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Patients to parents
Getting diagnosed with the big 'C' is a blow big enough for anyone. But for young women like Anubha Goel, who are faced with cancers of the reproductive system, the news is even more crushing. They not only have to deal with the dreaded disease but also the fact that they may never experience motherhood. Having settled in her career, Goel, a 38-year-old Delhi-based dentist, was planning to have a baby in 2005 when she learnt she had ovarian cancer. "Will I never be able to have a child?" was the question that troubled her the most.
Goel was lucky. Though the standard treatment for ovarian cancer is removal of the entire reproductive tract - including the ovaries, fallopian tubes and uterus - to ensure the disease does not spread, in Goel's case gynae-oncologist Dr SK Das opted for a conservative approach. She removed only the affected ovary and left the other one intact so that Goel could start a family. For this, she went for an open surgery - not laparoscopy which is preferred these days - to ensure she could remove the 17-centimetre tumour and the ovary en masse without puncturing it.
Goel was then asked to go for ultrasounds every three months to ensure she was cancer-free. With her right ovary functioning normally, Goel conceived naturally and gave birth to a healthy baby girl in December 2008. "My daughter means the world to me, " she says. "Cancer couldn't and shouldn't stop one from being a parent. "
There are not many stories like that of Goel's in India. But even the few that there are offer hope to countless young women and men who are diagnosed with cancer every year. Nearly all types of cancer - not just gynaecological - pose a threat to fertility as the treatment involves chemotherapy and radiation, which slow down or stop sperm production in men and destroy the ovaries of women.
With the prevalence of childhood cancers increasing and even cancers that used to affect the elderly now striking earlier, the pool of cancer patients in the reproductive age group is growing fast. (One in 250 young adults is a survivor of childhood cancer. Fifteen per cent of breast cancers are now diagnosed in women under 40. ) With improved cure rates, 80-85 per cent of patients survive, and while they are able to lead normal productive lives they are uncertain about whether they will ever be able to have babies.
"At least 25 to 30 patients I see every month are women under 40 years and at least once or twice a week I come across a woman who is yet to start a family, " says Dr Rajendra Kerkar, a gynae-oncologist at Tata Memorial Hospital, Mumbai. Kerkar points out that most of the latter group are educated women from metros who have delayed marriage and parenthood for the sake of their careers unlike women from rural areas and the lower socio-economic strata who usually complete their families by their mid or late 20s.
BE CANCER-FREE AND FERTILE
The good news is that advances in diagnostics, surgical techniques and better drugs have enabled doctors to retain the fertility of young patients. For starters, in cases where surgery is required, doctors opt for a 'fertility sparing surgery' like the one Goel underwent but provided the disease is diagnosed early. In cervical cancer, for instance, only the diseased part of the cervix is removed leaving the uterus intact. And, in the case of endometrial cancer - where the disease affects the lining of the uterus - the doctors can use high dose hormone therapy, instead of taking the uterus out. When a woman needs to undergo radiation on the pelvic area, the doctors can offer ovarian transposition - a simple laproscopic procedure in which the ovaries are swung away from the pelvis and placed above. More than 50 per cent of the transposed ovaries continue to function normally and one can expect a pregnancy at a later date. "For patients who need chemotherapy, less toxic drugs can be used for a shorter duration to prevent damaging the ovaries, " says Das who is attached to Action Cancer Hospital, Delhi.
Various studies in recent years have proved the safety and efficacy of these procedures. "With conservative treatment, the danger of the disease recurring always remains and regular follow up is very important. But the option is worth it for patients who desire children, " says Das. Kerkar says a few of his patients have conceived successfully after conservative surgeries.
Doctors advise women to get pregnant soon after completing the treatment to ensure they can have a child before there is further loss of reproductive ability or the cancer relapses. But, if required, patients can undergo special regimens of chemotherapy during pregnancy, too. Recent studies have proved certain chemo agents don't harm the foetus.
BABIES IN COLD STORAGE
Cancer patients also have the option of suspending their fertility for a few years till they are free of the disease and plan to start a family. Several infertility clinics across the country offer the facility to cryopreserve (freeze) the semen or testicular tissue of male cancer patients and eggs of women. If the cancer patient has a spouse, the clinics create embryos in the laboratory - with retrieved eggs and sperm - and store them in liquid nitrogen till the patient wants to use it for conception in the future, says Dr Durga Rao, who heads Oasis Centre for Reproductive Medicine in Hyderabad.
As of now, embryo freezing is the most efficient technique available. When the patient is cleared of cancer, these embryos are thawed and transferred to the uterus. One can expect a pregnancy rate in the range of 30 to 40 per cent per transfer. Another developing technique is ovarian tissue freezing. The doctors remove one of the patient's ovaries, cull out strips of it containing unripe eggs and freeze them. This works out better for patients who can't afford to delay their cancer treatment - egg retrieval can take an entire cycle or up to 45 days - as well as for women who are suffering from hormone-dependant cancers like breast cancer, where giving hormones to increase egg production would aggravate the cancer. The frozen ovarian tissue is re-implanted in the patient's body - usually in the forearm as it can attach to the blood vessels there easily - when she desires pregnancy.
The tissue of around eight cancer patients has been frozen at the Army Research and Referral Hospital in Delhi since it started offering the service in 2009. Two weeks ago, doctors from the Assisted Reproductive Technology Centre implanted one patient's frozen ovarian tissue in her forearm. Rita Kumar (name changed) had got her ovary preserved in 2009 when she was diagnosed with Hodgkin's Disease, a type of blood cancer. Though the 33-year-old already had one child, she yearned to have a second and wanted to ensure she had a chance. "We will know if the procedure has succeeded in another two months, " says Lt Col Sandeep Karunakaran.
If the ovarian tissue is accepted by Kumar's body, it will start producing eggs just like the ovaries of other women. Doctors will then be able to retrieve eggs and perform IVF to help Kumar conceive. If all goes well, baby Kumar would be the first child born to a cancer patient in India after transplant of frozen ovarian tissue. Seventeen babies have been born abroad thanks to cryopreserved ovaries since 2004.
SPREAD THE WORD
Kumar had acted in time because she was aware her fertility was at stake. But the possibility does not even occur to most patients who are overwhelmed by the cancer diagnosis, nor are they counselled about the danger by their doctors. "Very few patients come to us seeking fertility preservation and most of them do so only after their cancer treatment. Usually, by then the damage is already done, " says Rao. Dr Deepa Bhartiya from the National Institute of Research in Reproductive Health says most oncologists in India don't talk to patients about fertility because of their "busy practice" and sometimes also due to lack of knowledge. "But the most important reason is that they don't know where to refer the patient, " she adds.
There is no government facility that offers fertility preservation services to cancer patients. "Private IVF clinics may offer a few options but the prices are out of reach of the common man. " Bhartiya suggests the setting up of a governmentrun centre that could offer counselling and cryo-preservation to cancer sufferers. While all services should be subsidised, ovarian and testicular tissue freezing should be conducted for free as the procedures are still experimental and offer no guarantee of biological parenthood. "One such centre would be enough to cater to the entire country as the samples do not get affected even if they are frozen six hours after retrieval, " she says.
NIRRH and Tata Memorial Hospital are meanwhile chalking out plans for an 'oncofertility' programme and a fertility bank for preserving embryos and gonadal tissues - ovaries and testis - of cancer patients.
The doctors will tie up with fertility experts to whom they will refer young patients. "We hope to provide oncofertility services at a reasonable cost to our patients and also facilitate research in this rapidly developing field, " says Kerkar.
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