1. Dr. Kaberi Banerjee
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
• MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
• MRCOG, London, UK
• Commonwealth Fellow in Reproductive Medicine, London UK.
• More than 8000 IVF, ICSI, Donor and Surrogacy Cases
• Awards:
• Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
• India Today Excellence Award in Field of Medicine 2015
• BL Jhaveri National Award in Medicine 2015
• Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.
Medical Director- Advanced Fertility and Gynaecology Centre, New Delhi
Chairperson Delhi State Chapter ISAR
•MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
•MRCOG, London, UK
•Commonwealth Fellow in Reproductive Medicine, London UK.
•More than 8000 IVF, ICSI, Donor and Surrogacy Cases
•Awards:
•Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
•India Today Excellence Award in Field of Medicine 2015
•BL Jhaveri National Award in Medicine 2015
•Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
Economic tTimes Healthcare Award - 2019.

3. Psychosocial & Ethical Dilemma
surrounding fertility preservation in
young cancer patients
Dr Kaberi Banerjee
MD(AIIMS),FRCOG
Commonwealth fellowship in Reproductive Medicine(UK)
Medical Director
Advanced Fertility and Gynecology Centre
New Delhi/Noida

4. Facts
• Cancer incidence rate worldwide
(41%)
• 9% of cancer patients - Children,
adolescents, or adults of reproductive
age at diagnosis
• > 70% of child cancer patients -
Cancer survivors

5. Patient’s Attitude
• Adolescents more distressed than adults
• Girls are more distressed than boys
• Patients with inheritable cancers more
distressed than those with non-inheritable
cancers
• Cancer survivors have higher infertility distress

6. Awareness

7. Role of Cancer Specialist
• Discuss infertility as a potential
risk of therapy
• Start discussion at cancer
diagnosis and can occur
simultaneously with staging
and treatment formulation
• Refer all patients to
reproductive specialists earliest
• Refer patients to psychosocial
providers (d/t distressed about
potential infertility)

8. Role of Fertility Specialist
• Help patient to preserve reproductive
capacities
• Assist cancer survivors to use preserved
gametes and tissue in reproduction

10. Should all patients be referred to a
fertility unit ?
• All patients with potential interest should be referred
• Proper oncofertility counseling

11. • Higher degree of life satisfactions if all options
are discussed
• Sadness, Anger and Regret if not
• Even pre pubertal girls have rated having a
child as top 3 life goals

12. Options
Consent/Assent

16. Male child
• If invasive procedures are necessary, minors who are able to understand the
choice presented must give their assent This means that the procedure can be
done if they agree and their parents consent, but not if they object.
• If they are too young to give assent, no procedure involving more than minimal
risk and not for their proven benefit is permitted.
• Postpubertal males ordinarily will be capable of ejaculation and can provide sperm
for storage. Care and tact should be taken in discussing this option with them,
including discussions outside of the presence of their parents.
• If the children cannot ejaculate or are too young, then an epididymal sperm
aspiration and testicular sperm extraction can be done with their assent and
parental consent, as long as this is recognized as a safe and effective way of
maintaining male fertility.
Ethical concerns in FP in minors
Fertility and Sterility" Vol. 83, No. 6, June 2005

17. Ethical concerns in FP in minors
Female child
• With females, the question of fertility preservation would first arise with post-
pubertal minors who would be capable of assent or objection. If they object to
any of these alternatives, the procedures should not be done, despite parental
wishes.
• If ovarian tissue cryopreservation is shown to be safe and effective, efforts to
preserve the fertility of pre-pubertal females may also be possible. As with older
females, both parental consent and the child’s assent to ovarian tissue
cryopreservation procedures would be necessary.
• If the child is too young to give assent, parents may consent to removal of
ovarian sections if the procedure is deemed to offer a net benefit to the child. It
would be advisable in such cases to have an ethics committee or other
independent body review the parental and physician decision to go forward.
Fertility and Sterility" Vol. 83, No. 6, June 2005

18. Experimental procedures in minors for
FP
• Minor Assent
• Parent Consent
• Net Benefit
• IRB Approval
Fertility and Sterility" Vol. 83, No. 6, June 2005

19. Example cases of prepubertal fertility
preservation
J Med Ethics 2018;44:27–31.

20. What Pregnancy rates in cancer
survivors?

21. Should pregnancy after cancer be
considered safe?
• Pregnancy in cancer survivors considered safe
and not be discouraged
• Plan pregnancy
– When patient is at lower risk of relapse
– When anticancer therapy out of a patient’s system
(i.e. up to 3–6 months following the last
administered dose)

22. Risks to Offspring from Reproduction
• Published data on the health of children born
following IVF/ICSI finds little evidence to
support increased risk of most malformations,
cancer, or impaired psychosocial
development.
Fertility and Sterility" Vol. 83, No. 6, June 2005

23. Risks to Offspring from Reproduction
• A second set of issues concerns the possibility that the
cancer patient who appears to have been cured or be in
remission will have a recurrence of the cancer and die
prematurely leaving a minor child bereft of one parent
• Ethical analysis, however, shows that such a concern is not
persuasive.
– First, depending on the cancer type and stage at diagnosis, the
risk of cancer recurrence, while higher than in non-cancer
groups, may not be excessively high.
– Second, the child in question will have a meaningful life even if
he or she suffers the misfortune of an early death of one parent.
Fertility and Sterility" Vol. 83, No. 6, June 2005

24. Avoiding Cancer in Offspring
• An additional concern is the efforts of patients at risk for, or
who have, inherited forms of cancer to prevent its
transmission to offspring.
• When the genetic risks are substantial and preimplantation
tests for them exist, couples may ethically choose to screen
embryos to avoid having children with a high risk of those
cancers.
Fertility and Sterility" Vol. 83, No. 6, June 2005

25. Directions for Disposition of Stored
Gametes, Embryos & Gonadal Tissue
• As with directions for storing embryos, the person should specify what
should be done with stored gametes or embryos, if he/she becomes
deceased or otherwise unavailable, does not pay storage fees, or has
abandoned the gametes, embryos, or gonadal tissue.
• Patients should specify in writing in advance that they want those
materials discarded or used in research, or whether they consent to use of
them for posthumous reproduction and by whom.
Fertility and Sterility" Vol. 83, No. 6, June 2005

26. Posthumous Use of Stored
Reproductive Tissue
• It could lead to the deceased person reproducing after his or her
death either with the source’s partner at the time of storage or
with recipients of gametes or embryos donated to others.
• Courts have also accepted that children born after posthumous
conception or implantation are the legal offspring of the deceased
• A policy of allowing posthumous reproduction only when the
deceased has specifically provided an advance directive and the
surviving spouse or other designee agrees is a sound one.
Fertility and Sterility" Vol. 83, No. 6, June 2005

27. What other safer options in cancer
survivors?
• Use of donor gametes, gestational surrogacy,
adoption

28. Ethics of fertility preservation for
prepubertal
children
J Med Ethics 2018;44:27–31.

30. Take home message
• Coordinated efforts of oncologists and fertility specialists
• Patient needs emotional & psychosocial support and ethical
guidance
• Optimal treatment of infertility in cancer patients
– Effective fertility preservation therapies
– Fulfillment of patients’ psychologic needs
• Ongoing prospective studies to evaluate feasibility, safety
and efficacy of fertility preserving strategies