A cancer diagnosis brings a wave of uncertainty, and for many patients, concerns about fertility can add another layer of emotional distress. While advancements in cancer treatments have improved long-term survival rates for many patients, many cancer treatments can cause a loss of fertility, making it crucial for patients to consider fertility preservation early in their treatment journey.

Thankfully, several advancements have been made in the field of reproductive medicine, offering numerous options to patients to preserve their fertility. However, many individuals are unaware of their options or face barriers in accessing care. A specialized field called onco-fertility helps bridge oncology and reproductive medicine to empower patients to make informed decisions about their future and highlights the importance of incorporating fertility discussions into cancer care.

Lymphoma Research Foundation grantee, Foundation Adolescent and Young Adult Consortium member, and lymphoma specialist Adam DuVall, MD, MPH, of the University of Chicago, discusses the impact of cancer treatment on fertility, available preservation methods, and the promising advancements in the field. Additionally, Megan Scherer, co-founder and executive director of Worth the Wait – a non-profit that provides financial support and educational resources for fertility treatments – discusses the challenges that many patients face when considering fertility preservation as well as the support resources available to them.

Adam DuVall, MD, MPH, Assistant Professor of Medicine and Pediatrics at the University of Chicago:

What is onco-fertility, and why is it important for cancer patients?

Onco-fertility is the study and treatment of fertility and reproductive issues for patients who have cancer – either before or after treatment. It focuses on a patient’s ability to have children, whether it be through preserving fertility before cancer treatment, in the future, or afterward. This can also be done through the assistance of reproductive technology or even through adoption or other family-building practices.

How can cancer treatments, specifically lymphoma treatments, impact fertility in both men and women?

Lymphoma is commonly treated with chemotherapy and radiation, both of which can have an impact on a patient’s future fertility. Radiation can impact fertility if it is used on a patient’s pelvic area, but really, it’s the chemotherapy that we use for lymphoma that impacts future fertility more significantly.

It is hard to quantify who’s going to be most at risk for having future fertility issues, and so, when I talk to patients about it, I remind patients that there are many people who experience fertility issues without a history of cancer. People are born with a certain level of fertility, and a person’s ability to have children naturally declines with age and other factors, and chemo can make a person’s chances of conceiving reduce faster. If you’re somebody who already has a lower level of fertility at baseline, even chemo that we wouldn’t necessarily expect to impact fertility could end up impacting a patient.

So, there’s a lot of gray area in this, but we do know that specific classes of chemotherapy can sometimes lead to problems with fertility in the future.

At what point in a lymphoma diagnosis should fertility preservation be discussed?

I only see patients who are in the AYA age range – which is ages 15 to 39 – so I talk about it with every single one of my patients from the moment of diagnosis. Studies show that talking with patients about preserving fertility prior to therapy helps patients cope with the psychosocial stress of future family planning. Many patients are apprehensive to speak about family planning because they worry that there’s no way to preserve their fertility when facing a lymphoma diagnosis. But there are so many ways to preserve fertility now, and if a patient’s physician doesn’t bring up their options with them, it is something that patients should feel empowered and comfortable asking themselves.

What questions should patients ask their doctors about fertility after a cancer diagnosis?

Some of the most important questions a patient could ask are:

• Will treatment impact my future fertility, and if so, are there things that we can do now to try to preserve it for the future?
• Who can I speak to about the costs associated with fertility preservation?
• What is the timeline for preserving my fertility prior to receiving lymphoma treatment? Will delaying treatment impact my outcome?

What fertility preservation options are available for cancer patients?

Male fertility can be preserved through semen cryopreservation, which is the process of freezing semen to be used for insemination in the future. Then there’s two other ways that are surgically done for men to preserve their fertility. In some cases, sperm may be retrieved surgically from the testicles if ejaculation is not possible or sperm is not present in the ejaculate, and then the sperm is frozen for future use. The other surgical procedure is testicular tissue cryopreservation, known as TTC. In this procedure, pieces of testicular tissue are surgically removed, frozen, and stored. This procedure is experimental and is predominantly used on prepubertal boys who are not yet producing sperm.

For women, it is a bit more complicated. If the patient has hit puberty and has their period, that means the patient is probably producing eggs, and therefore, they can freeze their eggs. Egg freezing is achieved by stimulating the ovaries through the administration of hormones that help to produce multiple eggs, and then those eggs are extracted for later use through a procedure. You can also freeze embryos, which is similar to egg freezing, but the eggs are fertilized with sperm to create embryos, which are then frozen. The frozen embryos can be thawed and transferred to the uterus when the woman is ready to conceive. Embryos are traditionally more “shelf stable” – meaning they freeze and thaw better. This is a preferred method if you have a partner with whom you’re planning on building a family in the future. That all gets better, but that’s just kind of the nature of the beast of cancer itself impacting the body. Another option is called ovarian tissue cryopreservation (OTC), which involves surgically removing an ovary or portion of an ovary containing eggs, freezing the tissue, and potentially re-implanting it after cancer treatment or other medical conditions. This method is particularly useful for young women who may not have time to undergo egg or embryo freezing before starting cancer treatment, but it is very early in its use and still somewhat controversial.

How long do patients have to undergo fertility preservation before needing to start treatment?

Most patients who are of childbearing age who are diagnosed with lymphoma are typically diagnosed with Hodgkin lymphoma or subtypes of non-Hodgkin lymphoma like diffuse large B-cell lymphoma (DLBCL) or primary mediastinal B-cell lymphoma (PMBCL) – all of which are considered more aggressive types of lymphomas. However, unless a patient presents with significant symptoms, there’s usually time to be able to preserve fertility prior to starting treatment. There’s nothing in medicine or the world that is 100%, but I would typically say two to four weeks isn’t really going to change a patient’s stage or outcome significantly. However, overall, patients should discuss their options as soon as possible and take any desired action as quickly as they can.

What are the risks and success rates associated with fertility preservation methods?

The first and most unfortunate risk is that fertility preservation doesn’t always work as intended. Outside of that, if a patient opts for a surgical technique, there’s always a risk with any surgery. Anytime we break the skin with a needle or something else, there’s always a risk of bleeding or infections, but thankfully, those risks are relatively low for these types of procedures. There are also risks associated with hormonal therapy and the side effects from that. Overall, it is important to think and talk about any potential risks with your healthcare team prior to starting any fertility preservation technique.

What advancements are being made in onco-fertility research?

The biggest advancements are in the ways in which we are preserving fertility. One of the most exciting things we are investigating now is the effectiveness of using hormonal blockade, which in a way “puts the ovaries” to sleep and protects them from chemotherapy. We have traditionally used this for most women receiving chemotherapy, but it’s really unknown if it works well at all. However, we now have an active research study investigating if this is effective, and hopefully, in the near future, we can be able to tell people what the chances are of it working. The other advancements are in surgical methods to preserve fertility prior to chemotherapy initiation, discussed above.

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Megan Scherer, Co-Founder and Executive Director of Worth the Wait:

How does the possibility of infertility affect the emotional well-being of cancer patients?

Onco-fertility researcher Dr. Catherine Benedict at Stanford describes infertility after cancer as “double trauma.” These young patients have already dealt with so much, and facing the burden of infertility can be extremely emotionally taxing and isolating.

What challenges do cancer patients face in accessing fertility preservation services?

There are several challenges with accessing fertility preservation. The first is access to fertility preservation counseling. Some oncologists and/or care teams are talking with patients about the risks of infertility due to cancer treatment, but others are not. Without that initial conversation about how treatment might impact fertility, the patient is going in blindly, and in some cases, their ability to have a biological child is taken away.

For the patients who learn about their fertility preservation options, affording fertility preservation is a big challenge for most. Sperm banking costs several hundred dollars, egg freezing can cost $7,000-$10,000, and it’s even more to freeze embryos. Most young cancer patients don’t have enough money saved for these unexpected expenses, and that’s why fertility drug discount programs and nonprofits like Worth the Wait are so critical to ensuring patients can access fertility preservation.

Are fertility preservation treatments covered by insurance, or are they primarily out-of-pocket expenses?

Overall, most adolescent and young adult cancer patients don’t have insurance coverage for fertility preservation. Nineteen states have some sort of legislation that requires insurance coverage for fertility preservation. Still, those mandates have loopholes, so they only help a percentage of patients in those states (most exclude people on Medicaid). We hear that most patients are putting fertility preservation expenses on their credit cards, raising money through a GoFundMe, or getting support from family members.

How can cancer organizations and advocacy groups help raise awareness about fertility preservation?

Worth the Wait is partnering with many nonprofits like the Lymphoma Research Foundation to educate patients and clinicians about fertility preservation. We love bringing in reproductive endocrinologists to empower patients with options for fertility preservation and family building. Asking patients to share their personal stories about how they were or weren’t counseled is an effective way to humanize the challenges and opportunities with onco-fertility.

What advancements in fertility preservation can give hope to patients undergoing cancer treatment?

Egg freezing technology has come a long way since its experimental days, so females with and without partners can feel secure with that type of fertility preservation. Some clinics are starting to use AI to predict which eggs or embryos are the best quality. And there’s lots of research taking place with testicular cryopreservation that could aid pre-pubescent boys diagnosed with cancer.

What advice do you have for cancer survivors who want to start a family?

Don’t lose hope! Starting a family might not look like how you imagined it, but there are so many interventions and options, including donor eggs, sperm, adoption, and surrogacy.