PRESERVATION OF REPRODUCTIVE HEALTH IN WOMEN DIAGNOSED WITH CANCER
We are all aware of the increasing incidence of cancers in women of reproductive age and younger, in other words, women under the age of 45. Environmental factors certainly play an important role in this. However, during the process after diagnosis, psychological and physical changes, and especially focusing only on cancer treatment, may lead to neglecting reproductive expectations in these “young women” and cause regret about this after cancer treatment.
In this article, I would like to draw attention to the importance of not neglecting the issue of “preserving fertility” in women diagnosed with cancer and present what can be done in this regard in a question-and-answer format. I would also like to note before starting my article that although I address women here as a gynecologist, preserving reproductive potential is important for everyone. Teamwork is essential for people diagnosed with cancer; in other words, physicians dealing with cancer (oncologists), genetic counselors in terms of whether this disease may be passed on to their children, physicians related to fertility preservation (gynecologists, urologists), and mental health professionals involved in the decision-making stage (psychologists) all work together harmoniously to help patients.
How is ovarian function affected in people diagnosed with cancer?
The treatments that need to be applied affect our reproductive health. These can basically be summarized as surgery, chemotherapy (drug treatment for cancer), and radiotherapy (radiation treatment).
Surgery; Basically, if the surgery to be performed for cancer treatment requires the removal of the ovaries, reproductive health will of course be affected.
Chemotherapy (drug treatment for cancer);
Chemotherapy drugs negatively affect cell proliferation in the ovaries and the tiny structures of reproductive cells (through DNA breaks). In addition, they also affect the ovaries by causing changes in the blood vessels of the ovaries (stromal fibrosis).
The effect of these drugs ranges from having no effect on the ovaries at all to completely stopping ovarian function. Such different effects depend on 4 important factors: the woman’s age, the number of eggs in her ovaries (ovarian reserve), the type of drug to be given, and the dose of the drug.
Especially in girls who have not yet had their first menstrual period, the ovaries are more protected against these drugs. The older the age and the lower the ovarian reserve, the greater the effect of chemotherapy drugs.
The chemotherapy drugs that have the most negative effects are alkylating agents and platinum compounds. However, if these drugs are necessary for cancer treatment, they will of course be used.
Radiotherapy (radiation treatment);
Eggs are sensitive to radiation. Age, radiation dose, and duration of radiation are the factors that determine the effect of radiation on the ovaries.
As age increases, the radiation dose required to stop ovarian function decreases. For example, while a radiation dose of 18.4 cGy (centigray) may stop ovarian function in a 10-year-old girl, in women over 40 years old, a dose of 6 cGy may be enough to stop ovarian function.
Can ovarian function return to normal after chemotherapy?
The short answer is yes. However, this depends on certain conditions. As stated above, the determining factors are age, ovarian reserve (how many eggs we have), the chemotherapy drugs used, and their dosage. While this possibility is around 10% in women over 40, it may be around 25–50% in women under 40.
What can I do to preserve my reproductive health – my fertility – after diagnosis?
The things that can be done to preserve reproductive health can be listed as follows; pulling the ovaries surgically to the sides inside the abdomen (outside the radiation field) before radiation therapy that may affect the abdominal area, ovarian tissue freezing, and egg/embryo freezing.
Today, the most commonly used method is egg or embryo freezing. Egg freezing can be applied to patients diagnosed with cancer, while embryo (egg fertilized with sperm) freezing can only be applied to married couples.
How is egg freezing or – for married couples – embryo freezing performed?
Briefly, it is done in the same way as in IVF treatment. This can be explained as follows; normally, each month, a group of egg sacs (follicles) containing egg cells, including the egg that will ovulate, appears in our ovaries. In treatment, pills and injections (administered under the skin from the abdomen) are usually given to develop all of these follicles (and the eggs inside them). Especially in some cancer cases (for example, breast cancer cases), medications slightly different from classical IVF treatment (using anti-estrogen pills) are preferred. This pill + injection treatment lasts approximately 10–12 days. When the follicles reach a certain size, a trigger injection is given, and after a certain number of hours, the eggs are collected with ultrasound guidance either vaginally or abdominally. If only eggs are to be frozen, they are evaluated according to maturity and suitable ones are frozen at -196 °C. If married individuals will freeze embryos, after sperm preparation from the spouse, fertilization of the collected eggs is achieved in the same way as classical IVF treatment. The next day (after 16–18 hours), after checking fertilization and follow-up, the embryo is frozen on day 3 or day 5 at -196 °C.
Is it necessary to wait for the start of menstrual bleeding to freeze eggs or embryos? Wouldn’t this cause a delay in starting cancer treatment?
It is not necessary to wait for the start of menstrual bleeding! As practiced all over the world, in our country as well, treatment medications for egg or embryo freezing can be started on any day of the menstrual cycle – if there is no significant abnormality in the evaluation of the ovaries. Although it was previously thought that egg precursors that could be developed were only present in the early period of menstruation, current data have shown us that these egg clusters can be present and developed at any stage of the menstrual cycle. Starting this treatment at any time during the menstrual cycle is called “random start”.
Do the medications used for egg/embryo freezing in breast cancer or other cancers cause cancer progression?
The short answer is no. The results of studies conducted so far are reassuring. In the short-term treatment explained in detail above, cancer progression has not been shown.
When can I consider pregnancy after chemotherapy or radiotherapy?
Will my child be healthy in a pregnancy after cancer treatment?
It is known that pregnancy and egg collection procedures are safe after 6 months have passed since chemotherapy. In pregnancies occurring after this period, no increase is seen in the risks of congenital or genetic abnormalities, miscarriage, or similar conditions.
As women, preserving fertility potential or, in a broader sense, preserving reproductive hormones is one of the issues we must care about regardless of the diagnosis received. Therefore, it is clear that consulting gynecologists together with the diagnosis is necessary.
Wishing all of us days full of health…
Prof. Dr. Ümit İnceboz