Cancer can affect fertility in women in two ways
As medical science progresses, our aims, goals and boundaries also shift higher and further. Now, simply treating cancer is not enough. Quality of life issues are more important for cancer survivors than ever before. With this point in mind, fertility preservation for women cancer survivors has gained a great deal of importance.
Cancer can affect fertility in 2 broad ways. One, the effect of the cancer itself, in destroying the potential of the organ to be functional. In women, for eg its genital cancers, ie cancers of the uterus or ovaries. Uterine or cervical cancer can essentially destroy the uterus, and make it unable to hold a pregnancy. Or ovarian cancer, can by the growth itself destroy the ovaries' ability to produce healthy eggs. Second, and more likely way is the treatment for the cancer itself. Obviously, standard surgery for uterine or ovarian cancer involves removal of these organs, and that, by itself makes the woman infertile. Chemotherapy, has the potential to destroy the eggs in the ovary and similarly radiation ie high dose x-rays can also permanently damage the ovaries. In patients who suffer from non-genital cancers, but need chemotherapy or even radiation to the pelvis, can, by the same mechanism cause infertility.
Over the last decade, it has been noticed that there has been a sharp rise in gynaecologic cancers, especially uterine (endometrial) as well as ovarian. In fact genital organ cancers account for 65% of all cancers in women. The reasons are many and include, environmental, social and lifestyle factors. More importantly, we have seen a sudden rise in cancers in younger women. Traditionally, uterine, ovarian or even breast cancers were diseases that we saw predominantly in middle aged and older women. But over the last 5 years we have also seen a rise in these cancers in women in the 40s, 30s and also in their 20s. In fact, the younger the age, the more aggressive the disease. Thus, fertility preservation in young patients with cancers is an extremely important topic and considerable research has gone into it.
In younger women with genital cancers ie cancers of uterus, ovaries, fallopian tubes, vulva, vagina and pregnancy cancers, some form of fertility preservation is possible, only if certain criteria are me. Essentially, it has to be young women desirous of having children with very early stage and less aggressive (low grade) cancers.
These are patients where limited surgery (fertility sparing surgery) is possible and maybe one ovary and/or the uterus can be preserved and/or chemotherapy can be avoided or even if used, it may be relatively non toxic or low dose. In some cases, drugs and injections can be used to protect the ovaries from the toxic effect of the chemotherapy agents. If radiation is needed then perhaps ovary sparing radiation can be done (especially in some cervical cancers). There are some situations, where, with the help of fertility experts, one can harvest the patient's eggs before starting cancer treatment. These eggs can be cryopreserved (frozen) or if patient has a partner, then an embryo can be created (using invitro fertilization techniques) and the embryo can be cryopreserved. These can then be later be used for the same woman if her uterus still exists for a pregnancy of for surrogacy.
Patient selection criteria are extremely important and at no point does one want to compromise on the young woman's life in deference to a potential future fertility which may or may not happen. Therefore, the decisions to treat young women with cancers and for fertility sparing, is a complex process and involves a team effort. The gynae-oncologist along with radiation experts, chemotherapy specialists and infertility specialists have to sit together and discuss with the patient and her well wishers to arrive at a plan of action that is medically most sound and acceptable.
(Dr Samar Gupte, Consultant Gynae-Oncosurgeon, Hinduja Hospital, Breach Cnady Hospital and Surya Hospital, Mumbai)
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