Introduction
Becoming a mother is a dream for any woman; anything hindering it can be a nightmare. This is especially when it comes to cancer treatment or other health conditions. The incidence of cancer among women of reproductive age has been increasing. However, advancements in the medical field and technology have also increased the survival rates after cancer. Innovations like fertility preservation improve the quality of life of cancer survivors, giving wings to their dreams of having children.
What Is Fertility Preservation?
Preserving the ability to start a family at an individual's or a couple's own time is termed fertility preservation. It is an emerging field of study where there are many varieties of therapies for fertility for patients who anticipate treatments that could affect their future reproductive outcomes. Oncofertility is a term coined to mean fertility preservation in cancer survivors. Conditions other than cancer, like lupus, glomerulonephritis, myelodysplasia, and premature ovarian failure like Turner mosaicism, are some conditions that may affect a woman's fertility.
What Is Reproductive Counseling?
In most cases, topics regarding fertility preservation are rarely or never discussed with the patient before their treatment. Recent studies have shown that infertility post-treatment has become a significant concern among survivors. Patients who were well-informed about their sexual and reproductive health had lesser psychological stress than those who were never informed. People who were informed early tend to be less stressed and have lesser regret for their infertility.
The American Society of Clinical Oncology was the first to recommend fertility preservation in 2006. They stated that 'as part of education and informed consent before cancer therapy, oncologists should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer patients to reproductive specialists.' The American Society for Reproductive Medicine committee recommends that mental health professionals and genetic counselors counsel the patient and help them make wise decisions. Genetic counselors will be able to make the patient aware of any potential risk of transmission of the condition to the next generations and of any genetic testing that will help them understand it beforehand.
How Is Fertility Affected by Cancer Treatment?
Some kinds of cancer can adversely affect fertility. It can be temporary or permanent. The probability that cancer can affect an individual's fertility depends on the type of cancer, the individual's age, the stage at which the cancer was diagnosed, and the treatment it might require. The effects of cancer treatment can include:
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Surgery: The fertility of an individual can be hampered when cancer therapy demands the removal of the reproductive organs like the ovary, testicles, or uterus.
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Chemotherapy: The effect of chemotherapy on fertility is determined by the type of drug used and its dosage. Drugs like Cisplatin and alkylating agents are known to have more adverse effects on fertility. Older women are more likely to become infertile after cancer treatment when compared to women of younger age.
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Radiation: This is more potent for causing infertility than chemotherapy. Its effect depends on the area the radiation is given, the size of the radiation field, and the dosage given. For instance, a high radiation dose may destroy some or all eggs in the ovary.
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Other Medications: Other medicines, like hormones used in breast cancer, can adversely affect fertility. These might be reversible in some cases- when the treatment is stopped, the chances of fertility might increase.
What Are the Methods to Preserve Fertility Before a Cancer Treatment?
In the current era, there is a scope to preserve fertility in women before starting cancer treatment. They can include:
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Embryo Cryopreservation: In this procedure, eggs are harvested, fertilized, and frozen to be implanted later. Studies show that these fertilized embryos survive the freezing and thawing process in up to ninety percent of the cases.
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Oocyte Cryopreservation: In this procedure, unfertilized eggs are harvested and fertilized. However, studies show that human eggs do not survive freezing as well as human embryos.
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Radiation Shielding: Small lead shields are placed over the ovaries or the testicles, while radiation therapy reduces radiation exposure, thereby minimizing the adverse effects.
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Oophoropexy: It is also called ovarian transposition. In this procedure, the ovaries are repositioned in the pelvis to be outside the exposure area while radiation is given. Nevertheless, the ovaries do not receive total protection due to the scattered rays. The ovaries must be repositioned again after the treatment to conceive.
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Surgical Removal of the Cervix: Early stages of cervical cancer are treated by removing a sizeable cone-shaped cervix, including the cancerous area. This is called cervical conization. The remaining portion of the cervix and the uterus are preserved.
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Sperm Cryopreservation: The sperm is harvested and frozen for use at a later period. Sperm can be stored in this method for years.
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Ovarian Tissue Cryopreservation: In this procedure, the ovarian cortical tissue, rich in primordial follicles, is obtained by laparoscopy or laparotomy before ovarian failure. The obtained ovarian tissue is then sectioned into small fragments and cryopreserved by slow-cooling or vitrification. These tissues are then transplanted back after the cancer treatment into the pelvis. This is called an orthoptic transplant.
What Is Ferto-Protective Adjuvant Therapy?
This is the adjuvant therapy given before or along with chemotherapy to preserve the loss of ovarian reserve. This is still under research to find a drug that fits the bill, though a few promising drugs have been on the route to discovery. Sphingosine-1-phosphate (S1P) and Imatinib which inhibit apoptosis, Tamoxifen which works as an antioxidant, and AS101, which causes modulation of follicle activation pathway, are some drugs under consideration. However, gonadotropin-releasing hormone (GnRH) agonist is the only drug used in clinical practice to date.
Developing safe drugs on the ovary is essential for female cancer survivors. This can help them retain their natural fertility without undergoing additional procedures to preserve fertility. This can avoid the distressing side effects of premature ovarian failure (POF).
Conclusion
Fertility preservation is a blessing to young people, especially cancer survivors. This enables them to look into the prospects of starting a family after achieving a disease-free state. The need for fertility preservation must be weighed against the morbidity and mortality rate associated with cancer. Hence, oncologists and reproductive healthcare professionals must join hands to spread awareness in this field of study.
