Options for Women Before Treatment
What are the options for women before treatment?
Treatment for early cervical cancer or endometrial cancer generally includes hysterectomy. In a few select cases, this may not be necessary. In very early endometrial cancer, it is sometimes possible to treat the cancer hormonally without removing the uterus.
In very early cervical cancer, for example, removal of just the cervix (called trachelectomy) may be possible in order to retain child-bearing potential.
If radiation to the pelvis is required, the ovaries can sometimes be moved out of the area expected to receive the most radiation. This procedure (called ovarian transposition) can at least partially protect the ovaries from the effects of radiation.
While ovarian cancer is frequently treated by hysterectomy and removal of both ovaries, early stages can sometimes be safely treated by removal of the affected ovary only.
These possibilities can be discussed with a gynecologic oncologist.
In-vitro fertilization followed by cryopreservation (freezing) of the fertilized eggs can provide an opportunity to have a pregnancy after treatment for the cancer is completed. This procedure involves treatment with fertility drugs to cause development of multiple eggs. The eggs are retrieved under light anesthesia and fertilized with the partner’s sperm and then frozen. The whole procedure requires two to four weeks and is, of course, only an option for women with a partner (although use of a sperm donor is possible).
IVF with cryopreservation of embryos has been used extensively for infertility treatment since the early 1980s and is considered a safe and routine procedure. The embryos can be stored for a number of years until cancer treatment is completed. Even if the cancer treatment results in ovarian failure, the woman can be given hormones to mimic a normal ovulation cycle and have the embryos transferred back to the uterus by a simple outpatient procedure. The chance of pregnancy is about 30% each time 2-3 embryos are returned to the hormonally prepared uterus. If 12-15 embryos can be produced and stored, that should give the couple a reasonably good chance of achieving a pregnancy at a later date. The cost is $8000-10000. Sometimes this is not possible because of the need to start cancer treatment quickly. An IVF cycle takes about two weeks to complete and starts with the onset of a period so it can delay cancer treatment for several weeks.
Cryopreservation of Unfertilized Eggs:
Women who do not have a partner can still go through an IVF cycle and freeze unfertilized eggs. Unfortunately, freezing unfertilized eggs is still relatively new and has much lower success rate. The current success rate is about 1% per egg so that, it 12-15 eggs were produced and harvested, the chance of achieving a pregnancy at some point in the future would be 12 percent to 15 percent. This is an active area of research and it is hoped that this success rate will improve in the future.
Cryopreservation of Ovaries:
Another option which is also an area of active research is cryopreservation of ovarian tissue. In theory, this is an ideal option. It can be done immediately and therefore will not delay cancer treatment. A piece of ovary in a young woman probably contains hundreds if not thousands of eggs. At this point we are not able to use the eggs in a piece of ovary to produce a pregnancy because the eggs are immature at that stage. Maturation in the lab has been done in animals but is not likely to be possible in humans for years. Two pregnancies have been achieved in the world out of an unknown number of attempts using pieces of ovary that were frozen and then replaced into the patient, allowing maturation of the eggs to occur in a normal way. This has also been done in animals and looks promising. Although the pieces of ovary do not survive long after replacing them into the patient, they may last long enough to allow the woman to achieve a pregnancy. One concern with this treatment option is that an invasive surgical procedure is required to obtain the tissue. It is considered experimental and, therefore, generally not covered by insurance. The main concern with this option is the risk that by returning a piece of ovary to the woman, a few cancer cells might be returned as well leading to recurrence of the tumor.
Medical Suppression of the Ovaries:
Girls who have not yet gone through puberty are relatively protected from the effects of chemotherapy. However, even these girls can experience an early menopause years after the treatment has been completed.
Because girls who have not yet entered puberty are relatively protected from the effects of chemotherapy, it may be useful to use a medication to inactivate or suppress the ovaries. This medication is called Depo-Lupron and is given as a monthly injection. It should be given at least 10 days before the start of chemotherapy to have maximum effect. This medication also has the effect of stopping menstrual periods. This can be useful because chemotherapy often lowers the platelet count, increasing the risk of heavy or prolonged bleeding during menstrual periods.