Sitting down with the stunned parents you tell them there’s a good chance the chemotherapy will save the child’s life. But it is also likely to leave them infertile in adulthood. Their tears flow.
However, there’s a glimmer of hope you can offer; a fledgling surgical procedure that might allow the child to have children of their own one day.
It’s generally considered a low-risk procedure in carefully selected cases. In girls, a sample of ovarian tissue is removed via laparoscopy then frozen. When she grows up it might be possible for re-implanted tissue to start producing eggs. In boys, a biopsy of testicular tissue is removed in the hope that one day it will develop mature sperm.
But it isn’t yet thoroughly proven to work in children. To date, frozen ovarian tissue has resulted in 86 live births worldwide, including one to a woman whose tissue was removed as a child. Mature sperm have not been developed from a boy’s testicular tissue and no offspring have been born this way.
A bioethical decision.
This is the frontier in the emerging field of “oncofertility”, a bridge between cancer treatment and fertility treatment built from the recognition that many cancer survivors place high value on starting families.
But as the doctor treating this child you face an ethical decision. Offer what could be false hope? Or leave the patient facing the prospect of an infertile future?
To help medical specialists deal with this and other ethical questions around this challenging real-life scenario, University of Melbourne bioethicist Dr Rosalind McDougall, working with the bioethics team and medical staff at Melbourne’s Royal Children’s Hospital, has developed what is believed to be the world’s first ethical framework for decision-making about pre-pubertal children’s fertility.
The framework poses a series of questions which doctors work through to cover potential ethical issues relating to their patient. The hospital’s clinical ethics team reviews the responses and a full clinical ethics review is available if the ethicist, doctor or family is uncertain about the decision of whether or not to proceed.
LISTEN: Deb Knight did 14 rounds of IVF and then had a baby naturally. (Post continues below…)
“This is a crisis in each family’s life and it can be quite challenging for the clinicians too. Often parents have just found out that their child has cancer,’’ says Dr McDougall, from the University of Melbourne’s School of Population and Global Health.
“Sometimes we worry that we are just putting another thing on their plate to think about.”
Dr McDougall says earlier guidelines made it very clear specialists should discuss the effects on fertility of cancer treatment. The blank spot was around what to do about it. Should clinicians offer procedures for very young children, or just talk about the impacts on fertility?
Published in The Journal of Medical Ethics, the framework grew from Dr McDougall’s role in a team of ethicists at Melbourne’s Royal Children’s Hospital supporting clinicians to think slowly, carefully and collaboratively through complex situations.
Thinking about fertility preservation.
In 2012 Royal Children’s Hospital doctors began requesting ethical support for their decision-making around children’s fertility.
Dr McDougall says on the one hand doctors weren’t sure whether the hospital should even be offering the surgical procedure, but on the other, they worried that by not doing so they might be depriving young patients of an opportunity and choice to have children in the future.