Oncofertility is an expanding subspecialty that bridges oncology, reproductive endocrinology and assisted reproductive technology to improve the options for the reproductive future of cancer survivors. Oncofertility is becoming the standard of care in prepubertal, adolescent and young adult cancer patients who are at risk of infertility due to their cancer or gonadotoxic treatment. Westmead Fertility Centre has been providing oncofertility services since 1989. We describe two cases that highlight the challenges encountered in oncofertility.
The first case is an 18-year-old female with newly diagnosed Hodgkin’s lymphoma. She initially presented with spinal cord compression requiring immediate surgical decompression. Urgent chemotherapy was indicated due to high tumour burden. The challenge in this case is ensuring patient safety whilst preserving fertility with minimal delay to cancer treatment. The patient underwent ovarian stimulation with Gonadotrophin-releasing hormone (GnRH) antagonist protocol and oocyte collection under local anaesthesia without complications.
The second case is a 39-year-old female with newly diagnosed triple positive breast cancer. She has a long-term partner and has no children. The challenge in this case is to minimize estrogen exposure on estrogen receptor positive breast cancer during ovarian stimulation. The patient underwent ovarian stimulation with letrozole cover which effectively attenuated the estrogen level to that of an unstimulated cycle.
In both cases, fertility preservation was achieved without compromising patient safety and cancer treatment owing to the advances in assisted reproductive technology. The knowledge in reproductive physiology enabled the manipulation of the hypothalamic-pituitary-ovarian axis to achieve multiple follicular recruitment through ovarian stimulation. GnRH antagonists are used for pituitary suppression to prevent premature ovulation and to override dominant follicle selection whilst exogenous gonadotrophins are used to enable the maturation of multiple follicles. Ovarian stimulation has become an integral part in fertility preservation for female cancer patients with impending gonadotoxic treatment.