Issue 4 / 11 February 2013

A CASE involving a woman whose fertility was restored after cancer treatment has caused a mini media frenzy, prompting one fertility expert to warn against sensationalising the breakthrough.

Monash IVF reported the first Australian case of a woman becoming pregnant after having her ovarian tissue frozen prior to undergoing gonadotoxic chemotherapy for breast cancer. The clinical details are published online today by the MJA. (1)

Five years after successful treatment her ovarian tissue was reimplanted and she subsequently became pregnant at 43 years of age. The baby is due in August this year. It is one of only 20 successful cases internationally.

Earlier newspaper reports about the success of the treatment, claiming that science could “beat the fertility clock”, prompted study coauthor Professor Gabor Kovacs to hose down the possibilities of the treatment.

“We’ve now shown that this technique does work. We don’t know how well it works yet”, Professor Kovacs, international medical director of Monash IVF, told MJA InSight.

The MJA case study authors wrote that in late 2005, before starting chemotherapy, the woman underwent removal of an ovarian wedge, which was placed in chilled phosphate buffered saline and dissected so that multiple pieces of the ovarian cortex could be cryopreserved.

They wrote that when the women presented again in 2011 her serum follicle-stimulating hormone level was persistently above 30 IU/L and her oestradiol level below 44 pmol/L, which implied no ovarian activity, there were no signs of ovulation and she had an anti-Müllerian hormone level of < 1 ng/mL, compared to normal ovarian reserve of > 14 ng/mL.

In April 2012, the woman underwent an autologous ovarian tissue reimplantation and by, September 2012, natural menstruation occurred. In October, it was decided to proceed with an in-vitro fertilisation cycle and, in November, a viable intrauterine pregnancy was confirmed.

The study authors wrote that while the technology needed to be developed to increase the choices for fertility preservation for medical reasons, “there is also a possible application of this technique in delaying or avoiding the menopause”.

However, Professor Kovacs told MJA InSight that for a 30-year-old woman wanting to preserve her fertility for social reasons, the risks currently involved in this procedure were too high.

“If I were concerned about menopause for some reason, would I do this? No, I would not, because there are other options, like hormones, available”, he said.

“But if I were a young woman with cancer, I would do everything I could to preserve my fertility, because for people with cancer, there are not too many options.”

Ms Sally Crossing, a spokeswoman for national advocacy group Cancer Voices Australia, also warned that the breakthrough procedure had been overhyped in the media as a “possibility for women to avoid menopause altogether”.

“We’d advocate more caution … it’s a terribly small group of patients involved and there needs to be more study”, Ms Crossing said.

“Fertility is a major issue for women with cancer and, with breast cancer being diagnosed earlier and chemotherapy being prescribed earlier, it’s becoming a big issue for more people than before”, she said.

Professor Loane Skene, a medical law and ethics specialist at the University of Melbourne Law School, said the new procedure brought up some interesting ethical issues, mainly around the question of consent.

“A woman who has been diagnosed with cancer and is facing chemotherapy may be especially vulnerable and eager to try a new and relatively untested treatment”, Professor Skene said.

“It is vital that the clinicians have established the safety and effectiveness of the new treatment as far as possible and that they explain the nature of the procedure thoroughly to the patient before she consents to it.

“For women who do not have cancer, there are other issues as well as those regarding information and consent”, she said.

“Until it has been tested more widely, the issue is whether a procedure with unknown risks should be undertaken, even if the woman wants to have it, when it is not ‘necessary’”, Professor Skene said.

– Cate Swannell

1. MJA 2013; Online 11 February

Posted 11 February 2013

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