Fertility preservation in leukemia
Leukemia is a serious diagnosis, but it is by no means a final one! As we are creating the text for this section of our website, we know that with proper and timely therapy, chances of improvement are high. After you have successfully prevailed in this struggle, you should be able to have your own children. Believe in this and WE SHALL SUCCEED!
Talking about this disease, we have to say it is not just one disease but quite a heterogeneous and complex group of diseases that differ in manifestation, age of occurrence, and symptoms.
So what are they? Leukemias are a group of oncological diseases of the blood. The bone marrow, which produces all the blood cells, begins to produce blasts – altered and immature blood cells. These blasts do not mature and cannot perform the function of mature blood cells – erythrocytes, leukocytes and platelets, but in addition they also block their production.
That is why the most common symptoms of these diseases are associated with the presence of too few functional erythrocytes (a condition called anemia, leading to fatigue, getting easily tired, palpitations, pale skin, rapid pulse), leucocytes (frequent and recurrent infections, which can be life-threatening, if critically low) and platelets (easy bruising of the skin, bleeding from the gums, the nose, or other parts of the body).
Generally leukemias are divided into acute and chronic. Acute and chronic leukemias that affect the precursor cells of erythrocytes, platelets, and some leukocytes are called myeloid, while those affecting lymphocyte precursors are called lymphoblastic or lymphocytic.
Acute lymphoblastic leukemia (ALL) is the most common malignancy in childhood, but also occurs in adults, with a lower incidence rate.
ALL can be subdivided into B-lymphoblastic and T-lymphoblastic depending on the way the cells look under the microscope, and some of their cellular markers.
ALL in children was one of the first serious cancers to be completely cured by complex treatment with chemo- and radiotherapy. Nowadays, about 90% of children with ALL are cured.
In adult patients, the prognosis still remains more serious, but advances in recent decades have led to the cure of a significant proportion of adults.
Chronic lymphocytic leukemia (CLL) is a slowly progressing disease that occurs almost exclusively in adult patients over the age of 50 (median age 70), more commonly in men.
In the early stages of the disease, physicians often prefer active surveillance to medical treatment, as there is no evidence that earlier initiation of aggressive treatment leads to better outcomes.
In recent years, a number of alternatives to chemotherapy in the form of target therapy have been implemented, which have a much higher tolerability. The 5-year survival rate for patients with CLL exceeds 80%.
Acute myeloid leukemia (AML) is the most common leukemia in adult patients, occurring in all age groups and increasing with advancing age.
Depending on certain molecular genetic cell markers, OML is subdivided into those with good, intermediate and poor prognosis, which determines the intensity of treatment; it may include chemo-, radiation-, and targeted therapy, as well as high-dose chemotherapy with hematopoietic stem cell transplantation.
Chronic myeloid leukemia (CML) like CLL, is a slowly progressing type of leukemia, again occurring predominantly in elderly patients.
The treatment of CML has changed dramatically since the year 2000, with the advent of targeted therapy, which provides long-term disease control in over 90% of cases and has allowed the life expectancy of patients not to differ significantly from that of healthy individuals.
Should fertility preservation actions be taken at time of diagnosis?
Leukemias are diseases that often require aggressive treatment, including various combinations of chemotherapy, radiotherapy, targeted therapy, and more recently, immunotherapy.
Most adverse effects you will get from therapy are transient and will go away after its end.
But the adverse effect they will have on your ovaries and reproductive cells will in most cases be irreversible.
Therapy will cause ovarian function to stop – premature ovarian failure.
Early menopause is one of the manifestations of ovarian failure, but it is easily dealt with – we will replace your ovary by providing you with hormone therapy that will restore your menstruation. This way, no one will know that your ovary is not working.
As for the eggs, things are more complicated – once the ovary is dead, it will no longer produce eggs. If we preserve them before that, this problem will be solved as well! Don't give up, talk to your oncologist about doing it.
There is always a solution, and fortunately it is quite available in this country – preserving eggs or ovarian tissue prior to the start of active treatment.
Frequently asked questions and common situations you may run into
What is the risk to my fertility?
The risk of infertility depends on a number of factors, such as your age, the specific type of disease, and the intended treatment regimen.
The most commonly used chemotherapy regimens in the treatment of acute leukemias are considered as having relatively low gonadotoxicity (damaging to the ovaries). However, this therapy may change during the course of treatment, which means preservation of your eggs will become a more complicated affair.
Often in younger patients and with higher-risk diseases, the initial chemotherapy is followed by a high-dose one with hematopoietic stem cell transplantation, which will almost certainly have an irreversible effect on the ovaries.
As mentioned above, in the absence of a satisfactory response to standard regimens, your hematologist may recommend changing therapy to another regimen that is more traumatic to the ovary.
However, once treatment has begun, it is not advisable to attempt egg preservation, and so it is best to do this before the start of active therapy. We leave a loophole here – yes, it is not advisable, but there are alternatives – read on to find out what these are.
The target drugs used in the treatment of CML are not considered to be so gonadotoxic on their own, but their use before or during pregnancy is absolutely contraindicated. Furthermore, treatments involving them are usually lifelong.
Normally the solution is active treatment that would last for several years to get a complete response, then temporarily the treatment is discontinued, or is switched to interferon-alpha treatment, which is allowed during pregnancy.
However, the time taken to achieve a complete response depends on a number of factors and often takes years. In patients diagnosed after the age of 30-35, these years can make it substantially more difficult to achieve a spontaneous pregnancy because of the natural decline in ovarian reserve.
To put it another way – it's nice to have eggs stored ahead of time.
Won't consulting a reproductive specialist delay my treatment too much?
Cancer patients have a priority in our hospital; a consultation with one of our specialists will be provided within 24 hours of your call!
My hematologist wants my treatment to begin in 2-3 days. What should I do?
Don't hesitate to contact us – we have cases where, working as a team with your hematologist, we can also start ovarian stimulation in the first days of therapy, and achieve success. This is not always possible, but you should be aware that being told "This is not a good time to bother with this stuff," is not a good answer. Get in touch with us!
In conclusion – this disease appears unexpectedly in both genders and at different ages.
If your partner has been diagnosed, or if you want to have a child yourself, be aware that preserving reproduction is part of your and his cure, it is, in fact, the very first step towards it!
You should seek advice NOW!
Every woman with cancer at reproductive age should consult a reproductive specialist, regardless of the stage of her disease, and whether she has given birth or not. This is also the official recommendation of the most recognized international oncology and reproductive medicine organizations, such as ESMO, ASCO, ESHRE, ASRM.
This will not delay your therapy in any way.
Your consultation with our reproductive specialists will be done within 24 hours of your call, no matter where you reside in the country.
Fertility preservation options
In current best practices, the following procedures are used to preserve reproductive ability in cases with leukemia – egg/embryo freezing or ovarian tissue freezing.
|Fertility preservation options||Frequency of application and success rate of the approach|| |
Limitations of the approach in relation to cancer characteristics
|Egg/ embryo freezing||★★★|| |
Because of the nature of this group of diseases, we don't always have the necessary 10 days available for the procedure. Sometimes patients are diagnosed while their condition requires to start treatment within days or hours and the only option left is freezing ovarian tissue.
|Ovarian tissue freezing||★||A diagnosis of "leukemia" is a relative contraindication for the reimplantation of frozen ovarian tissue, as there is a risk of it being "contaminated" by cancer cells that could also be returned to the patient during the procedure. A way to reduce this risk is to do a detailed examination of the ovarian tissue for the presence of such cells, but this cannot guarantee their complete absence. In recent years, there more and more work has been done towards so-called in vitro maturation of immature oocytes and even primordial follicles, which would allow the safe production of mature oocytes from ovarian tissue. Currently this is considered an experimental method, but sometimes it is the only option.|
★★★ - most commonly used approach, highest success rate ★★ - less frequently used approach, lower success rate ★ - rarely used approach