After Cancer, Fertility Is Often Within Reach
By ANAHAD O'CONNOR
Michael Dwyer for The New York TimesKaren Cormier, with her sons Luke, left, and Ryan, struggled to conceive after cancer treatment at age 5.
Like many adults who survived childhood cancer, Karen Cormier always assumed she would never get pregnant.
Ms. Cormier, 39, developed a rare form of kidney cancer when she was 5 years old. Chemotherapy helped cure her of the disease, but her doctors warned that the treatments would damage her reproductive organs, almost certainly leaving her infertile.
Ms. Cormier, who works in online advertising and lives in Mendon, Mass., saw a fertility specialist when she and her husband were ready to start a family about eight years ago, hoping there was a chance she had survived her early ordeal with her fertility intact. But after two years of trying to conceive without success, they ended the fertility treatments and turned to the adoption process, finding their son, Luke, in 2008.
Then, three years later, the unthinkable happened: Ms. Cormier discovered she was pregnant.
“I was in complete and utter shock,” she said. “I couldn’t even get the words out to tell my husband.”
Ms. Cormier gave birth to a son, Ryan, 15 months ago.
“He is a walking biological miracle,” she said. “I am just so happy to have two kids I thought we’d never have.”
For children with cancer, chemotherapy and radiation treatments are a double-edged sword, one that is lifesaving but often toxic to the fast growing cells of the reproductive system.
Many children who live through cancer struggle to conceive once they reach adulthood. Clinical infertility, the failure to conceive after a year of trying, is particularly common among adults who received pelvic radiation and a class of chemotherapy drugs called alkylating agents. In some cases, when stem cell transplants and especially high doses of radiation are used, children may be left completely sterile.
At one time, oncologists rarely worried about the reproductive side effects of treatment because so few pediatric patients survived. But as more children with cancer live into adulthood — death rates have plunged 66 percent since the 1970s — the landscape of fertility has changed. Doctors are offering patients preservation options at the time of diagnosis, and researchers are finding that for many survivors, the odds of overcoming clinical infertility are surprisingly good.
Last month, a large study in The Lancet Oncology found that about two thirds of female survivors who sought out fertility treatments as adults ultimately became pregnant — a rate of success that mirrored the rate among other infertile women. Other recent studies have found that many men who experience low sperm counts after pediatric cancer, a side effect in two thirds of boys who receive chemotherapy, can undergo procedures that harvest viable sperm, allowing them to father their own children. Doctors say that while there is no doubt that childhood cancer increases the likelihood of infertility, the ovaries and testes of young cancer patients may be more resilient than they had previously thought.
“When we see cancer survivors as adults, depending on how late they are in their reproductive years, radiation and chemotherapy tends to have a pretty suppressive effect on their future fertility,” said Dr. Hal C. Danzer, a reproductive endocrinologist at the Southern California Reproductive Center. “But this speaks to the fact that the ovaries and sperm production are more resilient in young individuals. It’s very encouraging.”
But if fertility treatment is to be successful, time is of the essence. Normally, for example, women under 35 are encouraged to attempt getting pregnant for at least a year before seeing a fertility specialist. For those with a history of cancer, however, the new message should be, “Don’t wait,” said Dr. Lisa R. Diller, the chief medical officer of the Dana-Farber/Boston Children’s Cancer and Blood Disorders Center.
“The ovaries after childhood cancer have taken a hit, and they are almost aging more quickly than someone of the same chronological age without cancer,” said Dr. Diller, the lead author of the Lancet study. “In the setting of having had childhood cancer, if a woman is 25 and has been trying to conceive for six months, then I would say see a specialist.”
Typically, childhood survivors tend not to address fertility issues until they are in a relationship and their treatment is many years behind them, said Dr. Aarati D. Didwania, the director of the STAR survivorship program at the Robert H. Lurie Comprehensive Cancer Center at Northwestern University.
“A lot of young women will come in and say, ‘I’m married, we’ve been trying for six months, is this related to my treatment?’ ” she said.
Traditionally, the fertility discussion has involved finding out which cancer therapies patients received and what their hormonal status is like, so doctors can estimate their likelihood of being infertile. Then they can talk about their options, Dr. Didwania said, and whether they need to resort to things like surrogacy, using donor eggs and sperm, or adoption.
But the new goal in the field of cancer fertility, or oncofertility, is to be as proactive as possible, said Dr. Teresa K. Woodruff, chief of the division of fertility preservation at the Northwestern University Feinberg School of Medicine.
Oncologists are increasingly making a point of bringing up the subject of fertility at the time of diagnosis, discussing options like freezing eggs, sperm and embryos before treatment. In younger patients who have not gone through puberty, some fertility clinics offer the option of freezing ovarian and testicular tissue, which can be reimplanted when patients get older.
Studies show that up to two thirds of young patients are now counseled about fertility before starting their cancer treatment.
“Today 80 percent of kids will survive,” Dr. Woodruff said. “Now that patients are thriving and have decades of life ahead of them, fertility is a high priority for them.”
But cryopreservation procedures are expensive, typically starting at around $10,000. Some fertility clinics offer discounted rates to cancer patients, and nonprofit programs like Fertile Hope and Heart Beat can provide financial assistance and free fertility medications.
Brian Regan, who is 19 and lives in Dunstable, Mass., was told by his doctors earlier this year that he would likely develop a low sperm countthat could become permanent after undergoing chemotherapy for a rare form of testicular cancer.
“They recommended that I at least look into sperm banking,” he said. His insurance carrier, Harvard Pilgrim, covered most of the costs.
At Northwestern, Dr. Woodruff and her colleagues helped start a program called the Oncofertility Consortium, which assists cancer patients with their fertility options and brings together doctors and researchers around the country.
Dr. Woodruff is looking forward to a day when fertility will not be a casualty of cancer treatment. She and her husband, Thomas O’Halloran, a chemist at Northwestern, are working on a new delivery system forchemotherapy that delivers drugs in microscopic bubbles, or nanobins, that dissolve once inside the acidic environment of a tumor, sparing the reproductive organs.
In animal studies, the technique was effective against lymphoma without causing ovarian damage, and it likewise showed promise against breast cancer. Clinical trials in humans are not expected for a couple of years, Dr. O’Halloran said.
“Most of the chemotherapy and drug development community has not been thinking about this because we’ve been hell bent on the path toward killing this disease in any way we can,” he said. “But to have a treatment plan that preserves fertility is really critical.
“You’re giving back a whole life,” he added, “as opposed to, in some cases, a compromised life.”
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