When 22 year-old Rasik Mehta (name changed to protect identity), who was pursuing higher studies in the US was detected with hotchkins lymphoma (a type of blood cancer) three weeks ago, his shocked parents asked him to head back to India so that they could start chemotherapy as soon as possible. The oncologist treating Mehta, however, first asked him and his parents to see an infertility specialist to preserve his sperm samples.
Dr Ameet Patki, Chairman, Mumbai Obstetrics and Gynaecological Society, to whom Mehta’s case was referred, explains, “More and more oncologists are becoming aware of the irreversible effects of exposure to radiation on the reproductive organs. As a result, in the last two years, they have begun referring young men and women to infertility specialists.” With advanced prognosis, most of these young patients get cured of their cancers, says Patki. That is why it is imperative that they preserve their gametes so that they can procreate at a later stage. “The emergence of new technologies like vitrification have made it easier to freeze sperms, eggs and fertilised embryos,” he says. Like Mehta, an increasing number of cancer patients are being advised by their oncologists to freeze their sperms (in case of men) and eggs or fertilised embryos (in case of women) as chemotherapy puts them at a serious risk of infertility.
This is where vitrification, an internationally acclaimed technique introduced in India in 2010, plays an important role. Dr Patki explains, “Vitrification is a relatively new process of gamete preservation. It is a process wherein the sperms, embryo or harvested eggs are dipped in liquid nitrogen with a temperature of -196 °C. This process ensures that there is minimum damage to the cells, and helps preserve the health of the gametes until the patient wants to recover them.” Vitrification is more effective than it’s predecessor, a procedure called Slow Freezing, where the molecular water in gamete cells is replaced with a cryoprotectant and then frozen. “Since our cells are made up of 90 per cent water, freezing them directly, as was the case with Slow Freezing, turns the molecular water into ice, which leads to disintegration of the cells. Also, when we have to recover the gametes, we have to again replace the cryoprotectant with molecular water, and in this process, a lot of cells die,” says Dr Patki.
A new chance
Dr Firuza Parikh, Director, Department of Assisted Reproduction and Genetics, Jaslok Hospital and Research Centre, agrees. “In our labs, vitrification has ensured a 90 per cent plus chance of recovery of cells.” Patients too seem to have faith in the new procedure. Dr Patki says he has been carrying out sperm freezing procedures for around 10 cancer patients in a month and egg/ embryo freezing procedures for around four patients in a month. At Jaslok too, the numbers have been on the rise. In 2011, 91 samples of sperm freezing were carried out, whereas till July this year, the number has already touched 50. “The youngest sperm sample we have frozen is that of a 14 year-old boy with blood cancer,” says Dr Parikh.
Likewise, egg/ embryo freezing was carried out for five cancer afflicted women in 2011 at Jaslok. “This year we had the opportunity to help two young married women stricken with breast cancer. After undergoing minimal ovarian stimulation, the eggs were fertilised and each woman has frozen about 10 embryos, thus giving them a significant chance of becoming mothers in the future.” She adds, “There is a very high chance of women undergoing what is known as chemical menopause and men becoming azoospermic (medical condition of a male not having a measurable level of sperms in his semen. It is associated with very low levels of fertility or even sterility) following cancer treatment. Vitrification gives cancer-afflicted men and women the hope of becoming biological parents once their cancer is in remission.”
Thinking about the future
Dr Patki cites the example of a 37 year-old commercial pilot who was diagnosed with breast cancer two years ago. “The affected woman was unmarried but was in a steady relationship with her partner for a number of years. Before she underwent chemotherapy, I counselled them. They chose to preserve an embryo as it is easier to preserve than an egg. So we had to harvest the woman’s eggs and fertilise it with her partner’s sperms to develop an embryo which we then preserved by the process of vitrification.”
He adds, “Two years later, the woman has recovered from her illness and also resumed work. In a few years, when she will be deemed cancer resistant, we will implant the embryo in her womb and she can bear a child.” Dr Parikh recalls carrying out the vitrification process of sperm freezing for an 18 year-old commerce student who was diagnosed with testicular cancer. She says, “The boy noticed a dull pain in his testes. His family physician referred him to a urologist, who diagnosed the young boy with testicular cancer.
The oncologist then had to counsel him and his parents about sperm freezing. The family came to us on a Friday and told us that the chemotherapy was to start from Monday. Over the weekend we managed to freeze enough sperms to plan for a future pregnancy.” Dr Tapan Saikia, oncologist, Jaslok Hospital and Research Centre, who counselled the boy and his parents, said,“The patient and his/her family needed to undergo counselling sessions wherein we educated them about the gamete preservation techniques and why it is necessary for them. In India, as the opinion of the family is very important, typically 2-3 sessions need to be taken. The families are under tremendous stress after discovering that a loved one is suffering from a life-threatening
disease.” Similarly, Dr Patki says he had to counsel Mehta and his family about the gamete freezing procedure. “Even though they were preoccupied with how they could tackle their current crisis, I had to make them think ahead to five years down the line when their son would be cured of cancer and would be ready to start a family.”
The unlucky survivors
Unfortunately, a few years ago, when there was not much awareness about gamete preservation, many young cancer patients paid the price for chemotherapy with sterility. “I have had to counsel several young men who have had cancer in the past but had not advised to preserve their semen samples. Unfortunately, they developed irreversible azoospermia,” says Dr Parikh. Dr Patki adds, “I have counselled quite a few patients who were not advised to undergo gamete preservation by their oncologists prior to chemotherapy and had to deal with infertility issues later. These patients harboured a lot of anger in them about not being guided properly. I distinctly remember a patient dealing with infertility telling me that his doctor cured him of cancer but did not treat him as a complete person. Needless to say, procreation is an important human need,” he says.
Dr Mandar Nadkarni, head, breast care unit, Kokilaben Dhirubhai Ambani hospital, who refers around four young women in a year for egg/ embryo preservation, too believes that more cancer patients need to be made aware of newer techniques that can help circumvent possible sterility following their chemotherapy. “In 99 per cent cases, women undergoing chemotherapy stop getting their menses, and the chances of them returning are uncertain. It is imperative for young women to preserve their egg/ embryo samples, as this will help them procreate a few years later when they are declared fit.”
However, the procedure of gamete preservation is a little complicated in the case of women.
“The procedure has to take into account the menstrual cycle of the woman. A woman starting chemotherapy may not be in the right phase of the cycle to start ovarian stimulation, necessary for harvesting the eggs. However, in some cases, the hormones injected for ovarian stimulation, can have an adverse effect and worsen the patient’s condition. Thus, the procedure should be carried out with caution,” warns Dr Parikh. She adds, “For some women in the advanced stages of cancer. chemotherapy needs to be started quickly, thereby making it difficult to wait for the time period needed for stimulation.”
“However,” she concludes, “It is important for young men and women afflicted with cancer to save their reproductive biological tissues. Today’s technology can allow these survivors to become biological parents.”