I faced the young woman sitting in my office and discussed treatment options for her early-stage breast cancer, treatment necessary to give her the best chance of preventing recurrence. She faced the news of the recommendation for chemotherapy bravely. We then talked about the side effects of treatment, including the fact that her fertility could be adversely affected. She was incredulous that the treatment given to save her life could also change it so irrevocably, and was relieved to know that back-up plans were possible. We planned for her to meet with our fertility expert that same day, to learn about options for freezing eggs or embryos. Just having options and retaining some control over her future allowed this woman to move forward with treatment and all its challenges with a lifted spirit.
I am delighted to write the foreword to this groundbreaking book, Having Children After Cancer. As a breast cancer oncologist at the University of California San Francisco's Comprehensive Cancer Center, I face this issue with my patients on a regular basis. Unfortunately, for young women and men facing a diagnosis of cancer, the issue of future fertility is often not addressed or even considered when discussing treatment options. The overwhelming anxiety of the cancer diagnosis eclipses other considerations for patients, and physicians have focused on the immediacy of cancer therapy rather than the ability to have children later in life. For some patients, the concern about losing fertility may adversely impact decisions about treatment, potentially leading young adults to choose less-than-ideal therapies. In this book, Gina Shaw presents a detailed and thoughtful guide to a variety of approaches for preserving future fertility for both women and men, as well as a detailed list of options for becoming parents when having a biological child is not possible.
Although current chemotherapy regimens for many cancers cause relatively less permanent damage to the function of the ovaries or testicles than treatments given in the past, the impact of chemotherapy, hormone therapies, and radiation on the subsequent ability' to have children is largely unknown and is extremely complex. Some treatments are known to cause permanent loss of ovarian function or sperm production in all patients (such as whole body radiation), but most affect a subset of individuals. Risk factors include the type and duration of chemotherapy, patient age (particularly for women), and fertility- before treatment, which is often unknown.
Although there is information about risk factors that predict persistent loss of menses after chemotherapy and radiation, there is little data on the impact of these treatments as well as antihormone therapy on what is referred to in women as "ovarian reserve," making it difficult or impossible to accurately predict the effect of many anticancer therapies on fertility for an individual patient. For women, many therapies lead to a temporary cessation of menses. Whether menses restart, and whether fertility will remain intact, remains a question for most patients. Very young women, or women and men receiving less intensive therapy, may retain fertility'. Choices regarding treatment, and discussion of the potential impact of the chosen treatment on fertility, must take place as early as possible after diagnosis in order to maximize fertility' preserving options.
Fertility is an established subspecialty within obstetrics and gynecology, but the interest in preserving options for childbearing in young patients with a diagnosis of potentially curable cancer has given rise to a specialty within fertility, termed "oncofertility" by many. This term encompasses both service in the form of rapidly attainable consultations, egg harvesting, in vitro fertilization, and other fertility treatments, as well as research into the effects of treatment on ovarian reserve and subsequent fertility. Newer tests can more accurately predict the "ovarian reserve" or the ovary's potential to make fertilizable eggs, and help to predict the chances of achieving an unassisted pregnancy. At the University' of California, San Francisco, we work very closely with our colleagues specializing in fertility, obtaining consultations before patients start systemic therapy including chemotherapy and hormone therapy, as well as radiation, in order to maximize fertility options as much as is feasible for each interested patient.
Once a consultation is obtained, the patient and her partner or family can decide on the most appropriate plan for that woman's individual situation. Harvesting eggs that are then fertilized with sperm and frozen as embryos (the process followed for in vitro fertilization or IVF) is the most successful strategy but requires a partner or donor sperm. Many women who do not have a male partner are wary of using donor sperm but can now consider freezing unfertilized eggs, a process which is slowly becoming more common but is still associated with a lower success rate than IVF - although this is improving. As timing is critical in order to minimize the delay until the start of cancer therapy, and harvesting eggs is timed to the menstrual cycle, patients can usually be seen within one to two days of an initial call. As much as possible, we try to delay the start of chemotherapy and radiation therapy for these discussions and procedures to minimize effects on the ovaries. In most cases, a several week delay is both safe and feasible. Harvesting eggs is not for everyone, and options are discussed in this book for those who do not have this resource.
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