31 October 2016
ByAppeared in BioNews 875
If you ask someone whether fertility preservation should be offered to people who have an illness, or who are undergoing a treatment that places them at risk of infertility, then in my experience the answer is usually 'yes'.
There seems to be more sympathy for people in this predicament than there is for women who choose to freeze their eggs for non-medical reasons. However, public support does not mean that the topic is without scientific, legal and ethical challenges. This is why the Progress Educational Trust thought the area was worthy of discussion at 'Frozen Assets? Preserving Sperm, Eggs and Embryos', an event which took place in Edinburgh on 25 October.
As fertility can often be compromised by cancer treatment, it seemed fitting to start the discussion with a presentation from Alison Hume, a breast cancer nurse. She explained how the pathway for young breast-cancer patients at her unit included discussion of fertility preservation, and how – if appropriate – these women were then referred to the fertility unit for further discussion of their options. These might include fast-tracked IVF or egg freezing. For some women, just discussing future plans to have a family is of therapeutic benefit because this conversation implies they will survive.
However, Hume cautioned that many women do not have a conversation about their fertility as part of their cancer treatment. Research conducted by Breast Cancer Care earlier this year has found that just over half (53 percent) of younger women diagnosed with breast cancer in the UK have no discussion with healthcare professionals about fertility preservation. Hume has contributed to a fertility toolkit developed by Breast Cancer Care to address this situation.
The second speaker, Professor Richard Anderson, explained that fertility preservation for women is not new but remains challenging. There are issues of access and funding for the relevant treatments, and women need to weigh up the pros and cons of fertility preservation in light of the risk posed to their fertility by illness or treatment – and the risk posed to their health by delaying treatment. Women don't produce mature eggs every day, so there is generally a need for treatment to stimulate the ovaries, as in IVF. This takes time, which is not something that every patient has.
Fortunately, egg-freezing technology has improved dramatically in the last decade. Increasingly, young women are able to freeze their eggs rather than needing their eggs to be fertilised by their partner's sperm or a donor's sperm and then freezing the resulting embryos. But current evidence suggests that the chance of achieving a pregnancy using frozen eggs is still relatively low. So there is a need for a thoroughgoing discussion with female patients to decide how 'we' should proceed.
Freezing ovarian tissue is also possible. Earlier this year, a cancer patient in Edinburgh became the first woman in the UK to have a child following a transplant of her frozen ovarian tissue, and Professor Anderson led the team responsible for this breakthrough (see BioNews 860). This is potentially a good option for very young girls, who cannot produce mature eggs, although it requires an operation to remove the tissue. The advantage is that, if the tissue is transplanted successfully, there is no need for further treatment – the patient's periods will return, and she can conceive naturally. For the time being, however, this is still regarded as an 'experimental' treatment at any age.
Sperm freezing, by contrast, is far from being an experimental treatment. Professor Allan Pacey, our next speaker, explained that people have been freezing sperm since at least 1776, when an Italian priest recorded the effect of snow on human sperm. This was a dramatic start to Professor Pacey's presentation, and was made more dramatic by the fact that this renowned andrologist was sporting a bow tie decorated with images of sperm. Although he began in a jocular manner, he went on to deliver a serious message – banking sperm for men prior to cancer treatment, and prior to other treatments where there is a risk of infertility – should now be a routine part of medical care.
'It's technically quite straightforward and relatively cheap, but we know that it isn't always offered to the right men, and sometimes many men who would benefit from it also decline the offer when it's made. If you add to all this the fact that in some parts of the UK theNHS doesn't always fund sperm banking in the way that NICE says they should, then the future fertility needs of many men diagnosed with cancer (or other medical conditions) are not adequately taken care of.'
Consent was the watchword when it came to the final presentation by Dr Mary Neal, senior lecturer in Law at the University of Strathclyde. Dr Neal talked us through cases where consent was either ambiguous or absent – the landmark case being that of Diane Blood, whose husband's sperm was retrieved without his written consent. After protracted legal proceedings, the sperm was ultimately exported to Belgium, where Blood used it to conceive her two sons (see BioNews 144).
Next, Dr Neal discussed the key case where consent was withdrawn – that of Natallie Evans, whose former partner withdrew his consent for their embryos to be used in treatment. Ms Evans tried unsuccessfully to persuade the courts to allow her to use these embryos (see BioNews 402). We were then brought bang up to date with the case of Samantha Jefferies – an example of a situation when the wishes of the deceased partner are clear and undisputed but, because of an anomaly on a consent form, the case has to go to court to permit the embryos to be used (see BioNews 871).
The chair of the discussion – Alison McTavish, one of the founders of the Aberdeen Fertility Centre – then fielded questions from the audience, and also contributed her own observations from her extensive experience as a fertility nurse. Issues raised by the audience included keeping fertility options open for girls with Turner's syndrome, and there was a poignant reminder from a paediatrician in the audience that, for prepubescent boys – an often 'a forgotten population' in these discussions – there are currently no fertility preservation options.
What about women who freeze their eggs or embryos, but don't wish to use them before the age of 50? Professor Anderson said that older women would not be able to access NHS-funded treatment, and many in the UK's private sector would be reluctant to treat them, but older women may still seek to export their eggs and use them in treatment overseas.
More than one audience member raised the issue of fertility preservation prior to gender reassignment. Professor Pacey responded that since gender dysphoria is recognised by many clinics as a medical condition, and since gender reassignment is available on the NHS, then it would seem appropriate and ethical to offer egg or sperm storage to the relevant patients.
Perhaps the most challenging question came from a legal academic, who asked each member of the panel what they would change if they could change just one aspect of the law relating to this area. To find out what was on the panel's wish list you'll need to listen to our podcast of the discussion, which we will be publishing on BioNews in the next few weeks.
'Frozen Assets? Preserving Sperm, Eggs and Embryos' was supported by the Scottish Government.