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Female fertility preservation

Medical fertility preservation

There are many young women whose fertility is threatened by cancer or other serious diseases, and by the treatment for these conditions. Medical fertility preservation refers to methods to try to protect and preserve fertility for the future, using a variety of treatment options including medicines to protect the ovary, freezing eggs and embryos, and freezing ovarian tissue for grafting later on if required.

Cancer treatments are nowadays very successful and most young women can expect to go on to lead normal lives with the expectation of having their own family. However, the time of diagnosis of cancer is an extremely traumatic and distressing time for young women and their families. Often everything feels overwhelming, especially as there is so much information to take in about the disease, its treatment options and the short- and long-term risks. While thinking ahead to the future may seem just too much to deal with, it may be very important to find out about ways to maximise your future fertility.

It is now an established part of early cancer management to talk to patients about the risks of treatment, including the risk to fertility, so most young women are referred for discussion with a fertility specialist during this time. While many young women decide to have some fertility preservation treatment, for many others, just having a discussion and becoming more informed about their reproductive future can be extremely reassuring.

Risk of fertility damage

Chemotherapy drugs can cause damage to the ovaries and the risk increases with increasing age. This is because as you get older, the ovaries contain fewer eggs anyway and so are more vulnerable. The effects these drugs can have include:

  • short-term ovarian failure with temporary stopping of periods, which return in between three and 12 months
  • permanent ovarian failure, which is much less common and occurs with very high-dose treatments; in this situation the ovaries stop working for good because the eggs have all been damaged
  • later development of permanent ovarian failure a few years down the track, but often during the time when you would have recovered from the cancer and be wanting to start a family.

If radiation treatment (radiotherapy) is directed to the pelvis, it can also cause damage to the ovaries and sometimes to the uterus.

For some cancers, surgery is required that can mean removal of the ovaries or else disturb the function of the fallopian tubes.

Protection of fertility during chemotherapy

There are some medicines, called GnRH analogues, that may reduce the damage of chemotherapy drugs on the ovaries. These drugs work to keep the ovaries in a quiet, non-functioning state and suppress the normal menstrual cycle. This theoretically reduces the exposure of the eggs to the damaging effects of the cancer treatment. GnRH analogues are monthly injections during the time of the chemotherapy. Side effects include hot flushes, which tend to start after the second injection is given. Fortunately the side effects and the suppressing effects are only temporary, and there are no lasting effects of the analogue after this therapy finishes.

Preservation of eggs, embryos and ovarian tissue

If there is enough time before the cancer treatment starts, young women can undergo 10 to 12 days of hormone medications that stimulate many eggs to mature in the ovary, and these are removed in a very minor procedure under sedation (but you are asleep for it). There are no cuts on the abdomen as the entry is through the vagina. These eggs are then frozen for use later if required. On average, 10 to 20 eggs are removed, and these eggs may then later be made into embryos with your partner’s sperm. For every 10 eggs frozen, we can expect to make about two or three embryos.

Embryos can be created and then frozen after the extraction of the eggs. About 80 to 90 per cent of embryos will survive the thawing process.

Freezing of some ovarian tissue is also an important option. This can be considered in the following situations:

  • when the cancer treatment involves very high-dose chemotherapy drugs; for example, as part of bone marrow or stem-cell transplant
  • when there is not enough time for 10 to 12 days of hormone stimulation.

This process involves a laparoscopy (keyhole surgery) to remove part of the ovary, which is a day-stay procedure. As with all surgery, there are risks involved, but generally it is a very safe operation.

Grafting of this frozen and then thawed ovarian tissue is performed later if you want to have a baby but the ovaries have gone into permanent ovarian failure (premature menopause). It is very important to understand that making babies from eggs that have come out of an ovarian graft is still extremely difficult and we are not yet at a stage where this can be thought of as very successful.

Other fertility options for the future

Some young women may not have the opportunity to preserve fertility before cancer treatment; later on, if the ovaries don’t work, there is always the opportunity to create a family using donated eggs. This is an established and successful treatment that offers hope for young women with permanent ovarian failure.

If the uterus is damaged or you cannot, for medical reasons, carry a pregnancy, then surrogacy with another woman carrying the pregnancy can give you the opportunity to have children.

Social (non-medical) fertility preservation

As we get older, we have fewer good eggs and there is a higher risk of chromosomal damage to the eggs we have left. From the mid 30s there is a progressive decline in egg number and quality.

Some women think they will not have the opportunity to start a family with a partner in their years of maximal fertility. It is now possible to freeze some eggs for the future, but it is very important to understand that this offers at most a limited number of opportunities to try to have a baby. Thus, non-medical egg freezing should not be relied on as a guarantee of future fertility, more as offering a modest additional opportunity in the future.