As medical technology advances, women diagnosed with and treated for cancer not only have an improved likelihood of survival, but also the availability of emerging assisted reproductive techniques. Schover and colleagues assessed the attitudes of individuals with a history of cancer and found that younger cancer survivors view parenthood as a positive experience. Participants also expressed the belief that their experience with cancer would make them better parents, and 60% indicated that being a parent would be an important life goal even if they died young.[16] Traditionally, women with gynecologic cancer are coping with treatment options that consist of total or partial removal of the reproductive organs. In some cases, individuals may be eligible for conservative fertility-preserving treatment, as described above, enabling reproductive capacity in survivorship.
•Third-Party Parenting—For many cancer survivors, however, family-building options will require the assistance of another individual or third-party reproduction. Third-party parenting is the involvement of a third person, beyond the parenting couple or single parent, in order to create a baby. Techniques can include egg (oocyte) donation, sperm donation, embryo donation, in vitro fertilization (IVF) with or without a gestational carrier (surrogacy), and/or adoption. When possible, preservation of the ovaries offers the possibility of a biological child through assisted reproduction with egg retrieval.
•Third-Party Parenting—For many cancer survivors, however, family-building options will require the assistance of another individual or third-party reproduction. Third-party parenting is the involvement of a third person, beyond the parenting couple or single parent, in order to create a baby. Techniques can include egg (oocyte) donation, sperm donation, embryo donation, in vitro fertilization (IVF) with or without a gestational carrier (surrogacy), and/or adoption. When possible, preservation of the ovaries offers the possibility of a biological child through assisted reproduction with egg retrieval.
Gynecologic cancer survivors who undergo a hysterectomy as part of their treatment may not consider themselves as having fertility options, such as pursuing ovarian stimulation for oocyte retrieval and IVF with surrogacy. These techniques can offer hope to many cancer survivors, but awareness and access are necessary. For women who require the removal of their ovaries or are at high risk for treatment-induced acute ovarian failure,[60,61] oocyte donation can be a family-building option, allowing for pregnancy and childbirth. If treatment requires the removal of the uterus, a surrogate or gestational carrier would be necessary.
Even in the case of a woman needing a hysterectomy and oophorectomy as part of cancer treatment, advances in reproductive technology have given these women multiple options and alternatives to create a family, such as embryo donation, oocyte donation with a partner's sperm (or donor sperm) with IVF, and surrogacy. The practice of gestational surrogacy can be a controversial procedure in the field of assisted reproduction, with legal issues varying by state. Nonetheless, it is a successful treatment option for women who would otherwise be unable to have a child.[62] That said, cancer survivors with impaired fertility may not view themselves as appropriate candidates for reproductive services or as having family-building options, such as third-party parenting.
•Emotional Issues—Treatments for infertility can create a host of emotional issues as well as tax women and couples physically and financially.[63] Female survivors may also struggle with concerns about the health risks of pregnancy and risks to genetic offspring.[15] While adoption exists as an alternative, this option may entail a difficult and emotionally painful process for survivors who confront the loss of their own reproductive ability as well as the possibility of a hostile legal environment that may question the role of a cancer survivor as a parent. A recent study found that adoption agencies may be reluctant to consider cancer survivors as potential parents.[64] Growing concern over the late health risks after cancer treatment may also present barriers to the adoption process.[15,64]
•Economic Issues—The prohibitive expense of assisted reproduction generally limits its availability to those of higher socioeconomic status. Thus, reproductive assistance is far more prevalent among married, older, more educated, and more affluent women than in the general population of women with impaired fertility.[65,66] Moreover, most infertility services are not covered by insurance policies. Additional obstacles to accessing reproductive services may include low literacy or educational limitations, language barriers, and a lack of culturally sensitive information, all of which are more prevalent among patients of lower socioeconomic status.[67]
Many young cancer survivors experience financial constraints as a result of their cancer treatment. To compound such preexisting financial burdens with the added cost of assisted reproductive services may deter many from seeking treatment. Research suggests that having insurance coverage is significantly associated with the utilization of infertility services.[67,68] The lack of insurance coverage for infertility treatments raises several ethical considerations, particularly in the context of cancer care and impaired fertility secondary to treatment.[16]
Cancer-Related Infertility
Research has shown that infertility as a singular health concern can have distress levels comparable to those of coping with a life-threatening illness such as cancer.[69] The turmoil experienced by women simultaneously facing a cancer diagnosis and the possibility of infertility has been proposed to be a compounding event,[15,70] described as "adding insult to injury"[18] or a double trauma.[17,71] The synergistic effect of coping with two traumas increases vulnerability to psychological distress. Baider et al[17] described the phenomenon of double trauma while studying second-generation Holocaust survivors with a cancer diagnosis. Therefore, one could propose that the experience of both cancer and infertility would be a risk factor for prolonged grief reactions and poor coping. Survivors must confront both a perceived and real physical threat of infertility as they attempt to form families in the posttreatment period.
The emotional, psychosexual morbidity and quality-of-life impact of cancer-related infertility is not well documented. However, clinical observations have documented that these women experience severe psychological distress.[15] A number of factors may be responsible for the high level of emotional turmoil related to infertility associated with cancer. Women are forced to make treatment choices for survival that have a negative impact on fertility and decisions of childbearing. Although infertility is a common consequence of some cancer treatments, it is usually a secondary concern in relation to survival in the initial phases of treatment.[18] For some women, infertility may be unexpected because they were unable to process or retain information about the side effects of treatment outlined by the oncologist during the discussion of treatment.[15] Corney and colleagues[72] found that women experiencing infertility following treatment for gynecologic malignancies felt deprived of choice, and that medical professionals tended to minimize the sense of loss experienced by older women.[72]
A recent study in a small sample of gynecologic cancer survivors found that women with infertility as a result of their cancer treatment experienced persistent feelings of sadness and grief lasting more than 1 year posttreatment.[70] The psychological experience, however, varies from woman to woman, depending on the cause, the degree of fertility impairment, the importance placed on having a biological child, and the availability of reproductive assistance or willingness to adopt.
Fertility options are a critical consideration in the context of both having a first child and expanding family size. While there are more reproductive options today, such as egg retrieval with a surrogate, egg donation, and adoption, the sense of not having one's own biological child can be very traumatic. Additionally, the available assistive reproductive treatments are strenuous on a woman's physical, emotional, and financial resources. Our clinical experience with these women has revealed that many grieve their lost fertility. These grieving symptoms can contribute to greater distress[70] and negatively impact quality of life in survivorship.[14]
It is not uncommon for infertility to be coupled with sexual dysfunction and menopause secondary to cancer treatment.[70,73] These problems are often not discussed due to the stigma of gynecologic cancer, the sense of being "different" or "damaged goods," and the anger of being subjected to such an unfortunate fate. Many women experience social isolation concurrent with psychological, psychosocial, and at times psychiatric disorders, such as anxiety and depression—significant problems that would benefit from recognition and treatment.[18] Ideally, these issues should be identified during treatment with the hopes that early intervention might be able to prevent more serious long-term sequelae.
