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Fertility preservation refers to the method of enabling cancer patients to maintain their fertility. This is because chemotherapy, radiation and other treatment regimens destroy the reproductive system of the body by attacking reproductive cells such as sperms and ovas.While the loss of the reproductive ability maybe temporary in some patients, some never regain it. Women may experience menopausal symptoms while men display characteristics of andro-pause.
Ovarian destruction depends on the drug, the dose, and the age. As the age of the patient increases lesser doses, increase chances of failure of the ovaries. It may result from radiation of the abdomen, the pelvic, or the whole body. The case is worse for pre-pubertal girls because in addition to the risk of infertility, female survivors of childhood cancer are also at a risk of premature ovarian failure. Statistics from a study indicated that 25% of female childhood survivors had premature menopause before the age of 16 years (Donnez and Kim 74).
Improvement of cancer survival rates among children means doctors have to focus their attention on offering them a wholesome life in future. It is estimated that two-thirds of children with cancer will be cured and most of them will experience fertility deficiency. Fertility is a major aspect of such a life.
Fertility preservation in males, children, or adult are less expensive, less invasive, and more effective because they are a wide range of options available and procedures. For females, the methods are complicated, especially in relation to pre-pubertal children whose eggs are not yet mature.
Methods for preservation range from cryopreservation, protecting gametes during chemotherapy by using the gonadotropin-releasing hormone. Ovarian tissue cyro-preservation is a process in which normal functioning ovarian tissue is excised from the ovary and stored cryogenically and is the only option that can be offered to pre-pubertal girls (Donnez and Kim 77).
This opinion states that embryo cryopreservation after in-vitro fertilization as well as cyro-preservation of mature human oocytes are in most cases unsuitable for minors therefore cryopreservation of ovarian tissue containing small immature ovarian follicles remains almost the only option.
Pre-pubertal males have a gonad maturation process. In contrast, the process of establishing in-vitro maturation process for pre-pubertal females is still in progress.In spite of the fact that the process is still at an experimental level, ovarian tissue removed from pre-pubertal and adolescent cancer patients is being frozen in medical centers around the world.
Paedetriac surgeons use thorascopy and laparoscopy in pre-pubertal females. Lapascropy involves isolation of the fallopian tube from the ovaries to control supply of blood. Through an incision on the abdomen, the ovary is then removed in a special bag. The advantage of this method is that the abdomen is thoroughly explored through an incision and both ovaries can be examined before removal.
Legal and Bioethical Issues
Ethical and legal etiquette demands that any process involving a minor should be done in the best interest of the minor. The society’s obligation to act in the best interest of the child is a paramount feature of bio-ethics. In case of failure of the parent’s or the society, the state should intervene in its capacity as parens patriae i.e. parent of the nation.
Feinberg, a legal scholar proposes existence of special rights in relation to children, which he names as “rights in trust”. Such rights are to be preserved for them until adulthood and fertility is one such right (Weintraub et al 4). The concept of best interest means that fertility preservation procedures should be aimed at enhancing the survival of the child and minimizing risk to that child. This gives rise to myriad legal and bio-ethical issues.
A pre-pubertal girl is a minor in law and is therefore incapable of consenting to any procedure; he or she cannot understand the complications arising from the preservation procedure. The consent of the parents is therefore required. This is known as at two- test procedure because it involves the parents’ consent and minor’s assent.
Conflicting scenarios may arise whereby the parents consent and the minor does not assent or where the parents decline to consent and the minor requests the preservation. This creates a legal crisis, which is hard to solve considering the sensitive and vulnerable nature of pre-pubertal children (Moorland 78).
The issue of use of experimental procedures is a thorny issue in legal and ethical circles. The earlier discussion has revealed that cyro-preservation of ovarian tissue is the only available option. The process is not thoroughly established and is still at an experimental level.
So far, no baby has been born out of the procedure because the minors are still adolescents and there are no accurate statistics. Questions rise as to whether pre-pubertal females should be subjugated to the level of guinea pigs and what remedies should be available in case such a procedure backfires.
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Preservation of ovarian tissue means that in future the pre-pubertal minor may have to rely on a surrogate mother if her reproductive system is destroyed. She may also have to rely on sperm from a donor if she does not have a stable partner. Legal issues arise such as who is to have parental responsibility over such children. Should the secondary parents (surrogate mother and sperm donor) have a right to know the child or should they be completely out of the child’s life as is the case now?
There is a chance that cancer patients may pass the disease to their offspring or that such offspring would stand a high chance of cancer infection. The treatment regime may lead to defects in the chromosome, increase transmission of heritable diseases and other anomalies in the genetic structure of the child.
There are discussions on whether it is ethical to allow cancer patients to preserve fertility if they are going to pass medical conditions to their children. Those against preventing preservation of fertility on such aground argue that other people with heritable genetic conditions such as albinism and hemophilia are allowed to reproduce, and cancer patients should not be prohibited, as it would constitute discrimination.
The other bio-ethical issue stems from the fact that the cancer patient may suffer from a recurrence and die pre-maturely leaving the without one parent or rendering him an orphan if single. While one school of physicians suggests that it is unethical to assist cancer patients with expected short life span to have offspring, the other argues that “to deny cancer patients the right to preserve their fertility amounts to ‘forced sterilization’ which is ethically unacceptable” (Chian, 253).
Those in support of allowing preservation despite a reduced life-span suggest that it’ in the best interest of the pre-pubertal child to have the right to reproduce while those against say they consider the best interest of the pre-pubertal child’s child.
Storage, disposal, and post-humus use of the preserved ovarian tissue or embryo is a delicate ethical issue. If the cancer patient dies before using the preserved tissues, there are concerns as to whether such materials should be destroyed, whether they should be used for research, or whether they should be donated to other infertile couples. All those methods raise moral and religious issue.
Research into fertility preservation methods requires embryo and oocyte donation from humans. Creation of embryos and subsequent destruction in research is considered unethical because at the end of the day the tissues are capable of potential human life. To address these legal and bio-ethical issues, a coherent legal framework needs to be put in place.
How the Policy should be impacted
The cancer patient, particularly a minor is distinct from other fertility patients by virtue of the disease and the age. Every human being has an inherent desire to reproduce and propagate the species. Surveys indicate that cancer patients have a strong desire to preserve their fertility through procedures that involve minimum risk and are beneficial. They should not be deprived of the opportunity but qualified professions under stringent legal conditions, particularly in relation to pre-pubertal minors, should undertake the process.
In developing the fertility preservation policies for pre-pubertal girls, saving the life of the cancer patient must always take precedence over fertility preservation.
It should only be offered where chances of survival are realistic. The costs of fertility preservation for females are currently very high, estimated up to $10,000. The state should reduce the cost for pre-pubertal females in view of their age by establishing a fund for them. Funds should also be availed for research to increase options for them and make surgery procedures less invasive.
Complications related to anesthesia occur more commonly in infants than in adults. Children under 1 year suffer the greatest risk, which decreases when they turn 3 years and equalizes with that of adults at the age of 15 years. Because of the increased risk, ovarian cero-preservation in pre-pubertal females should not be performed before they turn three (Weintraub et al 5). Qualified pediatricians and oncologists should perform the surgery.
A cogent legal and bio-ethical issue that arises is disposal of cyro-stored gametes if patients die before the use them. If the cancer patient does not survive, there should be a framework for disposal of stored gametes or embryos and they should never be applied by the medical center for other purposes such as invitro fertilization of other infertile couples. “A minor child who survives to majority age should take full-control of the disposition of the bio-materials and should become the sole person entitled to consent to their use or disposal” (Chian 254).
Minors should give directions for disposal of such tissue at a time when there are healthy and lucid, preferably through a written agrrement.Such an agreement should be amendable at a future time if they wish to change the terms and proposals. This would give directions in case of death, failure of payment of storage fees or other contingencies.
The patients and their guardians should be approached by clinical professionals in charge of the therapy or by a multi-disciplinary team who will explain the fertility risks resulting from the anti-cancer therapy and the purpose and the potential of cyro-preservation of ovarian tissue (Gwendolyn and Thomas 135). Doctors should avoid exerting undue influence on the vulnerable patient and the anxious parents by issuing statements like “she will suffer later if she does not go through the process” (Gwendolyn and Thomas 135).
The minors and parents should have a right to be informed of the future fertility status of their children and all fertility options. If this is not done promptly or in time, the fertility options for the patient may be lost. In consenting to fertility preservation, parents should only accept established methods. They should never consent to experimental procedures that may increase the risk for their children.
An independent body such as an ethics committee should be established to review the decisions of the parents and the doctor’s decision as the state exercises its responsibility as parens patriae.This would ensure that the decision to preserve fertility is in the best interest of the child, and it is not for selfish motives or profit gains. It would also sort out legal crises where the parents assent, the minor does not consent, or where the parents do not consent, and the minor approves.
Genetic tests should be conducted to evaluate whether the patient has genetic conditions that maybe passed onto the offspring and increase the risks for transmission of cancer infection just for ethical considerations. If the chances are high, and the patient still insists on the procedure the information should be passed to an independent body such as an ethics committee which should vet whether fertility preservation should be allowed for such a patient, and whether the patient can be convinced to accept other options such as adoption.
Counseling services should be offered to the pre-pubertal female, her parents, or legal guardians. Before and after the removal of such tissue.Counselling should be progressive from the day of the removal, to the day the minor is cured, until the day she decides to undergo the reproduction process itself. It should continue to post-reproduction days and be extended to the child delivered if they are chances that the infection will be transmitted to the offspring, or a recurrence will occur to the patient, or the parent will die pre-maturely.
Chian, Ri-Cheng. Fertility Cryopreservation. Cambridge: Cambridge University Press, 2010. Print
Donnez, Jacques, and Kim, Stephen. Principles and Practice of Fertility Preservation. Cambridge, UK: Cambridge University Press, 2011. Print.
Gwendolyn, Quinn, and Thomas, Susan. Reproductive Health and Cancer in Adolescents and Young Adults. Dordrecht: Springer, 2012. Internet resource.
Moorland, Margarite. Cancer in Female Adolescents. New York: Nova Science Publishers, 2008. Print.
Weintraub, Mathew et al. “Should Ovarian Cryopreservation be offered to Girls with Cancer?” Review of Pediatric Blood Cancer 48.1 (2007): 4–9. Print.