Fertility Preservation for Girls and Young Women with Cancer
EDITORIAL
FERTILITY PRESERVATION FOR GIRLS AND YOUNG WOMEN WITH CANCER
Richard A Anderson
Professor of Clinical Reproductive Science
MRC Centre for Reproductive Health, Queens Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ UK
Phone: 0131 242 6386/ 6988
Competing interests: None
Melanie C Davies *
Consultant Gynaecologist
Reproductive Medicine Unit, Department of Women’s Health, University College London Hospitals, 250 Euston Road, London NW1 2PG UK
Mobile 07939 312402
Secretary 0203 447 9453
Fax 0203 447 9775
*corresponding author
Word count: 799
Competing interests:Both authors have read and understood the BMJ Group policy on declaration of interests and have no relevant interests.
Contributor statement: Both authors contributed to the planning, drafting, review and final approval of the manuscript.
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FERTILITY PRESERVATION FOR GIRLS AND YOUNG WOMEN WITH CANCER
Richard A Anderson1 and Melanie C Davies2
1MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh UK
2Department of Women’s Health, University College London Hospitals, London UK
Advances in the treatment of cancer in children and young adults have meant that more survivors are living with the long-term consequences of treatment[1].Loss of fertility is a major concern[2], andinfertility is a common outcome after high dose chemotherapy andpelvic irradiation[3]. Fertility preservation has been available to men for many years; semen cryostorage prior to treatment yields viable sperm later for use in in vitro fertilisation. For women, however, more complex and invasive procedures are required[4]. The recent announcement of the first baby born in the UK following regrafting of ovarian tissue which had been cryopreserved 10 years earlier for a young woman with cancer[5] highlights this aspect of the holistic care of young cancer sufferers.
The options forwomen facing loss of their fertility from treatment for cancer or other therapies include oocyte or embryo cryopreservation, or more experimentally, ovarian tissue cryopreservation. Embryo freezinghas been used successfully for 3 decades but oocyte freezing is technically more challenging; the development of vitrification has dramatically improved success rates from oocyte cryostorage[6].This is now a viable option for single women, and retains control over future use, whereas embryos are the joint property of the man as well as the woman. Both these approaches require ovarian stimulation and egg retrieval as used for IVF. This takesapproximately 2-3 weeks,introducing potential delay in cancer treatment, and there may be some risk to women with hormone-sensitive cancers from the high estradiol concentrations induced[7].
Ovarian tissue cryopreservation requires a laparoscopic surgical procedure and thus, while more invasive with a small risk of surgical complications, it can be carried out more quickly. Subsequent re-implantation of ovarian tissue can restore fertility, with the additional benefit of oestrogen production, although it carries anrisk of re-implantation of malignancy if micro-metastases are present within the cryopreserved tissue[8]. It is widely viewed as still experimental, particularly when applied to pre-pubertal girls[3].
The current NICE guidelines on fertility [9]recommend offering oocyte or embryo cryopreservation to women of reproductive age (including adolescent girls) before treatment for cancer that is likely to make them infertile, if they are well enough, it will not worsen their condition, and enough time is available.Fertility preservationmay also be of value in a range of non-malignant diseases where the treatment, for example bone marrow transplantationfor sickle cell disease, carries a high risk of loss of fertility.
Access to fertility preservation varies widely internationally, and the choice of technique differs according to national legislation, regulation, and local practice[10].Awareness amongst oncologists is variable and referral pathways may be lacking, and patients may be unaware of that fertility preservation is a possibility. Provision of fertility preservation services to women is haphazard across the UK. Despite the NICE recommendations, there are substantial obstacles in terms of access and funding.Oocyte storage is not yet available in all IVF laboratories, and ovarian tissue storage remains of very limited availability in the UK although there are good examples of national networks in Europe [11]. In some areas, NHSfunding is taken from infertility services, in others funding is requested from commissioners on a case-by-case basis. Funding from oncology budgets has been proposed, as it is argued that fertility preservation is part of the patient’s cancer care. Patients’ eligibility for fertility preservation may also be subject to access criteria for infertility treatment, for example exclusions based on previous children, BMI and smoking.
The chance of successful birth following fertility preservation in oncology patients is unclear.Fertility outcomes from cryostorage require long-term follow-up. The highly regulated assisted reproduction sector already records information that could be used more effectively; UK data collection does not distinguish between reasons for oocyte cryopreservation.We do not know how many women are undergoingfertility preservation, how many women who have stored oocytes or embryos come back to use them, nor the timescales involved. Reports of pregnancies following ovarian tissue reimplantation are small case series[11]. Evidence based criteria for access could identify those women at high risk of infertility and those who can be reassured that their risk is low[12], minimising unnecessary interventions and storage of reproductive samples that will not be used.These data are important to assess the efficacy of fertility preservation treatment, and its cost effectiveness.
Fertility preservation is an emerging medical specialty,which straddles oncology and infertility care but requires specialist services in its own right. For men, sperm storage is well-established, but recent advances have widened the options available to girls and young women.Long-term data collection is essential to determine the efficacy of treatment. There is a need to improve information for patients, education for oncologists, and equity of funding in the UK, to overcome barriers to more widespread use of fertility preservation.
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