Paediatric Oncofertility: looking to the future or neglecting the present?

Every year in the UK an average of over 1,700 new cases of paediatric cancer are diagnosed. In the 1970s there was a 50% survival rate, five years from treatment, whereas today over 80% survive beyond the five year mark. With this increased chance of a future comes an increased consideration of what the future may bring – for cancer survivors it is often a bleak outlook of premature menopause, infertility and the psychosocial issues associated with this.

Options for preserving fertility

There are six major fertility preservation options for pubertal teenagers with cancer with varying levels of success and intrusiveness.

  1. Egg collecting and freezing – By collecting mature eggs from the individual, these can be frozen to be used at a later date. There is a possibility for immature eggs to be collected and matured (in vitro maturation) in a laboratory and then stored. This option gives women sole control over their eggs, and has no set shelf life.
  2. Embryo development and freezing – This process is largely the same as that of egg collection, with the additional step of fertilisation to create an embryo. The major issue in paediatric oncology is that the likelihood is they won’t have a serious partner, and it is a risk to tie your eggs to just one partner. Equally they won’t have sole legal rights as to what happens with this embryo in the future.
  3. Ovarian tissue freezing (ovarian cortex cryopreservation) – Ovarian tissue freezing is a new and largely experimental technique, that involves a laparoscopy which removes a portion of an ovary. The immature eggs in this part of the ovary are then frozen with the tissue, which can be reimplanted post-treatment with the hope the ovary will begin functioning normally again.
  4. Ovary transposition (oophropexy) – During this procedure one or both ovaries are moved to another area in the body (usually around an inch from the upper radiation field). This only works for those having pelvic radiation, as it is not protective of the ovaries of those having chemotherapy.
  5. Radiation shielding – If the ovaries are near where radiation is being directed, but are not the direct target, then protective coverings can be used to protect them. However, this is not a guarantee of protection.
  6. Ovarian function suppression using hormone therapies (GnRH analogues) – Hormone therapy is used to slow down and stop the function of the ovaries, causing a temporary menopause. This is also a fairly new and experimental method, but has around a 40% early success rate of preventing permanent ovarian failure.

Should these options exist?

Recently in the UK a baby was born to a woman who had her ovarian tissue regrafted over 10 years earlier. She is a success story, the proof that these developments are worth exploring and offering to young cancer sufferers. However, before this incredible end result can be achieved, there are difficult decisions to be made, and debates about who should and can be making those decisions. But when this treatment is still considered experimental should it be suggested to those in such a vulnerable and desperate position?

Children are not the best people to make fertility decisions – they often won’t have a full understanding of what it means to be fertile, won’t know whether they want to be parents in the future, and have no understanding of the future psychosocial issues this will cause for them. Equally most can’t legally give full consent due to their age, they can only assent. Children and parents who have just been faced with the devastating news of a cancer diagnosis, who have often never thought before about their future reproductive health, are also not in the right place often to make what has to be a fairly immediate decision.

Equally some critics describe even having the conversation as ‘too much’. If fertility preservation is to be considered it has to be a decision that is made almost immediately, so that treatment can then commence. Children are often too sick to be able to spare the time, and there are multiple other decisions to be made, that many would consider more important. Some are not in the financial position to make this decision, or have religious beliefs that complicate matters. Having this decision to make alongside all others can be seen as unnecessary stress for patients and parents alike. Whilst infertility from cancer treatments can be more distressing than de novo infertility, in most cases the primary concern should be to save their lives rather than preventing infertility.

Criticism of paediatric oncofertility has abounded in recent years, mostly due to the level of control it gives to the parents regarding the patient’s future. The Chicago Times reported of a three-year-old with cancer, who’s mother’s first words upon hearing her daughter’s diagnosis were, ‘I want her ovaries saved.’ Options now exist for fertility preservation ‘from birth upwards’ meaning that parents are given choices which affect their child’s future decades down the line. Whilst all paediatric care to some extent requires parents to make decisions on their child’s behalf, in what they believe to be their best interests, usually these decisions are vital to their survival or health.

However, health is not limited to the physical – mental health and the holistic considerations about their wellbeing is equally as important. When considering their long term survival and health there must also be a consideration of what kind of life they should be able to live. Often there is talk of whether patients will be able to lead a ‘normal’ life again, and a part of that is reaching the same milestones as anyone who didn’t have that illness. Any treatment carried out is balanced against the risks to see what will provide the best quality of life afterwards – fertility preservation should be no different.

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