preservation – is also an umbrella term, but specific to the collaborative discipline between cancer care providers and fertility care providers. Oncofertility is an emerging field that ensures individuals who have been diagnosed with cancer have the information they need to make informed decisions about how treatment could affect their ability to have biological children.
The link between cancer treatment and infertility
A stark reality is that the number of adolescents and young adults facing cancer diagnoses is increasing. A global trend study found that, in 1990, the rate of cancer incidents was 44.2 per 100,000 for women and 32.4 for men. In 2019, nearly 30 years later, these incidents jumped to 52.3 (women) and 37.8 (men) per 100,000 individuals.
While multiple factors could have contributed to this increase, one thing is clear: with more young people dealing with cancer diagnoses, there are more questions about how cancer care may affect plans to have children.
Types of cancer treatments that may cause infertility
Can cancer treatments cause infertility? It depends. Some treatments may cause temporary infertility, others can lead to permanent infertility. Other factors, such as age, health, and type of cancer also play into how fertility is impacted.
Surgery
Cancer treatments may involve surgery in or around reproductive organs or other organs that can affect a patient’s fertility. In some cases, the effects of the surgery are more likely to impact fertility than the cancer itself.
Chemotherapy
Chemotherapy fights cancer by targeting and destroying active cells in the body. Because of this, treatment may damage the ovaries and testicles and affect the ability of these organs to produce viable eggs or sperm. Such factors as the type, duration, and dosage or treatment, along with the patient’s age, can impact the likelihood of infertility after treatment.
Radiation
Radiation, or radiation therapy, works by killing or damaging cancer cells so they can no longer grow and spread. Radiation is administered via a controlled dose either externally or internally. Infertility risks vary depending on the treatment area and dosage. For instance, radiation therapy in the pelvic area or near reproductive organs is likely to cause permanent infertility.
How cancer treatment affects male and female fertility
Cancer treatment puts both male and female fertility at risk, but it can affect them in different ways.
Common effects of cancer treatment on male fertility
- Damage to sperm and sperm-forming cells
- Decreased sperm production
- Lower sperm count and decreased testosterone levels
- Damage to, or removal of, reproduction organs
Common effects of cancer treatment on female fertility include:
- Permanent damage to the ovaries that stops the release of mature eggs and estrogen production
- Temporary primary ovarian insufficiency, which halts menstrual periods during treatment
- Disruptions to the menstrual cycle
- Damage to reproductive organs that may increase pregnancy-related complications
- Harm to reproductive tissues and permanent scarring
The best thing a patient can do is speak with their oncofertility care providers to learn how cancer care treatments are likely to impact fertility.
Risks of delaying oncofertility decisions
Making big decisions about family-building is hard enough, but even more difficult when a patient is grappling with a cancer diagnosis. It might not seem like the best time to think about whether you would like to have children in the future – but the choices are extremely time-sensitive since treatment may cause temporary or permanent infertility.
Delaying oncofertility decisions may result in:
- Limited fertility preservation options.
- Difficulty securing insurance coverage for fertility treatments, especially depending on where a patient lives.
- Making uninformed or under-informed decisions without understanding fertility risks.
- Long-term feelings of regret or loss.
- Lower quality of life as the individual goes through the next phases of cancer survivorship.
It’s always best to explore available treatment options, costs, side effects, and any other questions a patient may have for oncofertility care providers early in the treatment process.
Oncofertility options for women
Cancer diagnoses can mean having to consider family-building plans for prepubescent and premenopausal women and girls. Below are five key oncofertility treatments women may pursue as they plan for future family building. (Please note: "women," in this case, refers to cis women or anyone with female anatomy.)
Egg freezing
Egg freezing, or oocyte cryopreservation, is the process of extracting eggs, freezing them, and storing them for future use. By freezing eggs at a younger age, women can delay pregnancy to increase their chances of successful conception later. This method is ideal for preserving fertility before starting cancer treatments like chemotherapy or radiation, which can harm ovarian function.
Embryo freezing
Embryo freezing, also referred to as embryo banking or embryo cryopreservation, involves retrieving and fertilizing eggs via in vitro fertilization. This procedure creates embryos, which are frozen for future use. Embryo freezing is often considered one of the most effective fertility preservation methods for patients who plan to be parents because they can secure viable embryos before cancer treatment begins.
Ovarian tissue cryopreservation
Ovarian tissue cryopreservation is a fertility preservation technique for women and girls who may experience fertility problems due to surgery, chemotherapy, or radiation. This procedure works by removing the ovarian cortex (where eggs are produced), and then freezing and storing it. The frozen tissue can later be transplanted to increase the possibility of pregnancy and restore hormone production after cancer treatment.
Ovarian suppression
Ovarian suppression is used to prevent eggs from maturing and protect them from the negative effects of chemotherapy, including premature menopause. This treatment blocks the hormones that stimulate your ovaries using injections before and throughout a patient’s chemotherapy treatment. Ovarian suppression may be used with other fertility preservation treatments, such as egg freezing.
In vitro maturation
In vitro maturation (IVM) is an oncofertility preservation technique wherein immature eggs are retrieved from the ovaries to be matured in a lab. This option involves a minor surgical procedure to collect the eggs before they are matured using hormones. After maturation, the eggs are fertilized by sperm injection, given time to develop, then transferred to the womb.
In addition to these fertility preservation options, depending on the extent of impact from surgeries and treatment, it might also be important to look into gestational surrogacy.
Oncofertility options for men
Cancer treatment for men may contribute to infertility or difficulty with conception due to hormonal changes or DNA damage to sperm. For this reason, men may seek oncofertility options to counteract these potential risks. (Please note: "men," in this case, refers to cis men or anyone with male anatomy.)
Sperm banking
Sperm banking is one of the more popular fertility preservation treatments for men because it’s an easy way for men who have gone through puberty to store sperm for future use. Sperm banking involves collecting one or more semen samples to test for sperm count, motility, and morphology (shape) before freezing and storing. Sperm banking for cancer patients allows men who are undecided about building a family more time to make a well-informed decision later in life.
Testicular sperm extraction
Testicular sperm extraction is a sperm retrieval procedure using a small incision in the testes to examine for the presence of sperm. Because testicular sperm extraction requires an incision, it is either performed in an operating room under sedation or in a medical office with local anesthesia. This procedure is typically scheduled or coordinated with a female partner’s egg retrieval and often coincides with plans to freeze sperm for use with assisted reproductive technologies.
Testicular tissue freezing
Testicular tissue freezing differs from sperm extraction and sperm banking options because it is specifically for boys who have not gone through puberty but are at risk of infertility. This treatment, also called testicular tissue banking or testicular tissue cryopreservation, involves removing tissue from the testicles that would make sperm, then freezing and storing it. Testicular tissue can be thawed at a later date to retrieve sperm. At this time, testicular tissue freezing is still considered experimental with ongoing clinical trials.
Financial considerations for oncofertility
Oncofertility highlights the importance of fertility preservation, as well as the reproductive health challenges cancer patients face when pursuing treatment. Such essential care can be costly, and health insurance does not always cover the expenses.
Costs associated with fertility preservation
Costs of fertility preservation treatments can vary by location, insurance, and number of cycles. Learn more about the costs of fertility preservation.
Insurance coverage for oncofertility
A cancer diagnosis comes with a lot of questions and decisions – some that will impact patients for the rest of their lives, including if they want to have children. These individuals need to start the conversation about cancer treatment and fertility to understand their options. They should also know if their health insurance covers fertility preservation treatment and how to manage coverage to match their needs.
- Health insurance companies in the U.S. are not required by law to cover fertility preservation treatments.
- Insurers cannot set higher insurance rates for women, or discriminate against people with preexisting conditions (including infertility).
- Insurance providers cannot enforce lifetime caps on insurance coverage, which could prevent individuals from receiving fertility treatments.
- 13 states and the District of Columbia mandate that insurance companies cover IVF and fertility preservation. Several others require at least full or partial coverage of infertility treatment, IVF, or fertility preservation treatments.
The best practice for individuals with a new cancer diagnosis is to start the conversation about treatment and fertility options as soon as possible. This will give you the information you need to explore what your health insurance covers.
Fertility benefits
Unfortunately, many cancer survivors have to navigate a complicated healthcare system with very little help. Those exploring fertility preservation treatment have the added stress of juggling appointments with multiple specialists, understanding the right choices for them, and committing to potentially costly care plans that they will have to pay out of pocket.
In a 2021 survey, 97% of employers said that adding infertility coverage did not result in a significant increase in medical plans. Yet 63% of respondents to Carrot’s Fertility at Work report indicated financial challenges as the most common roadblock to starting a family. There is a gap between the need for fertility preservation and infertility treatment and the ability of individuals to access those options.
Carrot Fertility helps organizations provide much-needed oncofertility care to their employees. From inclusive, personalized support to a global network of clinics, Carrot’s fertility benefits enable members to access fertility preservation care where they need it, when they need it most.
Considerations for oncofertility
Oncofertility requires education, coordination, and communication between patients and their care specialists, and between experts in the fields of cancer care and reproductive health. With that in mind, here are some critical considerations for oncofertility:
- Informed consent. Patients should feel empowered to make the right choice after receiving all relevant information about the risks and benefits of care options.
- Disparities in equitable access. Oncofertility care may be limited by socioeconomic status, location, and insurance coverage or work benefits.
- Fertility preservation for individuals with genetic disorders. Patients with a predisposition for cancer or other disorders may want to consider options like embryonic genetic testing.
The future of oncofertility
Oncofertility is a fairly new field and as a collaborative, multidisciplinary effort between fertility specialists and cancer specialists, there are sure to be new developments and discoveries to come.
Advancements in oncofertility research and technology
According to CancerConnect, a resource for patients and experts in the cancer community, there are several exciting oncofertility developments to keep an eye on, including:
- Pharmaceuticals that protect reproductive organ functioning for cancer patients undergoing treatment.
- 3D bioprinting to create organoids that mimic the function of human reproductive organs and tissues.
- Genome editing to understand the effects of cancer treatment on fertility and explore fertility restoration.
- Home hormone monitoring to track hormone levels that are important to fertility.
- Using AI to predict fertility outcomes for cancer patients under treatment and make smarter fertility preservation choices.
The role of oncofertility in cancer survivorship
Cancer survivorship refers to the health and well-being of individuals diagnosed with cancer from the moment of diagnosis to end of life. It involves focusing on the experiences of follow-up care, cancer recurrence, side effects of treatment, and overall quality of life of cancer survivors. With more than 40% of people in the United States estimated to be diagnosed with cancer in their lifetime, survivorship is an especially important topic of conversation.
In 2006, The Institute of Medicine released a first-of-its-kind report about cancer survivorship, outlining four essential components of survivorship care:
- Prevention from new cancers and cancer recurrence, or other late effects
- Surveillance for cancer recurrence, spread, or new cancers, and assessment of medical and psychosocial late effects
- Intervention for the consequences of cancer and cancer treatment
- Coordination between specialists and primary care providers to fulfill ongoing health needs of the survivor
Based on these essential components, it’s clear that oncofertility plays an important role in cancer survivorship care. As a quality-of-life concern for survivors, oncofertility ensures survivors are informed about potential risks to their reproductive health and get help through coordinated care plans.
Oncofertility: Preserving options for the future
Cancer treatments can have a long-term impact on fertility and decision-making around family-building options. The development of oncofertility care is a step in the right direction for helping survivors understand the long term impact of treatment on fertility.
However, many individuals navigating cancer care won't have guaranteed insurance coverage for fertility preservation treatments. With comprehensive fertility benefits, cancer survivors experience greater peace of mind knowing they have access to built-in experts and cost-saving solutions tailored to their needs.
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