What is the oncofertility program
- Oncofertility is the medical specialty combining oncology and reproductive endocrinology. This field is intended to maximize the reproductive potential of cancer patients and survivors.
- In 2020, the Oncofertility Program was established as a joint initiative between the Naef K. Basile Cancer Institute and the Haifa Idriss Fertility Unit at AUBMC, to be the first integrative collaborative care Oncofertility Program in Lebanon and the region.
- As patients undergo cancer treatment, it is important to know that it might affect their ability to have children in the future.
- The program was established in order to provide medical care solutions to treatment-related infertility, a significant survivorship issue associated with reduced quality of life, depression, and distress. As Assisted Reproductive Technology is now endorsed by medical practice guidelines as the gold standard for fertility preservation in patients with cancer.
- The Oncofertility team works closely with oncology specialists to ensure that fertility consultation and discussion of preservation options are integrated into the medical care of all newly diagnosed patients.
- As such the program strives that options for fertility preservation and future reproduction be made available to patients prior to treatment.
- Oncofertility is a continuum of care that extends after treatment is completed as the patient actively strives to conceive.
Mission and Vision
The Oncofertility Program assists cancer patients in addressing reproductive health concerns to improve and preserve their chances to conceive. Our mission is to provide timely counseling and fertility solutions to support the patient’s and his/her partner’s ability to conceive.
The program aims to make oncofertility an integral part of care for every cancer patient and their partner, to ensure that they have the most suitable integrated medical and reproductive treatment plan.
Comprehensive, patient-centered fertility counseling and medical care before and after cancer treatment in collaboration with the Fertility Preservation Program at the Haifa Idriss Fertility Unit – AUBMC:
- Timely and comprehensive fertility preservation consultations for patients facing fertility-threatening treatments.
- Fertility status assessment.
- Parenthood options after cancer treatment.
- Access to a range of appropriate fertility preservation methods including: oocyte freezing, embryo freezing, sperm freezing, testicular tissue freezing, ovarian tissue freezing and fertility preservation surgery.
- Collaborative care with the hematology/oncology and psycho-oncology medical teams.
- Resource for patients and health-care providers who are seeking up-to-date fertility preservation information.
Meet our team
A closely coordinated team of highly dedicated oncologists, reproductive endocrinologists and fertility specialists provide individualized treatment options to maximally preserve your future fertility.
Ghina Ghazeeri, MD
Associate Professor of Clinical Specialty, department of Obstetrics and Gynecology
Reproductive Endocrinology & Assisted Reproductive Technology
Johnny Awwad, MD
Professor, Obstetrics & Gynecology: Reproductive Endocrinology and Infertility
Antoine Abu-Musa, MD
Professor, Obstetrics & Gynecology: Reproductive Endocrinology and Infertility
Antoine Hannoun, MD
Professor, Obstetrics & Gynecology: Reproductive Endocrinology and Infertility
Who can benefit from this program?
- The Oncofertility Program provides comprehensive fertility services to reproductive age men and women whose fertility may be affected by cancer and its treatment. According to latest published data from the National Cancer Registry 2016: female patients of childbearing age constitute 23.6% of all cancer patients
- The goal of the clinical Oncofertility program is to help patients navigate the impact of cancer treatment on future fertility. This program aims to facilitate fertility preservation efforts before treatment begins and offer fertility consultation after treatment.
- If you or your partner have recently been diagnosed with cancer, are going through cancer treatment, are a survivor, or are going through cancer care transitions, the Oncofertility Program has been developed to assist you in your reproductive health care journey.
- The program also advises patients who did not pursue fertility preservation prior to cancer treatment.
- The program equally counsels families of younger patients who have not yet reached puberty and provides long-term guidance on fertility issues as the patient moves into adulthood.
Why come to us?
- The Oncofertility program’s collaborative care services with fertility specialists is specifically intended to address cancer patients’ reproductive concerns.
- We strive to provide patients with a collaborative treatment plan tailored to the specific concerns and needs of the patient and family.
- Treatment may affect reproductive organs and glands that control fertility. Changes to your fertility may be temporary, long-lasting or permanent, though not all cancer treatments cause fertility problems.
- The Oncofertility Program ensures the timely and early comprehensive provision of fertility preservation counseling and interventions, enhanced through regular screening and close monitoring of fertility status before and after treatment.
Location and Appointment scheduling
Will cancer treatment affect my fertility?
Treatment may affect reproductive organs and glands that control fertility. Changes to your fertility may be temporary, long-lasting or permanent. Not all cancer treatments cause fertility problems.
Whether or not your fertility is affected depends on:
- Your age
- Your baseline fertility (reserve of eggs or number, quality/type of sperms before treatment)
- Type of cancer and its location
- Type, dose and duration of chemotherapy (number of cycles)
- Dose and area of radiation
- Type of surgery
- Length of time after completing treatment
- Other health and lifestyle factors (smoking, obesity, alcohol)
Effect of cancer treatment on women
There is no guaranteed way of knowing which women treated for cancer will become infertile (unable to have a child). The risk is related to the treatments used, the dose given, how long it is given for, and the woman’s age at the time it was given.
- The effect of cancer treatment may be temporary or permanent.
- Chemotherapy might affect fertility and damage eggs in the ovaries depending on the type, dose and duration of treatment. The risk increases with higher doses. Some chemotherapy drugs may destroy eggs in the ovary. Chemotherapy can cause the ovaries to stop releasing eggs and estrogen: what is called primary ovarian insufficiency (POI). Sometimes POI is temporary and your menstrual periods and fertility return after treatment. Other times, damage to your ovaries is permanent and fertility doesn’t recover. You may have hot flashes, night sweats, irritability, vaginal dryness, and irregular or no menstrual periods. Chemotherapy can also lower the number of healthy eggs in the ovaries. Women who are closer to the age of natural menopause may have a greater risk of infertility. Young women whose menstrual periods start back after chemo are at risk for early (premature) menopause.
- Avoid getting pregnant during chemotherapy: Many chemo drugs can hurt a developing fetus, causing birth defects or other harm. You might be fertile during some types of chemo, so you’ll need to use very effective birth control. Talk with your doctor about this. Remember, too, that some women can get pregnant even when their periods have stopped. For this reason, it’s important to use birth control whether or not you have periods.
- If you get pregnant too soon after chemo, it can harm the baby: Women are often advised not to get pregnant within the first 6 months after chemo because the medicine may have damaged the eggs that were maturing during treatment. If a damaged egg is fertilized, the embryo could miscarry or develop into a baby with a genetic problem. Studies about this are hard to find. This is something you should talk to your doctor about before trying to become pregnant.
- Radiotherapy to or near the abdomen, pelvis or spine can harm nearby reproductive organs. Whether or not fertility is affected depends on the amount of radiation given and the part of your body being treated. Radiation to the pelvis might affect the uterus and ovaries and might cause POI if radiation is aimed directly at the ovaries or pelvis. High doses can destroy some or all of the eggs in the ovaries and might cause infertility or early menopause. Due to scarring from radiation, an embryo may not be able to implant, or the uterus may not be able to expand to hold a growing fetus. This can result in complications during pregnancy such as miscarriage, preterm (early) birth, or low birth weight babies. Even if the radiation is not aimed right at the ovaries, the rays can bounce around inside the body and might still damage the ovaries.
- Radiation to the brain might harm the pituitary gland that signals the ovaries to make hormones like estrogen needed for ovulation.
You may be fertile when you’re getting radiation treatment. For this reason, it is important to talk to your doctor about how long you should wait to resume unprotected sexual activity. It is important not to become pregnant until treatment is completed because radiation can harm the fetus. Discuss with your doctor.
Some organs, such as the ovaries, can often be protected by ovarian shielding or by transposition —a procedure that surgically moves the ovaries away from the radiation area.
When chemotherapy and radiation are used together, the risk for POI is higher.
- Surgery for cancers of the reproductive system and cancers in the pelvic area can harm nearby reproductive tissues and cause scarring, which can affect your fertility. Surgery done to remove any part of the reproductive system has a direct effect on later fertility (such as the uterus, removal of ovaries, cervix or fallopian tube). The size and location of the tumor are important factors in whether or not fertility is affected.
- Bone marrow transplants and peripheral blood stem cell transplants, involve receiving high doses of chemotherapy and/or radiation. These treatments can damage ovaries and may cause infertility.
- Hormone therapy (also called endocrine therapy) can disrupt the menstrual cycle which may affect your fertility. Some hormone therapies may prevent ovulation completely, since a woman is put into temporary menopause. Women taking tamoxifen can get pregnant, but it also causes birth defects, so women are advised to use effective birth control while taking it.
Side effects depend on the specific hormones used and may include hot flashes, night sweats, and vaginal dryness. These side effects improve usually when treatment is over.
- Other treatments: Talk with your doctor to learn whether or not other types of treatment, such as immunotherapy and targeted cancer therapy, may affect your fertility. Some immunotherapy medications which can stay in semen for a few months after treatment ends (such as methotrexate) have a high risk of causing birth defects. It is recommended to use extremely effective forms of birth control.
Cancer treatment might also cause the following:
• Lack of female hormones: Hormones needed for bone and heart health might decrease. You might need to take hormone therapy.
Important: Women who smoke have more difficulty getting pregnant than women who don’t. Smoking raises your risk of preterm delivery, abnormal bleeding during pregnancy and delivery and your baby’s risk for birth defects and low birth weight.
EFFECTS OF CANCER TREATMENT ON MEN
Some cancers might affect the health of your sperm before treatment begins. They might cause:
- A low sperm count.
- Abnormal shape of sperm.
- Less sperm movement.
What is the effect of cancer treatment on male reproduction?
The effect of cancer treatment could be temporary or long-lasting. Not all cancer treatments affect your fertility. This depends on the:
- Number, quality and type of sperms produced before treatment.
- Type of surgery.
- Type, dose and duration of chemotherapy: Some drugs are more likely to affect fertility than others. The higher the doses of chemo, the longer it takes for sperm production to get back to normal after treatment, and the more likely it is to stop.
- Location and dose of radiotherapy.
• Stop the testes from making healthy sperms and damage sperm cells and sperm-forming cells (germ cells) in young boys.
• Reduce hormones that affect sperm production like testosterone
After chemo treatment, sperm production slows down or might stop. Sperm production usually takes up to few years to recover.
Radiotherapy to the reproductive organs or radiation near the abdomen, pelvis or spine might affect the testes and the production of sperm and:
- Lower sperm counts and testosterone levels, causing infertility
- Destroy sperm cells and stem cells that produce sperm.
- Damage nerves needed for erection or to ejaculate the sperms out of the urethra.
Radiation to the brain might damage the pituitary gland that signals the testes to make testosterone and sperm and decrease their production.
You may be fertile when you’re getting radiation treatments, but your sperm may be damaged by exposure to the radiation. For this reason, it is important to talk to your doctor about how long you should wait to resume unprotected sexual activity or try for a pregnancy.
Surgery for cancers of the reproductive organs and pelvic cancers (such as bladder, colon, prostate, testicles and rectal cancer) can damage these organs and/or nearby nerves or lymph nodes in the pelvis and might cause:
- Problems with erection (damage nerves linked to erection).
- Problems with ejaculation (damage nerves needed to ejaculate sperms out of the urethra)
Bone marrow transplants and peripheral blood stem cell transplants, involve receiving high doses of chemotherapy and/or radiation. These treatments can damage sperm and sperm-forming cells.
Hormone therapy (also called endocrine therapy) can decrease the production of sperm and cause erectile dysfunction, these side effects improve usually when treatment is over.
Other treatments: Talk with your doctor to learn whether or not other types of treatment, such as immunotherapy and targeted cancer therapy, may affect your fertility. Some immunotherapy medications which can stay in semen for a few months after treatment ends have a high risk of causing birth defects. It is recommended to use extremely effective forms of birth control.
Important: Men who smoke or who have a history of heart disease, high blood pressure or diabetes also may be at a higher risk of erectile dysfunction after radiation therapy.
Important: Men who smoke run a higher risk of sperm damage and erectile dysfunction.
Treatments with risk for ovarian failure or infertility
- It is hard to know how cancer treatment will affect you exactly. It it hard to predict if a woman is likely to be fertile after chemo. Some types of chemotherapy and radiation are known to affect fertility more than others.
- Combinations of chemotherapy drugs can have greater effects on fertility.
- If chemotherapy was used in combination with radiation to the belly (abdomen) or pelvis, the risk of infertility is higher.
approaches to preserve fertility
- For men and women undergoing cancer treatment and who wish to preserve their fertility, the oncofertility program makes several options available to increase your chance of having a baby once you recover from cancer.
- Talk with your doctor about the best option(s) for you based on your age, the type of cancer you have, and the specific treatment(s) you will be receiving. The success rate, financial cost, and availability of these procedures varies.
- Your doctor and the fertility specialist will work together to develop a treatment plan that includes fertility preservation, whenever possible.
Options to preserve fertility include:
- Egg freezing (also called egg preservation): Is a procedure in which eggs are collected and frozen then stored before treatment begins. The eggs are then used when you are planning to have a child and are unable to produce eggs any longer.
- Embryo freezing (also called embryo banking) is a procedure in which eggs are removed from the ovary. After receiving hormonal stimulation, oocytes are then fertilized with partner’s sperm in the lab. Developing embryos are then frozen for future use.
- Ovarian tissue freezing: The procedure involves extracting a piece of ovarian tissue or the whole ovary either laparoscopically or through laparotomy. Tissues are then frozenin order to be transplanted later. This method it is the only option available for prepubescent girls.
Embryos, eggs, or ovarian tissue before should be done before cancer treatment. This process often delays the start of treatment, it is not appropriate for every patient.
- Ovarian shielding is a procedure in which a protective cover is placed on the outside of the body, over the ovaries and other parts of the reproductive system, to shield them from scatter radiation.
- Ovarian Transposition is an operation to move the ovaries away from the area of the body receiving radiation treatment. This procedure may be done during surgery to remove the cancer or through laparoscopic surgery.
- Radical trachelectomy (also called radical cervicectomy) is surgery used to treat women with early-stage cervical cancer who would like to have children. This operation removes the cervix, nearby lymph nodes, and the upper part of the vagina. The uterus is then attached to the remaining part of the vagina, with a special band that serves as the cervix.
- Treatment with gonadotropin-releasing hormone agonist (also called GnRHa), a substance that causes the ovaries to stop making estrogen and progesterone. Research is ongoing to assess the effectiveness of giving GnRHa to protect the ovaries.
For cancers localized around fertility organs: Female patients requiring pelvic radiation may benefit from ovarian transposition to a site outside the region of maximal radiation exposure. This procedure may be performed at the time of an oncology procedure. In these cases, transabdominal oocyte retrieval may be necessary.
For women who have not done fertility preservation: As treatment side effects can be temporary or long lasting, the ability to get pregnant cannot be predicted. Some women may have a low ovarian reserve but will be able to get pregnant with fertility treatment. The Oncofertility program can offer fertility consultations after treatment.
- Sperm banking before treatment: Sperm banking is the most common way to save fertility in males treated for cancer who would like to have children in the future. Samples of sperm are collected then frozen and stored (banked) in order to be used later on. Sperm banking should be done before beginning treatment.
- Testicular shielding (also called gonadal shielding) is a procedure in which a protective cover is placed on the outside of the body to shield the testicles from scatter radiation to the pelvis when other parts of the body are being treated with radiation.
- Testicular sperm extraction (TESE) or testicular tissue freezing is a procedure for males who are not able to produce a semen sample. Sperm is collected through a surgical procedure and frozen for future use. For boys who have not gone through puberty and are at high risk of infertility, this procedure may be an option.
For cancers localized around fertility organs: Men facing potentially sterilizing therapies can be offered the opportunity to bank semen before they start treatment Systemic chemotherapy and pelvic radiotherapy can lead to testicular failure, testes unable to produce sperm in the future. Samples may be used within insemination treatment or within IVF and/or ICSI.
For men who have not done fertility preservation, the onco-fertility program can offer fertility consultations after treatment.
After treatment, you should:
- Do a medical check-up
- Check with your doctor and a fertility specialist for any concerns. You should consult your reproductive endocrinologist for regular hormonal check-ups, to monitor any side effects of chemotherapy and hormone therapy: such as irregular menstrual cycles, hot flashes, vaginal dryness, irritability mood disturbances.
You might need to receive hormone therapy if the level of hormones needed for bone and heart health is low. If you have ovarian failure, you should regularly test for bone weakening or osteoporosis.
Quesions to ask your doctor
Being diagnosed with cancer is challenging by itself. While it might be also overwhelming to consider fertility issues as you undergo treatment, learning how cancer treatment may affect fertility before starting treatment can help you plan ahead. Discuss with your doctor any questions about the effect of cancer or treatment on your fertility. If needed, your doctor can refer you to a fertility specialist at the start of treatment.
It is helpful to consider asking questions such as:
1. Could treatment increase the risk of, or cause, infertility? Could treatment make it difficult to become pregnant or carry a pregnancy in the future?
2. Are there other recommended cancer treatments that might not cause fertility problems?
3. Which fertility preservation options would you advise for me?
4. What fertility preservation options are available at the hospital?
5. Would you recommend I consult fertility specialists that I could talk with to learn more?
6. Are methods of protection like condom use advised, based on the treatment I’m receiving?
7. Is birth control also recommended?
8. How long should I wait to resume unprotected sexual activity or try for a pregnancy?
9. What are the chances that my fertility will return after treatment? How long might that take?