Fertility counseling for reproductive-age women with cancer should address gestational carriers

Major cancer organizations, including the American Society of Clinical Oncology and the National Comprehensive Cancer Network, recommend that all reproductive-age women with cancer should receive fertility counseling. Certain cancer treatments, particularly those for women with breast or gynecological cancers, can affect fertility and make it more difficult for women to conceive. Upon receiving fertility counseling before cancer treatment, some patients may decide to freeze their oocytes or embryos for future in vitro fertilization (IVF). Others may not seek family planning help until after receiving chemotherapy or pelvic radiation, which can damage their ability to have biological children.

Women in both groups may turn to gestational carriers, also called surrogates, to carry a child for them through IVF. Gestational carriers may be the only option for patients whose uterus was removed or damaged during cancer treatment.

In a study published in Cancer (doi:10.1002/cncr.35844), researchers sought to further characterize the role of gestational carriers among reproductive-age women diagnosed with cancer. The study assessed which patients used gestational carriers and how often, as well as their pregnancy outcomes.

Researchers used data from eight statewide cancer registries linked with the Society for Assistive Reproductive Technology Clinic Outcomes Reporting System (SART CORS). Reporting IVF cycles is federally mandated, and SART CORS includes information from more than 90% of US clinics. Drawing on these data, investigators assessed a retrospective cohort of women with a cancer diagnosis who subsequently initiated IVF procedures from 2004 to 2018.

The statewide cancer registries were in Arizona, California, Colorado, Massachusetts, Maryland, North Carolina, New York, and Virginia. Each state has a high number of IVF cycles performed annually and 1000 or more IVF-assisted births each year.

Modified Poisson models were used to estimate prevalence rates and 95% confidence intervals (CI). Discrete Cox regression models were used to calculate the hazard ratio and CI. Multivariable models were adjusted for age, state, and calendar year.

Of the 1095 women diagnosed with cancer who used IVF with cryopreserved embryos or oocytes, 19.1% worked with a gestational carrier. Women involved gestational carriers more often when they were initiating IVF for fertility preservation rather than after their cancer treatment. Those who had chemotherapy versus no chemotherapy also were more likely to use gestational carriers. In addition, the use of donor oocytes or embryos was more common in women who worked with a gestational carrier.

In the sample, 156 women were diagnosed with gynecologic cancer, with 89 having possibly threatened fertility related to surgery or pelvic radiation. In this group, 14.6% (n = 13) initiated IVF before treatment, with 12 ultimately using a gestational carrier. In the group that initiated IVF after gynecologic surgery or radiation, 31 women used a gestational carrier.

In the full gynecological cancer sample, the overall conception rate among women using a gestational carrier was more than 92% over four transfer attempts, with 50% conceiving after the first transfer attempt, compared to 90.8% and 47.4%, respectively, among women who did not use a gestational carrier. Among women with breast cancer, 87.6% conceived over four cycles with a gestational carrier, with 46.2% conceiving after the first transfer attempt. Among those who did not work with a gestational carrier, the rates were 91.6% and 45.1%, respectively.

The authors note that the costs of fertility preservation are substantial—an estimated $10,000–$15,000 for egg or embryo freezing and $10,000–$15,000 for each embryo transfer cycle. They report that five states mandate that private insurers cover the costs of fertility preservation for patients undergoing cancer treatment that may affect their fertility, but the majority of publicly insured patients on Medicaid do not receive any cost coverage. Meanwhile, there are no programs that cover costs associated with using a gestational carrier, and state laws regarding their use vary widely, with some not permitting surrogates to be compensated or contracts to be enforced.

The study results point to the need for fertility counseling to include information on the costs and available protections for using gestational carriers, the researchers say.

“I congratulate the authors because there are very few studies in this area despite its importance,” says Frédéric Amant, MD, a gynecologist–oncologist at UZ Leuven in Belgium. “This figure of nearly 20% of women using gestational carriers is higher than anticipated and higher than what we explain during counseling. Counseling will need to consider gestational carriership as a realistic option.”

Still, he points to the challenges of using gestational carriers, which range from financial concerns to ethical and religious questions.

“It’s also a challenge to predict the chance that a patient will use the cryopreserved oocytes or embryos,” Dr Amant says. “When patients later prefer not to have children, conceive spontaneously, choose to adopt, or die of their cancer, cryopreservation is futile. We need to try to be as precise as possible and better select patients for these procedures.”

He cites a 2018 study that he and his colleagues published in Gynecologic and Obstetric Investigation (doi:10.1159/000478045). One of the first to report on real-life experiences for fertility preservation, the study found that of 69 cryopreserved ovarian materials, only two were ultimately used.

Lidia Schapira, MD, a professor of medical oncology and breast cancer specialist at Stanford University in California, praises the authors for providing more detail on the use of gestational carriers.

“It’s important to bring to our attention because not everybody has access to one,” she says. “There are enormous costs. I appreciate having this information, and I think it helps with counseling patients who are thinking about using a gestational carrier.”

Although medical guidelines emphasize the importance of discussing fertility preservation options with women who are diagnosed with cancer, there is less focus on continuing communication and counseling after cancer treatment and throughout patients’ reproductive years, according to Dr Schapira.

“We need to study it more so we can better counsel our patients and ensure they have the necessary knowledge if they are interested in pursuing using a surrogate,” she says.

Dr Schapira and her cancer survivorship colleagues are researching a tool to help reproductive-age women think through their ideas and hopes about building a family.

“We need to find a way of introducing surrogacy as an option, and the question really is—who should be having these conversations with patients and when?”

As a breast cancer specialist, she points to research advances in fertility options that could benefit her patients. For example, the POSITIVE trial, published in The New England Journal of Medicine in 2023 (doi:10.1056/NEJMoa2212856), found that women with hormone receptor–positive early breast cancer can pause their adjuvant hormone therapy to try to conceive a child without experiencing a greater short-term risk of recurrent breast cancer.

“Making these fertility decisions is often complex, nuanced, and difficult for patients, and their cancer team can open up the space for conversation,” Dr Schapira says. “We may not be able to resolve things, but we can at least provide a safe space to help them articulate their goals and advise them about how a pregnancy may affect their ultimate outcomes.”