Fertility preservation in cancer patients

Dr S K Das

Cancer since long has been considered a deadly disease. The incidence of cancer cases particularly in younger population has seen an alarming rise in the recent years. Overall statistics show that 8-10 per cent of cancer patients are below 40 years and one per cent below 20 years of age. In the light of such increasing number of cancer patients falling in the reproductive age group, fertility preservation has become a growing concern among doctors and patients alike.

Every woman dreams of going through the phase of pregnancy when her mind and body prepares itself for the joys and responsibilities of motherhood. It brings with itself a positive feeling that life is purposeful and complete. The feeling of being able to bring a new life into the world is overwhelming. However, when this dream is not fulfilled and realisation dawns that one will not be able to bear children, it leaves a sense of incompleteness in the woman’s life. More so, when infertility is not natural but occurs due to the side effects of the treatment of a fatal disease like cancer.

The dual agony of suffering from cancer and not being able to conceive has become a serious issue among the medical fraternity. To counter this, there have been constant endeavours of doctors all over to come up with fertility preservation techniques for female cancer patients. With better management of various cancers, there are a host of ways in which it is now possible to preserve a cancer patient’s fertility.

Radical Trachelectomy

Cancer and its treatments — including surgery, chemotherapy and radiation therapy — can hamper a patient’s ability to conceive. In surgical procedures, generally the reproductive organs are removed when cancer is diagnosed in any part of the reproductive tract, thus, reducing fertility. However, in recent years the focus has been more on the conservative techniques of treatment especially when the patient is young and the disease has been detected in early stage. For young cervical cancer patients who have a desire to conceive later, conisation or radical trachelectomy are the surgeries performed. Conisation means removing the lesion on the cervix in the form of a cone and the margins are tested to confirm that the patient is free of disease. In radical tracheolectomy, the parametria (tissue adjacent to the cervix) and vaginal cuff (the end of the vagina close to the cervix) are also excised along with the cervix as part of the operation. This surgical procedure is generally accompanied with laparoscopic pelvic lymphadenectomy. As the uterus is preserved along with the ovaries, this technique is considered conservative in nature and has yielded good results as far as pregnancies and deliveries are concerned.

In a bid to conserve the fertility of young endometrial cancer patients, a high dose of hormone is administered instead of radical hysterectomy where the uterus is fully removed. This treatment makes use of hormones that cause the endometrial cancer to regress. For ovarian cancer patients, conservative treatment is advised when border line malignancy or patient has germ cell tumours. For earlier ovarian malignancy, unilateral salpingo-oopherectomy (removal of one fallopian tube and one ovary which preserves the uterus and the ovary and fallopian tube of the other side) along with omentectomy (removal of the abdominal lining) is performed. These procedures require a close follow-up.

One of my young patients suffering from ovarian cancer was devastated when she came to know that due to the treatment that she has to undergo for the disease, her fertility could be at stake. But the good thing was that since she was in the early stage of cancer, it was possible for us to preserve her future fertility with the use of conservative treatments (unilateral salpingo-oopherectomy and omentectomy). The patient’s cancer is now in control and she is the proud mother of a healthy baby girl.

Chemotherapy has adverse effects on a woman’s fertility due to their toxic effect on oocyte (germ cell involved in reproduction). The extent of damage depends on the dose, the type of drugs used and the age of the patient. One way of reducing toxicity in the oocyte is by suppressing ovarian function with drugs like gonadotropin-releasing hormone (GnRH) agonists or oral contraceptives. Another emerging treatment that has proved to preserve fertility is the use of apoptotic inhibitors (Sphingosine-1-phsphate) which protects oocytes from CT (cholera toxin) induced apoptosis (process of programmed cell death).

The risk of infertility from radiation therapy depends on the dose of radiation and the area of the body that is exposed to radiation. Radiotherapy causes reduced blood supply to the uterus causing atrophy of endometrial resulting in difficulty in implantation of fertilised embryo. Radiotherapy also causes damage to ovarian follicles, thus causing premature ovarian failure. To reduce the effect of radio therapy, two methods can be employed.

• By shielding the ovaries with lead shields, thus, avoiding effect of radiation on ovaries.
• While doing surgery, ovaries can be transplanted in paracolic gutter on both the sides saving its blood supply.

Other methods of fertility preservation of cancer patients include Ovarian Tissue Cryo Preservation where cortical strips from the ovary are removed laparoscopically and cryo preserved. This tissue is then implanted in the pelvis or grafted to the subcutaneous tissue as and when pregnancy is required. Ovarian cryo preservation has the advantage that wedges of ovarian tissue can be collected by laparoscopy from each ovary at any stage of the menstrual cycle without compromising a woman’s health. The ovarian tissue can also be cultured which results in achieving either primordial follicle or isolated immature oocyte in vitro maturation.

Embryo and oocyte cryo preservation are two technologies that have yielded satisfactory results for women cancer patients with partners. The process involves the thawing and freezing of the egg and the embryo. Both the treatments make use of the in vitro fertilisation (IVF) procedure. The fertilised embryo is stored and transferred to the uterus as and when the patient is ready to conceive. Although they have proved to be one of the most successful treatments for fertility preservation, care should be taken that the embryo is devoid of cancer cells before it is transferred to the uterus.

Despite the progress that has been made, the preservation of fertility in cancer patients is an emerging discipline; more awareness is required among oncologists, immunologists and endocrinologists regarding the issue. Patients should be counselled about the option of fertility preservation at the onset of the treatment.