Some young women will develop a cancer involving their reproductive organs before they have completed their family. The cancer may pose a significant threat to your subsequent chance of having a baby. This presents a further psychological burden when you are already coping with the recent distressing news that you have cancer.
In this time of anxiety and concern it is essential that you receive concise and up-to-date information from a recognised fertility expert. You should be referred to a respected unit for this advice. The Reproductive Technology Accreditation Committee (RTAC), under the Fertility Society of Australia (FSA), administers a national Code of Practice and a system for the accreditation of assisted reproductive technology clinics. For a list of accredited clinics in Australia and New Zealand, see the website of the Fertility Society of Australia at www.fertilitysociety.com.au
The way that the cancer may affect your chance of conceiving is two-fold. Fertility problems may occur as a result of essential surgery, or as a result of the chemotherapy or radiotherapy you may require after the surgery.
Many women also experience body-image concerns after surgery which may lead to having sexual intercourse less frequently. This is a major determinant of the chance of conceiving naturally; hence for many reasons, many women will seek fertility assistance.
In most cases, cervical cancer is treated either by radical hysterectomy (which removes the uterus but leaves the ovaries and fallopian tubes), or by chemoradiation (which destroys cancer cells, but also affects the lining of the uterus and causes the ovaries to stop producing eggs).
Younger women having a radical hysterectomy may retain their ovaries, which are sometimes transposed (moved out of the pelvis) so that they will not be affected by any post-operative radiation treatment, should it be required.
If you still have your ovaries after surgery you will still be producing your own eggs, and there are some options available for fertility, although you will not be able to ‘carry’ a pregnancy yourself. For more information see ‘Fertility-sparing options’, below.
In very early cases of cervical cancer (usually called ‘early stromal invasion’ or ‘microinvasive cancer’), it may be possible to do a relatively minor operation such as a cone biopsy. This has little effect on fertility as the uterus, cervix, fallopian tubes and ovaries remain.
Some cases of early invasive cancer may be treated by a radical excision of the cervix, which removes the cervix but is able to spare the body of the uterus, ovaries and fallopian tubes. This is called radical trachelectomy and has been followed by successful pregnancies, although there may be an increased risk of miscarriage. There are risks with such approaches, however, and these risks should be discussed fully with your gynaecological oncologist.
Chemotherapy and/or radiotherapy may affect the number of eggs left within the ovary, and in many cases, accelerate the normal age-related decline in egg numbers.
In some cases this may lead to an early menopause, and hence the need to use another woman’s eggs (egg donation treatment) to become pregnant. Hormone replacement therapy can help with managing the symptoms of early menopause.
As mentioned above, a surgical procedure called ovarian transposition, which lifts the ovaries as far from the source of the radiation as possible, can reduce the harmful effects of the radiation on the ovaries.
You can talk to a fertility specialist about your options to limit harm to your ovaries from chemotherapy. These may include:
Ovarian tissue freezing
One potential way to save some eggs for the future is to take a small slice of ovarian tissue. This is done by a minor operation before starting chemotherapy, or at the time of ovarian transposition surgery before starting radiotherapy.
The major downside to this technique is that it is still experimental – very few babies have been born from this treatment. Furthermore, it involves undergoing an operation, and then further surgery to re-implant the ovarian tissue when the time comes to try to get pregnant. Evidence suggests that many women do not want the ovarian tissue replaced due to their fear of re-introducing tissue that may still contain cancer cells.
Freezing of eggs
If you are not in a stable relationship, you may opt to go through an IVF cycle. This takes up to one month before starting chemotherapy or radiotherapy. It involves daily injections to stimulate the ovaries, and then after a couple of weeks, a minor surgical procedure to have the eggs collected. These eggs are then rapidly frozen until they are needed. However, this technique should still be considered developmental and success so far is limited.
If you are in a stable relationship and time permits, you may opt to go through an IVF cycle (described above), but in this case your eggs are fertilised with your partner’s sperm and the resulting embryos are frozen until they are used. The freezing of embryos is a more successful procedure than the freezing of eggs and is more likely to ultimately result in having a child.
An implant containing a drug called a GnRH analogue may be used to suppress the function of the ovaries for the duration of chemotherapy. This may limit harm to the ovaries, but little research has been done on this procedure and it is not used for women embarking on chemoradiation.
“Wait and see” policy
Many women find these choices are too hard to make at this time of great anxiety. It may help to talk to the fertility counsellor that is always attached to an IVF unit.
If you find you are unable to conceive after your cancer treatment and you have retained your uterus, you may consider embryo or egg donation treatment.
If you have had a hysterectomy you may consider embarking on a surrogacy arrangement using either your own eggs or a donor’s eggs.