When cancer treatment causes infertility

When Bridget Sein, a banker, fell ill in 2016, all she wanted when she sought treatment was a relief.

For a long time, she had experienced fatigue, abdominal pain, backache, and a heavy and prolonged menstrual cycle.

Unfortunately, the shock of being diagnosed with urethral cancer that February was soon followed by more bad news - the treatment would affect her fertility.

"My gynaecologist mentioned cancer treatment affecting my reproductive health, but I was more worried about cancer and did not want to think of anything else," Ms Sein says.

When she travelled to India for treatment, doctors who assessed her advised her to have a section of her uterus removed, a procedure she was hesitant to undertake, as she yearned to have babies in the future.

"Removal of the uterus was the most depressing part. Yes, I wanted to be treated but I also wanted to enjoy a quality life as a woman," she says.

Sein opted for chemotherapy and radiotherapy, and with adherence to medication, she has been put into remission.

Prior to the treatment, her gynecologist had told her about the option of having her eggs harvested so she could have access to them for reproduction later.

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"Now that I am on remission, I am realising there is life after cancer. You want to start a family, and now realise that I should have paid more attention when the doctor was telling me about freezing my eggs," Sein says.

And although she has not gone for fertility tests, she is anxious after the treatment.

"I am longing to give birth to three children. I already have their names," she says.

With an increased number of cancer survivors, experts have raised concerns about growing infertility among patients who have gone through cancer treatment.

Dr Gladwell Kiarie, a medical oncologist and physician, says oncofertility, a medical field that connects oncology with reproductive health, is an area of concern because the majority of cancer patients in Kenya are in their reproductive age.

Previously, she said more emphasis was put on the survival of patients, but doctors are currently observing a trend of younger patients being diagnosed early, treated, and cured. More and more of these patients are asking to have their fertility issues addressed.

"Fertility takes a primary focus because if a woman is going to survive her cancer and get cured, later on she will want to have children," she says.

Dr Kiarie adds that certain treatment like radiation tends to give permanent effects.

"Women with rectal cancer who get radiated, and those who undergo ovarian radiation, may experience permanent infertility and certain chemotherapy drugs once the treatment is over," she says.

Further, she says a number of treatments have hazardous effects on developing foetuses and embryos.

"It is advisable for experts to determine whether it is medically fit to carry the pregnancy because some effects of chemotherapy, radiation and some of the drugs may have a negative impact on the embryo and the growing baby, even if conception is achieved," she explains.

She notes that some treatments may not have been exposed to pregnant women in clinical trials to be able to know their full effects.

In some instances, if a pregnant woman is put on treatment, she may lose the pregnancy, and if she carries the pregnancy to full term, the effects of treatment on the unborn baby are not clearly known.

"All we know is that chemotherapy, radiotherapy and some of the targeted drugs are very hazardous and can cause abnormalities to the growing fetus," says the oncologist.

Dr Kiarie gives an example of a famous drug that was administered to pregnant women in the 1970s to manage nausea and vomiting. The drug was given especially in the first trimester, which proved effective for women who had hyperemesis gravidarum, severe nausea and vomiting throughout preganancy.

The drug became effective in treating certain cancers but it was later discovered that it would lead to children being born without arms and lower limbs.

Kiarie emphasises that some medicines are disastrous in pregnancy. A number of women are advised to terminate pregnancies because the effects of chemotherapy, radiotherapy, and some drugs administered have side effects.

Other cancer treatment complications like learning inabilities may be noticed when the baby is much older.

"A woman may carry pregnancy to term, but the baby is born without arms and legs. You may carry pregnancy to term but they have certain cardiac and other abnormalities that even medical science may not be able to document because it is not ethical to carry out a clinical trial in pregnant women to see the effects of drugs on a pregnancy," she says.

It is however not all gloomy for cancer patients in their reproductive age, with the adoption of modern fertility preservation technology.

"Fertility preservation is done before a patient is put on treatment. Patients are expected to consult with experts on the best way of protecting their fertility," says Dr Ogweno.

But the uptake of fertility preservation in Kenya is low according to Ogweno, due to lack of awareness among the general population and health practitioners. High cost is also a barrier to uptake. Harvested eggs are fertilised through In Vitro Fertilisation (IVF), whose cost ranges between Sh450,000 and Sh700,000 depending on the hospital.

Sperm harvesting is estimated at Sh40,000 and the annual fee for embryo/sperm storage ranges between Sh30,000 to Sh50,000. Preserved embryo and eggs can be kept for more than 20 years.

Extraction of ovaries is also costly. In some instances, doctors may have a section of the ovary removed, and have it patched back after treatment.

Some types of infertility are also temporary, for example, the ovarian suppression from chemotherapy and certain drugs is temporary, which preserves ovarian function.

Dr Kiarie adds that after full recovery, patients are expected to consult with specialists to determine on when they can carry a pregnancy or use IVF. In circumstances where patients need to be put on treatment immediately, experts balance the risks and benefits of fertility issues.

Discussion related to fertility is therefore done prior to treatment with patients, parents, and partners for psycho-social support and counselling, more so among women who have had their breasts removed.