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

08/24/2019 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 Date Subhead goes here OBJECTIVES • To understand the role of fertility preservation (FP) in oncology • To be able to counsel an oncology patient on fertility preservation options • To know how to contact MU Reproductive Health and Fertility Center 1

08/24/2019 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 of the Oncofertility Consortium 2

08/24/2019 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 oncology treatment commences 3

08/24/2019 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 4

08/24/2019 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 5

08/24/2019 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 6

08/24/2019 OVARIAN TRANSPOSITION • Division of utero- ovarian ligament and fixation of ovary in para-colic gutter • Sometimes combined with cryopreservation of contralateral ovary • Does not always prevent future infertility OVARIAN SUPPRESSION • Alkylating agents are most potent in inducing ovarian failure • Younger women are less affected • MOPP = 46 percent ovarian failure • Administration of gonadotropin-releasing hormone (GnRH) agonists or oral contraceptives 7

08/24/2019 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 8

08/24/2019 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 9

08/24/2019 HETEROTOPIC TRANSPLANTATION • Heterotopic is considered investigational • First ongoing pregnancy undergone bilateral oophorectomy 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 10

08/24/2019 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 of reproductive age and younger • Men: Advanced Paternal Age is 45 years (60 y) • Women: Advanced Maternal Age is 35 years (42 y) 11

08/24/2019 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? HOW MUCH TIME DO WE HAVE? • Date of Last Menstrual Period 12

08/24/2019 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 13

08/24/2019 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 14

08/24/2019 IVF: Manipulation of Normal Physiology FSH E 2 Preventing Ovulation • Birth control pill • Lupron • Ganirelix • De-programs hypothalamic/pituitary axis • Prevents ovulatory/LH surge. 15

08/24/2019 Stimulation of Follicles Using FSH (follicle stimulating hormone) to stimulate follicles Ultrasound Guided Oocyte Retrieval 16

08/24/2019 The Fertilization Procedure Intracytoplasmic Sperm Injection (ICSI) OOCYTE CRYOPRESERVATION Embryos at the Blastocyst Stage 17

08/24/2019 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 18

08/24/2019 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 19

08/24/2019 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 of 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 20

08/24/2019 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 21