Whats frustrating says Gina Fortunato
of Nesconset New York is the uncertainty in the
answers you receive from doctors. They cant tell you yes
you will be infertile or no you wont.
Fortunato a human resources specialist was 34 when she
was diagnosed with ovarian cancer in 2001. I was panicking
not only with my diagnosis and what was to come but also because
I wasnt yet married and I didnt have children.
She didnt have a complete hysterectomy and just the
one cancerous ovary was removedan example of the new fertilityconserving
surgical approaches that are sometimes suitable for ovarian or cervical
cancer patients. But soon she got the warning so many men and women
hear regardless of their type of cancer: There was a
very strong possibility that chemotherapy would make her infertile.
We cant tell a patient If you receive X
dose of this drug you have a Y chance of being sterilized
explains Daniel Green MD head of the LongTerm
FollowUp Clinic at Roswell Park Cancer Institute Buffalo
New York. The data are much less precise than that.
Research has lagged behind patient concerns because until
recently the compelling issue for oncologists was survival.
Now 60% of cancer patients live for at least five years
and about 10% live longer than 25 years according to the National
Institutes of Health Bethesda Maryland.
Attention is therefore turning toward survivorship issues
such as fertility. But not all oncologists counsel patients about
future fertility. In April 2002 the Journal of Clinical
Oncology reported that of 201 male cancer patients ages 14
to 40 who had been diagnosed within the previous two years
only 60% said their oncologists warned them about infertility
and only 51% were offered sperm banking.
For women its assumed that the number is much
lower says Lindsay Nohr founder of Fertile Hope
an advocacy group for cancer patients. Doctors in the cancer
world arent as informed on the different options for women.
We should be receiving more phone calls agrees
Jairo Garcia MD director of the in vitro fertilization
program at Johns Hopkins University Baltimore Maryland.
Many doctors are not informed about fertility preservation options
he says or if they are it becomes less important compared
to the seriousness of the cancer. Not all treatments are risky
Whether fertility preservation will be needed depends in part on
the proposed treatment. Certain chemotherapy drugs are risky
especially those known as alkylating agents because they attack
all rapidly dividing cellscancer cells sperm cells
and egg cells alike. Totalbody irradiation and pelvic irradiation
are also likely to kill some or all sperm and egg cells. Occasionally
though even completely sterile men and women recover their
fertility spontaneously sometimes a decade or more after cancer
In women the risk of infertility depends partly on age. Women
are born with all the eggs theyre ever going to have
and with each menstrual period some are eliminated. The younger
the woman the larger the egg supply. Women who have cancer
treatment prior to age 30 are considered to have the best chance
of conceiving naturally afterward.
Even if a girl or woman remains fertile throughout cancer treatment
she may have a shortened window of opportunity to conceive
due to premature ovarian failure (premature menopause) because of
a reduced egg supply.
We dont have great statistics to tell women how much
shorter its going to be says Dr. Green. But
if theyve been treated with pelvic radiation and/or alkylating
agents it is shorter.
Compounding the time issue is some research that suggests waiting
at least a year after chemotherapy before trying to conceive to
reduce the risk of miscarriage and birth defects. It isnt
clear that a year is either too long or too short Dr.
Green says. Again there really just are no data.
The risk of birth defects also suggests some researchers say
that cancer patients should not bank sperm or embryos during a break
in chemotherapy. Consequently patients who feel strongly about
preserving fertility are under tremendous time pressure prior to
Act as quickly as possible
Two weeks before she was scheduled to start chemotherapy Fortunato
made an emergency appointment with a fertility specialist to discuss
her options. Obliged to choose literally overnight
she decided to freeze some eggs. She had to start immediately injecting
GonalF® (follitropin alfa) a synthetic hormone that
stimulates the ovaries to release mature eggs.
I did not have time to sit down and research Fortunato
remembers. The only thing I was very very concerned
about was whether this would make the cancer run rampant through
After she told her oncologist of her plans he conferred with
the fertility specialist. He told her that since she was so
dead set on having children he would approve one cycle
of GonalF and egg retrieval.
Dr. Garcia says its typical for fertility specialists to get
lastminute calls from cancer patients. Theres
not much we can do if the patient needs to start chemotherapy in
a week. When the diagnosis is made act as quickly as possible.
Time can also be an issue for men and older boys. If a patient is
acutely ill Dr. Green says treatment may need to start
before samples can be collected for sperm banking. The usual
thing that we hear from the sperm banks is that you need to have
two or three samples. At least one day of abstinence is necessary
Cryopreservation (freezing) of sperm has been used successfully
by cancer patients for decades but there are no guarantees.
Sometimes men who are acutely ill have very low sperm counts
Dr. Green points out. Other potential problems he says
are reduction in sperm activity or abnormally shaped sperm.
Reproductive science at work
Low sperm count is less a problem today due to a specialized method
of in vitro fertilization called ICSI (intracytoplasmic sperm injection).
That changed the whole picture dramatically for men
says Dr. Garcia. He explains that for ICSI only a single sperm
is needed because it is injected directly into the center of an
egg. Fertility clinics can also remove sperm from a testicle for
use in ICSI.
For women some doctors suggest injections of drugs such as
Lupron® (leuprolide) during chemotherapy. Lupron a gonadotropinreleasing
hormone (GnRH) analog belongs to a family of hormones that
temporarily puts the ovaries into a pseudomenopausal state
suppressing egg production so that fewer eggs are harmed by chemotherapy.
While not proven by the few human studies to date doctors
can prescribe these drugs for this experimental use because they
are approved for other medical purposes.
Fortunato used Lupron on the advice of her oncologist and had a
horrible experience with side effects such as severe
hot flashes and weight gain in addition to the chemotherapy
side effects. She recalls The sweats were just unbearable
like your body was burning from the inside out.
Fortunato who was in a longterm relationship had
her significant other fertilize the eggs and had the
I was uncomfortable with that but the fertility specialist
pushed the issue she explains. He said there was
a very slim chance of an oocyte [unfertilized egg] surviving.
Whereas sperm and embryo freezing are established procedures
egg freezing is highly experimental.
Dr. Garcia who with colleagues reported that oocyte
banking isnt yet feasible in the April 2001 issue of
the medical journal Fertility and Sterility explains that
cryopreservation of the unfertilized egg is troublesome because
it is a very large cell containing a lot of water.
When were trying to freeze it it very easily forms
crystals of ice that damage the membrane of the egg
Dr. Garcia explains. This is why the emphasis has been placed
on freezing fragments of ovarian tissue.
In a very small number of patients researchers have successfully
removed the ovary before cancer treatment cut the eggproducing
section into tiny strips frozen them and reimplanted
them later usually in the arm for easy access to any eggs
that develop. Dr. Garcia has retrieved eggs from at least one woman
but has yet to be successful with in vitro fertilization.
Similar experiments are under way with testicular tissue and with
transplantation of the whole ovary and the whole testis. Ovarian
and testicular tissue transplantation are the only fertility preservation
techniques potentially suitable for prepubertal girls and boys
aside from freezing of immature eggs and sperm which so far
isnt promising. But a major concern is whether the tissue
can harbor cancerous cells that will later be reintroduced into
A major commitment
Another concern is more commonplace: Will insurance pay for hightech
fertility preservation procedures? Even with existing procedures
theres a stigma Nohr points out. Insurance
companies are wary of [healthy] women wanting to do things like
freeze their eggs so they can delay childbirth.
According to Resolve: The National Infertility Association
14 states mandate that insurance companies cover fertility treatment
or offer supplemental policies: Arkansas California
Connecticut Hawaii Illinois Maryland Massachusetts
Montana New Jersey New York Ohio Rhode Island
Texas and West Virginia (details vary so check the organizations
Nohr recommends that even outside these 14 states cancer patients
should petition if insurance companies deny their fertilityrelated
claims. A lot of times theyre accepted with the clause
that infertility is a side effect of a lifesaving medical
treatment. Without insurance coverage the costs can
Having your eggs retrieved is a regular surgical procedure
Fortunato says. I walked into the office for the actual retrieval
procedure and the receptionist says Thatll
be $9989. My jaw dropped. Although my insurance company
claims to cover all treatment up to the diagnosis of infertility
which I was never diagnosed with all medication and the actual
procedure were denied.
The clinic worked out a payment plan for the procedure but
Fortunato had already put nearly $4000 for the GonalF
injections on a credit card. She pays a monthly fee for storing
the embryos and has been told that the cost to attempt a pregnancy
will be $10000 to $15000.
I placed a serious financial burden on myself
she says. But I would go through it again. A lot of people
told me I was crazy but I really want to have children. Hopefully
with the help of God someday I will.