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April 2012
When Cancer Strikes In The Child-Bearing Age
Dr Srinivas Chakravarthy Gummaraju
Every cancer patient of childbearing age needs to have a thorough discussion with the medical team, involving the immediate family and requesting a referral to a specialised centre or a reputed fertility clinic if necessary.

The desire to have a child or the case for protecting one’s fertility must be carefully balanced against the possibility of losing the chance of cure, based on ground realities.

I reviewed the tests of the young woman who presented herself before me. It was apparent that it was a case of ‘Borderline Epithelial Cancer’ of the left ovary. It is a curable condition where standard care involves the removal of the uterus and the ovaries and is sometimes followed by chemotherapy. Curable being the word of optimism here, I explained the case to the young woman. A few moments of silence and after, she spoke - more to herself - “I really want to go to my husband. I want to give birth to his son. He will certainly never take me back if I cannot bear him children.”

What was I hearing? What could I say?
Pretty, demure and young, the woman before me was Mehreen, daughter of a house-painter and wife of a man based in Dubai. Her husband had returned to Dubai a month after their marriage and had not been back since. Her family meanwhile had been trying desperately to procure her a visa and ensure her reunion with her husband. In an existence caught between hope and desperation, Mehreen had for some time ignored the pelvic cramps that troubled her. But it wasn’t long before the pain became bad enough to necessitate a visit to the gynaecologist and end up in our oncology consultation chambers. Mehreen is a case example of how young female patients find themselves in a dilemma regarding their fertility. Their vital life-saving decisions all too often based on emotions rather than rationale.

Cancer In Women Of Childbearing Age Affects Fertility In Two Ways
  • When it actually affects the sexual organs - cancers of the ovary, uterus and cervix.
  • When certain treatments / medications given to cure cancer damage the function of the reproductive organs.
Preserving Fertility
Embryo Cryopreservation is the most common technique used to preserve fertility in women who are subject to treatment of cancers of the reproductive organs. The steps in this procedure are:
  • The patient’s ovaries are stimulated by a brief course of hormones. The eggs released during the process are collected and fertilised in a ‘test tube’ by sperm obtained from the woman’s partner or an unknown donor.
  • The resulting embryo is cryopreserved in a freezer for implantation into her womb (or of a surrogate) at a future date.
  • One or more embryos may be created and preserved at the same time.
The rate of successful pregnancies from cryopreserved embryos is 20 to 40 per cent. Apart from its cost factor, ‘Embryo Cryopreservation’ as a means of preserving the fertility of a woman affected with cancer of the reproductive organs, runs the risk of delaying cancer treatment till after the eggs are harvested through hormone therapy. An existing male partner or an unknown donor, if acceptable, is needed making this a difficult option when the patients are unmarried women.

Other techniques being explored are:
  • Oocyte Cryopreservation: preserving the female egg as it is
  • Ovarian Tissue Cryopreservation: preserving slices of the normal ovary with the eggs in them
  • Ovariostasis: injecting certain hormonal medicines to protect ovarian function from chemotherapy
These others have so far been technically challenging, expensive, unsuccessful or all of the above. For patients receiving radiation to the pelvis, Oophoropexy or Ovary transposition, a technique where the ovary is surgically moved to another site in the abdomen (where radiation does not affect) it is advised. A success rate of 15 to 80 per cent pregnancies is reported in such patients, but it is difficult to perform and fraught with risks. The question whether it is needed at all, also remains.

All in all, there are reasonable options for cancer patients wishing to preserve their fertility. After a lot of counselling, Mehreen chose to go with ‘Fertility Sparing Surgery’. The affected left ovary was successfully removed. Careful surgical staging did not show any cancer elsewhere and so Mehreen did not need any chemotherapy. She is well now and can look forward to bearing children.
Cancers affecting the ovary, uterus or cervix are typically treated first by removing these organs surgically. In young women desiring to preserve their chances of fertility, ‘fertilitysparing surgery’ may be done in certain cases. An attempt is made to preserve at least one ovary as well as the uterus. Successful pregnancies are eventually seen in 60 to 80 per cent of these cases.

In cancer of the cervix, special procedures called ‘Trachelectomy’ or ‘cone-biopsy’ may be considered. Successful pregnancies are reported in 40 to 60 per cent of these cases.
These are special techniques that are still evolving. They may be performed by propriately trained gynaecologists or surgical oncologists, in highly specialised centres only. It is very important to realise, that sometimes cure of the cancer may potentially be compromised by ‘nonstandard’ procedures. Also there may be increased risk of loss of the pregnancy, premature delivery, lowbirth weight of the baby and so forth.

For the proper treatment of many cancers, either chemotherapy or radiation affecting the ovaries may be required.
Dr Srinivas C Gummaraju is Senior Consultant Oncologist Apollo Health City Hyderabad

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