Lives in the balance: women with cancer and the right to fertility care.

The risk of infertility after cancer therapy has emerged as a major quality-of-life issue for cancer survivors. Indeed, cancer survivors have been galvanized to improve the dissemination of information about cancer-related infertility and have supported the development of reproductive technologies that allow survivors to have biologic children after cancer. The medical community has embraced oncofertility as well, and the American Society of Clinical Oncology (ASCO) recommends that patients with cancer of reproductive age be counseled about the reproductive risks of cancer therapies and the options available to preserve fertility. The article by Rodriguez et al describes some ethics-based concerns against the use of reproductive technologies in patients with cancer. When implementing a relatively new practice, such as oncofertility, it is critical that both potential risks and benefits be carefully examined. In this article, we provide another view of oncofertility counseling that is important for the practicing oncologist to consider. Although most of the concerns of Rodriguez et al are related to the social implications of oncofertility, it is also important to address the issue of patient autonomy, a critical principle in medical ethics. Substantial data demonstrate that patients with cancer are significantly invested in their future reproductive capacity and that there exist successful fertility preservation options to diminish the risk of infertility. Established fertility preservation techniques currently available to postpubertal individuals include sperm cryopreservation, oocyte cryopreservation, and embryo cryopreservation, and experimental options include testicular and ovarian tissue cryopreservation. Increasing success and significant evidence of safety have provided reassurance regarding the use of these techniques. Education about the risks and success rates of and alternatives to fertility preservation techniques (including adoption and use of donor gametes) is empowering for patients, allowing them to make informed choices about their future. Contrary to this notion of informed choice, Rodriguez et al suggest that the existence of reproductive technology “raises the imperative for one to participate.” Although the decision to pursue fertility preservation is complex, there is no evidence that informing patients about this option compels them to participate. On the contrary, evidence indicates that patients with cancer who receive counseling about fertility preservation experience less long-term regret than those patients who do not receive counseling, even if the patients choose not to pursue fertility preservation. In the fertility preservation program at the University of Pennsylvania, fewer than 50% of individuals counseled regarding the reproductive risks of cancer treatment and fertility preservation options available pursued assisted reproductive techniques. Moreover, at a time when young patients are forced to confront a life-threatening cancer diagnosis, the opportunity to discuss fertility preservation, related to the future restoration of health, allows patients to feel hopeful about their survival and life after cancer. Withholding available information and existingmedical technologiesfromwomenisindirectoppositiontothegoal of protecting patient autonomy. Educating oncologists to address fertility concerns and add this skill set to their care of young patients furthers the objective of caring for the whole patient and not the cancer alone. This advance in oncologic practice, which extends to survivorship at the outset of care, may serve to increase patient confidence in the medical community as a whole. One of the principal ethical concerns surrounding fertility preservation raised by Rodriguez et al focuses on the disposition of embryos and tissues.Theypointoutthatasmoreembryosandtissuesarecryopreserved for fertility preservation, more disputes may occur regarding ownership, which could become a social burden. Embryo disposition has been a particular concern for owners of embryos, because embryos usually belong to two individuals, and for those who believe that life begins at conception. Although the amount of cryopreserved tissue may increase slightly through implementation of fertility preservation, the additional burden on society will be minimal, because an overwhelming majority of cryopreserved tissues originate from healthy infertile patients attempting to conceive. Furthermore, as oocyte and ovarian tissue cryopreservation technologies evolve, fewer patients may elect to cryopreserve embryos. Thus, striving for advances in fertility preservation options for female patients will help to alleviate some potential disputes regarding embryo ownership in the larger field of reproductive medicine. Rodriguezetal alsopointoutthattheallocationofresourcestoward fertility preservation may be unwise because it affects a relatively small population of female patients with cancer. Although this may have been a legitimate concern in the past, the research accomplished under the auspices of fertility preservation thus far has furthered the understanding of reproductive physiology, leading to significant breakthroughs in the field ofreproductivemedicine. Thesebreakthroughshavethepotentialto extend treatments for infertility, contraception, and conservation of endangered species. Moreover, from a practical perspective, most fertility preservation procedures are not currently covered by insurance (even in states with mandated in vitro fertilization coverage), and affected individuals must pay out of pocket for fertility treatments. It may be that this JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES