Banking on her Future Fertility

Kate is a 24 year old Oxford graduate currently gaining teaching experience before beginning her PGCE qualification in 2010.  Over the coming years, her life will be filled with the many choices available to any bright, young woman, including how her career will progress, who she’ll fall in love with, where and when she’ll buy her first home and when she’d like to have children.  All quite ‘normal’ milestones for any young woman, but only three years ago, Kate wondered if any of them would be part of her life.

Although she is one of 3,899 young women (aged 15-34) diagnosed with cancer in the UK in 2006, Kate is one of only about a hundred young women since 2000, who have been able to ‘preserve’ their future fertility before beginning chemotherapy and radiotherapy by having some of their eggs collected and frozen, in case their ovarian reserve was damaged or reduced as a result of that treatment.

Recently she visited Dr Gillian Lockwood, medical director of Midland Fertility Services (MFS), the UK’s leading fertility-preservation clinic where she had her egg freezing treatment, to get the results of a test to measure any continuing impact of chemotherapy on her fertility.

Kate (right) with Dr Gillian Lockwood, medical direcor of MFS
Kate (right) with Dr Gillian Lockwood, medical director of MFS

In June 2006 while in Russia as part of her third year studies, she noticed a pea-size, painless lump under her skin near her collar bone.  After a few days, and now in Germany, she saw a local GP and a hospital consultant who carried out blood tests, an ultra-sound scan and a chest x-ray.  A subsequent CT scan showed two areas of swelling in her chest and neck, indicating the likelihood of Hodgkin’s lymphoma (HL).

“It wasn’t actually the bombshell that some people imagine and I remained quite calm – though I did get upset when I had to phone my mum to tell her I needed chemotherapy,” remembers Kate.  “I was already aware that different cancers have different prognoses and recovery rates but I researched HL via the internet for more specific information and was reassured that there’s a high recovery rate following chemotherapy and, sometimes, radiotherapy for young people with early stage HL.”

Two days later Kate returned home and within a week had a biopsy to remove three lymph nodes from her neck.  Following this, the oncologist confirmed that she definitely had stage 2A HL.

In the UK in 2006, 1,611 new cases of HL were diagnosed, peaking in two age ranges of 20-25 and 75-80.  HL accounts for about 0.5% of all cancers diagnosed in the UK and is the third most commonly diagnosed cancer in people aged 15-29 years – but it is also one of the most curable forms of cancer.  Since the early 1970s there have been significant increases in the survival rates for HL in the UK.  From 1971-2007, the age-standardised mortality rate for HL fell from 2.2 to 0.4 per 100,000 males, and from 1.1 to 0.4 per 100,000 females.  Such numbers reassured Kate that she would overcome this.

Her oncologist advised that she would be treated with ABVD chemotherapy over six months.  While this treatment can harm a woman’s fertility, there is evidence that it may recover over some years, but that the patient will probably have a premature menopause.  A family friend suggested Kate ask her oncologist about egg freezing to increase her chance of being able to conceive in the future.

“At the time, I hadn’t got specific plans for how many children I’d like to have, or when – or what their names would be! – but I knew I always wanted children to be a part of my life,” says Kate.  “I knew that chemo would damage or reduce my fertility and, because I was certain that I would beat the HL, I wanted to give myself at least a chance to be a mum.”

Her consultant researched fertility clinics which offered egg freezing treatment and contacted Dr Gillian Lockwood.  MFS was gaining a reputation as the UK’s national centre for fertility preservation for cancer patients as, by 2006 MFS was, and remains, the only clinic in the UK to have achieved live births using women’s own frozen eggs.  It was also the first clinic in the West Midlands to also offer vitrification egg freezing, the ‘flash-freezing’ method which offers improved pregnancy rates by increasing the survival rates of eggs after thawing from 65% to 95%.

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The NICE recommendation regarding fertility preservation for female cancer patients is: ‘Women preparing for medical treatment that is likely to make them infertile should be offered oocyte (egg) or embryo cryostorage, as appropriate, if they are well enough to undergo ovarian stimulation and egg collection, provided that this will not worsen their condition and that sufficient time is available.’

“The progress made in recent years in life-saving therapies available to young cancer patients has rightly focused emphasis on fertility-sparing treatments, and if these are not available, on methods of fertility preservation,” explains Dr Lockwood.  “While sperm freezing for male cancer patients has been available, effective and funded by the NHS for many years, for young women, egg freezing before chemotherapy, radiotherapy or surgery currently remains the only available option to give a chance of ‘genetic’ motherhood in the future.

 “While freezing embryos is long-established and can offer pregnancy rates similar toIVF cycles using fresh embryos, it is only suitable for women with a long-term male partner.  As very few young cancer patients are in such a relationship, freezing eggs avoids the ethical ownership issues which may result from creating embryos – where the man whose sperm was used to fertilise the eggs shares the same rights as the woman over storage or use of the embryos.”

Since MFS was granted a licence to freeze eggs in 2000, the clinic has frozen eggs for 157 women, including 58 young women diagnosed with cancer.  Initially restricted to patients with haematological cancers such as lymphoma, egg freezing is now available for a wider range of malignancies including breast cancer.

Some of the PCTs with which MFS has contracts to provide IVF treatments also fund the cost of egg freezing for cancer patients.  The unit is also able to secure funding from other PCTs for cancer patients whose egg freezing is not covered by any existing contract, as it did for Kate’s egg freezing treatment and continuing storage.

Kate’s oncologist agreed that her chemotherapy could begin at the end of August, allowing time for her ovaries to be stimulated with fertility drugs to increase the growth of the egg-containing follicles.  Careful monitoring was required to ensure that Kate did not over-respond to the fertility drugs and develop ovarian hyper-stimulation as she had previously been diagnosed with polycystic ovary syndrome (PCOS).

In late August 2006 staff at MFS collected 28 eggs from Kate, while she was under conscious sedation.  These eggs are now stored in liquid nitrogen at -196˚C, the point where all cellular activity ceases.  Under new legislation eggs may remain frozen for up to 55 years, so long as the woman has become prematurely infertile.

In the future, if the effects of the chemotherapy on Kate’s reproductive system has been harmful and she is unable to get pregnant naturally, she may try to conceive through ICSI IVF, when the eggs will be thawed, injected with the sperm of her future partner and allowed to fertilise in an incubator.  One or two of the embryos will then be returned to her uterus, hopefully resulting in a pregnancy.

Two days after her egg collection, Kate began her chemotherapy.  After 12 treatments over six months and following a PET/CT scan in February 2007, Kate was told that she was in remission.  And follow-up blood tests and CT scans over the last two years have confirmed that she remains cancer-free.

In November 2009 Kate had an ovarian reserve test at MFS to measure her current fertility potential.  “Kate’s ovarian reserve results are encouraging,” revealed Dr Lockwood.  “Her ovaries currently show signs of limited impact from the chemotherapy, although in a woman of Kate’s age this is not unusual, as younger women’s ovaries seem to be more resistant to the effects of chemotherapy.

“However, chemotherapy can add up to 10 years to a woman’s ‘fertility age’, so that when she is in her late 20s, her ovarian reserve, and therefore her fertility potential, will be the same as that of a woman in her late 30s, when fertility starts to decline naturally anyway.

“I would recommend that Kate and any young woman in similar circumstances repeats an ovarian reserve test every five years and, depending on her personal circumstances, assesses whether and if she should try to conceive naturally or, when the time is right for her, to attempt to conceive using her frozen eggs – and which will forever be just 21 years old.”

Kate resumed her studies in 2007 and graduated with first class honours in German and Russian the following summer.  Over the coming years, while she develops her career and future relationships, she can be reassured that when the time comes to start a family, she has eggs in the ‘bank’ if she is not able to conceive naturally.  She says: “I know it’s not a guarantee of a baby, but it gives me more of a chance than I would ever have had before egg freezing became available.”

A Dedicated Team at MFS

Nine years experience of both elective and emergency egg freezing has led MFS to create a dedicated team for fertility preservation for young cancer patients.  The team can be available at short notice, to maximise access to the service and minimise delay to the start of cancer therapy.  Working closely with the patient’s oncologist, an assessment for the viability of egg freezing may be made at a single consultation and the patient placed on a short protocol of follicle stimulating drugs.  Egg collection is performed under conscious sedation local anaesthesia approximately two weeks later after the start of stimulation.  Counselling is available at every stage of treatment and clinical follow-up is offered to address the patient’s concerns about her fertility.

ends

Issued: 30 November 2009

This feature also appears in the Winter edition of C21, Understanding and Coping with Cancer magazine.

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