February 16, 2021
What is fertility preservation?
Fertility is the ability to conceive or have a biological child (a child that is related by blood to the parent). This requires an oocyte (an immature egg) and a sperm cell. Oocytes are made by girls/ women in the ovaries and sperm cells are made by boys/men in the testes (testicles). In general, making healthy oocytes and sperm cells requires a child to have almost or completely finished puberty.
In some cases, children or adolescents need treatments that may hurt their ability to make healthy oocytes or sperm cells, leading to infertility (loss of fertility). Fertility preservation refers to certain medical procedures that can be done before starting such treatments, such as chemotherapy, to help maintain or preserve fertility. Sometimes, fertility preservation can be done after cancer therapy if the ovaries or testicles are still working.
What kinds of treatments may affect fertility?
Cancer treatments, such as certain chemotherapy drugs and radiation of the ovaries or testicles, can harm the ovaries and testicles.
Transgender patients are also at risk for infertility if they take cross-sex hormones. Examples of cross-sex hormone therapy are when a biologic female is treated with testosterone to develop male-like features or when a biologic male is treated with estrogen to develop female-like features.
Not all patients with cancer and not all transgender patients are at risk for infertility. Your child’s doctor should counsel you on the risks associated with your child’s treatment plan and discuss fertility preservation options before starting these treatments. Do not hesitate to ask your child’s doctor about your child’s ability to have biological children in the future.
What options are available to help preserve fertility?
Girls: For girls who have gone through puberty (had a first period), oocyte preservation (also called egg banking) is an option. For this procedure, girls will receive medications that cause their bodies to produce eggs. A doctor will then surgically remove the eggs and freeze them for later use. Egg banking typically takes about 2 weeks from start to finish.
Ovarian suppression is a procedure where girls are given a medication to put ovaries in an inactive state. Making the ovaries inactive means that they temporarily do not work. Doing this temporarily during treatment is thought to help prevent damage to the ovaries. This method is still considered experimental, since long-term studies have not been completed to prove that this works for everyone.
For girls who have not undergone puberty (are prepubertal), ovarian tissue preservation is an option. In this case, some tissue from the ovaries is surgically removed and frozen for use later in life. While there have been live births using this technique, it is still considered experimental, which means that long-term studies have not been completed to prove this works in everyone. If you would like to pursue ovarian tissue freezing, please discuss possible referral opportunities with your provider.
For both prepubertal and pubertal girls who need to have radiation treatments directed at the pelvis (where the ovaries are located), the ovaries can be covered (gonadal shielding) to decrease their radiation exposure. In cases where shielding is unlikely to protect the ovaries, the ovaries can be moved surgically to another part of the body so that they are protected from the direct effects of the radiation. This is called ovarian transposition.
Boys: For boys who have undergone puberty, sperm banking is an option. This requires boys to be able to masturbate to produce a semen sample, which is then frozen for later use. While masturbation does not cause physical harm, some boys may not be able to do it because they are very ill or emotionally distressed.
For boys who have not undergone puberty (prepubertal), testicular tissue preservation is an option. In this case, some tissue from the testicles is surgically removed and frozen for use later in life. Once again, this method is experimental and there have not yet been live births using this method. Your provider may be able to refer you to the right facility, if you would like to pursue testicular tissue freezing.
For prepubertal and pubertal boys treated with radiation that may involve the testes, gonadal shielding (where the testicles are physically covered) to help decrease radiation exposure may be an option.
Not all procedures described above will be options for every patient. It is important to talk with your child’s doctor to determine which procedures are possible and may work for your child.
If a patient undergoes a procedure for fertility preservation, does that mean he/she/they will be able to have a child naturally?
No, fertility preservation does not guarantee that someone will be able to conceive a child naturally. When ready to start a family, most patients who have had treatments affecting fertility will need to see a specialist in Reproductive Endocrinology and Infertility (REI) to discuss what options are available. At this time, the most used option is called in vitro fertilization (IVF) where the egg is fertilized by a sperm cell in a laboratory dish then transplanted into the uterus.
Is fertility preservation covered by insurance?
Fertility preservation is often not covered by insurance. At this time, fertility preservation is considered an ‘elective’ or ‘voluntary’ procedure. You should contact your insurance company to find out what procedures are covered by your child’s policy. Cost varies depending on the procedures used. Unfortunately, currently, fertility preservation is expensive. If your child is part of a research study, typically many of the costs are covered by the facility performing or funding the study. Ask your doctor about assistance programs that are available to help with the cost of fertility preservation.
Feelings about infertility?
For most families, learning about the need for fertility preservation is overwhelming, especially when this discussion immediately follows the diagnosis of cancer. Sadness and a sense of loss regarding the potential loss of having biological children (and grandchildren) should be anticipated. Infertility often impacts self-esteem and gender identity. The child with cancer may feel that he/she/they has/have been hit by a “double whammy” – cancer diagnosis and potential infertility. Girls may perceive a loss of femininity. Boys and girls may feel pessimistic about future romantic relationships. You should not hesitate to share these feelings with your child’s doctor and members of your child’s healthcare team. A child psychologist may be able to help with addressing such feelings.
Clinical Report: Counseling in the Pediatric Patient at Risk for Infertility and/or Sexual Function Concerns https://pediatrics.aappublications.org/content/142/2/e20181435
Clinical Report: Preservation of Fertility in Pediatric and Adolescent Patients with Cancer https://pediatrics.aappublications.org/content/121/5/e1461