Certain treatment options for cancer, malignancy or medical conditions can permanently impair reproductive function. Early referral for counselling on the specific risks of treatment-related infertility and options for fertility preservation is vital to optimise patient outcomes.

In Singapore, young patients undergoing cancer treatment such as chemotherapy, are the main group referred for fertility preservation. The incidence of cancer has steadily risen over the years, with the total number of malignancies diagnosed every five years increasing nearly six times from 12,072 between 1968 and 1972, to 71,265 between 2013 and 2017.1

Advancements in cancer treatment and improved survival in oncology patients have kept pace, with a key focus on survivorship and long-term quality of life after cancer treatment. This includes the effects of treatment-related infertility, which are of great concern to young patients. This group of patients may experience distress and regret if not provided the opportunity to discuss their fertility preservation options.

 

Options for Fertility Preservation

Fertility preservation aims to help patients retain their fertility potential, offering the chance of having their own offspring in the future. At KK Women’s and Children’s Hospital (KKH), common treatment options available to preserve fertility include:

  • Embryo / egg / sperm storage
  • Ovarian tissue storage
  • Suppression of ovarian function with medications during chemotherapy
  • Shielding the ovaries or uterus during radiation treatment
  • Transposition of the ovaries (i.e., temporary surgical transposition of the ovaries to move them away from the site of radiation treatment)

Deciding the fertility preservation option that is suitable for a patient requires the consideration of multiple factors, with the patient’s prognosis and medical futility of fertility preservation being the most important factors.

 

Case Study: Fertility Preservation for a Patient in her 20s with Ovarian Cancer

Patient A was diagnosed with stage IIIC ovarian cancer in her early 20s. She initially underwent a fertility sparing surgery to remove her right ovary while preserving her uterus and left ovary. Post-operatively, she completed six cycles of chemotherapy.

Unfortunately, seven months after treatment, there was recurrence of cancer at her left ovary. Surgery was planned to remove her left ovary, which would render her infertile.

After extensive discussion between Patient A and her husband, the oncology team and fertility specialists, a decision was made to harvest immature eggs from the left ovary for subsequent in-vitro maturation (IVM). The harvested eggs underwent maturation in the laboratory, and each mature egg was then fertilised to form an embryo which was frozen and stored.

Patient A was able to obtain three embryos from the IVM procedure. Fourteen months after the second surgery to remove her left ovary, two embryos were transferred into her uterus. This produced a normal healthy singleton pregnancy resulting in the live birth of a healthy baby boy.

This successful pregnancy post-IVM, was the first of its kind and marked an important milestone in the field of fertility preservation.2

  

​ ​Figure 1. Dispelling common misconceptions on fertility preservation in Singapore
Misconception:

Fact:

​There are no subsidies for fertility preservation procedures

Married couples may be eligible for government grants for IVF procedures, subject to eligibility criteria. Patients are encouraged to discuss with their fertility specialist for more information on grant eligibility.

Misconception:

Fact:

Only married couples can be referred for fertility preservation

Egg, sperm or ovarian tissue freezing are fertility preservation options available to patients as medically indicated, regardless of their marital status.

Misconception:

Fact:

Eggs or sperm can only be collected and stored in post-pubertal patients

Ovarian tissue freezing is a possible option for fertility preservation in pre-pubertal girls, as medically indicated.

Misconception:

Fact:

​Fertility preservation is not safe and will delay oncology treatment

Patients considering fertility preservation should be referred urgently so as not to delay medical treatment.

Fertility preservation options can range from days (e.g. surgery for ovarian tissue freezing, sperm freezing) to up to two to three weeks (for egg or embryo freezing).

Patients should always discuss with their oncologist and/or fertility specialist on the burden of disease, and the risks versus benefits of fertility preservation.

Misconception:

Fact:

Cancer treatment increases the risk of health problems in children conceived post-treatment

Apart from congenital cancer syndromes or pregnancy exposure to certain types of cancer treatment, there is no evidence to suggest that there will be an increased risk of health problems in children conceived after cancer treatment.

There is also no evidence to suggest an increased risk of congenital malformations or miscarriage as a result of the prior treatment for cancer.


New OncoFertility Clinic

In 2020, KKH has established a first-of-its-kind OncoFertility Clinic in Singapore to facilitate tailored treatment options for women of reproductive age with gynaecological cancers, who are keen to explore fertility preservation. The OncoFertility Clinic provides holistic counselling on cancer treatment plans, future fertility and fertility preservation options, through joint consultation with a gynaecological oncocologist and fertility specialist.

 

​REFER A PATIENT

Community healthcare practitioners can contact KKH at +65 6294 4050 to refer patients to the Department of Reproductive Medicine or the Department of Gynaecological Oncology for an assessment on their suitability for referral to the OncoFertility Clinic.

 

Dr Charissa Goh, Senior Resident, Division of Obstetrics and Gynaecology, KKH

Dr Charissa Goh completed her MBBS in Singapore, and is a Senior Resident in her final year of the SingHealth Obstetrics and Gynaecology Residency Programme. Dr Goh is also a member of the Royal College of Obstetricians and Gynaecologist, and the Royal College of Surgeons.

​Dr Felicia Chin, Consultant, Department of Gynaecological Oncology, KKH

Dr Felicia Chin completed her fellowship training in Fertility Sparing Management in Gynaecological Cancers at the Royal Women’s Hospital, Melbourne in 2020, and has a special interest in oncofertility. In collaboration with the Department of Reproductive Medicine, Dr Chin developed the Gynae OncoFertility Service in KKH, which aims to provide holistic care for young women with cancer.

Dr Jessie Phoon, Director, KKIVF Centre and Senior Consultant, Department of Reproductive Medicine, KKH

As the Director of KKIVF Centre, Dr Jessie Phoon spearheads the centre’s ovarian tissue preservation service. Dr Phoon is also Director at the National Sperm Bank. Beyond her clinical work, Dr Phoon is also Associate Programme Director for SingHealth Obstetrics and Gynaecology Residency Programme, and is passionately involved in teaching undergraduate and postgraduate students.

 

​References:

  1. Singapore Cancer Registry 50th Anniversary Monograph (1968 – 2017)
  2. Prasath EB, Chan ML, Wong WH, et al. First pregnancy and live birth resulting from cryopreserved embryos obtained from in vitro matured oocytes after oophorectomy in an ovarian cancer patient. Hum Reprod. 2014;29(2):276-278. doi:10.1093/humrep/det420