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FERTILITY PRESERVATION PROGRAM
The University of Illinois Fertility Preservation Program offers a comprehensive team approach
to help women faced with serious conditions which may impair future fertility. Our team
consists of reproductive endocrinologists, medical and surgical oncologists, rheumatologists,
pathologists, embryologists, research and clinical nurses, social workers and clinical ethics
consultants who are here to help.
Drs. Bert Scoccia and Jennifer Hirshfeld-Cytron at the University of Illinois Fertility Center are
Board Certified/Eligible specialists in Reproductive Endocrinology and Infertility.
1.
Bert Scoccia, MD
Professor of Obstetrics and Gynecology
Director of the Division of Reproductive Endocrinology and Infertility
Medical Director of the University of Illinois IVF Program.
2.
Jennifer Hirshfeld-Cytron, MD
Assistant Professor of Obstetrics and Gynecology
Director of the University of Illinois Fertility Preservation Program
We will be happy to discuss our Fertility Preservation Program and any other issues with you
during an office consultation.
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1801 West Taylor Street, Suite 4A, Chicago, IL 60612
To make a new patient appointment, please call:
UIC Call Center at 800-842-1002 or visit www.uicivf.org.
Existing patients please call:
UIC Fertility Center at 312-355-2740.
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INTRODUCTION
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The American Cancer Society estimates that in 2008, 700,000 women will have a
cancer diagnosis.
More than 11,000 breast cancer patients are diagnosed under the age of 40 each
year.
21% of gynecologic cancer patients are diagnosed under the age of 45.
The number of cancer survivors in the United States has increased from 3 million in
1971 to 10 million in 2001!
Over the past few decades 80-90% of patients with Systemic Lupus Erythematosus
(SLE) survive at least 10 years
Women of reproductive age with severe SLE are sometimes treated with
Cyclophosphamide, an Alkylating agent which may cause premature ovarian failure
(POF) and loss of future reproductive potential
Other severe Autoimmune Diseases such as Rheumatoid Arthritis, Systemic Sclerosis,
and Sjogren Syndrome are sometimes treated with Cyclophosphamide, putting women of
reproductive age at risk for POF
PATIENT CONSIDERATIONS
Patients of reproductive age with cancer and severe autoimmune disease need to be
informed about future fertility options as they undergo their treatment.
The American Society of Clinical Oncologists has issued Fertility Preservation
Guidelines which state:
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“As part of informed consent, prior to therapy, oncologists should address
the possibility of infertility with patients as early in treatment planning as
possible.”
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INDICATIONS FOR FERTILITY
PRESERVATION
A patient who is faced with a decision to preserve future fertility due to malignant or
non-malignant conditions must take into account her age at diagnosis, ovarian
involvement, time available prior to treatment initiation, type of cancer or severe
autoimmune or rheumatic disease, and proposed treatment plan. This is a partial list of
conditions which are amenable to fertility preservation:
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Breast Cancer
Cervical Cancer
Severe Autoimmune Disease
Patients Undergoing Pelvic Radiation
Stem Cell Transplantation
Leukemia
Non-Hodgkin Lymphoma
Severe Endometriosis
Turner Syndrome (Mosaic)
FERTILITY PRESERVATION OPTIONS
1. Patients who want to address future fertility concerns need to take into
account the timing during their treatment process, since this will impact the
fertility preservation options available. Options are listed according to their
medical status (Routine or Investigational Procedure).
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Before treatment starts:
o Stimulated Egg Retrieval, In Vitro Fertilization and Embryo Freezing (Routine
Procedure)
o Unstimulated Egg Retrieval, In Vitro Maturation, In Vitro Fertilization and
Embryo Freezing (Investigational Technique)
o Ovarian Transposition (Surgical repositioning of the ovaries away from
the radiation field – Routine Procedure)
o Stimulated Egg Retrieval and Egg Freezing (Investigational Technique)
o Unstimulated Egg Retrieval, In Vitro Maturation and Egg Freezing
(Investigational Technique)
o Ovarian Tissue Freezing (Investigational Technique)
o Radical Trachelectomy (Surgical removal of the cervix in patients with
cervical cancer while retaining the uterus – Routine Procedure)
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During treatment:
o Radiation Shielding of the Ovaries (Routine Technique)
o Ovarian Medical Suppression (Investigational Technique)
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After treatment completion:
o Frozen Embryo Thawing and Transfer (Routine Procedure)
o In Vitro Fertilization with Donor Eggs (Routine Procedure)
o Frozen Egg Thawing, In Vitro Fertilization and Embryo Transfer
(Investigational Technique)
o Embryo Transfer with Frozen Donor Embryos (Routine Procedure)
o Embryo Transfer to a Gestational Surrogate (Routine Technique)
o Adoption (Routine Practice)
o Frozen Ovarian Tissue Thawing and Transplantation with or without In Vitro
Fertilization and Embryo Transfer (Investigational Technique)
2. Patients need to take into account their current status with respect to a
partner or sperm donor. Options are listed according to medical status
(Standard or Investigational).
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Women without a male partner may wish to consider:
o In Vitro Fertilization with Anonymous Donor Sperm and Embryo
Freezing (Standard Technique)
o Egg Freezing (Investigational Technique )
o Ovarian Tissue Freezing (Investigational Technique)
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Women with a male partner may wish to consider:
o In Vitro Fertilization and Embryo Freezing (Standard Technique)
o Egg Freezing (Investigational Technique)
o Ovarian Tissue Freezing (Investigational Technique)
3. Patients should also discuss with a fertility specialist the decrease in future fertility
which occurs with advancing maternal age. In particular, there is a significant
decrease in the number of eggs available (about 25,000 per ovary) at the age of 37
years.
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RISK of PREMATURE OVARIAN FAILURE
The risk of permanent lack of menstrual cycles (amenorrhea and/or premature ovarian
failure) in a woman of reproductive age following treatment for cancer or severe
rheumatologic and autoimmune diseases depends on factors such as a patient’s age,
chemotherapy agent used and/or pelvic radiation therapy dosage. Chemotherapy and
radiation therapy may directly damage or destroy the eggs in the ovaries, which can
lead to premature menopause. Radiation to the pelvis can also lead to impairment in the
lining of or blood flow to the uterus.
The following are estimated risks of premature ovarian failure (listed from highest to
lowest) and, consequently, loss of future fertility potential in a patient of reproductive
age:
RISK
High
>80%
TREATMENT
1. High Dose External Beam Radiation to the Ovaries:
 Adult women > 6 Gy
 Post-Pubertal girls> 10 Gy
 Pre-Pubertal girls > 15 Gy
(Gy-Gray: Absorbed Dose of Radiation)
2. Bone Marrow Transplant or Stem Cell Transplant
 Alkylating Agent Chemotherapy (Cyclophosphamide, Busulfan
or Melaphan) in preparation for transplant
3. Breast Cancer Combination Chemotherapy in Women over 40 Yrs:
 Alkylating Agent Chemotherapy (Cyclophosphamide, Busulfan or
Melaphan) plus Methotrexate, Fluorouracil, Doxorubicin plus
Epirubicin
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RISK
TREATMENT
Intermediate
~ 30-70%
1. Breast Cancer or Severe Autoimmune Disease
Chemotherapy in Women 30-39 Yrs:
 Alkylating Chemotherapy (Cyclophosphamide, Busulfan
Melphalan or Chlorambucil)
2. Breast Cancer Combination Chemotherapy in Women over
40 yrs:
Alkylating Agent Chemotherapy (Cyclophosphamide,
Busulfan or Melaphan) plus Doxorubicin
RISK
Low
<20%
TREATMENT
1. Breast Cancer or Severe Autoimmune Disease Chemotherapy
in Women less than 30 Yrs:
 Alkylating Agent Chemotherapy (Cyclophosphamide,
Busulfan, Melaphan or Chlorambucil)
2. Breast Cancer Combination Chemotherapy in Women less
than 40 Yrs:
 Alkylating Agent Chemotherapy (Cyclophosphamide, Busulfan
or Melaphan) plus Doxorubicin
3. Cancer Chemotherapy for :
 Leukemia (ALL, AML)
 Non Hodgkin Lymphoma
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RISK
TREATMENT
Very Low/
None
Individual Chemotherapy or Radiotherapy Agents:
 Vincristine
 Methotrexate
 Fluorouracil
 Radioactive Iodine131
RISK
TREATMENT
Unknown
New Chemotherapy or Antibody Agents :
 Taxanes (Paclitaxel-Taxol, Docetaxel-Taxotere)
 Oxaliplatin (Eloxatin)
 Irinotecan (Camptosar)
 Bevacizumab (Avastin)
 Cetuximab (Erbitux)
 Trastuzumab (Herceptin)
 Erlotinib (Tarceva)
 Imatinib (Gleevec)
FERTILITY PRESERVATION OPTIONS
A. Before Treatment Starts :
1. Ovarian Stimulation, Egg Retrieval, In Vitro Fertilization and Embryo
Freezing
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Most commonly used fertility preservation option
Standard technique used for more than 30 years
Requires 4-6 weeks for ovarian stimulation, egg
retrieval, egg fertilization and embryo freezing
Elevated estrogen/progesterone levels may impact cancer
prognosis in patients with hormone sensitive cancers
Pregnancy rates per embryo transfer range from 10% to 40%,
depending on the patient’s age
Frozen embryos stored successfully up to 15 years
Costs: About $10,000 plus fertility medications (~ $5,000) and about
$400/year fee for long term storage of frozen embryos
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Patients who are not covered by medical insurance should be aware that
the UIC IVF program offers a complete IVF cycle for under $10,000.
Certain tests and procedures are excluded and medications are not
included in this package. Please contact Sandy Young at 312-4138779 for more information.
2. Unstimulated Egg Retrieval with In Vitro Maturation, In Vitro Fertilization
and Embryo Freezing
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Investigational (research) technique which requires Institutional Review
Board approval
Requires 1-2 weeks for egg retrieval, in vitro maturation, fertilization
and embryo freezing
No fertility drugs required
There is no rise in estrogen or progesterone hormone levels
Pregnancy rate per embryo transfer in women <35 years is 40%
There are 1,000 live births reported
Costs: $10,000 plus $250/year fee for long term storage of frozen
embryos
3. Ovarian Stimulation, Egg Retrieval and Egg Freezing
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Investigational (research) technique which requires Institutional Review
Board approval
Requires 4-6 weeks for ovarian stimulation, egg retrieval and egg
freezing
Approximately 2-5% live birth rate per thawed oocyte (>200 live births
reported)
Pregnancy rate per embryo transfer varies according to freezing technique:
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Computerized slow egg freezing 1-10%
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Immediate egg vitrification 20-40%
Costs: About $10,000 plus fertility medications (~$5,000) and about
$250/year fee for long term storage of frozen eggs
4. Unstimulated Egg Retrieval with In Vitro Maturation and Egg
Freezing
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Investigational (research) technique which requires Institutional Review
Board approval
Requires 1-2 weeks for egg retrieval, in vitro maturation and egg
freezing
No fertility drugs required
No rise in estrogen or progesterone hormone levels
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Pregnancy rate per embryo transfer in women <35 years is 20%
Approximately 2% live birth rate per thawed egg (>200 live births
reported)
Costs: $10,000 plus $250/year fee for long term storage of frozen eggs
5. Ovarian Tissue Freezing
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Investigational (research) technique which requires Institutional Review
Board (IRB) approval
UIC is part of the Oncofertility Consortium and we have received IRB
approval to obtain ovarian tissue from patients who are at risk of losing
future fertility to study the best ways to freeze and then thaw frozen
ovarian tissue and eggs
Outpatient laparoscopic removal of one ovary
Tissue divided into small strips and frozen in the laboratory
Costs: About $13,000-15,000 for outpatient surgery and about $250/year
fee for long term storage of frozen ovary
6. Surgical Transposition of the Ovaries
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Standard surgical technique used to reposition the ovaries away from the
pelvis in patients who are scheduled to undergo pelvic radiation therapy
Must be done before pelvic radiation begins if no chemotherapy is
administered
Laparoscopy outpatient surgery can be done to “shield” the ovaries behind
the uterus or high in the abdomen, away from the field of radiation
Ovarian function after treatment may be compromised up to 50% of the time
due to decreased blood supply to the ovaries or radiation scatter
Costs: About $13,000-15,000 for outpatient surgery
7. Radical Surgical Removal of the Cervix (Trachelectomy)
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Standard surgical technique to remove the cervix in patients with invasive
cancer (stages Ia and Ib) in order to preserve the uterus and ovaries for
future fertility
Involves inpatient surgery
It does not increase the risk of cancer recurrence in appropriately selected
patients (cervical cancer stages Ia and Ib)
Costs included in the treatment for cervical cancer
B. During Treatment:
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1. Ovarian Medical Suppression
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Investigational (research) technique which requires Institutional Review
Board approval
Must be started before chemotherapy begins
Requires 6 weeks for ovarian suppression and has to be administered
throughout chemotherapy
Severe menopausal side effects (hot flashes and vaginal dryness)
Few randomized trials with mixed results
No benefit in women undergoing high-dose chemotherapy with stem cell
transplantation
Costs: Each monthly injection costs about $1,000
2. Ovarian Radiation Shielding
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Standard technique which reduces the radiation exposure to the ovaries when
patients are being treated with radiation away from the pelvis
Involves shielding of the pelvis with a lead apron
Does not protect against toxic effects of chemotherapy to the ovaries
Costs are included with the radiation therapy
C. After Treatment Completion:
1. Frozen Embryo Thawing and Transfer
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Standard technique for patients who were able to store embryos prior to
undergoing treatment
Must have a functioning uterus to carry the frozen/thawed embryo
Patient must use estrogen and progesterone supplementation in order to
prepare the lining of the uterus to accept and carry the embryo during the
first few weeks of pregnancy
Overall frozen embryo survival ranges from 50%-70%
Pregnancy rates per frozen embryo transfer range from 10-40%,
depending on the age of the patient at the time of her egg collection,
fertilization and embryo freezing
Costs: Frozen Embryo Transfer charges range from $2,000-$4,000 plus
about $2,000-$3,000 for medications.
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2. Frozen Egg Thawing, In Vitro Fertilization and Embryo Transfer
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Investigational (research) technique which requires Institutional Review Board
approval
This technique is for patients who, after informed consent, were able to
freeze eggs prior to undergoing treatment
Requires several steps: Thawing of the eggs, In Vitro Fertilization of the eggs
with the partner’s sperm or the sperm of an anonymous sperm donor, and
Embryo transfer
Must have a functioning uterus to carry the embryo
Patient must use estrogen and progesterone supplementation in order to
prepare the lining of the uterus to accept and carry the embryo during the
first few weeks of pregnancy
Approximately 2-5% live birth rate per thawed oocyte (>200 live births
reported)
Pregnancy rates per embryo transfer vary according to freezing technique:
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Computerized slow egg freezing 1-10%
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Immediate egg vitrification 20-40%
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In Vitro Maturation and immediate egg vitrification 10-20%
Costs: Egg thawing and In Vitro Fertilization charges range from $1,500$2,000. In addition, Embryo Transfer charges range from $1,500-$2,000
plus about $2,000-$3,000 for medications
3. Egg Donation
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Standard technique for patients who have premature ovarian failure
after treatment and desire to use donor eggs
UIC has had an active egg donation program for more than 15 years
Patient needs to recruit a known or an anonymous egg donor and the eggs
can then be fertilized with either her partner’s sperm or an anonymous
donor’s frozen sperm
Patient will be able to carry the baby, but she will not have the same genetic
relationship to her child
The donor has to undergo ovarian stimulation with fertility drugs and egg
retrieval
Patient must have a functioning uterus to carry the baby
Patient must use estrogen and progesterone supplementation in order to
prepare the lining of the uterus to accept and carry the embryo during the
first few weeks of pregnancy
Pregnancy rates per donor embryo transfer range from 35-50%, depending
on the age of the egg donor
Counseling should be considered by couples considering egg donation due to the
emotional stress involved
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Costs: Anonymous egg donor charges range from $12,000-$15,000. In
addition, charges for ovarian stimulation, egg retrieval and fertilization, and
embryo transfer range from 15,000-20,000
4. Embryo Donation
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Standard technique for patients who develop premature ovarian failure after
treatment and desire to use donor embryos.
Frozen donor embryos are donated to help childless couples
Patient and her partner will be able to have the baby, but neither of them will
have the same genetic relationship to their child
Must have a functioning uterus to carry the donated embryo
Patient must use estrogen and progesterone supplementation in order to
prepare the lining of the uterus to accept and carry the embryo during the
first few weeks of pregnancy
Pregnancy rates per frozen donor embryo transfer range from 10-40%,
depending on the age of the embryo donor
Counseling should be considered by couples considering embryo donation
due to the emotional stress involved
Costs: Frozen Donor Embryo charges range from $2,000-$7,000. In addition,
the costs for frozen embryo transfer range from $2,000-$4,000 plus about
$2,000-$3,000 for medications.
5. Gestational Surrogacy
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Standard technique for patients who are unable to carry a pregnancy
A gestational surrogate is a woman who is willing to carry the pregnancy, but
has no genetic relationship to the child
The child has the same genetic makeup of the couple, but not of the
surrogate
Patients may also choose to use donor eggs and/or donor sperm in order to
produce embryos, which can then be transferred to the gestational
surrogate
Pregnancy rates per embryo transfer range from 10-40%,
depending on the age of the patient who is having the eggs retrieved
Patients considering gestational surrogacy should contact a reproductive
rights attorney in order to understand the surrogacy laws in their state
Counseling should also be considered by couples considering gestational
surrogacy due to the emotional stress involved
Costs: Gestational Surrogacy charges range from $50,000-$100,000
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6. Adoption
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Standard procedure to help couples who would otherwise not be able to have
a baby
For a domestic adoption a couple needs to decide between an independent
(non-agency) adoption and an agency adoption. There are also not-forprofit and for-profit organizations
For an international adoption a couple will be adopting a child from another
country and will need to follow the laws of that country
Clearly a couple considering adoption will need proper legal advice in order to
undertake this process
The adoption process takes between 1-5 years
Counseling should be considered by couples considering adoption due to the
emotional stress involved
Resolve is a national infertility association which can offer practical guidance to
couples seeking to pursue adoption. For more information please visit resolve.org
The American Society for Reproductive Medicine (www.asrm.org) also provides
patient information and has a fact sheet on adoption which may be helpful to
couples considering this process
Costs: An agency or international adoption plus legal advice charges may range
between $15,000-$25,000
7. Ovarian Tissue Thawing
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Investigational (research) technique for patients who were able to freeze and
store strips of ovarian tissue prior to undergoing treatment
There are several ways in which the thawed ovarian tissue can be used:
o Reimplantation of a strip of ovarian tissue back into the pelvis followed by
either natural conception or In Vitro Fertilization and Embryo Transfer
o Insertion of a strip of ovarian tissue under the skin in the arm or in the
abdomen followed by In Vitro Fertilization and Embryo Transfer
o Retrieval of immature eggs from the thawed ovarian tissue and In Vitro
Maturation in the laboratory followed by fertilization and embryo
transfer
There is a risk that the ovarian tissue that is being reimplanted after cancer
treatment may contain some cancer cells and the cancer may recur
Subsequent surgical placement back in the body after cancer treatment
Ovarian transplant lifespan: 3 months to 3years
As of 2007 six live births reported
Costs: The surgery to reimplant the ovarian tissue in the pelvis is about
$13,000-$15,000. In Vitro Maturation of the eggs, fertilization and embryo
transfer charges are about $10,000.
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FERTILITY AFTER CANCER TREATMENT
1. Women who have been treated for cancer or severe rheumatologic and
autoimmune diseases should consider having ovarian reserve testing within
4-6 months after treatment. Current tests for ovarian reserve include:
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Hormone tests:
o FSH and Estradiol at the beginning of the menstrual cycle
o Anti-Mullerian Hormone any time during the menstrual cycle
o Inhibin-B at the beginning of the menstrual cycle
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Ovarian Ultrasound
o Antral Follicle Count at the beginning of the menstrual cycle
2. Patients who are interested in future fertility should be evaluated for lung, heart,
kidney and liver damage due to chemotherapy or radiation therapy prior to
pregnancy
3. Some patients may have a genetic condition in which the cancer actually runs in the
family and can be transmitted from one generation to the next one. We have listed a
partial list of some of the genetic syndromes which can lead to familial cancer:
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Hereditary Genetic Syndromes
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Hereditary Breast/Ovarian Cancer (BRCA1 and BRCA2)
Familial adenomatous polyposis (Colon Cancer)
Hereditary Nonpolyposis Colorectal Cancer
Li-Fraumeni Syndrome (Bone, Breast, Brain, Adrenal or Soft-tissue
Cancer)
Multiple Endocrine Neoplasia Type 2A (Thyroid or Adrenal Cancer)
Neurofibromatosis 1and 2 (Brain, Spinal, Nerve or Skin Cancer)
Retinoblastoma (Eye, Brain, Bone or Skin Cancer)
Tuberous Sclerosis (Kidney or Brain Cancer)
Von Hippel-Lindau Disease (Kidney, Adrenal or Pancreas Cancer)
Patients with Hereditary Genetic Syndromes may benefit from pre-pregnancy
genetic counseling and testing
Patients with Hereditary Genetic Syndromes may want to consider In Vitro
Fertilization (IVF) with Preimplantation Genetic Diagnosis (PGD) to find out if
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they have embryos which are carriers for a particular cancer gene so that
they may avoid transmission of that gene to their children.
Costs: Charges for In Vitro Fertilization (IVF) are about $10,000 plus fertility
medication (about $5,000), and Preimplantation Genetic Diagnosis (PGD)
charges are about $6,000
3. Patients who are found to have Premature Ovarian Failure following treatment may
want to consider the following options, which were discussed under Fertility
Preservation Options:
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Oocyte donation
Embryo donation
Adoption
4. Patients who have conditions in which pregnancy is contraindicated may want to
consider the following options, which were discussed under Fertility Preservation
Options:
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Gestational surrogacy
Adoption
PREGNANCY OUTCOME IN CANCER SURVIVORS
1. The largest follow up of patients who were previously treated for cancer is the
Childhood Cancer Survivor Study (CCSS) with up of 20,000 childhood
Cancer Survivors. During this study, cancer survivors who conceived were followed
during pregnancy and after childbirth. The main findings in this study for patients
who were treated with chemotherapy were the following:
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Decreased live birth rates in cancer survivors compared to their siblings
No increased risk of stillbirth during pregnancy
No specific chemotherapy agent effect on adverse pregnancy outcomes
No increased risk of major congenital abnormalities
No increased risk in the offspring of developing subsequent cancer
Patients in the Childhood Cancer Survivors Study who were treated with radiation
therapy to the pelvis and then conceived had the following findings:
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Two-fold increased risk of low birth weight in the babies delivered
Increased risk of preterm birth
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3. Current research indicates that pregnancy after cancer treatment does not
negatively affect survival or trigger recurrence of the cancer in most patients,
including those with breast cancer
PATIENT RESOURCES
University of Illinois Fertility Preservation Program: www.uicivf.org
Oncofertility Consortium: www.oncofertility.northwestern.edu
Fertile Hope: www.fertilehope.org
Gilda’s Club Chicago: www.gildasclubchicago.org
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