Post-Treatment Family Building
Navigating your family-building options after cancer treatment is a critical part of survivorship. The first step is to understand your current fertility status. From there, you can explore pathways such as using gametes you may have preserved before treatment or considering third-party donation to help you achieve your family goals.
Fertility Testing
Once cancer treatment is over, patients are often anxious to learn about the status of their fertility.
Fertility Testing
Once cancer treatment is over, patients are often anxious to learn about the status of their fertility.
Fertility Testing For Women
Some women continue menstruating after cancer treatment. Others stop for a while before their periods continue. While menstruation may seem like a good sign for fertility, that isn’t always the case. It’s best to have comprehensive testing.
Cancer treatment can induce early menopause. So even if a woman still menstruates after treatment, it is uncertain how long she will continue.
The following blood tests can help estimate a woman’s ovarian follicle reserve:
- Follicle-stimulating hormone (FSH)
- Estradiol (E2) (on the third day of menstrual cycle)
- Anti-Müllerian hormone (AMH)
An ultrasound on the 3rd day of menstrual cycle can give clues on the number of remaining antral follicles, which contain maturing oocytes.
If applicable, a clinician should also check the health of a woman’s uterus, cervix, and fallopian tubes to make sure they are healthy enough for conception and carrying a pregnancy.
Fertility Testing For Men
Men’s fertility may be assessed in the following ways:
- Semen analysis. Laboratory experts can use semen samples to evaluate the number, motility, and morphology of sperm as well as the presence of any infections that might affect fertility.
- Sperm function tests. These tests examine how well sperm cells perform. Experts may look at how long sperm cells live after ejaculation and their ability to fertilize an egg.
- Hormone tests. Checking hormone levels and function can determine whether hormonal issues are affecting the count and quality of sperm.
- Urinalysis. Some men have retrograde ejaculation after cancer treatment. When they ejaculate, semen travels backward into the bladder instead of forward out of the urethra. Retrograde ejaculation can be confirmed if sperm is found in the urine.
- Genetic tests. Cancer treatment can change the DNA structure of sperm cells. Genetic testing can reveal any abnormalities.
References:
- American Society of Clinical Oncology (ASCO);“Fertility Concerns and Preservation for Men”;(Reviewed and approved: March 2014); http://www.cancer.net/coping-and-emotions/sexual-and-reproductive-health/fertility-concerns-and-preservation-men
- American Society of Clinical Oncology (ASCO);“Fertility Concerns and Preservation for Women”(Reviewed and approved: March 2014); http://www.cancer.net/coping-and-emotions/sexual-and-reproductive-health/fertility-concerns-and-preservation-women
- Mayo Clinic;“Male Infertility – Tests and Diagnosis”(June 13, 2014);http://www.mayoclinic.org/diseases-conditions/male-infertility/basics/tests-diagnosis/con-20033113
- OncoLink (Penn Medicine);Vachani, Carolyn, RN, MSN, AOCN;“Female Fertility and Cancer Treatment”;(Last modified: October 6, 2006); http://www.oncolink.org/coping/article.cfm?c=534&id=990
- OncoLink (Penn Medicine);Vachani, Carolyn, RN, MSN, AOCN;“Male Fertility and Cancer Treatment”;(Last modified: November 10, 2006); http://www.oncolink.org/coping/article.cfm?id=992&aid=1496
- Oncolog (MD Anderson Center);Munch, Joe;“Addressing Fertility Issues in Cancer Patients”;(January 2014);http://www2.mdanderson.org/depts/oncolog/articles/14/1-jan/1-14-1.html
Using Stored Gametes
Some patients are able to have gametes retrieved and frozen for the future.
When couples are ready to start families, the cells can be thawed and used accordingly.
Third Party Parenting
Third-party parenting involves the use of eggs, sperm, or embryos that are donated from a third person for the use of an infertile couple. Donors may be anonymous or they may be a friend or relative of the couple. It can also involve a surrogate or gestational carrier, who can carry the pregnancy if a woman cannot.
Third-party parenting can be a complicated process. Donors, surrogates, and gestational carriers must be thoroughly screened medically and psychologically before any procedures begins. Couples need to make important decisions about their relationship with the third party and come to terms with the emotional aspects of having another person involved with their family planning. Finally, the legal implications of third party parenting must be carefully considered and advice from an experienced attorney is highly recommended.
Using donor eggs is an option for women who have experienced ovarian failure or do not have their own oocytes available. However, they can still carry a pregnancy.
Egg donors may be found through a referral service or agency. Or, a friend or relative may volunteer to donate an oocyte to an infertile couple. It’s also possible that women who have undergone in vitro fertilization (IVF) have extra oocytes they are willing to donate.
Most donors are between 21 and 34 years old. Egg donors should be carefully screened for physical and mental health problems and tested for any infectious diseases. They should also provide information about their sexual history and family medical history.
Eggs cannot be retrieved immediately. The donor is given hormonal treatments to stimulate egg development first. When the eggs are ready, human chorionic gonadotropin (hCG) is injected to start ovulation.
Eggs are retrieved about 34-36 hours after this injection. In a procedure called transvaginal ultrasound aspiration, a clinician uses a needle to collect the eggs from the donor’s ovary.
At that time, eggs are fertilized in a laboratory with sperm from the recipient’s partner or with donor sperm.
As the donor gets ready for egg retrieval, the recipient is also preparing. When the donor starts her hormone treatments, the recipient starts estradiol treatments to prepare the endometrium for pregnancy. One day after the donor receives the injection of hCG, the recipient is given progesterone, which readies the endometrium for embryo transplant.
Three to five days after the eggs are fertilized, resulting embryos are transferred to the recipient’s uterus through a catheter. Extra embryos may be frozen for future use.
When donor eggs are used, the recipient is the biological mother of the child, but has no genetic relationship. Her partner (or sperm donor) has both a biological and genetic relationship to the child.
References:
- American Society for Reproductive Medicine;“Third-Party Reproduction: Sperm, egg, and embryo donation and surrogacy”;(2012);http://www.asrm.org/BOOKLET_Third-party_Reproduction/
- Up to Date;Sauer, Mark V., MD;“Oocyte donation for assisted reproduction”;(Topic last updated: January 29, 2014);http://www.uptodate.com (access via subscription only)
- Up to Date;Sonmezer, Murat, MD and Kutluk Oktay, MD, FACOG;“Fertility preservation in patients undergoing gonadotoxic treatment or gonadal resection”;(Topic last updated: December 4, 2014);http://www.uptodate.com (access via subscription only)
Infertile couples may obtain donor embryos from other couples who have undergone in vitro fertilization (IVF) and no longer need the embryos.
Screening of Donors
Most egg and sperm donors are subject to strict screening in accordance with guidelines from the U.S. Food and Drug Administration (FDA). However, couples who donate embryos usually create those embryos for their own use. As such, they might not undergo this screening process. Recipient couples should know whether their embryos’ donors have been screened and the risks involved if they have not.
When screened, donors should be tested for diseases such as HIV, hepatitis, syphilis, gonorrhea, and chlamydia. They should also give a complete medical history.
Assessing the Recipient Couple
Like the donors, the recipient couple should have their medical history evaluated and be screened for infectious diseases and mental health issues. A clinician will need to make sure that the recipient mother’s uterus is healthy enough for pregnancy, especially if she is over 45 years old.
Transfer of Embryos
Before embryos can be transferred, the recipient is given estrogen and progesterone to prepare her endometrium (lining of the uterus) for pregnancy. Once the endometrium is ready, the embryo(s) are transferred to the uterus through a catheter. The recipient continues with the hormone treatment until she tests positive for pregnancy. Once this occurs, she continues with the hormones through her first trimester.
Counseling
Using donated embryos can become complicated. It is recommended that recipient couples undergo counseling so that they fully understand the implications. Neither partner is genetically related to the child. The couple will need to determine how they will explain this situation to the child when he or she is old enough. They will also need to agree on whether the names of the donors will be revealed to the child. If so, then the type of relationship between donors and child will need to be discussed.
Legal Issues
Recipient couples are also encouraged to consult with an attorney who specializes in family planning. Couples should be aware of the parentage laws in their state and consider the liability implications associated with using donor embryos.
References
- American Society for Reproductive Medicine;“Embryo Donation”;(Fact sheet. Revised 2012);http://www.asrm.org/FACTSHEET_Embryo_Donation/
- American Society for Reproductive Medicine;“Third-Party Reproduction: Sperm, egg, and embryo donation and surrogacy”;(2012);http://www.asrm.org/BOOKLET_Third-party_Reproduction/
For couples who cannot use the male partner’s sperm, using donor sperm can be an option. In most cases, the donor is anonymous, but the couple may also ask a friend or relative to donate sperm.
Screening Donors and Specimens
Regardless the known or unknown status of the donor, it is recommended that all donors undergo a strict screening process. Screening should take place before the donation is made and at periodic intervals afterward.
Typically, donors submit their own medical history and provide medical information on at least two previous generations. Donors are also tested for infectious diseases. Current FDA regulations require that sperm donors test negative for diseases within 7 days of their donations. Anonymous donors are again screened every six months in accordance with FDA rules. Re-testing of known donors is not required, but the American Society for Reproductive Medicine recommends it.
Donors should also be evaluated and counseled by a mental health professional. It is important that donors understand their role in this type of third-party parenting, if any. They should also be clear about their expectations. Will their name be disclosed? What will their reaction if a child claims them as their father years later?
Sperm Donation and Processing
Sperm specimens are collected through masturbation after two to three days of abstinence. In most cases, more than one sample is collected. At least one test sample is frozen, thawed, and re-evaluated to see if the sperm meet minimum standards. As a guideline, samples should contain 20 – 30 million motile sperm per milliliter.
Most specimens are then quarantined for 180 days. If the donor tests negative for infectious diseases at the 6-month mark, then the samples are free to use. Samples are often “washed” – separated from the seminal fluid – increasing the chances that the healthiest, most motile sperm are inseminated.
Some donors provide recipient couples information about their appearance, race, education, hobbies, etc. Audio or video recordings may be provided as well.
Insemination
Both members of the recipient couple should have medical exams. A clinician should also evaluate the woman’s ability to conceive and carry a child.
Insemination may be scheduled in accordance with the woman’s ovulation cycle. Or, the woman may have ovulation induced with hormonal therapies.
The procedure itself can occur in a doctor’s office. Sperm is aspirated into a syringe and then delivered into the uterus through an insemination catheter.
References:
- American Society for Reproductive Medicine;“Third-Party Reproduction: Sperm, egg, and embryo donation and surrogacy”;2012);http://www.asrm.org/BOOKLET_Third-party_Reproduction/
- Up to Date;Ginsburg, Elizabeth S., MD and Serene S. Srouji, MD;“Donor insemination”;(Last updated: September 16, 2014);http://www.uptodate.com/contents/donor-insemination?source=search_result&search=artificial+insemination&selectedTitle=1~14
Surrogacy is an option for couples in which the woman cannot carry a baby to term. Instead, another woman undergoes the pregnancy.
A surrogate carries an embryo created from her own egg and a man’s sperm. She is the biological mother of the child and, therefore, a genetic relative.
A GC does not contribute her own egg. Instead, couples contribute their own gametes, which are fertilized in a lab. The resulting embryo is then transferred to the uterus of the GC. The child is considered the biological offspring of the parents, although the GC might be called the birth mother.
In both scenarios, the couple usually adopts the child at birth. Sometimes, a declaration of parentage is made beforehand.
Using a surrogate or a GC can be an emotional – and costly – route. Agencies can assist in finding a suitable third party, although some couples choose to have a friend or family member carry the baby. Surrogates and GCs should be carefully evaluated for any medical or psychological issues, as well as for drug and alcohol use.
Emotionally, all parties should be on board with the plan, including the surrogate’s partner, if she has one. They will need to decide how to handle any complications during the pregnancy, such as medical issues, treatments, or loss of wages if the surrogate is unable to work. In addition, they will need to think about how involved the surrogate will be involved in the child’s life.
Couples should be counseled on the expenses involved with this type of family building. They may need to consider whether their surrogate will be compensated or if they will pay for expenses incurred during the pregnancy.
Finally, couples should be aware of legal issues that may develop during the pregnancy or even afterward. For example, considerations must be made if there are multiple births or if fetal reduction is needed. For all aspects of the arrangement, parties need to agree on who the decision makers are.
References:
- American Society for Reproductive Medicine;”Gestational Carrier or Surrogacy”; https://www.asrm.org/topics/topics-index/gestational-carrier/
- American Society for Reproductive Medicine;”Third-party Reproduction: Sperm, egg, and embryo donation and surrogacy”;(2012);https://www.asrm.org/topics/topics-index/third-party-reproduction/
- National Infertility Association;”What is Surrogacy?”;https://resolve.org/what-are-my-options/surrogacy/