Fertility Preservation in Gynaecological Cancer Care - Safe Options for Future Motherhood
Gynecological cancers account for approximately 15%-20% of all cancers in women. Breast cancer is the most common, making up 46.9 %, followed by cervical cancer at 32.26 % and ovarian cancer at 15.24%. Approximately 20% of cancers affect women of child-bearing age (<40 years), and although most women survive cancer, infertility is a consequence of the treatment.
Surgery impacts the anatomy of the reproductive organs and radiation therapy, and chemotherapy affect the function of the ovaries and the uterus, causing temporary or permanent loss of fertility. The effect on fertility is dependent on many factors: age; type, stage, grade and site of cancer; drugs administered and the radiation field location. Cancer therapy can affect egg quality, hormone levels and ovaries and uterus function. In some cases, complete resection of the uterus and ovaries may be required.
Therefore, providing fertility-preserving treatment options has become a crucial part of cancer survivor care regimen aimed at improving their quality of life and fulfilling their desire to become mothers.
Fertility preservation strategies depend on the patient’s age, desire to use banked donor sperm or male partner, tumor type and stage and treatment type. Fertility preservation counselling is an important step in educating patients with cancer on the risks of treatment-associated premature ovarian failure and infertility and the options available for preserving them.
The American Society of Clinical Oncology has published international guidelines indicating that young adults and children with cancer should receive timely fertility counselling before initiating cancer treatment to protect their reproductive ability. Oncofertility is a new field that includes a multi-disciplinary team of oncologists, gynecologists, biologists, endocrinologists and psychologists who discuss fertility preservation and management, sexual and hormonal dysfunction, psychological support and contraception with the patients. These discussions can help patients make sound decisions without regret and better cope with the disease, improving their mental status and quality of life.
Factors that play an important role in decision-making for fertility preservation techniques include the following:
Cervical cancer treatment may involve radical hysterectomy (surgery to remove the womb), radiation therapy and chemotherapy drugs (affects the ovaries and could lead to early menopause).
Early-stage cervical cancer (Stage IA1) may allow the removal of cancer while sparing the womb, which may enable a future pregnancy. Some surgical options are discussed below:
The surgeon resects a cone-shaped cervical tissue piece. The cancerous tissue present high up in the cervical canal is removed along with some surrounding healthy tissue to ensure the removal of all the cancer cells. The procedure is often performed under general anesthesia and the surgeon inserts a scalpel through the vagina or uses a laser to remove the cervical tissue piece. There is a risk of pre-mature birth of babies with low birth weight.
This procedure involves removing the cervix along with neighboring tissue, part of the upper vagina and lymph nodes while keeping the ovaries and the uterus intact. The vagina is connected to the uterus, allowing a woman to carry the pregnancy. The women who become pregnant following this procedure exhibit an increased risk of pre-mature delivery and must have a caesarean section as the internal opening of the cervix is permanently stitched to close it.
If radiotherapy is the choice of cancer treatment, ovarian transposition is an option to protect ovarian function. It is a laparoscopic procedure in which the ovaries and fallopian tubes are separated from the uterus and attached to the abdominal wall keeping them out of the radiation field. This procedure is linked to several complications, including chronic pain in the ovaries, formation of ovarian cysts and infarction of the fallopian tubes.
Patients who undergo radiation therapy or chemotherapy damage their ovaries, which affects the production of eggs. This method involves controlled ovarian stimulation with gonadotropin injections or pills to produce many eggs, and the effect of the medication on the ovaries is observed via a trans-vaginal ultrasound. When the ovaries respond appropriately to the medication (typically two weeks into the cycle), oocytes are retrieved under sedation and with ultrasound guidance.
The oocytes are cryopreserved as immature germinal vesicle oocytes (a stage when the oocyte transitions from growth to maturation; the oocyte achieves fertilization capacity) and/or mature metaphase II eggs (mature eggs). This method is suitable for women who do not have a partner and wish to preserve their eggs for future use, or for those planning to use donor sperm. The cryopreserved oocyte legally belongs to the woman, avoiding custody battles associated with cryopreserved embryos. It is unsuitable for hormone-sensitive or aggressive cancers and pre-pubertal girls.
As the ovary is the primary site of cancer, it is difficult to maintain reproductive function as chemotherapy and radiation therapy can reduce the quality and quantity of eggs. In early-stage ovarian cancer, when only one ovary is affected, the gynecologic oncologist can remove the ovary with cancer cells and keep the other ovary along with the uterus intact, preserving the possibility of a natural pregnancy. Advanced-stage ovarian cancer is challenging as it may involve the removal of both ovaries and other reproductive organs leading to infertility.
The treatment options are based on the disease stage and histologic type.
It is a safe and widely used method in infertility clinics, resulting in many births each year. It is a method of choice when there is no urgency to start cancer treatment as it takes approximately 2 weeks to complete the procedure. However, it is not a strategy of choice for women with aggressive cancers where cancer therapy has to be initiated immediately. This strategy is impossible in pre-puberty girls and unsuitable for women with hormone-sensitive cancers as it requires controlled ovarian stimulation with subcutaneous injection of gonadotropins for 8–14 days or within the first 3 days of the start of the menstrual cycle to produce mature eggs. Without a partner, sperm can be obtained from the donor to develop the embryos. The embryos can be used for in vitro fertilization procedures in the future.
If there is no urgency to start the treatment, in that case, women can undergo more than one cycle of ovarian stimulation to ensure enough eggs have been collected for freezing to ensure the chances of a future pregnancy are higher. The pregnancy rates of oocyte cryopreservation are lower (4.6%-12%) than those of embryo cryopreservation (30%-40%).
This method is still considered experimental. This is suitable for women <40 years old because the ovarian reserve is high. This method does not require a partner or ovarian stimulation. The ovarian tissue or the ovarian cortex responsible for egg production (0.5–2 cm) is removed using a laparoscope, divided into small thin slices and flash frozen. Once the cancer treatment is complete, the patient can have the ovarian tissue re-implanted to restore hormone production. There is a possibility of reintroducing the cancer cells in the body, especially in patients with leukemia.
Post-menopausal women and women with an aggressive form of endometrial cancer must undergo a hysterectomy (removal of the uterus), which eliminates the chances of carrying a pregnancy. In some cases, radiation therapy and chemotherapy are also recommended, which effectively target the cancer cells. However, radiation can damage reproductive organs causing infertility, and chemotherapy can cause hormonal imbalance, impacting conception and maintaining a healthy pregnancy.
Most endometrial cancers (80%–90%) are type I and are associated with the uncontrolled action of estrogen on the endometrium. Progesterone is a steroid hormone that hinders the carcinogenic action of estrogen by activating the enzymes responsible for estrogen metabolism and downregulating estrogen receptors. Thus, progestin therapy comprises oral administration of medroxyprogesterone acetate (MPA, 400–600 mg/day) or megestrol acetate (MA, 160–320 mg/day).
Levonorgestrel-releasing intrauterine device (IUD) locally releases 20 µg of levonorgestrel per day. Compared with oral treatment, this method reduces the systemic effects of progestin, including oedema, nausea, weight gain, headache, breast discomfort, acne and liver dysfunction. Patients can be prescribed a combination of levonorgestrel IUD and oral progestin.
Hysteroscopic resection of the endometrium (includes endometrial lesion removal, followed by surrounding endometrium removal and finally underlying myometrium removal) followed by progesterone treatment has shown improved rates of complete response (no tumor growth) and higher rates of pregnancies. Gonadotropin-releasing hormones can also be used in combination with endometrium resection.
The follow-up involves endometrial sampling 3 months after initiation of progesterone therapy. Patients with complete remission continue the treatment for another 3 months, which is followed by another endometrial sampling; once complete remission is confirmed, the patient can proceed with the pregnancy. After a successful pregnancy and childbirth, endometrial sampling is to be continued every 3 months after delivery as the risk of recurrence is high.
Complete remission is achieved in 9 months; however, obese and non-ovulating women may take longer. If there is no response after 3 months, the progestin dose is increased. If the disease is persistent or progressive even after 9 months of progesterone therapy, hysterectomy is the only treatment option.
Patients with advanced endometrial cancer cannot be offered fertility preservation treatment options. However, their desire to become mothers can be fulfilled using assisted reproduction technologies, including oocyte/embryo cryopreservation.
Depending on the stage of the disease, radical surgery (removal of the organ with cancer cells and surrounding tissue) is often the treatment option. Therefore, patients develop body image disorders, sexual dysfunction, anxiety, depression and reduced quality of life. Women with cancer who experience changes in their marital, work or financial statuses tend to undergo depression. Therefore, it is essential to conduct interviews using the Female Sexual Function Index or Brief Index of Sexual Functioning for Women to identify patients at risk of developing sexual and psychological issues by determining their sexual function before cancer diagnosis, current sexual activity and modifications in relationship with partner following cancer diagnosis.
For comprehensive gynaecological cancer care and fertility preservation strategies, consult the expert team at Kauvery Hospital. With branches in Chennai, Hosur, Salem, Tirunelveli, and Trichy, we are committed to providing compassionate, personalized treatment to support your health and future family goals.
Fertility-preserving treatments for women with gynecological cancers are primarily based on the desire and potential to become pregnant without compromising the oncological outcomes. Adequate counselling must be provided to patients so that they can make informed decisions after discussions with the Oncofertility team. The fertility-preserving treatments are carefully selected based on the patient’s age, type, stage and grade of tumor, ethical concerns, personal beliefs and finances. Despite the present challenges, fertility preservation treatments provide improved opportunities to women with gynecological cancers who wish to preserve their reproductive ability for future pregnancies.
What is fertility-preserving treatments?
They are treatments that remove or treat cancer while keeping reproductive organs intact, allowing women to have children in the future.
How does cervical cancer treatment affect fertility?
Treatments like hysterectomy, radiation, or chemotherapy can impact fertility. However, procedures such as conization and radical trachelectomy help preserve the uterus and increase chances of future pregnancy in early-stage cervical cancer.
What fertility options are available for ovarian cancer patients?
In early-stage ovarian cancer, doctors may remove only the affected ovary while keeping the other one and the uterus. Additional options include egg or embryo freezing (cryopreservation) to preserve fertility.
What fertility preservation methods exist for endometrial cancer?
For selected early-stage endometrial cancer cases, hormone therapies (like progestin treatment or levonorgestrel IUD) and hysteroscopic resection can treat the cancer while maintaining fertility.
How does cryopreservation work in fertility preservation?
Cryopreservation involves freezing eggs, embryos, or ovarian tissue before treatment. This allows women to use them later for pregnancy after completing cancer therapy.
Why is fertility counselling important for women with gynecological cancer?
Fertility counselling educates patients on the risks of cancer treatments on reproductive health and helps them choose the best method to preserve their fertility while ensuring effective cancer treatment.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
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