Fertile Future? Potential Social Implications of Oncofertility
Authors: Sarah Rodriguez, Lisa Campo-Engelstein, Linda Emanuel
Journal: Journal of Clinical Oncology (2013)

Recently, ethicists, legal scholars, and social scientists have turned their attention to a developing form of assisted reproductive technology (ART): oncofertility. This new field has emerged to preserve the fertility of young men and women who need to undergo cancer treatments that may cause reduced fertility or sterility. Roughly 10% of those diagnosed with cancer are younger than age 45 and thus within their reproductive years. Many of the emerging options within oncofertility are in the investigational stage, particularly those for girls younger than reproductive age. These include whole-ovary and oocyte cryopreservation and the freezing of ovarian tissue. For boys younger than reproductive age, and thus unable to cryopreserve semen, investigational options include freezing testicular tissue. For many within this demographic, fertility preservation is a significant quality-of-life issue. Indeed, the American Society of Clinical Oncology recommends that all oncologists refer patients for counseling regarding oncofertility options. In a recent article, physician Patrizio and ethicist Caplan noted some potential problems with oncofertility, including concerns regarding the long-term safety of the experimental options in fertility preservation for patients with cancer, the possibility of reintroducing cancer with the transplantation of cryopreserved tissue, and the welfare of the offspring of parents who have a shortened life expectation. Overall, however, they argued that on an individual-patient level, as long as the standard of informed consent/assent with particular attention to pediatric patients is followed, there should be no ethical issues in offering fertility preservation to patients with cancer. Although there are perhaps few ethical issues concerning oncofertility on an individual level, this does not mean there are not larger social implications worth considering. Deliberation of the potential larger social implications of fertility preservation for people without cancer is an important discussion; however, in this article, we focus on the possible larger social implications of oncofertility in an attempt to foster a full consideration of this emerging ART. Future use and disposal of stored gametes, embryos, and gonads and gonadal tissue are major concerns for all types of ART. However, it is especially pertinent in regard to oncofertility, because the goal is to store these materials, the materials may belong to minors, and because the patients have cancer (regardless of age), they are more likely to die in the near future than traditional infertility patients. According to US law, gametes and embryos are classified as property, and disputes over frozen material sometimes have to be resolved in court—often with different results for similar cases. Future use and disposal of gonads and gonadal tissue are somewhat trickier than use and disposal of embryos and gametes, because it is unclear whether gonads and gonadal tissue should be classified as organs or as gametes. Classification of the materials must be addressed not only to prevent and resolve disputes between individuals, but also to engender healthy debate regarding the moral status of these materials and to ensure fair allocation of organs and tissue under the United Network of Organ Sharing. There is also the question of who should pay for the preservation of these materials. Some have argued that insurance companies should cover oncofertility (even if they do not cover other forms of ART), because it does not differ from other treatments for iatrogenic conditions currently covered for patients with cancer. However, there is concern over whether this is a just use of finite health care resources, because as noted, only approximately 10% of cancers affect those younger than age 45 years. According to the American Society of Clinical Oncology, the infertility-inducing risks associated with certain forms of cancer treatments are unknown, in part because of a paucity of information from human data and in part because of the importance individual patient factors have in influencing fertility. It may not be a wise allocation of resources (either personal or social) to preserve ovarian tissue, gametes, or embryos for someone whose chances of iatrogenic infertility from cancer treatment are unknown. Moreover, given the modest success rates of established forms of ART, some may question whether an allocation of resources toward options that are not currently highly reliable in bringing forth the expected baby is worth the financial investment. The success rate for ovarian freezing is unknown, and we do not know whether the frozen tissue will be viable in the future. Furthermore, we know from research on short-term health outcomes that those conceived using ART have greater health risks compared with naturally conceived children, particularly risks associated with multiple pregnancies, higher rates of prematurity, and low birth weights, which can lead to serious health complications. Hundreds of studies have evaluated these risks, but most have been limited to newborns and children. As for research beyond the early years of life, studies in mice have found some long-term health effects, for example, in imprinting and in behavior. Information from both mice and short-term human studies underlines the need for long-term health outcomes research. JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 31 NUMBER 6 FEBRUARY 2