ASCO Releases Updated Fertility Preservation Guidelines

In July the American Society of Clinical Oncology (ASCO) updated its guidelines for fertility preservation for people with cancer. These guidelines had last been updated in 2013. This 2018 update adds information to two of the existing guidelines, including a recommendation to offer ovarian suppression, treatment or surgery to stop the ovaries from making estrogen when other options are not available.

Background

Breast cancer treatments can affect a person’s fertility, or ability to have children. Because of this, people diagnosed with breast cancer at a young age and who may want to become pregnant are often encouraged to take steps to protect their fertility so that they may have a higher chance  of having children after treatment ends. The ASCO guideline helps doctors and people with cancer make decisions about how to protect fertility based on results from clinical trials.

Design

All studies reviewed to support the 2018 update were completed between January 2013 and March 2017. In total, the results of 61 studies led to the recommended updates, which added clarifying information to two of the existing recommendations already in the 2013 guidelines. The group studied the other 2013 recommendations and found they are still the best practice based on current research.

Results

The 2018 update guidelines keep many of the recommendations from 2013. These include key recommendations for everyone whose fertility could be affected by cancer treatments:

• Healthcare providers should talk about the possibility of infertility as early as possible, before starting treatment.
• If someone is interested in fertility preservation, their doctors should refer them to a specialist called a reproductive endocrinologist.
• Fertility preservation options should be discussed early, before treatment, to make sure that the person understands all the options available to them.

Updated Information

New in 2018 is information about ovarian suppression, which includes surgery, radiation therapy or medicine to stop the ovaries from making estrogen. One class of medicines used in ovarian suppression is gonadotropin-releasing hormone agonists, or GnRH agonists, which are often used for ovarian suppression in breast cancer.

The 2018 guidelines say that because using ovarian suppression to protect fertility has conflicting results, other fertility preservation methods such as freezing eggs, embryos or ovarian tissue should be recommended first. GnRH agonists may be offered if these other options are not available, or for young women with breast cancer. Studies have more consistently shown that GnRH agonists help young women with breast cancer preserve their ability to have children.

The update also expands information on freezing ovarian tissue. To freeze ovarian tissue, part or all of the ovary is removed from the body and frozen during treatment. If a woman’s ovaries stop functioning (menopause occurs), this tissue can then be thawed and placed back in the body where it can produce hormones and release eggs. This method of protecting fertility does not require ovarian stimulation, which makes the ovaries release many eggs used in other types of fertility preservation (egg and embryo freezing), so it can be done without any delays. Freezing ovarian tissue is still considered experimental, but the guidelines say new and upcoming evidence may change that in the near future.

What this means for you

If you have just been diagnosed with cancer, it’s important to discuss fertility concerns with your doctor as early as possible. You may be focused on the cancer diagnosis and planning treatment, but talking about fertility preservation early gives you the chance to consider all the options available to you.

You may not know whether you want to have children when you are diagnosed, and that is OK. You do not need to make that decision today. Fertility preservation is done before treatment, so taking steps to protect fertility now may allow you to make that decision in the future when you are ready. Your doctor may refer you to a reproductive specialist, called a reproductive endocrinologist, who will also help guide you through your options. Visit ASCO’s website for details on their fertility preservation guidelines or find fertility preservation resources from the American Society for Reproductive Medicine.

Oktay, K, Harvey, B, Partridge, A,  et al. Fertility preservation in patients with cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology. July 2018; DOI: 10.1200/JCO.2018.78.1914.