Oncofertility Shvetha M. Zarek, M.D., FACOG Assistant Professor of - - PDF document

08/24/2019 1

Date Subhead goes here

Oncofertility

Shvetha M. Zarek, M.D., FACOG Assistant Professor of Obstetrics and Gynecology Director of IVF, MU Reproductive Health and Fertility Center Division of Reproductive Endocrinology and Infertility

OBJECTIVES

• To understand the role
• f fertility preservation

(FP) in oncology

• To be able to counsel

an oncology patient on fertility preservation

• ptions
• To know how to contact

MU Reproductive Health and Fertility Center

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INTRODUCTION

• Oncofertility refers to the

interdisciplinary field at the intersection of oncology and reproductive medicine that expands fertility options for cancer survivors

• Term was coined in 2006 by
• Dr. Teresa K. Woodruff from

Northwestern University

OC: National Physicians Cooperative

• The NPC was originally

comprised of four core centers: Northwestern University, University of Pennsylvania, Oregon National Primate Research Center and University of California, San Diego

• 91 Institutions in 37 countries
• MU Health is a proud member
• f the Oncofertility

Consortium

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CRITICAL NEED

• Advances in oncology

treatment have led to higher survival

• Survivors are faced

with infertility

• 1 in 12 cases detected

before 40 years

• Delayed childbearing

also plays a role ESSENTIAL COMPONENT OF CANCER CARE

• Men and Women with a new

cancer diagnosis are interested in fertility preservation

• Oncology Providers MUST

address possible infertility related to oncology treatment

• It is key to provide fertility

preservation BEFORE

• ncology treatment

commences

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FERTILITY PRESERVATION METHODS FOR MEN

MALE FERTILITY PRESERVATION

• The Guys are easier…
• Sperm Banking,

Testicular sperm extraction, testis shielding

• Post Pubertal Males

can ensure fertility preservation by cryopreserving sperm

• Our facility includes a

full andrology laboratory and suite

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MALE FERTILITY PRESERVATION

• TESE- performed near

Andrology Laboratory

• Sperm Extraction

directly from the testes

• Requires co-

management with Urology team

FERTILITY PRESERVATION METHODS FOR WOMEN

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FEMALE FERTILITY PRESERVATION

• Oocyte cryopreservation
• Embryo cryopreservation
• Ovarian Transposition
• Ovarian Suppression
• Ovarian Tissue

Cryopreservation Orthotopic v Heterotopic transplantation

OVARIAN TRANSPOSITION

• Option when pelvic

radiation is to be part of treatment

• Strongly recommended

in pre pubertal females requiring radiotherapy

• Does not provide

complete protection, as radiation can scatter

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OVARIAN TRANSPOSITION

• Division of utero-
• varian ligament and

fixation of ovary in para-colic gutter

• Sometimes combined

with cryopreservation

• f contralateral ovary
• Does not always

prevent future infertility OVARIAN SUPPRESSION

• Alkylating agents are

most potent in inducing

• varian failure
• Younger women are less

affected

• MOPP = 46 percent
• varian failure
• Administration of

gonadotropin-releasing hormone (GnRH) agonists

• r oral contraceptives

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OVARIAN SUPPRESSION

• Effective?... Not really
• No evidence that GnRH

agonist co-treatment improves spontaneous pregnancy

• Not a reliable method of

fertility preservation OVARIAN CRYOPRESERVATION

• Only FP option for

prepubertal girls

• Ovarian cortical tissue

is removed via laparoscopy

• Strips of 1mm thickness

to promote early revascularization

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OVARIAN CRYOPRESERVATION

• 2017 meta-analysis:
• 309 OTTs = 84 live birth

and 8 ongoing pregnancies

• 37.7 percent live birth rate
• 64% had restored

endocrine function

• Allows for spontaneous

conception ORTHOTOPIC TRANSPLANTATION

• Orthotopic is preferred
• Reconstructed on a

human extracellular matrix

• Not performed until

woman is ready to conceive

• 2-5 months to restore

function

• Now considered a

standard clinical technique

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HETEROTOPIC TRANSPLANTATION

• Heterotopic is considered

investigational

• First ongoing pregnancy

undergone bilateral

• ophorectomy for a

granulosa cell tumor

• Ovarian stimulation with

retrieval of two oocytes followed by IVF with intracytoplasmic sperm injection. FEMALE FERTILITY PRESERVATION

• Oocyte cryopreservation
• Embryo cryopreservation
• Ovarian Transposition
• Ovarian Suppression
• Ovarian Tissue

Cryopreservation Orthotopic v Heterotopic transplantation

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HOW TO COUNSEL A PATIENT WITH A NEW CANCER DIAGNOSIS ABOUT FP

ONCOFERTILITY COUNSELING

• Fertility Preservation

should always be a component of counseling for anyone

• f reproductive age and

younger

• Men: Advanced

Paternal Age is 45 years (60 y)

• Women: Advanced

Maternal Age is 35 years (42 y)

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ONCOFERTILITY COUNSELING

• Important to have a

multi disciplinary approach to convince patient to have a FP consultation

• www.savemyfertility.org

iPhone App

ONCOFERTILITY COUNSELING

• Male/Female
• Age
• Previous Childbearing
• Type and Staging of

Diagnosis

• Plan for Oncology

Treatment

• Co-Morbidities-

Previous h/o thromboembolism?

• Date of Last Menstrual

Period

HOW MUCH TIME DO WE HAVE?

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FERTILITY MEDICATIONS

• Commons Medications

used

• Low Dose Birth Control

Pills

• GnRH agonist
• GnRH antagonist
• FSH (recombinant)
• Menotropin (75 IU FSH

& 75 IU LH)

• Hcg
• Prophylactic

Anticoagulation CONTACT MU REPRODUCTIVE HEALTH

• Dr. Danny Schust- REI

Division Director

• Dr. Shvetha Zarek- IVF

Director

• Dr. Albert Hsu- REI and

IVF Physician

• Dr. Hsu and Dr. Zarek

perform IVF procedures

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CONTACT MU REPRODUCTIVE HEALTH

• We are located on the

Women’s and Children’s Campus

• Keene Medical

Building, Suite 203

• Clinic Number:

(573) 817-3101

• Goal is for patient to

have a consult within 24 hours, even over the phone

OOCYTE AND/OR EMBRYO CRYOPRESERVATION

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IVF: Manipulation of Normal Physiology

FSH E2

Preventing Ovulation

• Birth control pill
• Lupron
• Ganirelix
• De-programs hypothalamic/pituitary axis
• Prevents ovulatory/LH surge.

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Stimulation of Follicles

Using FSH (follicle stimulating hormone) to stimulate follicles

Ultrasound Guided Oocyte Retrieval

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The Fertilization Procedure

Intracytoplasmic Sperm Injection (ICSI)

OOCYTE CRYOPRESERVATION

Embryos at the Blastocyst Stage

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Embryo transfer LOGISTICS OF CRYOPRESERVATION

• Livestrong provides

free or significantly discounted fertility medications

• Scholarships require a

good amount of paperwork

• Consent forms cover

nuts and bolts of storing oocytes and embryos at MU

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LOGISTICS OF CRYOPRESERVATION

• Livestrong provides

free or significantly discounted fertility medications

• Scholarships require a

good amount of paperwork

• Consent forms cover

nuts and bolts of storing oocytes and embryos at MU ANY CANCERS WHERE FP IS NOT AN OPTION?

• Estrogen Sensitive

cancers

• Letrozole, aromatase

inhibitor, can be used

• Breast cancer patients

who undergo ovarian stimulation do not appear to have an increased risk of disease recurrence or death

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ANY CANCERS WHERE FP IS NOT AN OPTION?

• GYN related cancers

provide the most potential for seeding during oocyte retrieval

• Decision to move

forward with FP would be in close conjunction

• f oncology team

CONCLUSION

• MU Fertility Team is

always on call to provide a fertility preservation consult

• Need for further options

for prepubertal patients

• Oocyte and embryo

cryopreservation are excellent options

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CONTACT INFORMATION

• Dr. Albert Hsu
• (573) 817-3203
• hsual@health.missouri.edu
• Dr. Shvetha Zarek
• Mobile: (703) 608-5039
• Email: zareks@missouri.edu
• Instagram: drzarekinfertility