Fertility Option After Cancer Treatment – Ovarian Tissue Transplant

The development of better cancer treatments has resulted in much improved survival rates for cancer patients, which in turn, has led to many new options and concerns. One of the many concerns for young female cancer patients is the high risk of premature ovarian failure as a result of the life saving cancer treatments. The risk of ovarian failure varies depending on many factors:

•The patient’s age
•Area or field of  irradiation

Additionally, the type of chemotherapy used plays a huge role, with the group called alkylating agents posing the greatest risk. This group includes:

•Busulfan
•Chlorambucil
•Cyclophosphamide
•Ifosfamide
•Nitrosoureas
•Melphalan
•Procarbazine

Bone marrow transplantation is thought to be most responsible for ovarian failure with 80% of patients experiencing premature failure.

New Treatment Therapies
Until very recently, fertility treatment centers could offer those patients very few options. Today, one of the most exciting and promising treatment options is the cryopreservation of ovarian tissue as a method of preserving fertility. This treatment option is best for patients too young or are otherwise not a candidate for egg or embryo banking.

What is Cryopreservation of Ovarian Tissue?
Cryopreservataion of ovarian tissue is performed before radiation or chemotherapy treatments and does not require ovarian stimulation. Performed at a fertility treatment center or at an oncofertility center, an ovary is removed from the patient and then frozen. The outpatient laparoscopic procedure takes under an hour, is simple, done under general anesthesia and is not especially painful. Recovery time is minimal and patients can begin cancer treatments in a few short days after the procedure.

Usually within 5 years, after the patient is cleared of cancer, the ovarian tissue is then grafted back onto the patient’s fallopian tubes, and in many cases, restores fertility.

Areas of Concern
Patients should make sure that their physician is very familiar with medical oncology, histopathology and reproductive endocrinology. Although no cancer recurrance from ovarian grafts has been reported has been reported yet to date, it is still a concern. Not every patient is a candidate for the procedure and type of cancer plays a critical role in whether or not this therapy is a suitable option. Of particular concern is breast cancer, as this cancer metastasizes haematogenously.

A thorough evaluation of the tissue must be made to rule out any metastasis.  Additionally, a physician may find the procedure is not an option for young breast cancer patients as the patient may be harboring certain gene mutations which may also harbor a co-existing primary ovarian cancer.

The occurrence of ovarian cancer in women under the age of 35 is rare, but it is still a risk that should be considered. Patients with endometrial cancer are also not considered candidates. As promising as the treatment may be, not every treatment is right for every patient. Cryopreservataion of ovarian tissue is still a very new procedure and any concerns should be discussed with your fertility treatment center reproductive endocrinologist.

Early Endometriosis – Surgical Treatment Leads to Unexplained Fertility Outcomes

Fortunately for those who have experienced difficulty conceiving, many significant advances have been made in reproductive diagnosis, treatment and technology. These advances have helped fertility treatment centers to determine the individual causes of infertility and develop an optimum treatment strategy for many couples.

Endometriosis and Unexplained Infertility
However, even in light of these advances, some causes and contributing factors in infertility remain elusive or disputed. Endometriosis, for example, remains a source of controversy. While it is widely accepted that advanced stage endometriosis causes a significant disturbance of the pelvic anatomy which can cause infertility. The impact of early endometriosis is not as clear.

What Is Endometriosis
Endometriosis is a common gynecological disease which occurs in  3-10% of women of reproductive age. In women experiencing infertility, the rate increases to between 20 and 40% of that population. It is defined by the American Medical Association, as the presence of endometrial cells outside of the uterus that may result in pain and infertility.

How Does Endometriosis Develop?
Although not fully not understood, it is thought that the disease develops as a result of the drainage of menstrual debris, cells and blood, back into the abdomen and pelvis through the fallopian tubes. Genetics are likely to also play a contributing role, as women with close relatives suffering from the disease are nearly 7 times more likely to develop the disease.

Clinical Diagnosis
There are several possible ways of diagnosing endometriosis, with varying levels of accuracy. A fertility treatment center may base a diagnosis on the presence of pelvic pain, excessive menstrual pain, and painful intercourse. However, not all patients, even with advanced cases experience pain. A physical examination confirm the presence of the disease, but also may not be reliable or conclusive. Frequently, a diagnosis is reached based on the exclusion of possibilities. The most reliable form of diagnosis is surgical.

Does Surgical Treatment of Endometriosis Improve Fertility?
Many studies have been done to determine the pregnancy rate between women who were surgically treated for endometriosis and those using controlled ovarian hyperstimulation and intrauterine insemination, and the verdict is still out. Part of the problem is that a clear understanding of the association has yet to be determined.

However, it has been established that the management of the disease through medications alone does not positively impact a person’s ability to become pregnant. The question then becomes, which is more effective; surgical treatment or COH- IUI? In many randomized trials, fertility treatment centers found that women with early stage endometriosis and surgically treated did see an increased rate of pregnancy, as did those using COH-IUI.

Fertility Treatment Centers Help Develop Treatment Strategy
There is much data to support that ablative therapy is as effective as surgical therapies but must be considered on a case by case basis. Most fertility treatment centers agree that management plans for couples experiencing unexplained infertility and endometriosis must be individualized based on many clinical factors, such as:

• The stage of endometriosis
• The age of patient
• The anatomy
• The duration of infertility
• Other contributing factors

Based on your individual clinical profile, your fertility treatment center will develop a plan that is most likely to yield positive results. Discuss your options with your physician.

For many couples experiencing fertility problems, in-vitro fertilization can seem like the one last hope at having the baby that they so desire. Already they have endured months of quenched hopes when they come to the fertility treatment center and embark on an emotional journey of treatment. Most people do expect fertility treatments to be a hard and emotional process-but few are aware of the true magnitude. The process is grueling, both physically and psychologically, and there is little way to prepare for it except through experience.

The Emotional Process of IVF
Since IVF has the highest success rates, and often considered the last course of action, it  is difficult to leave room for the possibility of failure. Seemingly endless trips to the fertility treatment center, shots, date checking, temperature taking, and scheduling all take the forefront of the relationship leaving little room for much else. The days are filled with expectation, and the relationship is consumed with this one goal.

Financial Factors
In addition to the monthly cycle of high hopes and deep disappointments, the couple often begins to feel financial pressures mounting. No doubt most couples would give up anything to have a child, but it does not mean that it will come without difficulty, or that other unexpected expenses will not arise.

After Failed IVF
Many couples experience a wide range of feelings after an IVF failure. There are likely strong feelings of grief, disappointment, and even guilt. The woman may not only feel a deep loss for herself, but also a terrible guilt in not being able to conceive and carry a child her partner so longs for. There may be some secret resentments, however unreal, unreasonable or unfair.  There may be some regret in investing so much of their  time, money and energy into something, only to be so terribly let down.

Grief
As hard as the in-vitro fertilization process can be, while in it, there is always at least the hope of future success. If the IVF process has not been successful, the emotions can range from deep disappointment to a deep depression. Initially, the hopelessness can be overwhelming. Grief has as a schedule unique to each person that can not be forced, hurried or ignored. The good news is; grief does have an end. The time spent in the fertility treatment process with all the hopes and dreams, will remain important and vivid, but the emotions will eventually become bearable.

The Good News
While experiencing depression is a real and reasonable reaction, it does have an end. Studies show that even though infertility can shake the foundations of a relationship, most develop a core strength that others, not experiencing the hardship, do not have. One study notes that an overwhelming majority of couples successfully take an alternate path to parenthood.
Getting on Track
The key to getting through the most difficult times is getting the right help. After  and unsuccessful procedure, the fertility treatment center is like to be able to connect you to professionals that deal specifically with the issues you are facing. Most fertility treatment centers also have support groups to offer the unconditional support of common experience.

A couple experiencing infertility faces an emotional journey filled with many questions and considerations. After choosing a reputable fertility treatment center, it is important to discuss those concerns with the reproductive endocrinologist in the development of a treatment plan.

One of the most common concerns about fertility treatment is whether or not there is a connection between fertility medications and ovarian cancer. Early reports suggested a strong link, but those reports have since been challenged. This concern has been at the center of debate and research for over a decade with experts falling on both sides of the argument.

Recent Studies in ovarian Cancer and Fertility Medications
One of the most in depth studies to date exploring the possible link between fertility medications and ovarian cancer found no convincing association between the two. The study, which was published in the February 2009 British medical Journal followed a group of women under the care of a fertility treatment center and given either gonadotropins, clomiphene citrate, human chorionic gonadotropin, or gonadotropin-releasing hormones, and were compared with women who were not given the drugs.

The study, which is consistent with other recent studies, did calm some fears but did not completely rule out a possible cancer link. The study did note a slight elevation in the instances ovarian cancer and the use of clomiphene, but so low that it cold be a statistical aberration.

The Early Data
One of the major flaws in 1990s research was that it compared statistics from the general population of mostly fertile women with data collected from women being treated at fertility treatment centers, which makes the data skewed. Conversely, critics also note that the study did not follow women long enough and many cases of ovarian cancer occur past the age of 45 where the study ended.

Most Resent Studies
Another recent study suggested that there may be an increased risk of ovarian cancer for those who took clomiphene citrate for more than 12 cycles, compared to those who took the medication for less than 12 cycles. Though the results are unclear and the actual incidence of ovarian cancer very low, it is recommended that individuals considering fertility treatments consult their physician and ask about the fertility treatment center’s practice regarding clomiphine citrate.

Understanding Ovarian Cancer
The risk for developing ovarian cancer in a woman’s lifetime is between 1-2%. Women with certain conditions that may cause them to seek the help of a fertility treatment center such as endometriosis or “unknown infertility” are at a higher risk of developing the disease.
The known causes are multifactorial and include:

• Early onset of menses
• Irregular cycles
• History of untreated infertility
• Never having children

The study also notes that some factors may help reduce a woman’s risk of developing ovarian cancer. Some of those factors include:

• Use of oral contraceptives
• Removal of ovaries
• Late onset of Menses
• Early onset of menopause
• Repeated pregnancies
• Prolonged lactation

Though most studies either find no link, or the incidence is low and the connection unclear, most fertility treatment centers will suggest each patient weigh the desire of having a child against any possible risks.

Surgical Reversal of Tubal Ligation Versus IVF
As one of the results of divorce and subsequent remarriage, a common question posed to fertility treatment centers is whether microsurgical tubal reversal (MTR) or IVF is a better option to attain pregnancy when no other factors contribute to infertility. Both options are clinically reasonable and each woman should become educated about the advantages and disadvantages of each before making a decision.

About Tubal Ligation Reversal Surgery
Tubal ligation reversal is a procedure that rejoins the segments of the fallopian tubes so that eggs can become fertilized. It was once primarily performed in an inpatient situation, requiring 3 hours of surgery, several day hospital stay and month long recovery though things have vastly improved. Fertility treatment centers now perform tubal reversals as an outpatient procedure, frequently using laparoscopy technology; greatly reducing pain, recovery time and procedure expense.

Pregnancy Success Rates After Tubal Ligation Reversal
It is difficult to get specific estimates on the success rates for pregnancy after tubal ligation reversal because not as many studies have been done and, like in IVF, success varies between fertility treatment centers. While studies do suggest that IVF has a higher immediate success rate, it is limited to the amount of procedures a patient can afford, should it not be successful or more children are wanted. The opportunity to conceive after a reversal of tubal ligation is limited only by the couple’s individual contributing fertility factors.

Contributing Factors
As in any course of fertility treatment, it is difficult to know the exact possibility of success or failure. Whether it is success or failure, for the patient experiencing it; it is 100%. It is however possible to know the facts and weigh the possibilities in the balance.

• Before making a decision, it is advisable to know the male partner’s sperm quality. If it is poor and either low in count or motility, it may necessitate and IVF procedure.
• Age of the patient in any fertility treatment is always a consideration. The chances of pregnancy significantly decrease at age 43.
• The status of the tubes also plays an important part. The length of the remaining stumps can determine increase the patients chances if they are longer or decrease the chances if they are shorter. The condition of the fimbria at the end of the tube which essentially pick up the egg upon release, also determines the chances of success.
• Current pelvic conditions. The amount, extent and location of scar tissue can impact the successful outcome after a reversal.

Advantages of Tubal Reversal
There are two main advantages to a surgical reversal of a tubal ligation. One is that because no fertility medication is used, the multiple pregnancy rate is only 2% compared with 25% for IVF treatment. The second major advantage is that there is no need to have another procedure to try to achieve another pregnancy.

When weighing the options, it is important to discuss the options with the reproductive endocrinologist and know the preference of the fertility treatment center, as well as their expertise in tubal reversals.

By the time many couples reach the fertility treatment center, they are ready for a little hope; and according to many recent studies, there is good reason to have it. The traditional course of treatments most patients take may change as more options are offered.

Choosing the most Common Course of IVF Treatments
Patients come to the fertility treatment center because their greatest hope is to have a child. They are soon met with various treatment options, depending on their individual diagnosis. Very often, the course of treatment chosen is greatly impacted by the affordability of the treatment and whether or  not insurance will cover that particular treatment. Frequently, the less effective treatments are tried repeatedly before resorting to the treatments infrequently covered by insurance. While IVF has the highest success rates, it is often considered a last resort treatment because it is the most expensive.

Standard Protocol

•    3 cycles of clomiphene citrate/intrauterine insemination (CC/IUI)
•    3 cycles of gonadotropin/intrauterine insemination (FSH/IUI)
•    No more than 6 cycles of  in-vitro fertilization (IVF)

Accelerated Protocol

•    3 cycles of clomiphene citrate/intrauterine insemination (CC/IUI)
•    No more than 6 cycles of  in-vitro fertilization (IVF)

New Study  Offers a New Course for Hope
A major study recently found that an accelerated path to in-vitro fertilization (IVF) can offer couples beginning fertility treatments a shorter, more cost effective way to pregnancy. This is great news for fertility treatment centers wanting to offer patients as many options as possible. Elizabeth Ginsburg, President of the Society for Assisted Reproductive Technology, commented in a July 2009 Science Daily article, “This is a very important study that will likely influence physicians to reduce the number of stimulated inseminations for patients with unexplained infertility. Adoption of such an accelerated course of treatment could result in many patients conceiving in less time with less expense.”

The accelerated treatment, know as FASTT for “fast track and standard treatment trial,” eliminates the gonadotropin-stimulated artificial insemination cycle that usually precedes assisted reproductive technology . In the study, 503 couples were divided in to two groups. One group underwent traditional therapy with an average of 11 months until pregnancy. The other, underwent the accelerated protocol resulting in an average 8 months until pregnancy.

Success Rates of Accelerated Infertility Treatments
Fertility treatment centers believe the treatment protocol has a huge potential for many patients. The study showed the results very favorable, with 55.4% of patients achieving pregnancy undergoing standard protocol and 65.4% achieving pregnancy undergoing the accelerated protocol.

Cost Effectiveness
With many patients faced with the economics of infertility treatments at fertility treatment centers, the new study has the potential to put IVF as first choice. The study concluded that the use of follicle stimulating hormones and intrauterine insemination treatment did not add value to the fertility process and therefore could be eliminated, also eliminating added cost. The average savings per delivery of treatment was nearly $10,000 lower than standard treatment, a savings which can open the doors to many patients.

What are the side effects of IVF?
For many couples experiencing infertility, in vitro fertilization (IVF) treatments offer their best chance at conception, yet it is not without some considerations. IVF requires a commitment of time, money, emotion, and some physical risks. Before beginning the IVF process, it is important research the risks, as well as the benefits of the process with the reproductive specialists at your fertility treatment center.

Expected Side Effects
The in vitro fertilization process involves suppressing the normal menstrual cycle so the reproductive endocrinologist can induce ovulation when it is optimum to harvest the eggs. The treatment includes frequent blood tests and nasal spray or injection of hormonal drugs, and some bruising can be expected.  Since the menstrual cycle is suspended for a short time, a patient may experience some menopausal symptoms that include:

• Hot flashes
• Mood Swings
• Nausea
• Headaches

Most women experience only mild side effects but any severe headaches or vision disturbances should be discussed with your physician.

Side Effects of Stimulation
Most fertility treatment center protocols require the patient continue to take the suppression drugs while on the stimulation drugs, to prevent premature ovulation. The symptoms women experience from the stimulation drugs vary, and most experience them only minimally.

• Abdominal Bloating
• Fatigue
• Diarrhea
• Weight gain
• Nausea

It is important to discuss any concerns with your physician at the fertility treatment center.

Ovarian Hyper Stimulation Syndrome (OHSS)
OHSS is a potential complication from any fertility drug and is a condition in which the ovaries produce many follicles which become larger than usual. Most commonly, the condition is mild and improves without intervention. However, severe cases can lead to blood clots and kidney failure. Symptoms include:

• Bloating
• Abdominal pain
• Rapid weight gain (As much as 10 pounds within 3-5 days)
• Decreased urination
• Nausea
• Vomiting
• Shortness of breath

Severe OHSS has only been reported in 3-8% of IVF cycles. Fertility treatment centers closely monitor each patient for OHSS, and encourage patients to discuss any concerns with their physician. Fertility treatment centers also reduce the risk of severe OHSS by:

• Reducing the dosage of fertility drugs
• Withholding the human chorionic gonadotrpin (hCG)
• Proceed with egg retrieval but freeze embryos for a later cycle

Egg Retrieval and Embryo Transfer
During the process of egg retrieval, the physician uses a vaginal ultrasound to guide the insertion of a needle through the vagina into the ovary to retrieve eggs. The procedure is performed under sedation or anesthesia. The risks are minimal, but do include:

• Discomfort during or after the procedure
• Possible injury to organs near the ovaries such as the bladder, blood vessels and bowel.
• Bleeding from ovary or pelvic vessels
• Pelvic infection

During Embryo transfer, a patient may experience cramping, bleeding or spotting during the procedure. Infrequently, infections develop. Though the problems many be minimal, it is important to report them to your fertility treatment center and physician.

Is Ovarian Cancer a Risk?
Despite early reports of a possible connection between fertility treatments and ovarian cancer, recent studies fail to provide convincing evidence of any connection. However, fertility treatment centers understand the concern and encourage the patient to discuss their concerns.

When fertility problems are experienced, a number of treatment plans are available depending on the underlying cause or causes of the diminished ability to conceive, length of infertility and the age of the person trying to conceive. To identify those causes, a patient should visit a reputable fertility treatment center for a thorough evaluation.

Infertility is usually defined as the inability to conceive after two or more years of trying. Factors inhibiting conception can be caused by the male or female, a combination of factors from both male and female, or of unknown causes. Fertility treatment centers specialize in finding the cause of fertility problems and developing a plan of treatment to help achieve conception.

Male Fertility Issues
Fertility problems most frequently experienced in men may include general sexual problems or problems with the production of sperm or its ability to reach the egg. A thorough examination by a physician specializing in reproductive health can help identify and treat these problems.

Treatment for male fertility treatments, may include:

• Medication
• Behavioral changes
• Diet and exercise modifications
• Surgical intervention
• Hormones
• Assisted Reproductive Technology

Treatment for women experiencing fertility problems may include:

Fertility Drug Interventions

• Clomid- Clomiphene citrate is the most widely used fertility drug and usually the first level of intervention.
• Femara and Arimidex – most commonly used to induce ovulation in women with ovulation disorders.
• Gonadotropins- hormonal medications

Surgical Interventions
Many conditions can play a role in the ability to conceive such as cervical narrowing, scar tissue, blocked fallopian tubes, fibroids, endometriosis or abnormal shape of the uterus. Fertility treatment centers offer surgical interventions that can be used to correct cervical, pelvic, tubal or uterine problems.

Intrauterine Insemination (IUI)
Commonly known as artificial insemination (AI) is a process where sperm is “washed” and injected directly into the uterus. This intervention is sometimes used in cases involving male infertility, when conditions of the woman’s cervical mucus necessitates, or in unidentified fertility problems. Though more affordable than IVF, success rates with this treatment vary at each fertility treatment center and are generally not as high as with IVF.  More info about IUI treatment.

IUI, or intrauterine insemination, is a relatively simple infertility treatment and the procedure involves a small tube being specially placed with washed sperm directly into the females uterus. You may hear others call Intrauterine Insemination (IUI) by its’ more commonly used term artificial insemination (AI). But, keep in mind that  IUI and AI are one and the same fertility treatment.

Why IUI?

When considering fertility treatments above and beyond fertility drug use, IUI artificial insemination may be the first tried by many couples. It’s an easier method than assisted reproductive technologies, like IVF, and  the costs for this type of fertility treatment are much less than other treatment options. According to a survey done by RESOLVE, the average IUI fertility treatment costs $895 (compared to $8,000 to $15,000 for IVF).

IUI may be used in some cases of male factor infertility diagnosis,  such as low sperm counts or if a sperm donor is being used for artificial insemination. IUI may also be used if the woman’s cervical mucus is less than the ideal situation.  Also, in cases of unexplained fertility issues, IUI may be tried if fertility drugs like Clomid (clomiphene citrate) don’t help.

IUI may also be used if a couple would like to avoid the higher cost of IVF treatment. Even though IUI artificial insemination is less effective per cycle than IVF, a couple may be able to afford more attempts with IUI.

IUI is pretty simple and while fertility drugs are not always used, most doctors choose to use an ovulation drug like Clomid to increase the chances of success when using IUI treatment for fertility.

Whether or not you’re using fertility drugs, you’ll probably be asked to use an ovulation predictor at home during the cycle that treatment is planned for. Once you detect the LH surge (the hormone that is highest right before ovulation and detected by ovulation kits), you’ll need to call your doctor.

The IUI Process

Assuming you’re not using a sperm donor, your partner will be given instructions for sperm collection (either at home or at the fertility treatment center.) The doctor will then “wash” the collected sperm and the doctor will place the sperm directly into the women’s uterus via the cervix.   This treatment is usually painless, with maybe a little cramping. It is performed in the doctor’s office, and the procedure can be done by a nurse or a doctor.

In reviewing the success rate for IUI artificial insemination, just 4% of women got pregnant per cycle without fertility drugs, and 8% to 17% got pregnant when fertility drugs and IUI were combined.

Though IVF success rates per cycle are much higher, IUI is significantly less expensive, and a much easier procedure.  So, If IVF is out of your price range, multiple IUI cycles might be the better choice, depending on the cause of infertility.