Preserving fertility in the face of cancer
At the Oncofertility Clinic, oncology and reproductive medicine intersect to help cancer patients preserve fertility before treatment.
"What would you like for your birthday?” Mike Lingerfelt would ask his wife each year.
Pati Lingerfelt’s response was always the same: “A baby.”
This year, Pati will get her wish.
After 11 years of marriage, the Lingerfelts are expecting a baby girl in October.
“We’re ecstatic,” says Pati, 45, cradling her growing baby bump. “Motherhood is the greatest gift.”
For years, the couple tried to conceive the “old-fashioned way,” as Pati puts it, but with no results. Determined to not give up, they visited a fertility specialist in 2014. But the week they agreed to begin treatments, Pati learned she had breast cancer. Even more crushing was her doctor’s prediction that she’d never have a child. The harsh chemotherapy and radiation designed to cure her cancer would also make her infertile, the doctor said.
“I left that appointment in tears, trying to grasp this challenge to my faith,” says Pati, who served with her husband as an overseas missionary before returning home to Houston three years ago.
Bolstered by her beliefs, she summoned her strength and decided to knock the curve ball she’d been dealt out of the park.
“I was on a mission to conquer cancer and have a baby.”
“Being diagnosed with cancer and told that it may rule out parenthood can be devastating for people who haven’t yet started or completed their families,” says Terri Woodard, M.D., assistant professor of Gynecologic Oncology and Reproductive Medicine.
“A cancer diagnosis alone is bad enough, but the treatments that go with it can reduce or erase future chances to have children.”
Radiation and chemo can cause ovaries to fail and sperm production to stop. Effects can be temporary or permanent, depending on the type of treatment and its duration. Age also plays a role.
“Women are born with all the eggs they’ll have in a lifetime,” Woodard explains. “Younger women typically are starting out with more eggs, so they can usually take a bigger hit.”
Sometimes reproductive organs must be surgically removed to eliminate cancer, “and patients may assume the door has shut,” Woodard says.
Securing the future
Even then, the dream of having a child may still be possible if patients take steps to preserve their fertility before cancer treatment begins.
Woodard directs MD Anderson’s Oncofertility Clinic, where oncology and reproductive medicine intersect.
Working collaboratively with Texas Children’s Hospital’s stateof-the-art in vitro fertilization lab nearby, clinic staff offer the latest fertility preservation procedures to patients with cancer.
“It’s there that patients boost their chances to have biological children after their cancer is gone,” says Woodard, who has a dual appointment at Texas Children’s.
“Parenthood may not happen the way it was expected to before cancer, but if you can be flexible, you’ll find there are other options.”
A family of options
Preserving fertility in men is as simple as freezing and storing sperm for future use. “It’s usually a slam-dunk,” Woodard says of this straightforward and simple solution.
Even if a young man with cancer is unsure whether he wants children, he should still consider banking sperm, she advises.
“By storing sperm, he can decide later. If the samples aren’t used, they can be discarded or donated for research.”
David Rainey, 32, was diagnosed with Hodgkin’s lymphoma at age 20. A doctor urged him to consider freezing his sperm before treatment.
“I was young and single and hadn’t thought much about starting a family,” says Rainey, who now is a successful Houston real estate agent. “Looking back, I’m glad I followed my doctor’s advice.”
After undergoing radiation, chemo and a stem cell transplant, he’s cancer-free and expecting a baby with his wife, Amelia, later this year.
“If I hadn’t been proactive a dozen years ago,” he says, “this baby wouldn’t be happening.”
“I’m happily single. I don’t want kids until I’m in my 30s, but i do want the chance to have children when I’m ready.”
For women, preserving fertility isn’t as easy.
“If a man needs to start cancer treatment the next day, he can bank his sperm in an hour,” Woodard says. “Women have several options, and unfortunately, all require a considerable amount of time and coordination.”
Freezing eggs is the usual route for a single woman who doesn’t yet have a partner or a sperm donor. Years later when she meets the man or identifies the donor she wants to have a child with, her eggs can be thawed and fertilized in a laboratory dish with his sperm. The resulting embryo will be implanted in the woman’s uterus or in a surrogate, if she’s unable to carry a child.
“Egg freezing is a choice that’s available to someone who is unsure of whom she wants to share this journey with,” Woodard says.
Freezing literally suspends the age of a woman’s eggs. A 22-year-old woman who freezes her eggs will have 22-yearold eggs available, even if she waits until age 32 to become pregnant.
“The bottom line for extracting eggs is generally ‘the younger, the better,’” Woodard says. “The younger the woman, the greater the number of healthy eggs she’ll produce.”
Sarah Benys, 20, froze her eggs after she was diagnosed with non-Hodgkin’s lymphoma in January.
A geology major at the University of Texas in San Antonio, she’s delaying her graduation by a semester to battle cancer at MD Anderson. Surrounded by family back home in a suburb of Corpus Christi, she maps out her future.
“First I’ll beat cancer, then graduate and get a job, a husband and two children — in that order,” says the ultra-organized Benys.
Boosting the odds
Women with husbands, long-term partners or sperm donors can undergo in vitro fertilization, where their eggs are combined with their partner’s sperm. The resulting embryos are frozen, then implanted after cancer treatment ends.
“Freezing embryos has a longer track record of success than freezing eggs,” Woodard says. “Eggs are more delicate and we can’t predict their ability to fertilize. But with embryos, fertilization has already taken place so we’re one step ahead.”
Two-year-old Margaret was conceived through in vitro fertilization and delivered by a surrogate after her mother, Caroline, completed breast cancer treatment at age 30.
“My doctor advised me not to become pregnant – now or possibly ever,” recalls Brown. “He said pregnancy could create a surge in hormones that could cause my cancer to return and spread.”
Brown and her husband were devastated.
“We really wanted children,” she says. “In some ways, the news that I couldn’t get pregnant was worse than the news I had breast cancer.”
The couple visited Woodard who suggested they freeze embryos before Brown’s treatment commenced.
“Dr. Woodard was very reassuring, and we followed her advice,” Brown says.
After four months of chemo followed by a double mastectomy and breast reconstruction, “one of the embryos we froze was implanted in a surrogate, and we were pregnant!” she says.
Margaret was born April 1, 2014.
“She’s our silver lining,” Brown says. “I’d go through it all again for another like her.”
And she did. Once again, Brown and her husband underwent successful in vitro fertilization. Margaret will welcome a baby brother or sister in October.
New life for failed ovaries
Egg, embryo and sperm banking are tried-and-true, but other, less traditional ways to achieve parenthood after cancer treatment are also on the rise.
One such method involves snipping tissue samples from a woman’s ovaries before she begins treatment, freezing those samples, then transplanting them back into the woman’s body when she’s completed cancer treatment and is ready to have a baby. Within a few months, the tissue grows follicles with maturing eggs, and fertility is restored. So far, almost 70 babies worldwide have been born this way.
Woodard says pediatric patients will benefit from this procedure even more than adults.
“They haven’t gone through puberty yet, so we can’t get eggs that are mature enough to extract and freeze. The only option for preserving their fertility is to freeze ovarian tissue.”
A 9-year-old girl doesn’t have a concept of what it means to reproduce and be a mother, she says. “But years later, she might care.
Without this, she may never get a chance to become pregnant.”
The technique can be performed on the youngest patients, even toddlers. An 18-month-old from Ohio is believed to be the youngest child so far to undergo the procedure.
The world’s first baby conceived through childhood ovarian tissue freezing was born in 2014 to a 27-year-old Belgian woman who at age 13 had tissue frozen. The case was reported in the journal Human Reproduction.
“Four out of every five children survive their cancer and become long-term survivors,” says Woodard, who’s leading an initiative to offer the technique to MD Anderson’s pediatric patients. “Protecting their future ability to become parents is a major concern.”
But can you afford it?
Medical advances aside, cancer patients face other roadblocks to fertility, like insurance — or lack of it.
Few insurance plans cover cancer-related fertility preservation, even though they pay for procedures like hair-loss treatment after chemo and breast reconstruction after mastectomy.
“Fertility preservation should be treated no differently from any other post-cancer health issue,” Woodard says.
The American Society for Reproductive Medicine estimates the average cost for a single cycle of in vitro fertilization is $12,400. Add to that medications, monitoring and storage, and patients can expect to pay out as much as $20,000, with additional cycles costing more.
Facebook and Apple announced in 2014 that they would begin paying $20,000 toward fertility preservation for their employees.
Woodard says those companies are the exception.
“We still have a long way to go,” she says. “Most companies cover only part of the expenses, or nothing at all.”
The power of pre-implantation genetic screening
Pati and Mike Lingerfelt used in vitro fertilization to conceive their soon-to-arrive-daughter.
And they did something more.
Because Pati is 45 years old, her embryo, while still in a lab dish, was tested for chromosomal abnormalities before being transferred to her uterus.
The test known as pre-implantation genetic screening, detects missing or extra chromosomes or those with structural defects. Down syndrome, for example, is caused by an extra copy of chromosome 21. About 70% of miscarriages in early pregnancy and a large number of failed in vitro fertilization attempts are also caused by chromosomal defects.
“Older women have a greater risk than their younger counterparts for conceiving a child with a chromosomal defect,” says Banu Arun, M.D., medical co-director of MD Anderson’s Clinical Cancer Genetics Program.
National Institutes of Health statistics show that a 23-year-old woman has only a one in 500 chance of having a baby with a chromosomal abnormality, compared with a 45-year-old, whose odds escalate to one in 20.
Given those numbers, Pati and Mike were “hugely relieved” to learn that out of their four embryos tested, one was free of abnormalities.
That’s the embryo they implanted — “our little girl,” Mike says.
“Pre-implantation genetic screening can almost completely eliminate chromosomally abnormal embryos from the pool of embryos being considered for transfer,” says Arun. “This significantly increases the chance for a healthy baby.”
While Pati’s test looked for chromosomal abnormalities, another test known as preimplantation genetic diagnosis examines embryos for a specific genetic disease.
“Many diseases such as cystic fibrosis, sickle cell anemia, hemophilia and Tay-Sachs are caused by a specific gene mutation,” Arun says. “This is where preimplantation genetic diagnosis comes in to determine which embryos are carriers for such diseases and which are not.”
The test looks for a specific gene that has been identified within a family. More than 100 different genetic conditions can be identified.
Testing is conducted on day five or six of the embryo’s development, when it’s grown to include about 100 cells. Five or so cells are snipped off and analyzed for mutations — a small enough number to avoid any damage.
Prospective parents can choose not to implant embryos that are found to have the mutation identified by the test, and can instead select an embryo that is free from the genetic abnormality.
“With pre-implantation genetic diagnosis, future parents can cross one worry off their list by knowing that they won’t pass along a known hereditary risk for disease,” Arun says.