A diagnosis of cancer is often devastating. Prognosis varies greatly and treatments can be debilitating; even as they cure, treatments may cause significant and lasting damage. One possible consequence is the loss of fertility, (a significant risk in many radio- and chemo- therapies). Fortunately, advances in fertility preservation techniques now mean many men and women diagnosed with cancer often have the opportunity to take steps to ensure their reproductive futures. Ova, sperm, fertilized ova and even ovarian tissue can be preserved and, if required, used by patients who later wish to have children once they are cancer-free.
With cancer survivorship doubling over the last forty years, and women having the highest five and ten year survivorship rates overall in the UK, future fertility is becoming a vital consideration in cancer treatment plans. Preserving reproductive tissue may be the only option for avoiding the damage caused by cancer treatment and, therefore, the only way to secure the possibility in the future of having a family. Restoring what the patient has lost through their life saving treatment is not without precedence in other areas of medicine; women who undergo mastectomies are offered breast reconstruction and men who lose a testicle to cancer are offered a prosthesis. Caring for patients with cancer should also address the consequences of treatment, i.e. treatment plans should routinely consider the patient’s quality of life after cancer. With this in mind fertility preservation is not just an optional extra; it is an essential part of cancer treatment. Nevertheless, whilst replacing a breast or a testicle that has been lost due to treatment is the norm, recently introduced technologies for safeguarding the fertility of cancer patients are far from the norm, indeed the seem to be under threat.
While providing access to fertility preservation should be an important part of treatment, these procedures are not without their physical, emotional, and now financial costs, particularly for women. Whilst harvesting sperm is a relatively cheap and simple procedure, the same is not true for ova. Women who would like to preserve their fertility must undergo the difficult preliminary procedures of IVF; going through the process of egg retrieval, possible fertilization and then freezing of the reproductive material. For many individuals whose fertility is threatened, preservation of their fertility is sufficiently important for them to undergo these additional procedures which are often physically and emotionally demanding. In the UK, the NHS has been on hand to cover some of the costs but this may be changing.
Whilst egg retrieval, fertilization and freezing procedures may be fully covered, the storage of these materials can be subject to charge across different NHS trusts. Despite the necessity of fertility preservation, many patients are being asked to cover the costs of storage beyond a period of one year, (these costs can be hundreds of pounds per year). Most cancer patients are not given the all-clear until they have five (and in some cases ten) years’ remission, so postponing fertility treatment until some years after the cancer treatment is not only to be expected but is advisable. Given the advertised costs of storage, the price-tag for ‘fertility preservation’ could be upwards of £2,000.
The provision of this service varies dramatically from one NHS trust to the next; some trusts have been storing frozen reproductive tissue for free, others are now looking at introducing charges for this service. For those patients that cannot afford to pay there are risks that their biological material may be destroyed, leaving these patients facing a ransom-like demand for their own reproductive materials. Others are faced with this choice at the point of diagnosis and treatment: if you want to take steps to preserve your fertility you must accept an ongoing charge.
For many patients, this new cost will present too high a financial burden and the only option may be to abandon their reproductive future. Those who have already had their material harvested and stored but who cannot subsequently pay for ongoing or in some cases newly imposed costs may even find themselves being pursued by debt collectors, which could have an adverse effect on their credit rating and subsequent access to loans and mortgages. In some extreme cases material may be destroyed without prior consent, due to small-print clauses in storage agreements, whilst others may have to pay a large bill before they can attempt to start a family. This may then be subject to the IVF criteria of their particular trust, who may require further fees.
Just as the NHS covers the costs of breast reconstruction and testicle prosthesis, if the destruction of a patient’s fertility is an unavoidable risk of life-saving treatment, then taking steps to preserve and store reproductive tissue is not an optional extra for the patient to cover out of pocket, the NHS ought to cover all the costs. While the NHS would never offer patients an incomplete breast reconstruction it would seem that, by not covering the costs of storage, some units do offer an incomplete service when it comes to fertility preservation. If the NHS is going to offer this service to patients as part of their cancer treatment (and as advised by NICE guidelines 18.104.22.168 and 22.214.171.124) then they must provide a complete full service.
The need for fertility preservation does not stop when cancer treatment is complete, or when the patients is declared ‘cancer-free.’ Preserving the fertility of patients involves a commitment to store reproductive material until the patient decides how they would like to make use of that material. Cancer patients should not have to decide whether they can afford their reproductive futures at the expense of their financial futures, the NHS should cover the costs.
Alexis Paton is a PhD student at the Policy, Ethics and Life Sciences (PEALS) Research Centre at Newcastle University where she is conducting research into oncofertility in the UK. A website about her research on breast cancer patients and oncofertility can be found here.