Amit Patel

Some gynaecological cancers are common at younger age (for e.g. cervical cancer) and there is also a trend towards younger age of onset in some gynaecological cancers. Many women are also choosing to delay their pregnancies to a later age. Fertility therefore can be an important issue when women of reproductive age is diagnosed with a cancer.

If fertility is an issue, please discuss this with your doctor as soon as possible.

Most treatment of gynaecological cancers have an adverse effect on the fertility. Fertility however can be conserved or preserved in most cases. It is generally easier to do so in early stages of gynaecological cancer. Options available to the patient are dependant on keen desire to retain fertility, stage of cancer and risk of cancer recurrence. Decisions are very much individualised, discussions are complex and the process can be quite emotional.

Effect of cancer treatment on fertility:
Ovaries contain a fix number of eggs. All the eggs women will ever have are present in the ovaries at birth. Women are not able to grow new eggs. Uterus provides space and environment for the fertilised ovum to grow for nine months.

Cancer treatments with surgery, chemotherapy and radiotherapy can adversely affect the eggs and/or uterus leading to sub fertility or infertility. Removal of ovaries or radiation affecting ovaries can also lead to premature menopause.

Chemotherapy can damage eggs, ovaries and hormone production required for pregnancy. Radiation can damage ovaries and uterus if these are exposed to radiation field. Surgery for gynaecological cancer may require removal of ovaries and/or uterus.

Not all women have their fertility compromised after one of these treatments. Actual effect on fertility depends on many factors such as…

1. Site of cancer
2. Stage (spread) and grade (aggressiveness) of cancer
3. Radicality and type of treatment required
4. Age and previous fertility problems

Fertility options available to gynaecological cancer patient:

1. Fertility sparing surgery: If uterus and at least one ovary and fallopian tube can be spared during surgery, fertility can be maintained. For example removal of single ovary and fallopian tube in early stage ovarian cancer or removal of just cervix in early stage cervical cancer.
2. Ovarian transposition: Ovaries are lifted out of pelvic radiation field by performing small laparoscopic (key-hole) surgery prior to radiation treatment. They can be later used to induce ovulation. Harvested eggs are fertilised and transferred in uterus of a patient (where possible) or a surrogate.
3. Egg or embryo freezing: Prior to cancer treatment ovaries are stimulated with ovulation induction treatment and eggs are collected. They are either frozen as eggs or as embryos after fertilisation. They can be used later in a patient (where possible) or in a surrogate.
4. Ovarian tissue freezing: Small portion of ovarian tissue is removed and frozen and later re-implanted (for e.g. on arm) and is stimulated for ovulation. Ovum is harvested, fertilised and transferred in uterus of a patient (where possible) or a surrogate.
5. Donor eggs: If both ovaries are involved in cancer or removed without possibility of egg or embryo freezing, donor eggs can be used to create embryos which can then be transferred in patient herself (where possible) or in a surrogate.
6. Surrogacy: If uterus is affected by cancer treatment or removed during surgery, embryo using either eggs from patient or from egg donor can be implanted in a surrogate uterus. Surrogacy can be achieved by natural fertilisation of surrogates own eggs and patient’s partner’s semen. This requires artificial insemination (transfer of semen using syringe) at right time.
7. Hormonal treatment: Endometrial cancer of low grade and low stage can be treated by hormonal treatment such as Insertion of Mirena(R) IUS or high-dose progesterones.
8. Uterine transplantation: This is very new technique, mostly used in research settings and is not suitable in most cancer cases. It may be of use in future, particularly in endometrial cancer patients.
9. Adoption

Delay in cancer treatment:
Fertility options requiring ovulation induction (such as egg or embryo freezing) can take time and therefore may delay the start of cancer treatment. This is usually not very long and harm due to delay is generally very minimal.

Chances of successful pregnancy:
These depends on type of treatment and can be different in each individual even with same treatment. In general there is some reduction in rate of successful pregnancy compared to normal population.

After completion of cancer treatment:
Not all women with gynaecological cancer have their fertility compromised after treatments. If your periods continue or return after treatment it does not always mean that fertility is not affected or has returned.
After completion of treatment and before trying for a pregnancy it is necessary to reassess and thoroughly consider likelihood and implications of cancer recurrence and issues of prognosis and child care in such situation. Even if all is well after treatment, it is generally advisable to wait for about 3 months before trying for a pregnancy.

Pregnancy after cancer treatment:
Depending on the type and radicality of treatment, risk of miscarriages and pre-term births may be higher than normal population. There is no evidence to support that the cancer treatment affects development of foetus or causes foetal anomaly. There is also no evidence that pregnancy increases risk of cancer recurrence.