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Table of Contents
EDITORS CORNER
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 59-60

Ethical concerns in fertility preservation in the young


Department of Reproductive Medicine, Mother and Child Hospital, New Delhi, India

Date of Web Publication22-Feb-2019

Correspondence Address:
Nalini Mahajan
Mother and Child Hospital, D–59, Defence Colony, New Delhi - 110 024
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tofj.tofj_10_18

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How to cite this article:
Mahajan N. Ethical concerns in fertility preservation in the young. Onco Fertil J 2018;1:59-60

How to cite this URL:
Mahajan N. Ethical concerns in fertility preservation in the young. Onco Fertil J [serial online] 2018 [cited 2019 Mar 23];1:59-60. Available from: http://www.tofjonline.org/text.asp?2018/1/2/59/252685



This issue of TOFJ contains a case report on fertility preservation (FP) in a young girl with sickle cell anemia (SCA) who had not yet attained menarche, using ovarian stimulation and oocyte freezing. The authors state that this is among the very few such cases reported in literature, bringing into focus the ethical concerns of FP procedures in young patients. Increasing numbers of young cancer survivors in recent years lend further importance to the subject. Though individual risk varies with the type of cancer and ovotoxicity of the treatment administered, the overall risk of infertility in girls after childhood cancer is 16%,[1] and survival rates can be as high as 80%–90%. There is indeed a definite need to offer these children a life which includes the ability to have a family in future, if they so desire.

Both provider and patient appear to be the driving force behind the upsurge in the “Oncofertility movement.”[2] The provider, in pursuit of scientific advancement and the patient, in pursuit of a lifeline to future reproductive fulfillment. Reproduction and fertility are regarded as the essence of life, and an existence without progeny is often regarded as incomplete. Genetic parenthood still remains an important goal for cancer survivors despite the availability of gamete donation and adoption.

What FP procedures can we offer prepubertal and pubertal children and why the dilemmas? All FP procedures are invasive by default and carry the associated surgical risks. Oocyte cryopreservation and ovarian tissue freezing are the currently applicable techniques. Oocyte cryopreservation is available to young women who have attained maturity of the hypothalmo–pituitary–ovarian (H-P-O) axis; in other words, puberty and menarche. Oocyte cryopreservation requires ovarian stimulation with hormones and surgical retrieval of oocytes, the number of eggs being limited to what can be retrieved in the cycle. Though the efficacy of this procedure has improved with time, the limitation regarding number of oocytes required to generate a successful pregnancy has not been overcome. Ovarian tissue cryopreservation (OTC) requires collection of ovarian cortical tissue through laparoscopy or laparotomy and is the only procedure available for prepubertal girls. It has the advantage of preserving a large number of primordial follicles which can be used over a long period to maintain endocrine profile and ovulation, through transplantation of the cortical strips. So far, one live birth has been reported using tissue collected from a pubertal but premenarchal girl and one live birth using ovarian tissue collected prepubertally.[1] All other births reported approximately 100 are from ovarian tissue collected in adulthood or late adolescence. Availability and expertise of this procedure is limited to some centers globally. OTC needs to be carried out under a research protocol in countries where it is still considered experimental.

Is it ethically justifiable to offer FP to the pre-/peri-pubertal child? There are a multitude of questions and doubts which surface when offering FP to young children? Most importantly are we creating a false sense of hope not only of the possibility of a future pregnancy, but also of survival? The clinician must balance risk against benefit when considering FP. The efficacy of the procedure offered, the possibility of long-term survival of the child, surgical and oncological risks, against the moral and medicolegal aspects of not offering a potentially beneficial, and generally a low-risk procedure.

Preprocedural counseling and informed consent are a fundamental prerequisite. Counseling presents an ethical dilemma – how do you counsel someone who is not equipped to make a decision or even understand the implications of reproductive compromise. What about consent? Is the child fully aware of the physical implications of the procedure and its efficacy? Assent of the child is required for the procedure, but consent for an underage child (<18 years) is given by the parent. During assent, age-appropriate information about sexual reproduction has to be given to the child in the presence of a psychologist or a child development psychiatrist[3] keeping the parent's sensitivities in mind. What about the parent's perspective they have to make a tough decision on behalf of the child? Are they making a right choice? If they refuse FP, will the child feel betrayed when she/he gets older? Does their religion or society allow such interventions? A transvaginal intervention in an unmarried girl is unacceptable in some societies. If they give consent, then what risks are they taking given the current status of such procedures and the health and oncological needs of the child? Consent for posthumous disposal of gametes can also be an area fraught with difficulties. On the one hand, hope is being offered and, on the other hand, a reaffirmation that the disease is life-threatening.

Mc Dougall et al., 2018, argued that for many children the “balance of benefits and burdens makes the procedure ethically permissible but not ethically required.” They propose that if the procedure is low risk and could be beneficial in future, it should be offered and the final decision should be left to the parents after detailed counseling. However, it is crucial to minimize risks, have a thorough preprocedural evaluation, and follow ethical guidelines. Unfortunately, guidelines regarding FP in prepubertal children do not offer definitive answers, and each institution must present such cases to its own ethical committee for evaluation and clearance.

The case reported here is that of a young girl with SCA who had to undergo an hematopoietic stem cell transplant (HSCT). HSCT involves prior myeloablation with total body irradiation or alkylating chemotherapeutic agents which carries a high risk of infertility and an 80% risk of premature ovarian insufficiency, making it imperative to offer FP. The girl had not attained menarche, so ideally the procedure offered should have been OTC. However, parents refused an operative procedure and the clinician planned oocyte cryopreservation. Since the girl was 15 years old had attained thelarche (Tanner stage 3) and adrenarche (Tanner stage 1), ultrasound showed multiple antral follicles the clinician took a calculated risk and went ahead with ovarian stimulation. Estimation of the hormones follicle-stimulating hormone, luteinizing hormone, and E2 was not done before starting stimulation to ascertain the maturity of the H-P-O axis. When offering any FP procedure, a careful evaluation is vital to avoid medicolegal complications. Had ovarian stimulation failed the distress and ire of the parents can be imagined! The only other case report of oocyte cryopreservation in SCA in literature involves young girls who had attained menarche.[4]

The science of oncofertility and the supporting technology is in its infancy, and there are major gaps in our understanding of the underlying biology and techniques, especially for prepubertal/pre- and peri-menarchal young girls diagnosed with cancer.[2],[5] There is a paucity of data on the efficacy of procedures which hinders the counseling process. The future may negate the need for FP procedures and offer noninvasive ways of fertility protection. Till then, offering hope, a better quality of life, and reproductive capability through FP is an imperative. It goes without saying that this should be done after a careful assessment of the risks and benefit.



 
  References Top

1.
McDougall RJ, Gillam L, Delany C, Jayasinghe Y. Ethics of fertility preservation for prepubertal children: Should clinicians offer procedures where efficacy is largely unproven? J Med Ethics 2018;44:27-31.  Back to cited text no. 1
    
2.
Woodruff TK. The oncofertility consortium – Addressing fertility in young people with cancer. Nat Rev Clin Oncol 2010;7:466-75.  Back to cited text no. 2
    
3.
Stegmann BJ. Unique ethical and legal implications of fertility preservation research in the pediatric population. Fertil Steril 2010;93:1037-9.  Back to cited text no. 3
    
4.
Lavery SA, Islam R, Hunt J, Carby A, Anderson RA. The medical and ethical challenges of fertility preservation in teenage girls: A case series of sickle cell anaemia patients prior to bone marrow transplant. Hum Reprod 2016;31:1501-7.  Back to cited text no. 4
    
5.
Quinn GP, Vadaparampil ST, Gwede CK, Miree C, King LM, Clayton HB, et al. Discussion of fertility preservation with newly diagnosed patients: Oncologists' views. J Cancer Surviv 2007;1:146-55.  Back to cited text no. 5
    




 

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