To Preserve Fertility After Cancer
words by maryann brinley / photograph by pete byrony

Hossein Sadeghi-Nejad, MD, professor of urological surgery, NJMS

email this print this Share this: digg this! del.icio.us facebook newsvine

he healthy-looking young man, in his late twenties, walked into Hossein Sadeghi-Nejad’s office for an evaluation of possible male infertility. His wife had sent him after the obstetrician/gynecologist doing her fertility workup noticed that he had an abnormal semen analysis. They were trying to become pregnant.

A professor of urological surgery and expert in male reproductive medicine at UMDNJ-New Jersey Medical School (NJMS), Sadeghi-Nejad was pleased to see this male partner being evaluated because men in fertility crises are not always given the benefit of a full medical evaluation. The high-intensity focus is mainly on the woman. “In many cases, failing natural conception after a few trials, the couple will be directed to high level assisted reproduction without an adequate work-up for the male.” This man was lucky. Another unfortunate and frustrating issue which disturbs Sadeghi-Nejad is that future fertility is not discussed routinely with men before they undergo cancer therapy. “I see many men who are cancer survivors and wish to consider fatherhood but alas, it may be too late.

“This patient’s story illustrates a number of very important points,” he says. It happened last year. After taking a detailed medical history, the doctor asked him to step into the examining room for a physical. “He had not complained of testes pain or any other symptoms,” Sadeghi-Nejad explains. “But it was immediately apparent that something was drastically wrong with one testis because it was hard as a rock and three times larger than the other.” This is a clinical picture where in most cases, according to the expert, it’s “cancer until proven otherwise.”

Blood work was ordered immediately to determine the type of malignancy and an ultrasound was also scheduled.The race was on. A CT scan was done right away to make sure there was no evidence of metastasis and within days, this man was scheduled for a radical orchiectomy, or removal of the affected testis and spermatic cord. It was cancer. Because of Sadeghi-Nejad’s intervention, the couple was also counseled about the possibility of sperm banking before any therapy was initiated — in spite of that rush to remove his cancer. They also took the time to go to a center where sperm banking could be performed. This turned out to be a critical step.

“Indeed, many patients who undergo therapies for testis cancer, Hodgkin’s disease and even prostate cancer are not thinking of fertility when they are first diagnosed. I cannot emphasize enough the value of pre-intervention counseling.”

The full impact of the counseling became even more significant when his cancer turned out to be of an unusual type, requiring additional surgery. After consultations with top oncologists, lymph nodes were removed. “He came through all this brilliantly and is doing well,” his doctor says. “The important point here is that his pathologies and treatments will result in abnormal or sometimes the absence of sperm in the ejaculate.” Yet, because of that sperm banking, “he and his wife can still pursue their wish for parenthood.”

In cancer of a testis, the bad news is also that “the other, or good, side may be affected. There is a near certain decrease in number of sperm by about 50 percent.” For his patient with testicular cancer last year, that additional surgery also raised the possibility that he might not be able to ejaculate due to the effects on the sympathetic nerves.

Sadeghi-Nejad, Chief of Urology for the VA New Jersey Health Care System and also Director of the Center for Male Reproductive Medicine at Hackensack University Medical Center, believes that sperm cryopreservation is the “most prudent approach” to protect fertility in male cancer patients. “It can be difficult to predict the final effect on the fertility potential of any patient,” Sadeghi-Nejad explains. Even if the anti-cancer treatment doesn’t lead to infertility, he raises the fear of single gene and chromosomal mutations that might be induced in the surviving germ cells and passed on to children, eventually leading to genetic diseases. Any type of cancer can also have adverse effects because of nutritional deficits caused by symptoms, the hyper-metabolic state of the cancer itself and altered blood flow. Chemotherapy and radiation can cause long- term or even permanent infertility in men.

While studies indicate sperm counts may eventually return, Sadeghi-Nejad is cautious. “I generally recommend that patients wait at least 18 months after chemotherapy before attempting conception or moving on with assisted reproduction. We have to exercise extra vigilance.” These are the cases where sperm banking wasn’t done prior to the cancer intervention. “Sperm retrieval can still be successful for many of these patients,” he says. Testicular tissue cryopreservation can also be done when there are no sperm in a man’s ejaculate. “I perform this operation microsurgically so the most promising seminiferous tubules (where sperm are produced) that may contain sperm can be identified and removed for sperm retrieval.”

The good news in all this is that “the technologies now available for sperm and testis tissue freezing are very advanced and readily available. At each step, however, the goal is to use the least invasive yet most effective possible therapy.” Sadeghi-Nejad explains that even immature testis tissue in boys who have not yet gone through puberty but who are facing cancer therapies can be saved. He is one of just a few male fertility experts in New Jersey who can offer specialized care, microsurgery and testicular biopsy to retrieve sperm even in cases of azoospermia, where no measurable amounts of sperm are in semen.

Sadeghi-Nejad is writing a chapter for Fertility Preservation in Men with Cancer (Cambridge University Press) and works closely with Peter McGovern, MD, NJMS professor and Director of the Division of Reproductive Endocrinology and Infertility, as well as Aimee Seungdamrong, MD, Director of Fertility Preservation and a principal investigator for the National Physicians Cooperative of the Oncofertility Consortium. “Any physician caring for cancer patients in their reproductive years must take the time to provide the latest information pertaining to the disease as well as future expectations,” insists Sadeghi-Nejad, “especially the chances of fatherhood and the simple steps that can be taken to optimize outcomes.”

Aimee Seungdamrong, MD, assistant professor, Obstetrics, Gynecology and Women's Health, NJMS A Counseling Conundrum words by maryann brinley Making motherhood an option after cancer “A diagnosis of cancer is devastating but infertility as a result of that cancer is devastating, too,” says Aimee Seungdamrong, MD, UMDNJ- New Jersey Medical School (NJMS), Director of Fertility Preservation at University Reproductive Associates (URA), “especially if you had simply been given information before treatment and known your options.” In fact, at the very top of Seungdamrong’s list of innovations in fertility preservation is not a brand new technological tool but something so simple: counseling before cancer treatment. Statistics show that cancer survival is more possible than ever but the prognosis for having a baby after having cancer is not so clearcut. “After a cancer diagnosis and before any woman or man of reproductive age has chemotherapy or radiation, we suggest a consultation with a fertility preservation specialist.” Not everyone is interested in a procedure aimed at protecting fertility, “but everyone should have the counseling,” insists Seungdamrong, who completed a fellowship in reproductive endocrinology and infertility in 2007. She is also a principal investigator at NJMS for the National Physicians Cooperative of the Oncofertility Consortium, an interdisciplinary initiative which is exploring the reproductive future of cancer survivors and is supported by the National Institutes of Health (NIH). She runs this groundbreaking study in collaboration with Hackensack University Medical Center, a UMDNJ affiliate. Technological advances in fertility preservation have multiplied in the last five to 10 years, especially for women. “What is really becoming mainstream now is egg freezing,” Seungdamrong explains. Since 1978, when the first successful “test tube baby” was born after in vitro fertilization (IVF), embryo freezing has been done on a regular basis. An egg is taken from a woman’s ovary, fertilized by a sperm outside the womb and the fertilized egg (zygote) can be frozen for later use when it would be transferred to a patient’s uterus. “This is mainstay therapy for our patients who want to sustain their fertility and are either married or with stable partners,” explains Peter McGovern, MD, Director of the Division of Reproductive Endocrinology and Infertility and a professor of obstetrics and gynecology at NJMS. McGovern also practices with Seungdamrong at URA, which has offices in Newark at University Hospital, in Hoboken and also in Hasbrouck Heights. For women who may not have partners to supply sperm at the time of their cancer diagnosis, there used to be problems. Freezing eggs was possible, but difficulties arose later when sperm were placed next to them in a petri dish. Sperm are supposed to naturally move in to fertilize the egg but they didn’t. “There was very poor fertilization of those thawed eggs using standard IVF. During cryopreservation, the wall of the egg had become very hard.” Now, a technique called intracytoplasmic sperm injection has solved this dilemma. “We inject the sperm directly into the thawed egg,” Seungdamrong says. And it works. In a successful pilot study of this technique with 10 infertile patients, her team achieved a 40 percent pregnancy rate, “which is very good.” What makes a woman’s anatomy more problematic than a man’s is the fact that females are born with all the millions of eggs their body will ever produce. “They are made only once, when you are gestating in your mother’s womb,” Seungdamrong explains. “It’s fascinating. Over the years, they are either ovulated or dissolve in the body in a process called atresia.” For guys, sperm production happens throughout life. Even if a man’s existing set of sperm are damaged by chemotherapy or other cancer treatments, his body has stem cells that could possibly allow sperm regeneration over time. In women, however, after chemotherapy or radiation destroy the ovarian follicles, there is no opportunity to create new eggs. The fertility preservation program, which is under the direction of Seungdamrong, an assistant professor of obstetrics and gynecology at NJMS, began just two years ago and is still in its infancy because “we wanted to have a whole set of techniques available that can produce pregnancies,” she explains. So far, less than 10 cancer survivors have put either eggs or embryos into cryopreservation there. “No patients have come back yet,” she says, but when they do, “this gift of being able to have a family will be huge.” . To find out more or to reach Dr. Seungdamrong, go to www.uranj.com or call, 1-888-770-9080.