Fertility preservation in cancer patients and physician--patient communication.

With cancer survival rates increasing, the new focus is on survivorship and quality of life. Infertility is an expected consequence following treatment of most cancers, with sustained infertility developing in 50-95% of cancer survivors. Although medical options for fertility preservation exist, most are not well understood or accessible to patients and their health care providers. However, recent guidelines from the American Society for Clinical Oncology recommend that physicians should offer their patients the option of fertility preservation prior to cancer treatment. Numerous barriers to the communication process including the focus on the immediate issue of treatment and survival; lack of physician knowledge about fertility preservation; lack of resources in the system; comfort level in discussing this subject, particularly if reproductive health is outside the physician's area of expertise; concerns about the delay in treatment necessary for fertility preservation to occur; patient priorities; and financial and practical barriers. (1)

Less than 20% of women with breast cancer are pre-menopausal, yet the impact of cancer treatment on fertility is a major cause of distress among young breast cancer survivors. The effects of chemotherapy on fertility are well known, and women who do not lose their fertility must wait at least two years to attempt subsequent pregnancy. Fertility-sparing options before, during, and after treatment are possible with the use of assistive reproductive technology. Embryo cryopreservation combined with in vitro fertilisation has been successful but the procedure takes four weeks and may require delaying cancer treatment, and the patient must have an available partner or donor sperm. Oocyte preservation is considered an experimental option for single women. Despite concerns of the women involved, clinical evidence shows that women with breast cancer do not show an increased risk of disease recurrence with subsequent pregnancy. Women with fertility concerns should be referred to a reproductive endocrinology team at the time of diagnosis for discussion of treatment options and realistic expectations of pregnancy outcomes. (2)

Chemotherapy often destroys ovarian follicles, causing women to become infertile. Researchers have now found a way to store and grow a woman's immature ova in the laboratory, which they hope will enable conception after chemotherapy. Pieces of ovarian tissue taken from six women during elective caesarean section were cultured for six days and 74 intact follicles were collected and grown in the presence of human recombinant activin A. 30% reached an advanced stage of development. It took just ten days for an egg to mature, while it takes several months inside the ovary. One piece of tissue is able to provide dozens of eggs, rather than the dozen or so harvested during in vitro fertilisation (IVF). In addition, the technique avoids the need for hormone injections used in IVF to stimulate the ovaries to produce eggs. There is still work to do before laboratory-matured eggs are suitable for fertilisation, but now there is evidence that normal eggs can mature in vitro. (3,4)

(1.) Quinn GP, Vadaparampil ST, Bell-Ellison BA, et al. Patient-physician communication barriers regarding fertility preservation among newly diagnosed cancer patients. Social Science and Medicine 2008; 66:784-89.

(2.) Dow KH, Kuhn D. Fertility options in young breast cancer survivors: a review of the literature. Oncology Nursing Forum 2004;31(3):E46-53.

(3.) Jha A. New technique could help safeguard cancer patients' fertility. The Guardian (UK), 21 April 2008.

(4.) Teller EE, Mclaughlin M, Ding C, et al. A two-step serum-free culture system supports development of human oocytes from primordial follicles in the presence of activin. Human Reproduction 2008; 23(5):1151-58.