By Dr Shanujeet Kaur
Fertility preservation is becoming increasingly important to improve the quality of life for cancer survivors. Men and women, who have been diagnosed with cancer, may not be comfortable about bringing their fertility issues to the forefront. Patients may also not be aware of their options for preserving fertility as they focus on their cancer diagnosis and treatment.
Burden of disease
According to the National Cancer Registry Programme (NCRP) data, the incidence of cancers is rising in India. In the year 2011, nearly 1,193,000 new cancer cases were estimated; a higher load among females (603,500) than males (589,800) was noted. It is estimated that the total number of new cases in males will increase from 0.589 million in 2011 to 0.934 million by the year 2026. In females, the new cases of cancer will increase from 0.603 to 0.935 million.
Major international guidelines (ASCO, ASRM) on fertility preservation in cancer patients recommend that clinicians/oncologists should discuss with their patients the potential impact of anti-cancer treatment on fertility as early as possible, ideally before initiation of therapy.
Fertility preservation aims to preserve reproductive tissues for future use. Oncofertility is a term coined for fertility preservation in cancer patients. Oncofertility counselling with specialists including oncologists and psychologists can reduce stress and improve quality of life.
Chemotherapy and radiotherapy remain the mainstay of cancer treatments. Both can be damaging to the ovary depending on the agent used, dose given, and age of the patient.
Fertility sparing surgeries (FSS) for cancer patients
FSS for patients requiring radiation to pelvis: Ovarian transposition moves ovaries out of the field of radiation.
FSS for cervical cancer: In place of total hysterectomy and lymph node dissection, radical trachelectomy is performed for women with early-stage cervical cancer (<2 cm in size) who have not yet completed their childbearing.
FSS for ovarian tumours: Traditional management is total hysterectomy with bilateral salpingo-oophorectomy (BSO). Unilateral salpingo oophorectomy may be done in select cases of well differentiated early stage tumours.
Fertility preservation techniques
Fertility preservation is the effort to help cancer patients retain their fertility, or ability to procreate. Research into how cancer affects reproductive health and preservation options are growing, sparked in part by the increase in the survival rate of cancer patients.
· Embryo cryopreservation: This is an established method of fertility preservation. Embryo cryopreservation requires ovarian stimulation (COS), oocyte retrieval and IVF with the provision of male gametes. Women without a male partner who are unwilling to use sperm donation cannot be offered embryo cryopreservation.
· Oocyte cryopreservation: Cryopreservation of unfertilised oocytes is an option for women who do not have a male partner or postpubertal girls (18 years).
· In vitro maturation (IVM) of immature oocytes: For patients unable to undergo ovarian stimulation, such as women with aggressive or hormone sensitive cancers. IVM has been shown to improve outcomes in breast cancer patients undergoing COS for FP.
· Ovarian tissue cryopreservation (OTC) and transplantation: Ovarian tissue cryopreservation for the purpose of future transplantation does not require ovarian stimulation and can be performed immediately. In addition, it does not require sexual maturity and hence, may be the only method available in children.
· Ovarian suppression: Gonadotrophin releasing hormone agonist analogue (GnRh A) is indicated in young women with breast cancer. Patients with leukemia may be good candidates for GnRH agonist co-administration in order to manage the ovulation and menstrual bleeding during chemotherapy.
Fertility preservation in adult men
In men, sperm cryopreservation is an easily accessible and widely available option in more than 95 per cent of patients and should be encouraged before starting anticancer treatment.
Pregnancy outcome after treatment
Pregnancy after cancer should be considered safe and not be discouraged in general. The ideal interval to wait between the end of anticancer treatments and conception is not very clear. Two main interval issues should be considered, to wait until the patient is at lower risk of relapse, and to wait until the anticancer therapy is out of a patient’s system (i.e. up to 3-6 months following the last administered dose). According to expert opinion, the timing should be personalised for each case depending upon various factors.
It has also been found that from an obstetric/neonatal perspective, there is no significant increase in miscarriage, congenital malformations or genetic abnormalities found when conception has taken place after completion of therapy with the help of oocytes/embryos obtained after FP techniques. This is, barring a few situations like women undergoing pelvic irradiation, who might experience uterine damage with a possible increased risk of miscarriage, preterm birth, and low birth weight.
With the advent of oncofertility, there is a new perspective for cancer survivors, which is not only a prolonged life but a long and fulfilling one.
Lack of awareness
Unfortunately, fertility preservation services are rarely offered or even discussed with the patient before starting cancer therapy. Studies have shown that infertility is a significant survival concern. Patients who received information regarding their sexual and reproductive health had lower levels of psychological distress than patients who did not receive this information. An informed decision reduces reproductive regret in these young men and women.
Starting the conversation
Discussing fertility preservation is important. Once the treatment plan is about to begin, patients must ask what the associated risks (high/low) are and the available options for fertility preservation. Not all women experience infertility after cancer treatment, however it is still important to explore your fertility preservation options before treatment.
(The writer is Consultant Gynaecologist, Cloudnine Group of Hospitals, Chandigarh.)