When a cancer diagnosis is made, we as providers do everything possible to start treatment immediately. Often times we can overlook the value of reproductive health counseling, as we are focusing on providing swift interventions. Under certain circumstances it’s possible to delay starting treatment so the patient can explore fertility options. Under other circumstances treatment initiation can’t be delayed. In those instances we must provide information about fertility after cancer treatment and allow patients to explore fertility options when treatment completes.
As providers we must be mindful that the discussions should begin as close to diagnosis as possible. It’s believed that these discussions should also occur regardless of whether the treatment will affect fertility. Klosky notes that inclusion of fertility topic as part of patients’ treatment plan can alleviate concerns about infertility, encourage safe sex practices during treatment and promote future discussions. In addition, it’s important to realize that when patients lose their fertility it can lead to psychological distress which includes grief, depression, anxiety, anger, frustration and regret.
Some topics of discussion include contraception during treatment, sexuality for both males and females, ethical/legal concerns and even adoption and surrogacy. It’s important to recognize that not only chemotherapy can cause fertility challenges, but also radiation treatments, hormonal therapies, and targeted therapies. For example, female young cancer survivors may encounter early menopause, fertility challenges, and emotional distress. Adolescent male young cancer survivors can have azoospermia, but no change in sexual function, therefore discussion about sperm banking is of importance. According to Klosky, when male patients were questioned about fatherhood, 77% reported having the desire to have biological children.
Despite the fertility challenges these patients face there are alternatives that offer patients the opportunity for family planning. Family planning also incorporates consideration of cost associated with these options. For female patients the discussions incorporate more options. Bates, Taub and West note that female fertility preservation options include ovarian suppression, oocyte freezing, and freezing of embryos. Ovarian suppression or gonadotropin-releasing hormone treatment can protect the eggs from damage by preventing ovulation. Oocyte freezing is when eggs are removed and frozen unfertilized. This is an ideal option for patients without partners. Embryo freezing commonly occurs with female patients that have partners and is the most successful method of conceiving. This method removes eggs and they are fertilized by vitro fertilization by her partners’ sperm. The embryos are then frozen and saved for a later date.
For males, sperm banking is the most successful method. This should be done before the patient starts radiation therapy or chemotherapy. Male patients should be provided a private place for sperm collection and given ample time. This process typically takes anywhere for 2-4 hours. Sperm are collected frozen to be used at a later date.
Many may question what costs are associated with fertility preservation. Costs can vary by state and insurance. Some insurance companies partially cover theses services, while others require the patient to pay entirely out of pocket; some employers cover costs. Oocyte freezing costs about $6,000-$10,000 for collection; $600 cryopreservation/year and $4,000-$5,000 at thaw. Embryo preservation has initial costs of $8,000-$12,000 with about a $600 cost per year for cryopreservation and additional costs for thawing and implantation. Sperm banking is the least expensive and costs about $600 per year inclusive of collection and storage. These staggering numbers can be overwhelming to patients, but options should be explored.
The key to patient education starts with nursing education and providing nurses with the tools needed to make appropriate referrals and recommendations. These discussions with cancer patients of childbearing age give the patient and family something to consider, as it can impact their lives after cancer is treated and gone.
Jill E. Toledo is a registered nurse in New York, New York.
Bates GE, Taub RN, West H. Fertility and cancer treatment. JAMA. 2016;2(2):284.
Kim J, Mersereau JE, Su HI, Whitcomb BW, Malcarne VL, Gorman JR. (2016). Young female cancer survivors’ use of fertility care after completing cancer treatment. Support Cancer Care. 2016; 24(3):3191-3199.
Klosky JL, Simmons JL, Russell KL, et al. Fertility as a priority among at-risk adolescent males newly diagnosed with cancer and their parents. Support Cancer Care. 2015; 23:333-341.