Fertility Preservation for Cancer Patients
It is largely through propagation of our biological offspring that we as humans feel we can leave a lasting legacy of our existence. Perhaps this explains why the desire to have children is a basic human instinct, and why an inability to achieve this goal (infertility) often leads to considerable psychological and social strain. Infertility evokes a strong sense of failure, loss, and helplessness, leading to one of life’s most distressing crises.
According to an article published a few years ago in the Journal of Philosophy, Science and Law: “Seven out of ten children and young adults with cancer can be cured. Accordingly, by the end of this decade, an estimated one in two hundred and fifty adults will be survivors of childhood cancer.” Unfortunately for many of them, one of the long-term risks of treatment is infertility.
Many cancer chemotherapy and/or radiation regimens that are directed at the reproductive organs will render the patients infertile. It is argued by some that cancer survivors should be so grateful as to ignore the “inconvenience” of having been rendered infertile by the treatment they underwent — that the burden of post-treatment infertility pales in significance when compared to the long term and often life-endangering complications associated with radiation and chemotherapy. Moreover, those who make this argument often take the position that such patients could always have a baby through using donated eggs or sperm. But this dispassionate attitude ignores the fact that most people crave having their own biological children.
In the last decade, the advances in Reproductive Technology have made it possible for cancer patients to have their sperm or eggs collected and cryopreserved (frozen) for post-recovery dispensation. For males, the collection and cryopreservation of sperm specimens is quite uncomplicated and efficient, while for females gaining access to eggs for cryopreservation is significantly more involved and costly. It requires the prior administration of fertility hormones for more than a week followed by a surgical procedure (egg retrieval), performed under local or general anesthesia.
The recent introduction of a procedure known as in vitro maturation (IVM), where the woman has her eggs harvested without having to undergo prior hormonal stimulation, would simplify the procedure of egg collection for cryopreservation. It would shorten the delay in starting cancer therapy and would reduce the cost associated with egg banking. The bad news is that as yet, the efficacy of the IVM process in securing viable eggs for banking is by no means established.
Another troublesome problem is the fact that conventional egg banking has until recently been much of a hit-and-miss proposition. The baby rate per frozen egg has hovered around 3-4%….hardly sufficient to give a woman confidence that that her banked eggs will ultimately produce a baby for her. This low yield per frozen egg is the reason that most egg banks advise women to freeze a large numbers of eggs (15-20) in advance of undergoing cancer therapy in order to provide reasonable level of confidence that banked eggs will ultimately produce a baby. Sadly, ignorance of this reality has led many women to freeze eggs with only a false sense of expectation that by doing so, they will ultimately be able to be mothers.
A recent major advance promises to change all this. It involves a genetic test [comparative genomic hybridization (CGH)] that selectively identifies those eggs that are most likely to make a baby. In fact, a CGH selected frozen egg yields a baby rate of 27%, which is eight-fold higher than previously attainable. As such, the selective banking of 4-6 such “competent” eggs should provide a far greater level of confidence and offer particular promise for young female cancer victims scheduled to undergo chemotherapy/radiotherapy.
Another obstacle to fertility preservation via egg freezing is that cancer patients rarely have the luxury of time to undergo these procedures. Additionally, some patients (e.g. young women with estrogen-receptor-positive breast cancer), the use of fertility hormones might be contraindicated for medical reasons, due to the potential for increasing the rate of cancer cell growth. This is perhaps where IVM, once the technology matures, could provide a significant advantage.
Then there is the issue of financial cost of fertility preservation. Insurance companies and government payers rarely cover the costs. While the freezing and storage of eggs is not that much more expensive than the analogous service for sperm, the costs associated with the ovarian stimulation, egg retrieval, and anesthesia can be considerable – and in the current economic environment must be totally borne by the patient and/or her family.
The bottom line is that technology is indeed available to help cancer patients preserve the option of having biological children. Since we now have the know-how to preserve human gametes (eggs and sperm), the preservation of fertility for cancer patients should become a standard service available to all those in need of it, rather than a “luxury” reserved only for those who can afford it. Unfortunately, major challenges remain that prevent this from becoming a reality.