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Preserving the Future

Young adults undergoing cancer treatment who may want to have children should talk with their doctors about ways to preserve their fertility. By Marci A. Landsmann

​Amid the uncertainty of a cancer diagnosis, planning to have children may seem like checking your car’s gas gauge just before you brace for a crash. Still, men and women of childbearing age who are diagnosed with cancer often need to take a step back from making treatment decisions and find time to examine fertility preservation options that could help safeguard their hopes for a future family.

 

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“There’s such a time crunch between the time you are diagnosed and when treatment starts. There is so much to learn and [you have] so many decisions to make,” says Juliana Fuller, a four-time cancer survivor who was diagnosed with stage I Ewing sarcoma in 2004, when she was 19. She was treated with chemotherapy and surgery. Seven years later, Fuller was diagnosed with cancer again, this time follicular lymphoma, at age 26. Within a week of being diagnosed, she met with a fertility specialist and started taking fertility drugs that stimulated her ovaries to make more eggs than normal. Once these eggs matured, they were extracted and joined with her husband’s sperm in a process called in vitro fertilization. The resulting embryos were frozen for later transfer to her uterus after cancer treatment.

“The decision to plan to have children [in the face of a cancer diagnosis] is multidimensional,” says Fuller, who has been disease-free since having surgeries for melanoma in situ in April 2013 and stage I basal cell carcinoma in August 2014. “I wanted to survive. I wanted the treatment I needed. But I always knew I wanted children,” she says. The Loma Linda, California, resident didn’t need to use her frozen embryos and was able to conceive naturally, but she felt reassured knowing she had done all she could to keep her options open. Fuller, now 30 years old, and her husband had their first child in June 2015.

 
Let’s Talk About It
​Juliana Fuller and her husband, Corey, chose to do embryo cryopreservation after learning she was diagnosed with follicular lymphoma. The couple was able to conceive naturally. | Photo by Myra Peterson
About 147,500 people under the age of 44 will be diagnosed with cancer this year in the U.S. To help guide patients in their childbearing years through what can be overwhelming choices, the American Society of Clinical Oncology (ASCO) issued clinical practice guidelines in 2006, with updates in 2013, emphasizing that health care providers should talk to their patients, and the parents or guardians of minors, about the effects of cancer treatment on fertility. The guidelines also stress that providers should refer patients to reproductive specialists, who can assist them in choosing fertility preservation options.

Despite these efforts, surveys indicate that young adults with cancer do not always receive fertility counseling. One survey published in the Dec. 10, 2009, Journal of Clinical Oncology indicated that only 47 percent of 516 oncologists referred cancer patients of childbearing age to fertility preservation specialists. In another study published March 15, 2012, in Cancer, just 61 percent of 1,041 women who received cancer treatment that could affect their reproductive function remembered talking with their doctors about it. Those who did talk with fertility specialists and trained fertility counselors reported a better quality of life and less regret years after treatment.

“It’s not uncommon that young adults feel that fertility, or even sexuality, has not been addressed at all within their cancer care,” says Kristin Smith, a patient navigator at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. Smith specializes in helping newly diagnosed cancer patients through fertility preservation decisions and attends meetings with patients and fertility specialists. She says patients who are not informed of fertility options often feel a lot of regret and anger because “no one thought to say, ‘This may mean that you can’t have your own children in the future.’ It’s frustrating for young adults to not have been given the full picture.”

The best time to have a discussion about fertility preservation is before chemotherapy, radiation or surgery that could damage delicate eggs or sperm, experts say. Many factors, including age, treatment and type of cancer can affect a person’s future ability to have children.

“One cannot predict what reproductive function will be after treatment, so getting that conversation done early, when the patient may have more options, is clearly the best course,” says Don Dizon, a medical gynecologic oncologist at Massachusetts General Hospital in Boston. Options for fertility preservation before treatment include egg and embryo cryopreservation for women and sperm banking for men.

However, exploring these options can be especially challenging for young adults, often defined as between ages 15 and 39, since they may not be ready to have children. For example, Ashley Goldman was just 23 in October 2010 when she learned she had a stage III immature teratoma, a rare type of ovarian cancer that had spread to her stomach lining. At the time, she had been dating the man who is now her husband for eight months. “I knew at that point we would probably end up together, but I was in no position emotionally to make a decision that [would affect] the rest of our lives,” she says. Goldman met with a fertility specialist to explore her options, but when her oncologist explained that her chemotherapy regimen would most likely not affect her ability to have children, she decided not to pursue fertility preservation.

​Ashley Goldman, an ovarian cancer survivor, and her husband, Jamie, recently got married and hope to have children. | Photo by Peter Oberc Photography
Goldman, who lives in Greenwich, Connecticut, had surgery to remove her left fallopian tube and ovary, and then completed nine weeks of a chemotherapy protocol known as BEP (bleomycin, etoposide and cisplatin). Goldman hopes she and her husband, who were married in May, will be able to conceive naturally. “Even though I didn’t make a plan to do anything, I’m glad I went. Just having the conversation opened my eyes to different options,” she says. These discussions can also make people aware of alternatives, including surrogacy and adoption, if treatment makes it impossible for them to conceive on their own.
 
Some people, often already overwhelmed with decisions regarding their cancer treatment, may struggle to find time and energy to fit in an appointment with a fertility specialist.  “A lot of people don’t even make it to the first step just because they have so much going on,” says Karine Chung, a reproductive endocrinologist at USC Fertility, a program of the University of Southern California Keck School of Medicine, in Los Angeles.

 

06/26/2015
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