BY DARCY LEWIS

For many of us, family planning includes a host of questions, from when to have a family to how many children to have. For some, that list of questions also includes: Are there health limitations that might prevent us from having a family—and if so what help is available to help us achieve our goal? And for those who face life-changing health events, the need to answer such questions may come sooner rather than later—if they want to preserve the option of having biological children in the future.

KENAN OMURTAG, MD, DISCUSSES FERTILITY PRESERVATION WITH A PATIENT.

Photo by Mike Speckhard

But people facing such challenges don’t have to make decisions about their future reproductive options alone, says Kenan Omurtag, MD, WashU Medicine fertility and reproductive medicine specialist at Barnes-Jewish Hospital. “We often see patients who have concerns about their fertility. Our role is to help them assess their reproductive options, including fertility preservation,” he says. “Fertility preservation is a great tool for anybody confronted with a threat to their reproductive organs.”

Specialists in reproductive endocrinology and infertility are experts in fertility preservation, a process that saves or protects eggs, sperm and reproductive tissue, thus making the choice to have biological children an option for the future. “Even if fertility is not a priority for someone during their initial crisis, we reassure them that there are many ways to build a family. Fertility preservation options have become accessible,” Omurtag says.

For Lindsay Kuroki, MD, MSCI, a WashU Medicine gynecologic oncology specialist at Barnes-Jewish Hospital who also treats patients at Siteman Cancer Center, the process begins with a single question: Are you interested in preserving your fertility? “I know it’s often too much for patients to really process at the time, but I tell them that, fortunately, we can offer treatment options,” she says. “But those treatment options are heavily dependent on how they answer that one important question.”

Threats to fertility

Many people may find themselves facing situations that can affect their fertility, including:

• - Endometriosis and uterine fibroids
• - Cancer and the onset of treatment
• - An autoimmune disease, such as lupus, and the onset of treatment
• - A genetic disease
• - Gender dysphoria and gender-affirming treatment
• - Exposure to toxic chemicals
• - A plan to delay having children until later in life, when fertility may not be as reliable

Fortunately, effective standard-of-care fertility preservation treatments are available for both male and female patients.

PEOPLE HOPING TO PRESERVE FERTILITY HAVE A NUMBER OF OPTIONS THEY CAN DISCUSS WITH THEIR PHYSICIAN, INCLUDING CRYOPRESERVATION, IVF, OVARIAN TRANSPOSITION AND RADICAL CERVICECTOMY

Illustration courtesy of Shutterstock

Preserving male fertility

Men—and boys in puberty—who are facing cancer treatment that may affect fertility can preserve sperm before the cancer treatment begins. Samples are collected then sent to a lab, where specialists analyze and prepare them for storage using a freezing solution. The samples can then be held in liquid-nitrogen tanks indefinitely until the donor is ready to use them.

Preserving female fertility

When women or girls who have reached puberty face fertility threats, they can talk with a fertility specialist about their options, one of which is in vitro fertilization (IVF). Also known as oocyte cryopreservation, this process requires two to three weeks to complete, says Omurtag.

“During that time, the patient undergoes egg stimulation via injected hormone medications that stimulate the ovaries,” he says. “When the eggs are mature, we retrieve them using a simple, outpatient, transvaginal surgical procedure to remove all available eggs.”

After the 20- to 30-minute retrieval procedure is complete, a specialist examines the eggs for maturity. The more mature the eggs are, the more likely they are to be successfully fertilized later. Harvested eggs are quickly frozen to sub-zero temperatures and then stored in tanks of liquid nitrogen in an embryology lab.

Fertility-sparing surgery

Kuroki and other WashU Medicine gynecologic oncologists at Siteman Cancer Center offer a variety of fertility-sparing techniques that can help people preserve their fertility after a diagnosis of gynecologic cancer.

One such option, called ovarian transposition, involves moving the ovaries to a different location in the abdominal cavity. This procedure may be done separately or during a larger surgery to remove the cancer. The goal is to locate the ovaries away from areas of the body that might be damaged during any postoperative radiation therapy the patient receives.

“We suture the ovaries above the anticipated field of radiation in the pelvis, being careful to preserve the ovaries’ blood supply so they can continue to function,” Kuroki says. After cancer treatment is complete, pregnancy is possible without medical assistance if the fallopian tubes remain present and undamaged. If the fallopian tubes are not available, then IVF can be used.

For women with early-stage cervical cancer who want to preserve fertility, gynecological oncologists at Siteman Cancer Center, including Kuroki, can offer a surgery known as radical trachelectomy or radical cervicectomy. In this procedure, the surgeon removes the cervix, nearby lymph nodes and the upper part of the vagina. The remaining section of the uterus is then attached to the remaining section of the vagina. With functioning ovaries and uterus still in place, pregnancy is possible.

It’s also worth noting that, in addition to surgical interventions, fertility may also be preserved by using special shielding during radiation therapy for cancer. This option can help protect testicles and ovaries during treatment. Radiation therapy protocols are also improving rapidly, helping to ensure that treatment precisely targets the cancer while sparing as much healthy tissue as possible.

The value of coordinated care

When considering fertility preservation options, Kuroki encourages people to choose a health care center where coordinated care is the norm. In coordinated or multidisciplinary care, physicians of different specialties work together to benefit the patient. “It’s hard to overestimate the value of having collaborative multidisciplinary care, especially when planning cancer treatment,” Kuroki says.

For example: After a conversation with a patient and the patient’s consent, Kuroki has the option to perform oocyte retrieval while the patient is under anesthesia for a procedure to diagnose cancer. Combining the two procedures can spare extra expense and worry. “For a variety of reasons, it takes a lot of coordination to make this work. But when it’s an option, it’s a significant benefit for the patient,” she says.

Kuroki also emphasizes the value of having a multidisciplinary tumor board available to provide guidance when a cancer diagnosis is known or suspected. All National Cancer Institute-designated cancer centers, including Siteman Cancer Center, based at Barnes-Jewish Hospital and WashU Medicine, have tumor boards made up of specialists from various disciplines who meet regularly to devise treatment plans for patients with cancer. (To learn more about tumor boards, see the story on Page 22.)

If a treatment plan includes fertility preservation, a fertility and reproductive medicine specialist will join the tumor board’s array of medical, surgical and radiation oncologists, as well as pathologists and other specialists. “It’s important that we all agree on a plan, including the time-sensitive nature of stimulating the ovaries,” Kuroki says.

The purpose of each of the many preservation options available is to offer the potential for future fertility while safely protecting a patient’s health. “In each situation,” Kuroki adds, “we consider the benefits and potential complications of delaying current treatment long enough to preserve fertility.”