Being diagnosed with cancer can send you spinning into a web of emotions.
The burning question every patient asks the oncologist is usually, "How long do I have left?"
That aside, what happens if you're about to start a family or plan to expand the brood, only to receive the devastating news, which may seem like a death sentence?
For many women, especially those of childbearing age, having a baby is furthest from their mind at this point. They proceed with chemotherapy or radiation and when the cancer is in remission, they want to conceive, but sadly, are unable to do so because part of their reproductive organs have been affected by the treatment.
Female fertility can be affected by cancer treatment that may include the removal of ovaries or the uterus. Treatment may also affect eggs, hormone levels, or the functioning of the ovaries, uterus or cervix.
For men, cancer treatment can damage sperm and testicles, or disrupt ejaculation.
The most common cancers in women are breast cancer and lymphomas. Women below 40 can also get ovarian cancer while uterine cancers are mostly found among menopausal women.
Depending on what stage the cancer is detected, there is still hope for women to get pregnant after treatment.
"If they want to have a child, the first question we ask is whether they are single or married. If they are single, the option is to take them through an in vitro fertilisation (IVF) cycle and freeze their eggs or oocytes.
"If they are married, we take them through the IVF cycle, fertilise the eggs with the husband's sperm and then freeze the embryos.
"All this is done before treatment commences because we know chemotherapy will cause some amount of damage to the ovaries. We're not saying that you're completely sterilised after chemo because we have seen young patients getting pregnant after chemo, but the numbers are very small.
"Generally, we know the gonads (primary reproductive organs) get affected badly when you go through chemo, so patients would want to maintain their fertility. Sadly, not many patients are aware of the options out there," says consultant obstetrician and gynaecologist, and subspecialist in reproductive medicine and IVF, Dr K.K. Iswaran.
If the patient has breast cancer, doctors have to determine whether she is oestrogen positive or negative.
He explains, "In breast cancer, there are two kinds of tumours. If she is oestrogen positive, the therapy has to continue for a few years before the woman can consider getting pregnant because in pregnancy, the oestrogen rises very high.
"Initially, we had long periods of stimulation to get a woman to produce an egg, but now, stimulation is very short. Our aim is to harvest a minimum of 15 oocytes. Normally, we say an average of 12 oocytes equals one pregnancy."
Thanks to advances in medical technology, there is now a test called anti-mullerian hormone (AMH) that can reveal how many eggs women have left in the ovaries. The level of AMH in a woman's blood is a good indicator of her ovarian reserve.
At birth, a woman has one million eggs, and at puberty, it is around 500,000. For every menstruation cycle, about 20 to 40 eggs are removed, out of which one ovulates and the rest disintegrates.
"It is now standard for us to do this test for any patient who comes in related to fertility. We used to think young women had no issues, but when we take them through a cycle and they don't respond, we didn't know why. Now, we have an idea after doing the test.
"AMH can tell if your reserves are already low and what your chances are. If you intend to get pregnant, you need to do it quickly because your reserves are dropping. If the level of AMH is low, we give them hormonal pre-treatment before we take them through an IVF cycle.
"In some ways, yes, the reserves drop but this depends on how many cycles of stimulation they go through. We take them through a maximum of three cycles," says Dr Iswaran, who helped set up the first public IVF facility in Hospital Kuala Lumpur in 2006.
The preferred IVF method is the frozen embryo transfer. Most people are moving away from fresh transfer to frozen embryo transfer because the former causes changes to the endometrial lining due to the injections given to the woman, so the implantation window is narrow.
He says, "We freeze the embryos, put patients on some hormonal support tablets, and then transfer the frozen embryos in the next cycle. Pregnancy rates are much better."
If a single woman walks in with early stage ovarian cancer, Dr Iswaran says her treatment would probably include taking out one or both ovaries, and/or other reproductive organs.
"In a scenario where she has not experienced intimacy, we shave the ovarian capsule as that's where all the eggs are and we want to preserve this area. We shave the outer layer of the ovarian capsule, cut them into small chips and freeze them. So, we're actually freezing the ovarian tissue, not eggs.
"When they're better, we unfreeze these chips and transplant them into an area quite close to where the fallopian tube is i.e. the broad ligament, before taking them through the IVF cycle."
Unfortunately, if the uterus has already been removed, then there is nothing that can be done, except looking into surrogacy.
If a cancer patient wants to have a baby, it involves a multidisciplinary team. First, they need counselling on the methods available.
"When a lady is pregnant and discovers she has cancer, it depends on the gestation of the pregnancy. Her health always comes first; the baby is secondary.
"If the foetus is more than 24 weeks, we might be able to prolong the pregnancy for another one or two weeks before doing a Caesarean section.
"But, if it is less than that, we advise them to terminate the pregnancy because the hormones are going to rise very high and cause an issue. If you're going to wait until full term, the cancer might spread from stage one to four, and the five-year survival rate drops, so you may not be around to look after the baby. This is how we counsel them," says Dr Iswaran.
If women do not opt for this method, he says the response rate may not be as good after chemotherapy.
He adds: "We may not get as many eggs, and generally, we find that the oocyte quality is very poor. We may need to do a repeat cycle before the eggs can be extracted.
"A lot of my medical colleagues are treating cancer and they don't counsel the patient - have you thought about the fertility aspect? Doctors must be aware that there are centres that can freeze eggs.
"For women, this is an option: to store either ovarian tissue or oocytes. It only takes 14 days and frozen embryos can be kept for more than 10 years. This gives them hope and a chance to have kids later."