Chenault* had a lot to look forward to as last summer approached. With her MBA from Yale in hand, she had landed a job in Seattle as a management consultant. Before making the cross-country move, she and her partner had planned a months-long journey abroad, traveling through Spain and Morocco, with a quick trip to New York City to attend a wedding before heading to India. That was before everything changed.
While on the first leg of the trip, Chenault, who is 30, felt a lump on her neck. When it didn’t go away, she stopped into an urgent care center in New York to get it checked out. The PA who saw her suspected lymphoma and urged her to get a CT scan, which she did on the Friday before her scheduled Monday flight to India. When the scan revealed enlarged lymph nodes, she and John*, her partner of five years, changed their destination: instead of India, they came to Seattle to be near Chenault’s parents on Vashon Island while Chenault sought treatment at Seattle Cancer Care Alliance.
Chenault and John had talked in the way that young lovers do about their future and about wanting to have children. But once Chenault’s diagnosis of Hodgkin lymphoma was confirmed, that vision for the future required immediate attention. Treatment for cancer can leave patients infertile.
“That’s one of the first things I had questions about,” says Chenault, who asked her oncologist, Dr. Ryan Lynch, about the possibility that chemotherapy might leave her unable to have children.
Dr. Lynch told Chenault that her particular Hodgkin lymphoma treatment regimen doesn’t typically make women infertile, but he also shared information about the new Oncoreproduction Clinic at SCCA, which consults with patients who have cancer about various options to help safeguard their fertility. “He told me that he didn’t think I would lose my fertility,” says Chenault, “but if it made me feel better, I should do it.”
Chenault chose to freeze embryos, which involved medication to stimulate her ovaries to produce more than the single egg that is typically released each month. The eggs were collected then combined with John’s sperm through in vitro fertilization (IVF) to create embryos that can be cryopreserved for use in the future. Chenault did two rounds of IVF, which produced about half a dozen embryos. “My mom calls them my insurance policy,” she says.
The process of egg stimulation and collection takes about two weeks; after eggs are collected, cancer treatment can begin. It’s not typically a problem to postpone the beginning of treatment, but that is a decision to be made in partnership with an oncologist. “Dr. Lynch told me that starting tomorrow or a month later wouldn’t affect the outcome,” says Chenault, who began treatment in February and will have her final infusion on July 1. She has been participating in a clinical trial that combines chemotherapy with immunotherapy.
Laura Lavell, an SCCA social worker who helps interested patients connect with the Oncoreproduction Clinic, wants doctors and nurses to tell more patients about the option of fertility preservation. She is working with the intake department to identify which patients should be told, which requires casting a wide net. Although most providers would agree that patients in their 20s should be informed, a woman in her late 30s or early 40s may want to know about the option too. Likewise, doctors may assume that a patient who is already a mother may be done having children, but that may not be the case. Informing women in their 30s and 40s about fertility preservation is particularly important because they often are at high risk for menopause and infertility following cancer treatment.
Even if cancer treatment doesn’t leave a patient infertile, it can take a toll. “Age of diagnosis matters tremendously,” says Dr. Genevieve Neal-Perry, director of the Oncoreproduction Clinic and reproductive endocrinology and infertility at SCCA and UW Medicine.
A woman who is diagnosed at age 37 then undergoes treatment and a recommended waiting period before trying to get pregnant may find that she faces the same age-related conception difficulties experienced by 40-year-old women who haven’t had cancer.
“We’re trying to educate everyone,” says Lavell, who notes that the clinic also supports patients who don’t necessarily have a cancer diagnosis (patients with sickle cell anemia, for example, who may be starting chemotherapy associated with a transplant). The clinic has also welcomed patients with female sex organs who don’t identify as female. “Nurses are often the people who develop more of a day-to-day relationship with patients and get to know them. And we want to empower patients to ask how their treatment will affect their fertility.”
Lavell also helps patients figure out how to pay for fertility preservation, which is not often covered by insurance. The clinic partners with Lance Armstrong’s LiveStrong organization, which offers grants to patients. Qualifying patients with cancer receive free medication and pay $6,500 for IVF, which amounts to a discount of more than 50 percent.
A sense of security
Giving patients the option to preserve their fertility can not only reassure patients diagnosed with cancer; it may also make them more likely to comply with their recommended cancer treatment. It's a welcome message in June, which is National Cancer Survivors Month. Dr. Neal-Perry has seen patients who have been reluctant to follow a treatment plan because they are worried they won’t be able to start or expand their families.
“The idea of losing that ability to have a family can be devastating and have a profound impact on how patients decide to proceed,” says Dr. Neal-Perry. “When patients freeze embryos or eggs, it gives them a sense of security that when they are ready to have children, they can have children.”
She sees her role as an advocate as well as a physician. Fertility preservation is not often top of mind for the clinical team, which is laser-focused on treatment. She notes that better treatment has led to improved survival rates, which translates to a whole slew of quality-of-life issues that need to be addressed post-cancer. One of the most significant is childbearing.
So Dr. Neal-Perry has embarked on a “road show” in which she convenes groups of providers at SCCA to explain what fertility preservation involves and why it matters. For starters, she emphasizes that the timeline of fertility preservation typically delays cancer treatment by just two weeks.
“Now that people are getting past the concept of just surviving, they are wondering what their lives will look like,” she says. “For many people, living longer often includes having a family.”
Dr. Lynch, Chenault’s oncologist, attended one of Dr. Neal-Perry’s information sessions. As a lymphoma specialist, he takes care of a fair number of young cancer patients; Hodgkin lymphoma is one of the most common cancers in young people.
He typically raises the idea of fertility preservation with patients who are of reproductive age. Dr. Lynch estimates that about half of his female patients who don’t already have children and are able to briefly postpone treatment choose to do fertility preservation. Male patients, of course, may also opt to preserve their fertility, but the process is far simpler and quicker: it involves freezing sperm. “There can be long-term psychological effects even after successful treatment if you think you can’t have children,” says Dr. Lynch.
For Chenault, pondering the possibility of not being able to start a family has been the most emotional piece of her experience with cancer. Freezing embryos has helped her look toward the future. “This has given me the ability to feel really optimistic about what my world will look like post-treatment,” she says.
*Chenault and John requested that their last names not be used to protect their privacy.