Cancer Treatment And Female Fertility
In order to treat your cancer you will have been offered surgery, chemotherapy, and /or radiotherapy.
These treatments may have a damaging affect on your reproductive organs, in that they may cause your ovaries to no longer have eggs, or, in the case of radiotherapy, your womb may be damaged and either have a reduced capacity to conceive or no longer be able to carry a pregnancy.
In the case of surgery it might be necessary to remove your ovaries or your uterus. This depends upon the condition you are suffering from.
Options
The options below are the main alternatives offered when making a decision about fertility preservation. Not all are appropriate for all treatments. The urgency of treatment may depend upon the disease and some solutions may take too long to complete. Treatment may need to be started before completion of fertility treatment
1. Not Undertaking Any Fertility Treatment.
Some women feel they do not want to have any fertility treatment. There may be pressure to have treatment by partners, family or doctors. The choice is yours, and you may feel that all you want to do is to explore the implications with a counsellor. The oncology department will often have an available service.
The odds of preserving fertility following treatment can vary greatly from one individual to the next depending on the type of cancer, your age and type of treatment. The oncologists should be able to give you an idea of your chances of preserving the function of your ovaries and your womb after treatment. This can only ever be a guide, due to the variability between one women's natural fertility and another's.
Some women decide that they would rather concentrate on returning to full health rather than embarking on a course of fertility treatment. This is most likely if they have been given good odds of preserving their fertility.
Other women may not wish to delay their cancer treatment. Delay might be detrimental to the chance of a successful treatment is some cases. Your oncologist can advise you.
In some cases the normal (natural) stimulation to the ovary can be switched off, keeping the ovary dormant during chemotherapy which may help to maintain future fertility. This is done with medication and will temporarily have the side effects of the menopause. This will only be possible with some cancers and usually is only offered with chemotherapy. It is unlikely to protect from radiotherapy. You can discuss this with your oncologist. The drug is called a GnRH analogue and the results are variable.
2. Embryo Freezing (Cryopreservation)
This is often the most successful choice for women prior to undergoing chemotherapy. However, the creation of embryos requires sperm as well as eggs. It is necessary for you to undergo an IVF cycle to create the embryos. Any embryos created as a result of this cycle can be frozen, to be used at a later date.
The ownership issues surrounding are important. Essentially each person involved has an equal share in the decision-making as to what might happen to these embryos in the future. YOU ONLY HAVE A 50% SAY IN THEIR FATE. This means that if there is dispute between yourself and the male providing the sperm in the future you may not be able to use the embryos. Because embryos survive freezing well this is probably the most successful option and is appropriate for a couple in a stable relationship
If you do not have a partner (and consider using donor sperm acceptable) then donor sperm can be organized for you. You should be aware however that the embryo can only be stored for 5 years (not 10) if that is what the donor consents to. It might have implications in any future relationship if your only remaining genetic material is already fertilized by another party. Any child resultant from that treatment has the right of identifying information about his/her genetic father once reaching the age of 18.
This treatment needs to be organized as soon as possible so as not to delay your cancer treatment any longer than necessary. Treatment to stimulate your eggs requires starting with the start of the period (day 1 or 2) and takes about 2-4 weeks to reach egg harvesting.
Treatment could start with your next period. If you are on the oral contraceptive pill do not stop it and ask for advice on continuing to take the pill till seen in the clinic.
Unfortunately not all frozen embryos survive the freezing process. Usually there is an approximate 70% survival rate of embryos on thawing. Embryos may be frozen up to 10 years in women undergoing cancer treatment.
We can provide you with information regarding what is involved in an IVF cycle, and will be happy to discuss this with you further should you have any unresolved questions.
3. Egg Donation
If your ovaries are no longer able to produce eggs following cancer treatment or if other options have been unsuccessful then egg donation could be considered. This involves another woman (the egg donor) undertaking an IVF cycle for you. Her eggs will be collected and mixed with your partner's sperm. This should then lead to the creation of embryos, which can either be transferred into your womb or be frozen and used at a later date. One or two embryos are usually transferred to give you a good chance of conceiving. Egg donors should be under 35 years of age, but individual circumstances can be taken into account. All donors will be screened for the standard tests that are recommended by HFEA (Human Fertilization and Embryology Authority) for all donors of sperm or eggs.
The waiting list for anonymous egg donation is long (6 months to up to 3 years). Women may sometimes move up the list by either finding a donor who will donate for another woman on the list, or by finding a known donor who will donate directly to them (remember the child has the right of identifying information about the donor).
Egg donation does mean that you can wait until after your oncology treatment and for the right time when you feel you wish to start trying for a child, obviously taking into account the waiting time which may be required.
4. Egg Freezing
The freezing of eggs is particularly appropriate for single women who do not wish to have embryo cryopreservation or women who feel their relationship is not secure enough to give away sole ownership rights over their genetic material. Unfortunately the chances of ultimately having a baby from egg freezing are less than when frozen embryos are used.
You will need to undergo ovarian stimulation as if for an IVF cycle prior to commencing cancer treatment. The doctor will decide upon which type of ovarian stimulation is appropriate for you considering your condition and the time available.
It is possible to start ovarian stimulation at any time in the menstrual cycle. You do not have to wait for a period. This is because the eggs/embryos are not being replaced and so the state of the endometrium in the womb does not matter. It is also possible to use a drug called letrozole, if it is desirable to block oestrogen levels rising. This will depend upon the reason for treatment. Oestrogen levels would otherwise rise as the treatment progressed.
Ovarian stimulation lasts about 12-14 days. The egg collection is usually done under either an anaesthetic or sedation. You could go directly for treatment afterwards.
In cases where it is not clear if post-operative chemotherapy is needed you could have this between surgery and possible chemotherapy.
Any eggs, which are collected, will be carefully assessed according to their maturity and only mature eggs will be frozen for you. These eggs will remain in storage until such time as you require them. At this point they will be thawed and will need to be fertilized using your partner's sperm. This fertilization procedure will entail injecting a single sperm into the egg in order to create an embryo. This is called Intra Cytoplasmic Sperm Injection (ICSI) .
Egg freezing is a relatively new technique. Until recently it was not as successful as embryo freezing. Eggs are extremely sensitive to changes in temperature and the chemicals used for freezing. Recently a rapid freeze technique called vitrification has been introduced. This has improved these chances but they are unlikely to exceed frozen embryo chances. Approximately 70-80% of eggs survive the freezing and thawing procedure, Don't forget that they still have to fertilise. Usually about 70% of eggs fertilise. Advances in these techniques are being made in order to reach an equivalent rate to embryo freezing.
5. Surrogacy
Surrogacy involves the transfer of an embryo that was created from one of your own eggs, prior to commencing cancer treatment, into the womb of another woman (the surrogate). If this then results in pregnancy the surrogate will carry the pregnancy and deliver the baby.
Surrogacy is offered to women who have their womb or cervix (neck of the womb) damaged or removed by cancer or its treatment (for instance women who have had pelvic radiotherapy) but their ovaries are and functional.
The surrogate can also act as an egg donor with the male partners sperm being inseminated into the surrogate in mid cycle (at ovulation).
As the surrogate will deliver your baby she and her partner (if she has one) will be the legal parents of any resulting child even if they are not the genetic parents. After the baby is born you will need to adopt the child. The process needs to be planned carefully with involvement from solicitors
You will need to find your own surrogate, as we feel that this is a very personal decision. It needs to be someone whom you feel you can trust. Occasionally family members may act as a surrogate. Some independent agencies may be able to help put you in touch with women who are interested in becoming a surrogate. Both the COTS organization and the British Medical Association have information available. It is illegal for any money to be exchanged between parties other than for reasonable expenses.
6. Ovarian Tissue Preservation
A moderate amount of your ovary (or your whole ovary) can be stored outside of your body for future use. This piece of your ovary would be protected from your cancer treatment, and could hopefully produce eggs in the future either if it is transplanted or stimulated in the laboratory. Unfortunately this treatment is extremely experimental with only one successful pregnancy in the entire world.
Although several (sometimes short lasting) transplantations ( replacing the ovary back into you) have been performed a significant proportion of the tissue is damaged by freezing. The option of taking eggs from the ovarian tissue and maturing them outside the body has not yet been successfully done. So far no-one has successfully matured eggs taken from these immature ovarian follicles and it is unlikely that this technique will be perfected soon.
The ovarian tissue is taken during a laparoscopy (key hole surgery). You are likely to be a day case patient, and so not need to stay overnight in hospital.
There is also a risk that if the ovarian tissue is re-implanted into your body it may still contain cancer cells which will have been untouched by your therapy. The risk depends upon the type of cancer.
7. Embryo Donation
Some couples have embryos that they no longer need for themselves, and have consented to have the embryos used by other women.
This form of treatment is suitable for women who had their ovaries damaged or removed during their cancer treatment, without prior embryo or egg cryopreservation. This treatment is also an option when using your own eggs or embryos has failed.
Depending on your hormone levels, you may need medication prior to the embryo transfer. The procedure itself is straightforward and no anaesthetic is required. If you become pregnant and carry the pregnancy successfully, then the baby will be legally yours.
Unfortunately, there is often a long waiting list for donated embryos. Embryos from some ethnic groups are in very short supply.
Funding
Some Primary Care Trusts will fund this treatment prior to therapy. Most will fund oocyte or embryo freezing prior to treatment. There may be qualifying criteria and the commonest is that you should not have existing children. We know of no Primary Care Trust funding Surrogacy. Egg donation is unlikely to be funded unless you have considered one of the pre-treatment options.
You always have the right of appeal
If you disagree with any of the criteria please discuss this directly with your local Primary Care Trust and not with us. We have absolutely no say in the matter. This information is put together in good faith and is as far as we believe accurate. Because criteria vary you should contact your local fertility expert who can approach the local Primary Care Trust on your behalf or contact them direct.