The diagnosis of cancer can be overwhelming. It is a diagnosis that affects both the physical and emotional health of a person. It can also have far reaching impacts on a person’s sense of self, body image, relationships, intimacy, and financial wellbeing. Cancer tends to impact not only the person who was diagnosed, but also their families and caregivers as well. Having a social support network of friends and family or support groups may help with the stress of the diagnosis. Professional counselling support may also be helpful.
In addition to deciding which treatment plan is best, it is important to consider the impact of treatment on fertility as well. While oncologists may not be able to provide specific fertility risk assessments or recommend fertility preserving options, a general discussion about the possibility of infertility should be undertaken as early as possible in the treatment process. This will allow time for a referral to a fertility specialist in order to discuss fertility preservation (FP) options.
In some situations, your oncology team may be able to suggest treatments that have less impact on your fertility than others, but that will depend on the specific circumstances of your cancer.
How does one decide whether to undergo FP prior to cancer treatment? This depends on a number of factors including how healthy you are overall (i.e. type and extent of cancer, the presence of other health problems) which helps to determine if FP would be safe. Other important things to think about are what cancer treatment is needed and how soon does it need to start; also, how fertile you are before starting your treatment (i.e. your age, having a history of infertility problems), your wishes in terms of your short and long term reproductive goals, how comfortable you are with using donor eggs, and how fertility treatment might affect you, including the physical and emotional burden, as well as financial considerations and the access to fertility care.
Understanding Risks and Limitations
There are risks and limitations to egg freezing and given that it involves at least 10-14 days of injectable medications and an egg retrieval procedure that is often performed under sedation, a patient may be too unwell to pursue it. The proposed cancer treatment also plays a role in decision-making as some treatments are more harmful to fertility than others. For example some chemotherapy treatments are more harmful to eggs than others and in situations where multiple types of treatment are needed, for example chemotherapy and pelvic radiation, then the risk of infertility can be quite high.
Timing of Treatment
Timing of cancer treatment is also an important consideration as treatment plans that involve chemotherapy prior to surgery (if surgery is required) is known as neoadjuvant chemotherapy and that generally means that there is less time
to complete the FP cycle than for those for whom surgery is planned to take place after the chemotherapy. However, with some forms of fertility treatment the treatment cycle can be completed within 2-3 weeks of starting it, so FP may still be possible in either case. How fertile a woman is before she has treatment also helps inform the decision about whether to undergo FP as success rates are tied to the woman’s age and ovarian reserve at the time of egg freezing. For example, when a patient is older they may have fewer eggs to freeze and the quality of those eggs may not be as good due to age, therefore that patient may be less inclined to pursue FP due to the low chance of those eggs leading to a successful pregnancy. However, because such a patient would be at high risk for infertility given their advanced age and low egg count, they may want to do everything possible to try to freeze eggs before treatment despite the low success rates.
Plans for Parenthood
Patient wishes and goals for parenthood are also important considerations. Desires for parenthood range from not wanting to be a parent, to only willing to parent if they can conceive with their own eggs, while others are comfortable using donor eggs to build their family should they be infertile after treatment. The burden of treatment may also weigh into decision making and this may involve the physical burden of undergoing the FP process and/or the emotional burden of having to undergo an additional treatment which may or may not be successful. In addition, there is a financial burden in areas where there is no health coverage for FP, or the difficulties caused by of having to travel long distances for treatment in areas that are far away from a fertility clinic.
Having a history of cancer does not necessarily reduce the desire to be a parent. Given that cancer survivorship rates are high and many cancer treatments can cause infertility, the fertility of people with cancer should not be overlooked.
Therefore, all children and adults of childbearing age should be offered the opportunity to discuss FP as part of comprehensive cancer care. Having a robust conversation so that all questions can be answered by the health care team in a timely way is key.