The Right to Bear Children: Preserving Fertility in Women With Cancer

Although cancer risk is known to rise with age, the disease can strike people at any stage of life. Cancer patients of all ages tend to be highly focused on getting through cancer therapy, fighting the disease, and surviving cancer-free. But premenopausal women with cancer have an additional set of concerns. Each will be forced to ask herself the following questions: As a woman with cancer, do I feel the same way about having children as I did before I was diagnosed? Do I want to protect my ability to get pregnant at all costs? What can be done to preserve my fertility through the arduous chemotherapy process? Are fertility treatments hard to endure? Are they effective? What are my chances of getting pregnant once I'm out of the woods? Is it worth the trouble?
Lynn Westphal, MD, Assistant Professor and Director of the Donor Oocyte Program at Stanford Reproductive Endocrinology and Infertility Center, is a leader in the field of fertility preservation. Dr. Westphal has worked with oncology teams to help a growing number of women conceive after cancer therapy. Below, she outlines women's options, both common and experimental.

What steps can a woman take to preserve her fertility before starting cancer therapy?
A woman's treatment options will depend on the type of cancer she has, the type of treatment she's going to receive, and how much time she has before starting treatment. If she's going to start therapy very soon, her only option may be a gonadotropin-releasing hormone agonist (GnRH), a medication that may ultimately preserve ovarian function by shutting down the ovaries during chemotherapy. Although unproven, it is believed that putting the ovaries to sleep during chemotherapy may actually protect them. Afterwards, ovarian function may return to normal or close to normal.

Another thing we sometimes do is freeze a woman's eggs or embryos before therapy. If she has a couple of weeks before the start of chemotherapy, we may discuss stimulating her ovaries, removing several eggs, and then either freezing the eggs or fertilizing them with male sperm and freezing the embryos. This is essentially the same as an in vitro fertilization cycle.


What factors affect a woman's chances of getting pregnant after she completes cancer therapy?
The most important factor is her age at the time that she's receiving chemotherapy. If she's in her late thirties or forties, it's less likely that her ovarian function will return to normal. In addition, the type of chemotherapy drug and the total dose are important. Some types of chemotherapy are much more damaging to the ovaries than other types.

If preserving fertility is a primary concern, a woman may request a type of chemotherapy that could have a less toxic effect on the ovaries.

What are the options for women undergoing radiation treatment?
Radiation can damage tissue that is in the path of the beam of radiation. Sometimes the radiation oncologist can localize the radiation far enough down in the pelvis so that the ovaries won't be affected. Another option is that before the start of radiation therapy, we can surgically move the ovaries further away from the radiation field. We can simply move them up and out of the pelvic region.
Are there any additional fertility-preserving drugs or procedures available to women with cancer? If a woman has already lost her ovarian function, she can get donated eggs and have the embryo or embryos implanted into her own uterus.

There's also another highly experimental surgical procedure, involving the following steps: A piece of ovarian tissue is removed, frozen, and then replaced after the end of cancer therapy. Thus far, no pregnancies have resulted from this still experimental procedure. Perhaps more promising, researchers have been culturing ovarian tissue in the laboratory to get eggs that could be used to fertilize embryos for implantation in the uterus.

Given the harsh side effects of most cancer therapies, how many women with cancer are willing to subject themselves to additional treatments to help them stay fertile?
Most patients are very focused on getting rid of the cancer, but there's a minority who are really dedicated to preserving their fertility. There are some women who will delay or change their treatment plans, because fertility is even more important to them than treating the cancer. They know there's a tradeoff: Maybe they'll have a slightly lower chance of a cure, but they'll have a better chance of getting pregnant in the future. So there is a range in how strongly women feel about it.


How many women actually achieve a pregnancy after cancer therapy?
You know, it really depends on the woman's individual situation. If she's young and being treated for certain types of cancer with agents that are less toxic to the ovary, then her fertility potential is very, very good. But if she's in her late thirties or in her forties, her odds of having good ovarian function afterwards are going to be much lower. Remember, by the time she's in her late thirties, a woman has a smaller number of remaining eggs, anyway, so she may not even have optimal ovarian function at that point.

I've had quite a few patients who have frozen embryos in the past, used them after they went through their chemotherapy, and went on to become pregnant. Recently, I had a patient with endometrial cancer who froze her embryos before having a hysterectomy. Later, when she regained her health, she found a surrogate, and had a baby boy in December.

Are you seeing more people with cancer looking for ways to preserve fertility?
Now that we're curing more cancers and more people are living longer after their diagnosis, quality-of-life issues like preserving fertility have come to the fore. There are many more people thinking about fertility than there were even ten years ago. Many people with cancer don't even realize yet that there are things they can do about it.

It's extremely important to make this information available to as many people with cancer as possible. This is a case where patients can do a lot to educate their oncologists, many of whom don't know much about fertility issues and what can be done to help women keep their reproductive function.

What is your best advice for women with cancer who are committed to preserving their fertility? How can they be proactive in their own care?
I'd recommend one very good resource - the Fertile Hope website. Fertile Hope is an organization that was started by a woman who went through cancer treatment when she was very young herself. The organization's primary aim is to make cancer patients aware of things they may be able to do to help with their fertility in the future. The site contains a list of places in the country that freeze eggs and embryos and offer other treatments that may help in the future.

http://womens_health.healthology.com...cancer&spg=FLA