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INTRODUCTION

The treatment of cancer in young women is increasingly turning from focusing purely on survival to recognition of the long-term effects of treatment on subsequent quality of life. In this regard, fertility is a very high priority for patients. That cytotoxic therapies have adverse effects on fertility has been recognized since the very earliest days of the administration of mustard gas derivatives, and specifically in relation to the ovary, with demonstration of the effects of chemotherapeutic agents on growing follicles, resulting in amenorrhea, and in the longer term resulting in loss of fertility and premature menopause. Pregnancy after cancer is also associated with increased risk, notably of prematurity and low birth weight.1 The recognition of the importance of late effects on fertility have been paralleled by a substantial growth in the development and provision of fertility preservation services in reproductive medicine centres and the development of the necessary close links with oncology and other services, although this remains an area where much work needs to be done in improving awareness and access to services in the UK. Fertility preservation is a complex area, requiring a balance between accurate identification of those at risk and the provision of a sufficiently encompassing service, with issues including equality of access, informed decision making regarding the experimental nature of some procedures and provision of funding. From the patient’s perspective, this is all undertaken at very short notice at a time of enormous stress following a recent diagnosis when many other tests and investigations also need to be undertaken. Subsequent fertility is also part of a broader survivorship agenda, recognizing that most cancer survivors have significant health issues which may impact directly or indirectly on their fertility, for example the recognition that survivors of brain and CNS cancers have reduced chance of marriage or co-habitation. There may additionally be concerns about starting or completing a family following such a serious diagnosis, as well as concerns, now recognized to be unsubstantiated, that a pregnancy following, for example breast cancer may increase the risk of recurrence.

RECENT DEVELOPMENTS

The effects of chemotherapeutic agents on the ovary will almost invariably involve loss of the growing population of follicles, related to their rapid cell proliferation and sensitivity to cytotoxic agents. This is likely to result in a rapid decline in oestrogen levels, and often amenorrhea. However it is the risk to the non-growing primordial follicle pool that is most important in determining the long-term effects, and potential recovery of the ovary,2 as they constitute the ‘ovarian reserve’. Primordial follicles are formed in fetal life and thereafter a small proportion start to grow every day; subsequently the growing follicles develop fluid-filled cavities (antra) and increasingly produce oestrogen, culminating in ovulation. The number of primordial follicles is therefore progressively depleted over time, with near-exhaustion resulting in the menopause. Premature loss of primordial follicles, as occurs with some chemotherapies, will therefore bring forward ...

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