OB/GYN Practice Today
Preserving Fertility in Young Female Cancer Survivors
Medscape Ob/Gyn & Women's Health 8(1), 2003.
Future fertility is often forgotten when a young girl is diagnosed with cancer. Even obstetrician/gynecologists are sometimes guilty of this oversight, according to Dr. Jay Spence, Professor of Obstetrics and Gynecology at the University of Ottawa, Ontario, Canada. "I call these patients the forgotten females," he said, alluding to his recent journal article entitled "The Forgotten Female: Pediatrics and Adolescent Gynecological Concerns and Their Reproductive Consequences."
In the article, Dr. Spence writes, "unfortunately, physicians responsible for the care of young gynecological patients are often not familiar with adult reproductive issues." In addition, he said that ob/gyns who specialize in adult patients "have minimal exposure to patients prior to when a female becomes sexually active, and so they don't recognize or appreciate the implications of earlier developmental concerns or rare diagnoses."
All gynecologists who consult young cancer patients about their future fertility have a responsibility to understand and consider the many fertility-sparing options available, said Dr. Marc Laufer, Chief of Pediatric and Adolescent Gynecology at Children's Hospital in Boston, Massachusetts, and a reproductive endocrinologist at Brigham and Women's Hospital, also in Boston. "It's sometimes challenging to address these issues with the parents and/or the child with cancer because they are usually quite overwhelmed, and understandably so," he said in an interview. "They may think that it's a lot to ask the child to go through another procedure to spare her ovaries, after she's just gone through some type of surgical procedure for her cancer." But looking to the future and discussing the girl's potential for pregnancy can take a very positive spin, he adds. "I present it as a sign of hope. I tell patients we need to talk about this for 'when you survive your cancer and you want to have a baby,'" he said.
Dr. Laufer noted that the risks to fertility of radiation and chemotherapy can vary, depending on the age of the patient; the type, severity, and location of her cancer; and the degree of treatment that she needs. Chemotherapy has a drug-specific, dose-dependent, age-related effect on fertility, whereas radiation therapy tends to pose much higher risks -- especially if it is total-body, or pelvic radiation. Young girls receiving radiation tend to have fewer fertility problems in the future than teens or adult women because they start their therapy with a greater ovarian reserve, he said. Given these various considerations, Dr. Laufer said young cancer patients have 2 fertility-sparing options -- surgical or medical.
The surgical option involves oophoropexy -- the removal of usually 1 ovary out of the field of radiation and transplanting it somewhere else in the body. He performs this procedure routinely, by laparoscopy, for patients receiving cranial-spinal radiation for brain tumors. "These patients need radiation therapy that reaches as far down the body to the level of S2 in the sacrum. Young girls have ovaries higher in the pelvis than adults, so this puts their ovaries in the field of radiation -- but if we move an ovary inferiorly and laterally about 2 centimeters, it may be protected," he said.
Ovaries that are moved in this manner continue to function normally in terms of hormone production and ovulation. However because the ovary is detached from the fallopian tube, oocytes have to be aspirated for in vitro fertilization when patients want to get pregnant, he explained. "We only move one ovary and leave the other one in place because there is a 50% chance that it will survive the radiation -- which would mean the patient could get pregnant naturally," he added.
Dr. Laufer has performed approximately 25 of these surgeries since 1991 on patients between the ages of between 2 and 14 years, and he reported that many of his patients are now showing signs of normal pubertal development. Analysis of the long-term follow-up data from these patients is under way.
Medical options for fertility protection involve administration of oral contraceptives or treatment with gonadotropin-releasing hormone agonists, before cancer therapy, said Dr. Laufer. The mechanism by which these treatments protect fertility is still not fully understood, but a theory is that they suppress ovulation, thus preserving ovarian reserve. Another theory is that these medications shrink the ovary, resulting in less chemotherapy or radiation exposure.
He said all young girls who undergo cancer therapy should be warned that despite efforts to protect their ovaries, and even when normal puberty and menstruation have occurred, many of them face a much higher risk of premature ovarian failure. "One study shows their risk of early menopause is 4 times that of healthy controls. It's very important to counsel cancer survivors that even if they have normal ovarian function, this may not last, and if they want to become pregnant, they should consider not delaying," he said.
Dr. Laufer refers patients and physicians to his clinic's Web site for more information:
Elford KJ, Spence JE. The forgotten female: Pediatric and adolescent gynecological concerns and their reproductive consequences. J Pediatr Adolesc Gynecol. 2002;15:65-77. Abstract
Kate Johnson is a medical journalist living in Montreal, Quebec.
Kate Johnson has no significant financial interests to disclose.
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