CANCERS- FERTILITY AND FERTILITY PRESERVATION
In the words of the quintessential Maya Angelou- “Do the best you can until you know Sbetter. Then when you know better, do better.”
In the field of medicine, we have technology to thank for helping us harness the intrinsic power of knowing better and doing better.
Decades ago, a diagnosis of cancer whether solid organ (e.g breast, ovary, testes) or blood cancers (e.g leukaemia) was a race against time for survival alone. The preservation of fertility potential was a far second place consideration.
However, with giant steps in research and development in the pharmaceutical world and advances in the medical application of technology, it is now possible to offer more than survival to individuals with a cancer diagnosis. Cancer survivors are living many more years after surviving their cancers and have the natural yearnings to start their own families.
There are various modalities to treat cancers, I will however want us to focus on how they impact fertility.
When the first test tube baby Louise Brown was born in 1978, Steptoe and Edward may never have conceived the expanded indications for in-vitro fertilization (IVF) as applied today.
Today, women with a cancer diagnosis, depending on the type of cancer, stage of the disease and how imminent they should start their treatment regimens- surgery, chemotherapy and/or radiotherapy can be offered a glimmer of hope using IVF and its ancillary techniques.
Today, it is now acceptable for a woman with a solid organ tumour or blood cancer to have her oncologist offer multi-disciplinary consultation with a reproductive endocrinologist and fertility preservation techniques where appropriate.
If she has no partner, she can have an IVF stimulation cycle and have her eggs cryo-preserved. If she has a civil partner, she can proceed to fertilise her retrieved eggs with her partner’s sperm and then cryopreserve the embryos. For women whose malignancy is located in the abdomino- pelvic region, and the ovaries are spared from the malignancy, they can have these ovaries mobilized out of the abdomino-pelvic region and transplanted to safer areas to protect the ovary from accidental trauma. In more recent times, pre-pubertal females have a new option where the ovarian tissue itself is being cryopreserved. The in-road is now being made for ovarian tissue transplant surgeries (back into the women from which it was removed ab initio).
There are also third-party fertility options available. For women who have had hysterectomies, they can have their own genetic children through a gestational carrier who can carry their already cryopreserved embryos. For women who lost their ovaries due to ovarian tumours but didn’t require a hysterectomy, they can be offered Donor egg IVF with their partner’s/donor sperm and proceed to have a recipient cycle and carry the pregnancy to delivery.
These are truly exciting times!
In males, it is important to note that spermatogenesis commences at puberty; thus, there are currently no fertility-preserving techniques for prepubertal males. Therefore, parents of pre-pubertal male children with a cancer diagnosis should have frank conversations around fertility and gonadotoxic treatment options early.
Males who have reached puberty can definitely produce semen samples that can be cryopreserved for many years before undergoing any gonadotoxic treatment- surgery, chemotherapy or radiotherapy. Of course, there’s the associated anxiety that comes with wanting this last sample to be the best. With the help of a good counsellor, most men are able to cope with the anxiety and go on to give good samples before commencing their treatment. For some men, testicular extraction of sperm can be done.
The advent of immunotherapy has also changed the landscape of cancer management especially with solid tumours. One recent study published in The Oncologist in April 2020, highlighted that long term data doesn’t yet exist and therefore patients in the reproductive age group (15-49 years) who receive immunotherapy should use effective birth control for at least 5 months after therapy. This is to ensure that there is adequate time for the washout of toxic substances that may affect the availability of normal gametes for fertilization.
Cancer therapy especially for blood cancers has seen remarkable results with the advent of stem cell therapy leading to long-term remissions, cure and improved survival. Stem cell therapy for leukaemia or lymphoma is usually preceded with ablative radiation therapy or chemotherapy to kill the cancerous cells. It is this ablative chemotherapy or radiation therapy that has the most significant adverse impact on fertility.It is best to explore fertility preserving options before commencing treatment when appropriate.
Without doubt, the legal world has had to step into the world of medicine to ensure that there are no ethical conundrums or at most reduce these to the minimum. What happens to an embryo if the genetic parents split? What avenues for re-dress are available to cryopreservation facilities if the client defaults on his/her payments? Did the client include the embryos in his/her last will and testament? Who inherits the embryos and has legal guardianship etc
I believe medicine will continue to evolve alongside technology and legal practice and we humans will continue to find meaningful answers to our complexity as human beings.
On a final note, I want you to remember there is so much to live for. Keep fighting!