Cancer treatment has already started

Even if you are already undergoing cancer treatment, we can still try to safeguard your future fertility. The options available are partly the same as those applied before cancer treatment, even though they will sometimes be less effective.

Some options you have as a woman to try and safeguard your fertility for the future are similar to those available before cancer treatment. Others are related to cancer treatment itself.

As a method to protect your fertility during chemotherapy hormonal suppression of your cycle may be suggested. This medication temporarily switches off the hormonal function of your ovaries, which could protect them to some extent against the harmful effects of the chemotherapy.
Unfortunately, the effectiveness of this method has not been fully demonstrated to date. Besides, there could be some objection from an oncological perspective, because hormonal therapy may sometimes have negative effect on the efficiency of cancer therapy.
Therefore we are currently not offering this technique at CRG.

Nevertheless, further research is ongoing in this field. It cannot be excluded that an efficient hormonal or pharmaceutical fertility protection method may become available in the future.

In addition, we can also expect the harmful effect of chemotherapy to be reduced in the decades ahead. Oncological research is focused on the development of new treatment schemes.
Chemotherapy causes the suppression of your menstrual cycle. As we discussed in What is gonadal toxicity? the purpose of chemotherapy is to destroy quickly dividing (cancer) cells.
But chemotherapy will also arrest the development of growing follicles, which will result in arrested production of ovarian hormones and finally lead to menstrual cycle cessation.

During chemotherapy, collection of egg cells from growing follicles cannot be performed, neither mature (after hormonal stimulation) or immature egg cells (which are matured in vitro), because these egg cells are of bad quality because of the damage inflicted by chemotherapy.
Instead, removal of ovarian tissue for cryostorage is available, because this tissue contains non-growing primordial follicles that have not been affected by chemotherapy

In other words, it is possible to bank ovary tissue during the chemotherapy treatment period to try and preserve your fertility or that of your daughter. However, this approach can only be proposed when biomarker tests of the ovaries indicate an adequate ovarian follicular reserve. This can be discussed with your cancer specialist and with the fertility doctor.
When the pelvis is irradiated, a direct harmful effect on all organs in that area ensues. Because of this, it may be an option to (temporarily) displace the ovaries before the start of radiotherapy to a higher position in the abdominal cavity. This is called ovarian transposition.
The objective is to move them away from the area receiving radiation therapy and to shield them better from the radiation by means of neighbouring tissues. The procedure is also called 'ovariopexy' and is usually performed by means of keyhole surgery (laparascopy).
In the majority of cases, the ovaries continue to function normally in hormonal terms and the egg cells can be collected later for an IVF/ICSI procedure.
Unfortunately, the transposition of ovaries is not guaranteed effective: it is still possible that the follicle reserve is affected due to indirect radiation. The preservation of the ovarian function also depends on your age and the radiation extent and dose.
During the radiation sessions we can also try to protect the ovaries (and womb) against irradiation by means of lead shielding. The lead shields will be positioned on the abdomen where the ovaries are located before the start of radiation therapy.
Even though no data are available about the success rate of this method, oncologists and radiologists agree that lead shields reduce radiation and that it may reduce the damage to the ovaries.
A number of screening procedures or diagnostic tests are available which are aimed at detecting cancer at an early stage. In this respect, you can be referred to the gynaecology department and/or the Advice Centre for Reproductive Health (ARG) at UZ Brussel.

However prevention cannot prevent cancers from developing in reproductive organs of girls and young women. The gynaecological cancer itself and the treatment of cancer can result in damage to these organs. This implies that the chances of a pregnancy and the successful outcome of a pregnancy may ultimately be reduced.
When these cancers develop in young women, we pay additional attention to a treatment strategy that offers maximal protection of the patient's fertility. A key measure is to avoid drastic, radical, irreversible surgery whenever possible.
Without being exhaustive we will list some options of fertility-sparing procedures in case of common gynaecological cancers.

The Gynaecology-Oncology department at UZ Brussel is in charge of the surgical procedures involved in gynaecological cancers.
The doctors in charge are Dr. Philippe De Sutter and Dr. Stef Cosyns.
Cervical cancer
Uterine cancer
Ovarian cancer

Cervical cancer (cervix carcinoma)  

Cervical cancer can be detected in an early stage by means of regular pap smears. If the test reveals the presence of precancerous lesions of the cervix, these can easily be treated without involving any risks for your fertility.
It is our strategy to avoid conisation (cervical cone excision, removing a part of the cervix) for small significant lesions. Excessive or repeated conisation may be detrimental to the course of later pregnancies.

In case of invasive cervical cancer (invasive cervix carcinoma) the treatment depends on the size and extension of the tumour. If the tumour is small and restricted to the cervix, we can sometimes perform local excision of the tumour, together with a part of or the entire cervix (conization or trachelectomy). The procedure may either or not involve a laparoscopy (keyhole surgery) and, where appropriate, the removal of the lymph nodes in the abdominal cavity.
In other words: the womb is left intact during this procedure and therefore a future pregnancy is still possible, albeit with an increased risk of complications during pregnancy.

In case of more advanced-stage tumours, however, a more radical treatment is required: the removal of the womb (hysterectomy) or radiation of the womb (radiotherapy). In both cases you will no longer be able to get pregnant after the procedure.
We can, however, consider to perform an ovarian transposition together with this operation. This will make sure that the ovaries continue to function normally and the egg cells can be collected later for an IVF/ICSI procedure. However: in these cases, your desire to have a child with your own egg cells will only be possible through surrogate motherhood.


Uterine cancer (endometrial carcinoma)  

Uterine cancer usually occurs after menopause and at an advanced age, sometimes before the age of fifty, but rarely before the age of forty. Standard treatment consists of removing the womb and the ovaries, either or not together with the lymph nodes in the lower abdomen.

This cancer exceptionally occurs in young women who still have a desire to have children. If the medical evaluation indicates that it is not possible to preserve the womb, you may be offered oncofertility treatment: see banking of egg cells, banking of embryos and banking of ovary tissue.
However: in this case, your desire to have a child with your own cells will only be possible through surrogate motherhood. Furthermore, there is currently no legal framework available in Belgium that regulates surrogacy.


Ovarian cancer (ovarian carcinoma)  

There are many types of benign and invasive ovarian tumours.
If benign tumours are surgically treated, the key message in young women is to always perform surgery with preservation of the ovaries in the abdomen. It is usually not necessary to completely remove the affected ovary. However, if technically possible, we will remove the tumour from the ovary and leave the normal ovarian tissue in place to the best of our ability.

In case of invasive ovarian cancer it depends on the severity of the cancer whether or not we can preserve the patient's fertility after surgery. If only one ovary is affected and the other ovary, the lymph nodes and other organs appear not to be affected, the other ovary and the womb can be preserved in the abdomen. If the cancer has spread beyond one ovary, a radical operation, usually followed by chemotherapy will be required to achieve recovery and survival.
If we can still identify normal ovarian tissue, we can – in exceptional cases – collect mature egg cells through IVM (in vitro maturation). These can be banked immediately or after fertilization and embryo development in the lab.
Only if (exceptionally) the womb can be spared, a pregnancy will be possible. In all other cases you will have to refer to surrogate motherhood (or adoption) to fulfil your desire to have a child. Remember: no legal framework currently exists for surrogacy in Belgium.


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