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Fertility preservation

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Read this summary and then ‘Test and reflect’ using our multiple choice questions
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Introduction

  • Fertility preservation involves freezing and storing sperm or eggs (gametes), ovarian reproductive material or embryos for use in a person’s future fertility treatment

  • There are two distinct areas for increasing knowledge and understanding among nurses: 

    • option 1—those who require more general information to refer for specialist care

    • option 2—nurses working in fertility services who have roles in fertility preservation

  • Nurses working in oncology and haematology, gynaecology, children and young people’s services, where medical treatment may affect future fertility, and those working in general practice, are all best placed to provide information about the availability of fertility preservation prior to surgery and/or treatment such as chemotherapy or radiotherapy. These conversations should take account of individual circumstances and include:

    • the likely effects of the specific treatment on fertility

    • prognosis

    • fertility preservation options (such as freezing sperm, eggs, ovarian reproductive material, or embryos)

  • In addition, nurses need to be aware of the availability of services locally, as well as funding options. All information should be provided in a timely, informed, and supportive manner. Any discussions should also include the possibility of posthumous use of stored gametes or embryos

Areas to consider when contemplating fertility preservation

  • Inform patient (and the family) of diagnosis, prognosis, and individual risk

  • Determine an individual’s risk. Factors to include cancer type, prognosis, age and treatment plan

  • Provide risk factor of infertility, with first line treatments and also consider potential for second line (e.g. radiotherapy) treatments

  • Current fertility status (existing child/children, reproductive plans prior to diagnosis). Consider, for example, who takes an adolescent male to the clinic for sperm freezing (it may not be comfortable for the parents to do so or for him to have parents present)

  • The possible health risks of undergoing fertility treatment

  • Some treatments can cause temporary or permanent infertility and, in women, early menopause

  • The emotional issues and requirement for sperm/egg collection at a time of crisis

  • Timing (for women)—is there enough time for the fertility treatment cycle to be completed before she commences treatment for her condition?

  • In some cases, lifesaving treatments may be put on hold (if already pregnant or to allow the patient to conceive) and treatment resumed at a later stage. Fears for health and the hopes of having a baby need to be considered carefully

  • The realistic assisted reproduction options open to them in the future

  • The possibility that they (women) might not respond to fertility treatment and (for men) post-thaw samples may be inadequate

  • Thinking and planning for a future family at a time of uncertainty, including posthumous use

  • The reactions of those close to them, including partner, family, and close friends

  • How relationships with family and friends influence their decision making

  • The fear of cancer recurrence after a child is born, and implications for the child/partner

  • The potential disposal of the stored gametes

  • When a person (of reproductive age/prepubescent children) is diagnosed with cancer or an illness that may impact on their ability to reproduce, it is essential to provide an opportunity to discuss fertility preservation

  • A full assessment in a dedicated fertility centre will be required to provide the patient with an accurate understanding of treatment options

  • There may also be cultural and/or religious issues to consider, therefore nurses require a sensitive approach to best understand specific individual needs

  • The Human Fertilisation and Embryology Authority (HFEA) sets out the requirements that must be met before gametes can be stored. Both patients and nurses should understand the complexities involved (see www.hfea.gov.uk)

  • There are specific consent requirements, outlined in the Fertilisation and Embryology (HFE Act; 1990; as amended) and the HFE (statutory storage period for gametes and embryos) Regulations 2009. These relate to storage and use, including issues that may arise where posthumous use is a possibility for a surviving partner. In these circumstances, gametes cannot be stored without consent

  • The law requires that the patient is given the opportunity to receive counselling before giving consent. There are many physical and psychological issues that will be raised at this difficult time and these should be explored with a specialist counsellor/psychologist who understands oncology/relevant medical condition and fertility preservation

  • When a patient is considering fertility preservation, the partner/family may wish to be involved and it is important that they are given the opportunity to seek counselling and advice on options available. A specialist fertility counsellor can provide this and they can be contacted either through a fertility clinic or a specialist counselling organisation:

    • British Infertility Counselling Association (BICA): www.bica.net

    • British Association of Counselling and Psychotherapy (BACP): www.bacp.co.uk

  • When taking consent for storage, all scenarios (including posthumous use) should be discussed. Patients should also be provided with information about the maximum storage period for which they can consent

Box 1: Storage time limits

  • Counselling is required to ensure informed choice
  • The statutory period which gametes can be stored is 10 years
  • However, in cases of oncology/haematology diagnosis or, for example, premature menopause, gender reassignment or other medical conditions that impact on fertility or when the patient is likely to be prematurely infertile, this can be extended (in increments of 10 years with a medical practitioner’s statement) up to 55 years
  • The consent to storage should remain separate from any contractual agreement (costed treatment plan) regarding costs between the patient and the clinic and future use of gametes/embryos
  • The specialist counsellor (option 2 activity) requires a specialist knowledge so they can provide the high quality of care needed. This care should cover the following areas:

    • a diagnosis of cancer will inevitably affect partners and immediate family members and they may experience a wide range of emotions. It is equally important to provide support and accurate information for the family, as the patient may find it difficult to communicate or share with them. Counselling may be provided within oncology/haematology services; there are also counselling organisations that provide specialist knowledge (eg, BICA or BACP)

    • where there is a high likelihood of death, the question of posthumous use should be explored; clinics and patients should seek medical opinion to comply with the 2009 Regulations (HFEA, 2009) which allow for extended storage beyond 10 years. This will ensure that the surviving spouse is able to use the gametes/embryos long after the death of the patient. Each case must be judged accordingly and it may not be appropriate to have this conversation with some patients

    • consent to fertility treatment (including surrogacy), as appropriate

    • the cost implications of freezing of gametes should be clarified before considering fertility treatment

    • further screening will be required if the gametes/embryos are to be used or donated (including in a surrogacy arrangement)

  • For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision. This means that the decision to either consent or not to consent to treatment must be made by the person themselves, and must not be influenced by nurses, friends or family. The person must be informed of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments and what will happen if treatment is unsuccessful

  • For consent to be effective, the patient should have received counselling about the implications of the proposed steps. This should include being provided with relevant information on their particular personal and medical circumstances

  • Consent can only be provided by someone with capacity, which means they understand the information given to them and they can use it to make an informed decision. It is the responsibility of the health care professional gaining consent to establish whether or not the patient has capacity (GMC, 2016)

  • They should always be informed of the right to vary and/or withdraw consent at any time

  • All such consent must be on a HFEA consent form. See www.hfea.gov.uk/about-us/how-we-regulate/consent-forms/

  • Nurses should be confident that they have given the information needed to make a considered decision and the essential elements of discussions should be documented in the medical record. Further details can be found in the HFEA Code of Practice (2017)

  • Informed consent involving children and young people is more complex; the principles of ensuring the right information is delivered in a way that they can engage with and understand is particularly important. Children and young people should be included in discussions and consent about preservation of fertility. Age-related information should be presented in an appropriate format

  • It is the specialist fertility team who will ultimately initiate the process and obtain consent. Other health care professionals may be involved, especially when confirming consent from a child or young person. These may include a nurse, counsellor/therapist, paediatric team, social worker, health visitor or school nurse

  • Nurses caring for children should be familiar with the specific issues around gaining informed consent from a child/children and young people up to the age of 16, in particular that they meet the Fraser guidelines and Gillick competency criteria (GMC, 2016, HFEA, 2017a and b). The Gillick competency assesses whether they have sufficient intelligence, competence and understanding to fully appreciate what is involved, and then their right to consent or refuse consent stands. The GMC (2016) and HFEA (2017a and b) provides further details of consent with children and young people

Male preservation of fertility

Key considerations for sperm storage

  • Counselling about potential sperm quality is important

  • The process involves masturbation and semen analysis

  • If there is sexual dysfunction/impotence, electro-ejaculation may be required (can be carried out in a specialist fertility centre or a general clinical area with the involvement of a reproductive medicine specialist/andrologist). Surgically retrieved samples require immediate transfer to a HFEA licensed clinic for storage

  • There is a potentially higher risk of genetic damage to sperm following exposure to chemotherapy agents

  • The samples are then treated with a cryopreservation media; the specimen placed in vials or straws and suspended in liquid nitrogen

  • Gonadal shielding is also a technique used to protect the testicles with a lead shield during radiation treatment for cancer and other conditions thought to be gonadotoxic (harmful to fertility), especially if applied directly to the pelvic area. Some radiation treatments use techniques to aim the rays on a very small area

Female preservation of fertility

  • The process of retrieving oocytes or ovum from a woman is more complex than sperm retrieval and involves a surgical procedure to remove eggs from the woman’s ovaries

Fertility preserving options for women

  • Ovum freezing or cryopreservation is when unfertilised eggs are ‘vitrified’ and stored. There have been successful cases of oocyte vitrification in adolescent females

  • Embryo freezing, also known as embryo cryopreservation is the most common and successful option for preserving a woman’s fertility. Conventional slow freezing or vitrification can be applied

  • Gonadal shielding—aiming radiation rays at a small area or covering the pelvic area with a lead shield to protect woman’s ovaries

  • Ovarian transposition—a minor surgery to move the ovaries from the area that will receive radiation

  • Ovarian reproductive material freezing—an effective method of enabling a successful pregnancy in women who have had oncology treatment. It is also the only option for younger girls who have not commenced ovulating. However, this carries a risk of xenotransplantation (re-introduction of cancer cells)

Controlled ovarian stimulation and egg retrieval

  • In a natural menstrual cycle, only a single egg is generally produced, therefore the woman administers daily injections of follicle stimulating hormone over a period of 10 to 14 days (controlled ovarian stimulation) to stimulate the production of several eggs prior to removal/retrieval under ultrasound guidance

  • The ovarian response to medication is monitored by ultrasound and, on occasion, serum estradiol assays. When a number of follicles have reached an appropriate size (≥18mm diameter), a final injection of gonadotropin releasing hormone agonist (GnRHa) is given to prevent ovarian hyperstimulation and to facilitate egg maturity. This helps the release of the egg from the capsular binding of the follicle 36 to 40 hours prior to timing of the egg retrieval

  • Egg retrieval is usually carried out under conscious sedation or general anaesthetic. A needle guide is attached to a vaginal ultrasound probe and inserted into the vagina. Using the ultrasound, the ovaries are located, the needle advanced through the guide and the vaginal wall into ovarian reproductive material and each follicle. Gentle suction is applied to remove the follicular fluid and the egg within the follicle

  • After retrieval, the woman may experience some vaginal bleeding and abdominal cramping. As with any invasive procedure there are associated risks (less than 1:1000) such as bleeding, bowel or bladder perforation and risk of infection. The eggs will either be frozen later the same day or mixed with either her partner’s sperm or sperm from a donor to achieve fertilisation. Any good quality embryos will be frozen for future use

  • There is no ‘upper limit’ for freezing in the UK (this is at the discretion of the clinic). NHS centres usually have a cut off age of 45 years and requests are considered on a case-by-case basis

Considerations in the preservation of fertility in children and young people

  • Whilst certain medical treatments will affect fertility in the short term, others may have a longer-term effects or may prohibit the possibility of fertility permanently for both children and young people. Some may affect a girl’s menstrual cycle, but this does not mean that she will be sub fertile or infertile. In many cases, young girls will resume a normal menstrual cycle pattern following completion of cancer treatment. However, it is not possible to predict those likely to relapse and subsequently require second line treatments (for example, radiotherapy), which may lead to permanent gonadal damage. This needs to be considered when discussing options

  • Fertility is a complex issue to discuss with children and young adults. The best time, place and facilitator for this will vary. Counselling can be offered to them and/or members of the family before, during and after treatment irrespective of treatment outcome. Specialist fertility counsellors may help facilitate a session where the concept is discussed and explored. They may also support the child/young person and/or parents during appointments with the fertility specialists when options are discussed

  • Information should be provided in a format that uses plain English and which is culturally sensitive and should also be available for parents and family members. It is important to remember that relationships between the patient, their partner/parent and/or the wider family may become strained and, at times, dysfunctional due to stress and anxiety. Consequently, ongoing assessment, support and early specialist interventions can be invaluable in preserving and maintaining relationships during this time

  • Tests to ascertain fertility following treatment can be undertaken. A discussion between the medical team and the patient should take place to ensure this is at a time to produce reliable results and gives the information the patient requires that is best for their wellbeing. For young girls who have never been sexually active, consideration should be given to an assessment of ovarian reserve and monitoring ovarian response to stimulation with the use of ultrasound. In those who may be sexually active, it is essential to exclude existing pregnancy prior to commencing fertility treatment

  • A young person should be advised and supported to avoid pregnancy during treatment (with contraceptive advice for them and their partner). Some contraceptive methods may reduce fertility for a time following the cessation of its use


Now Test and reflect: view our multiple choice questions

full guideline available from…

www.rcn.org.uk/professional-development/publications/pub-005986

Royal College of Nursing. Fertility Preservation. April 2017.

First included: January 2018.