July 2, 2021 3:53:11 pm
The extent of breast cancer in India has been steadily increasing for a very long time. Statistics show that fertility issues in this group have also increased due to drastic changes in lifestyle, lack of future fertility awareness, and delayed marriage. Awareness about breast cancer has spread across all age groups and therefore they have a chance of early detection. But our society needs to be made aware of the fertility issues surrounding cancer treatments and the available fertility-preserving treatments.
Before going ahead with the cancer treatment, the patient should be made aware of the possible impacts of the cancer treatment. It may result in an inability to conceive a child in future and adverse reproductive outcomes like poor quality and quality of the eggs post-cancer treatments, ovarian failure, early ovarian ageing, the inability to procure their own biological child.
How do we generally identify fertility problems in females?
When a woman is unable to bear a child after repetitive attempts (generally after trying for a year), they are termed as sub-fertile. Problems with fertility might usually occur when reproductive hormone levels are abnormally low or high or if gamete producing organs are removed or are not functioning properly. Problems in the uterus, tubes and ovaries might also trigger infertility. Scarcity of healthy eggs, disruptions in the sex hormone, blocked fallopian tubes caused by pelvic inflammatory disease, polycystic ovary syndrome (PCOS/PCOD), uterine fibroids, endometriosis, primary ovarian insufficiency (POI), and cancer treatments are amongst the many other conditions.
Effects of cancer on female fertility
Chemotherapy works by destroying the cells in the body that are dividing themselves at an abnormally fast rate. In many cases, the possibility of cancer medication/ surgery/radiation causing more harm to the female tissues and organs than cancer itself is very high. The radiation might hamper the reproductive system and that might result in sub-fertility or infertility (sterility) i.e., difficulty in conceiving a child naturally, in most cases permanently.
Oocytes (eggs) have a tendency to divide quickly and are often destroyed by chemotherapy which ends up impacting fertility. Diversity of oncology surgeries, chemo drugs, and radiations used for cancer treatment can have different effects and the proportionate risk of infertility, hence varies. The common risk factors are:
The patient’s age and stage of reproduction; for example, before or after puberty/menopause, etc.
The type of treatment given (radiation therapy, chemotherapy, hormone therapy, targeted therapy, immunotherapy, stem cell transplant)
The dose and frequency of treatment
There are a variety of drugs associated with the risk of infertility- cisplatin, busulfan, carboplatin, doxorubicin, lomustine to name a few. In addition to the medication, if the radiation is given near the pelvic area the risk of sterility (permanent damage to egg production) increases.
Savita, a 33-year-old unmarried lady was diagnosed to have a lump in her breast during her annual health check-up. Upon further investigation, it turned out that she had breast cancer that needed immediate medical attention. Before she started her treatment to battle cancer, she was counselled about the benefits of fertility preservation. As a result, she underwent fertility treatment and managed to store 18 mature oocytes. Now, once she overcomes this disease and gets a clearance from her oncologist, Savita can undergo ICSI (IVF) with her future partner’s sperms and form embryos out of her own eggs and undergo an embryo transfer to reproduce her own biological child.
Women should be made aware of all cancer and cancer procedure-related fertility risks and the fertility treatment options that are available to suit them. Her cancer care team must provide a detailed plan, as to what fertility options are open to her before or while planning her cancer treatment.
Women undergoing cancer treatment should be made aware of the impact of cancer treatment on reproduction and that it can be extremely harmful to the foetus if one conceives during cancer treatment, possibly leading to miscarriage. The logical step would be to preserve fertility, even if the woman awaiting cancer treatment is presently unsure whether she wants to have children in the future.
Fertility preservation in breast cancer patients
Here are a few recommendations for preserving fertility in breast cancer patients that would not hamper their journey to become a biological mother.
Oocyte (unfertilised egg) freezing: Women can freeze unfertilised mature eggs. This procedure is like embryo freezing, but the eggs are frozen without being fertilised by sperm. This is an option for younger unmarried women/ women without a male partner at present.
Ovarian tissue preservation: Here the ovarian tissues are surgically removed and frozen. The surgeon can transplant the tissue after cancer treatment. This might be the only option for girls who cannot undertake oocyte or embryo freezing, as some girls might lack the time or sexual maturity. But unfortunately, this is an experimental process and not a standard option.
Radiation shielding that protects the ovaries: There are chances that women may receive lesser radiation, and this preserves fertility.
Cancer treatment is an extremely taxing procedure. Patients have a lot of difficult decisions to make for themselves. The risk of infertility that could crop up unexpectedly in the future just adds more pressure and stress on the patient which can be a cause of concern. It is the job of the combined cancer care team along with the fertility team to show the right path and give viable options. Here, it must be reiterated (after considering all possible options) that embryo/ oocyte freezing is the most simple and effective way to enjoy biological motherhood even after undergoing breast cancer treatment.
It is high time that reproductive women with breast cancer are made aware of these fertility preserving options so that they can embark on their journey to first become cancer-free and then become a mother without any mental limitations. The patient should be made aware of all choices that are available for her. This process might be overwhelming, but we fertility experts will be there at every step of your oncofertility pathway to help you throughout the journey to parenthood.
(The writer is Fertility Consultant, Vadapalani and MRC Nagar, Nova IVF Fertility Chennai)
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