A cancer diagnosis often comes out of the blue and starting or extending your family will probably be the last thing on your mind. However, it’s important to consider your options for the future, explains Shonagh Walker.
A cancer diagnosis is a frightening enough prospect, not to mention the thought of months of gruelling treatment. On top of this, many young girls and women discover they have just a tiny window to decide on their future fertility options. It’s something they may not have even planned to consider for many years to come, particularly if they’re pre-pubescent.
However, with medical advancements and technology being more effective and more readily available than ever before, this window of hope is widening and allowing increasing numbers of cancer patients the chance to realise their dreams of starting or extending their family. Here, experts share their best advice on preserving your fertility in the face of a cancer diagnosis.
Don’t be afraid to ask questions
For many women, the situation is daunting enough, so important questions can frequently be forgotten. Also, there are some doctors who aren’t well-versed in the fertility issues surrounding cancer treatments, or who may see the importance lies in treating the disease rst and foremost. The lesson here is, ‘there are no silly questions’, so ask everything and anything!
Naturally, cancer is a scary prospect for any woman to face, says Krystal Barter, founder and CEO of Pink Hope. ‘For those who develop cancer at a young age or carry a genetic predisposition, it is often doubly scary,’ she says. ‘You are dealing with your own health, difficult decisions and are often confronted with the very real likelihood that the decisions you make will affect your ability to have children in the future. All this at an age where having children mightn’t even be on the radar.
‘Taking preventative measures often means that high-risk women can live cancer free and go on to have happy, healthy pregnancies,’ says Krystal. ‘However, for many women in the Pink Hope community impacted by a high- risk mutation or carrying a BRCA gene, cancer can strike at a young age and aggressively, leaving you little time to make the necessary decisions about future family plans.
‘Women and their partners need more information and better consultation with their doctor around their fertility before considering preventative measures and, most importantly, women with cancer need to be given urgent fertility preservation opportunities,’ she says.
What are your options? For the majority of women facing a cancer diagnosis and subsequent treatment, hope for a family is tangible, especially if they are of fertile age, stresses Dr Raewyn Teirney, Australia’s leading fertility specialist and gynaecologist.
‘Couples, and indeed single women, should know that all is not lost,’ says Dr Teirney. ‘I regularly see patients with cancer to help them continue or begin their fertility journey once their treatment is complete and they are in remission.
‘Women are sent to us for urgent egg retrieval and we can then harvest and freeze their eggs, which at a later date we can inseminate with their partner’s sperm and create a beautiful healthy baby.’
According to Dr Teirney, there are typically two options available:
1. Egg freezing
‘We often do this for single women who are about to undergo chemotherapy for cancer, which can send them into menopause,’ she explains. ‘It gives them peace of mind that they may be able to have a healthy, happy family later in life, either with donor sperm, or a future partner.
‘If a woman is diagnosed with cancer, their oncologist can refer them for this procedure typically within 24 to 48 hours. IVF Australia has methods in place to fast-track such cases, as we understand just how stressful these situations can be. We also have minimised your out-of- pocket costs for your fertility preservation treatment, which can be discussed in more detail during your appointment.’
2. Embryo freezing
‘We look at this for couples,’ explains Dr Teirney. ‘We look at having an urgent ‘ IVF cycle and creating embryos that we then freeze for couples to implant at a later date. The uterus is normally unaffected by most cancer treatments and to implant an embryo, we administer hormones to maintain a healthy pregnancy, teamed with regular check- ups and the correct pregnancy vitamins.’
While every case is an individual one, the younger the woman and her eggs, the better the chances are of a pregnancy and healthy baby. Dr Teirney estimates that:
- For a woman aged 35 or under, one stimulated IVF cycle would result in the collection of 10 to 12 eggs, of which between seven and nine would be suitable for vitri cation and storage;
- Approximately 80-90% of eggs would survive warming in the future;
- Approximately 50-80% of surviving eggs would fertilise;
- Approximately 80-90% of fertilised eggs would develop into embryos; and
- A single embryo would have a 20-35% chance of developing into a pregnancy.
(Source: IVF Australia)
‘So, we see that medically, many women who have been diagnosed with cancer are able to achieve their dreams of conceiving, enjoying a healthy pregnancy and becoming a mother,’ says Dr Teirney.
Often there are only a few days between diagnosis and beginning treatment, explains Professor Bill Ledger who heads up the Fertility Research Centre at the Royal Hospital for Women in Sydney. ‘It is something the oncologists want to do quickly for obvious reasons. If the cancer is aggressive, they might not have much time.
‘The likelihood of these women achieving their dreams of having a family is generally quite good,’ says Professor Ledger. ‘If we can freeze five or six embryos, or 12 eggs from someone under 35, then her chance of having at least one child is better than fifty- fifty. You can never guarantee, of course. Things can go wrong – eggs don’t always fertilise, embryos don’t always implant, but if we get a reasonable number in the bank and she is younger, then it is a better chance.
If a woman is 40 or over then of course the chances aren’t as high.’
Pre-teens and Pre-Pubescent girls
But what of girls who haven’t yet reached puberty? What are their options? Australian-led technology is proving to pave the way globally for such patients, by freezing ovarian tissue from pre-pubescent girls with the plan to graft it once cancer treatment is completed and when fertility is required. Melbourne fertility specialist, Dr Kate Stern, is leading the advancements in this area and, to date, her group has taken tissue from over 400 women and young girls facing infertility as a result of their cancer treatment.
‘We have been storing ovarian tissue for 20 years now,’ she says. ‘Obviously, in the early days, we weren’t as con dent of success, but in the last few years there has been enormous progress in research. Our rst birth – twins – was in 2014. We have now put tissue back into around 26 patients and have had ve babies. We have only been storing tissue taken from young girls for a few years, in collaboration with the team at the Royal Children’s Hospital. We have not yet had any requests to graft tissue into women who were children at the time of their cancer treatment.
These patients have not yet reached an age where they are ready to become parents, however we are optimistic that the technology will be very successful’.
We now get referrals to help preserve fertility for children and young women, especially those with breast cancer, which is one of the commonest cancers in women of reproductive age. For these women with breast cancer, we mainly still do egg freezing. However there have been some women who have not had enough time, so we have taken ovarian tissue. For some women we do both.
‘We also currently have a grant with the Sony Foundation which, for young patients aged between 13 and 30, covers the cost of transport and processing, allowing young people now the opportunity for best practice fertility preservation, even if they live a long way away from a major city. This is such an exciting opportunity to expand access to care for all young people who need our specialised services.’
Jess’s Story
Two days after her 30th birthday in 2017, Jess Braude was riding high. She had just enjoyed wonderful birthday celebrations with beloved family and friends and was looking forward to a year of happiness, love and joy with her childhood sweetheart Travers Marony, also 30 at the time. Neither of them could have imagined their world would be turned upside down just two days later.
But then, the unthinkable happened. Doctors found a lump in her breast.
‘It was two days after my birthday – can you believe it?’ she asks with a wry smile. ‘I mean, I knew there may have always been a chance – I discovered that I had the BRCA2 gene in October 2016, so I was having six-monthly testing anyway. But to nd out so close to my birthday was a bit of a rude shock!
‘On my second-ever test in July 2017, they found a one-centimetre lump. It turned out to be breast cancer, speci cally triple-negative breast cancer. Triple-negative breast cancer is a cancer that tests negative for oestrogen, progesterone and HER2 receptors.
‘Put simply, it’s the worst kind, as it’s considered to be more aggressive and have a poorer prognosis than other types of breast cancer, mainly because there are no targeted medicines that treat triple-negative breast cancer.’
If there was a silver lining, it was probably that Jess and Travers had been together for over a decade,
so the conversation about fertility preservation wasn’t as highly pressured as it might be for those who’d just started a relationship, or indeed, those who are single.
‘Travers and I had been together for 12 years, so we were in a lifelong commitment anyway,’ says Jess. ‘I am so lucky I was in that position. I have spoken to other women who aren’t in relationships and it is an added layer of complexity having to have that conversation. It is hard enough to meet someone without knowing you have to explain all of this too!’
With a family history, Jess was well armed with the facts.
‘My paternal grandmother had died of breast cancer at 34, when my dad was five years old. We had heard of this testing and my cousin was keen. She had mentioned it to my family, so my dad and uncle did the genetic screening first and both had the BRCA gene. My sister then got screened and, yep, we both have the gene too.’
From there it was a matter of screening every six months. Rather than wallow in self-pity or fear, Jess and her sister decided to make a six- monthly event of the tests.
‘We thought we would have this ‘date’ every six months, to do something for ourselves and make it special. That way it was no more routine than a pap smear, but we also had some sisterly bonding to look forward to.’
‘You have a mammogram and an ultrasound, and at six-monthly intervals, an MRI. I had the mammogram and ultrasound in December and had the MRI in July, which is when they picked it up. It was deep within my breast and wasn’t detectable to touch. Because of my age and dense breast tissue it may not have been there six months before, but it may have been and was just not detectable.’
Jess’s positivity stayed with her throughout the entire ordeal and she remains as buoyant as ever today.
‘I am one hundred per cent one of the lucky ones – for some reason fate had it and I knew to have the test. A lot of people don’t have the luxury of being able to intervene so early. It was the family thing that threw us a little though.
‘At some point, of course we wanted a family, but I wanted to be the one to choose when the time was right. Travers and I are both very practical. We are not deep talkers – we didn’t even talk about it. We just knew we were going to go down the path of fertility preservation. Neither of us had the energy or time to have an in-depth conversation about it. We were told that ‘this is what we should do’, so that is what we did!
‘I was told early on that chemo could ‘fry my eggs’. My biggest fear was that chemotherapy would place me into early menopause and I would become infertile. I had the opportunity to do one round of IVF before chemotherapy started, but I experienced a looming sensation that that was the only option I would have.
‘I was given a monthly injection of Zoladex, which switches off the ovaries and puts them to sleep. I had that and even though there was every chance it wouldn’t work; it was successful, and I was able to do another round of IVF after my chemotherapy was over. I was so lucky that my breast surgeon, Dr Kylie Snook, was open with me from the start and was well schooled in all options available to me. She was the one who made me the appointment – she was like my case manager.
‘Straight after my rst surgery she told me I would need to do a round of IVF as an ‘insurance policy’ as chemotherapy was the only treatment for my type of cancer and she made me an appointment to see the IVF doctor. And then of course, my IVF doctor recommended I take Zoladex during chemotherapy, which turned my ovaries off through the duration of the treatment and protected my eggs.
‘Even though Travers and I were in a long-term relationship, having children was way down the list of priorities for both of us at the time. We had just moved to Singapore for his work and I was about to start a two-year master’s program. The doctor recommended creating and freezing embryos as there was a higher success rate when it came to implanting them. Obviously, this was not my area of expertise, nor my partner’s, so we basically went with what the doctor recommended.
‘And so, I had a lumpectomy followed by one round of IVF, which took about two weeks. The following week I started chemo. The most painful part was having to deal with the fact that suddenly I was staring down the barrel of a future I’d had no part in writing.
‘In terms of the medical side, I basically became a human pin cushion. There were daily injections for two weeks to stimulate my ovaries, along with blood tests and ultrasounds every couple of days to track my progress. This was followed by day surgery under a light sedation to retrieve the eggs. Other side effects I experienced were bloating, stomach cramps and mood swings.’
Despite her traumatic ordeal, Jess remains hopeful and happy and is overjoyed that through her experience, she can help others.
‘It helped me to connect with other young women who were going through this and that is how I found the Pink Hope community. My friends and family, as supportive as they were, had no idea what I was going through and were not able to provide me with advice.
‘Pink Hope fosters a community where there is no judgement – something that is rare among young women in today’s society. Through this community I have met other young women who have provided me with the knowledge, coping skills and support to get me through what has been the hardest time of my life.
And as for her future, Jess holds nothing but high hopes!
‘I am really lucky that the injections I had during chemotherapy worked for me, and Travers and I just completed a second round of IVF. This is because we were fortunate enough to be able to genetically test the four embryos we create at the start of this process. Less fortunately, three of them had the BRCA gene, which meant we were left with one embryo that had a 40 per cent chance of working. During this second round we were able to get ve more embryos, three of which don’t have the gene. This places us in a really good position to be able to have a family!’
‘Travers and I got married in October last year, and my little dog Ari was in the wedding party. We know have four embryos that we can use to start our family. Everyone wants to know when we are going to start. It is a hard one because we were living overseas when it was diagnosed. I had come back for my 30th and to get the MRI and I was not at a time in my life where I could have a child. Not that there is ever a good time!
‘Cancer ruined my fricken plans!! There is still a lot to do before I have kids and can’t do what I want to do. This sounds sel sh but it is the way it is. The ‘kids’ are there ready to go when I need them! At the moment, I need my sleep. I can’t be up all night with a crying baby. Maybe in six months, maybe in a year… at the moment it’s a bit daunting.
‘I am back at work full-time and
I feel really good. I am trying to get back into a normal routine, although my energy levels are not where they were. But I am doing really well, and I am so grateful!’
