Overview
Even the cancer treatments are improved, the complications faced by survivors of cancer are more. Many survivors are young and are diagnosed and treated before they have children. Cancer and its treatment can significantly affect the chance of a patient having a child in the future. It is important to the doctors to discuss the effects of fertility after the cancer treatment, they have to give advice or explore whether they store eggs, sperm or embryos before cancer treatment. This helps the patient to have their biological child in the future. If the patient faces cancer and infertility problems, they have to consult the counselors to avoid distress.
The Effects of Cancer Treatment on Fertility
Following cancer treatment, most patients will be advised to delay conceiving for some time. Female fertility declines sharply in a woman’s mid to late thirties and even just this delay can significantly reduce the chance of conception.
Chemotherapy
Oocytes (eggs) are highly susceptible to the effects of chemotherapy. Women treated with chemotherapy are therefore at risk of damage to their eggs, which may ultimately fail the ovaries. The risk of ovarian failure is higher with increased dose and duration of chemotherapy and with particular types of chemotherapeutic medication. A woman’s period may stop during chemotherapy but may come back up to nine months after chemotherapy treatment has finished. Although some women will retain eggs in their ovaries after chemotherapy treatment, unfortunately, many will suffer premature ovarian failure and would need to consider treatment with donated eggs if they wish to conceive.
Radiotherapy
Whilst most chemotherapy treatments are administered systemically (throughout the body), most radiotherapy treatments are directed to a local area. Therefore, damage from radiotherapy is usually limited to the area treated. Pelvic radiotherapy damages egg highly. Retaining ovarian reserve after the treatment is very rare. Additionally, pelvic radiotherapy can cause damage to the uterus (womb) caused by fibrosis (the formation of excess fibrous connective tissue in an organ or tissue) and a reduction in blood flow. Following pelvic radiotherapy, it is likely that a woman would need to consider fertility treatment using donated eggs and a surrogate host.
Surgery
Surgery for gynecological malignancies can impact on a woman’s chance of pregnancy in the future. It is important that a woman’s decision for future pregnancies is considered and that treatment is performed whenever possible.
Fertility Preservation Options
1. Oocyte cryopreservation - Egg FreezingWomen may attempt to ‘freeze’ eggs for future use before they undergo treatment such as chemotherapy, which may affect their egg store. Oocytes (eggs) are stimulated to develop within the ovaries by daily administration of hormone injections. Following this, the eggs are removed from the ovaries under ultrasound control. The eggs removed are then frozen very rapidly using the technique of Vitrification. Eggs can be stored for up to 55 years. Vitrification is the most effective way of freezing human eggs with more than 90% of vitrified eggs surviving after thawing. Women under the age of 35 years have the chance of 1 in 3 cycles of egg freezing resulting in an ongoing pregnancy. The number of pregnancies depends on the number of eggs stored, with each egg having approximately a 5% chance of leading to pregnancy in women under 35 years. The chance of pregnancy will be more to the younger women. Oocyte Vitrification is still a relatively new technique, however, many babies have now been born after using this technique. Initial data suggest that there is no increase in abnormality rates in babies conceived after eggs frozen in this way.
2. Embryo cryopreservation (Freezing)If a woman is in a stable relationship, the couple may wish to freeze embryos instead of eggs. The woman undergoes a cycle of ovarian stimulation and egg retrieval as in conventional IVF. On the day of egg collection, the male partner is asked to provide a fresh sample of semen, produced on-site in the Andrology Department. All mature eggs retrieved are injected with a single sperm using a technique known as ICSI (Intracytoplasmic Sperm Injection). On average, about 50-60% fertilize and form embryos. The laboratory will ring you the morning after egg collection to tell you how many eggs fertilized. The embryos are now at the ‘pronuclear’ one-cell stage. It is at this stage that embryos will be vitrified for fertility preservation. Embryo freezing is a relatively successful procedure and follow-up studies on babies born are reassuring. Embryo storage should only be carried out for couples in a stable relationship as, if the couple separates, the male partner may withdraw his consent for continued storage and treatment. As a result, the embryos would have to perish.
What Treatment Involves
For both egg and embryo freezing, you will need to undergo ovarian stimulation and egg collection.
1. Ovarian Stimulation- • Ovarian stimulation involves daily injections of a drug (Gonadotropin) to stimulate your ovaries.
- • Injections are subcutaneous (beneath the skin) – given through the abdomen or thigh.
- • The site of the injection needs to be changed daily – usually from side to side (left/right). We recommend you do the injections at the same time every day. We will advise on the timing at the start of treatment.
- • The drug dose may change during treatment depending on your response to the drug.
- • You may experience a feeling of heaviness or pressure inside the abdomen as the ovaries get bigger – this is normal.
- • It is important to follow all instructions on drug dosage and timing. You should inform us immediately if there are any problems with this.
- • You will need to administer this injection for approximately 10-12 days.
In addition to your stimulating injection you will be prescribed GnRH before Antagonist (cetrotide) in the form of injections. You will be advised how and when to administer these injections. You may be asked to continue the antagonist for a week following your egg collection. From 4 to 7 days after egg collection, women with hormone-sensitive breast cancer should take letrozole tablets. The treatment you are prescribed will be individual to you. The protocol and time to start stimulation will be decided depending on any other treatment you are undergoing and to minimize any delay to oncology treatment. If you have any questions, please ask.
3. Monitoring through stimulation- • During stimulation, you will be monitored using blood tests and scans.
- • 2-3 scans are usually done during the treatment cycle to monitor response to treatment – by way of the growth of follicles in the ovaries.
- • All scans during the treatment cycle are performed vaginally, as very detailed scans can be obtained in this way, giving accurate measurements of the ovaries indicates the stage of growth of the follicles and readiness for egg collection.
Buserelin is the last and final injection before egg collection is carried out. The timing of this injection is very crucial. The injection must be taken at the time advised by the Unit (this is 34-36 hours before egg collection). This is a late-night injection. This is the last injection you have before the egg collection.
5. Egg collection- • Egg collection usually lasts 20-30 minutes and is usually performed in the morning under intravenous sedation.
- • The procedure is guided by a vaginal ultrasound.
- • You will be required to starve from midnight before egg collection (no food, water or chewing gum).
- • Not all follicles seen on scan yield eggs.
- • You may experience some pain and bleeding after the procedure.
- • Chemotherapy, when indicated, could be arranged to commence from as soon as the day after egg collection.
What are the Risks of Fertility Preservation Treatment?
Throughout treatment, Prasad Hospitals work closely with the team planning cancer treatment, to minimize any risk to you or delay your cancer treatment.
Delay to cancer treatment
When the intention is to freeze eggs or embryos, ovarian stimulation can start at any time in the menstrual cycle as there is no need to ensure that the lining of the womb is at the same stage of the cycle as the ovaries. However, ovarian stimulation takes a minimum of just over two weeks. It is therefore crucial that women are referred to as early as possible in their treatment pathway to allow them to consider fertility treatment if they wish without delay to their oncology treatment. Women who have acute leukemia and delay for the treatment, are not able to freeze eggs or embryos.
Risk of high oestrogen levels during stimulation
High levels of oestrogen are seen during ovarian stimulation cycles. This could pose a risk to women diagnosed with oestrogen sensitive breast cancer. The addition of the drug Letrozole is known to significantly lower oestrogen levels and we use this routinely for oestrogen positive breast cancer patients.
There are no large, long-term follow-up studies, but early data has not demonstrated an increased risk of recurrence or disease progression in these patients.
Risk from egg retrieval
There is a potential risk for women with ovarian malignancies following egg collection when there could be a spill of malignant cells from the ovary into the abdomen, although in practice this is rarely thought to be significant. We always discuss this with the oncologist to minimize any risk.
Ovarian Hyperstimulation Syndrome (OHSS)
About in 1% of women undergoing a cycle of ovarian stimulation for egg recovery, Ovarian Hyperstimulation Syndrome (OHSS) is seen. The risk is no higher in patients undergoing fertility preservation, but we usually continue with drug therapy for one week after egg collection to try to reduce the risk further, so that the woman is in the best position to commence her oncology treatment.
Your Options
Once you have considered all the information you may choose:
- • Not to proceed with fertility preservation.
- • To consider possible egg donation in the future.
- • To proceed with egg or embryo freezing.
If you choose to proceed with egg or embryo freezing you will initially be asked to consent for 10 years of storage. Once your oncology treatment is complete you will have the opportunity to discuss your future options. You will be assessed and treated in line with the Clinical Commissioning Group (GGC)/Trust Infertility/assisted conception guidelines.
Counseling
Patients have found counseling extremely helpful and it is available to all patients referred to us. To make an appointment please ring our reception desk on +9188012333333, or visit: www.prasadhospitals.in