cwallace's blog

More than two years ago, Kara DeFrias began a blog about her journey to conceive a child. Over two years, this journey was unsuccessful. In the attempt to determine the cause of her infertility, doctors discovered that Kara had uterine cancer in February of 2010, at age 34. The cancer was still relatively immature so while Kara had to undergo a hysterectomy to remove her uterus, she did not need chemotherapy or radiation. Soon after the surgery, Kara began working with Oncofertility Consortium members at the University of California, San Diego to undergo embryo banking. Since her uterus was removed, Kara and her husband have begun to look into getting a surrogate for their child and it is looking promising. Kara’s chronicles are an inspiration to other fertility preservation patients. Read them here.

Radiation therapy is a tried-and-true method for treating cancers. However, this treatment also causes tissue damage and DNA mutations to the patient. Damage to the sexual organs or DNA mutations within male sperm or female eggs may cause pregnancies to result in miscarriages, stillbirths, or neonatal death just after birth. The effects of radiation on the offspring of cancer survivors are not well studied. A recent study of patients from the Childhood Cancer Survivor Study shows that radiation to most parts of the body do not cause an increase in stillbirths or neonatal death. However, radiation to the ovaries and uterus does increase this risk.

In the paper titled “Stillbirth and neonatal death in relation to radiation

exposure before conception: a retrospective cohort study,” stillbirth or neonatal deaths occurred in 2% of pregnancies from cancer patients not treated with radiation therapy. Those with low doses of radiation to the uterus and ovaries also reported few cases of these fetal deaths (1-4% of pregnancies). However, 18% of cancer patients who received high levels of total radiation exposure reported pregnancies that resulted in stillbirth or neonatal death.

The cancer survivors in the paper that were at high risk for fetal loss were exposed to radiation levels equal or greater to 10 Gy (call gray), the unit of measurement for absorbed radiation. To give you an idea of that level of radiation, if a person was exposed to 10 Gy at one time, they would die within one month. But spread over the weeks and months of cancer treatment, this technique actually saves lives.

Interestingly, of the women treated with uterine or ovarian radiation prior to their first menstrual period, lower levels have greater effects on future pregnancies. In younger women, radiation treatment as low as 2.5 Gy can cause a 13% risk of later stillbirth or neonatal death.

In contrast to radiation, chemotherapy with the alkylating agents that most frequently cause ovarian failure did not increase the likelihood that pregnancies would result in stillbirth or neonatal death.

The study made me wonder if women treated with ovarian radiation therapy could use ovarian tissue cryopreservation. This could provide fertility preservation for women with a variety of pelvic cancers. However, the authors in the article suspect that the increase in stillbirth and neonatal death in these cancer survivors may be due to tissue damage of the uterus. Because the uterus and ovaries are so close, they could not determine if one organ or both are causing fetal death. Further research will be needed to determine the cause of increased stillbirths and neonatal death in these cancer survivors and to determine if ovarian tissue cryopreservation can preserve their fertility.

In 2007, the first book about Oncofertility discussed many of the scientific and medical advances available to cancer patients wishing to preserve their fertility. Collaborators at the Oncofertility Consortium now examine the humanities and social science aspects of the field in the book Oncofertility: Ethical, Legal, Social, and Medical Perspectives. These experts also emphasize other important issues in fertility treatments for cancer patients including communication, economics, history, and religion. The book is now available for pre-order on Amazon.com.

I read an article last week and just can’t stop thinking about it. The article, posted in the New England Journal of Medicine, is a case study of a patient at Massachusetts General Hospital. Briefly, the case study tells the story of a woman who suffered a blood clot that traveled to the lungs and prevented oxygen from getting to her brain. While ventilators kept her heart beating, the patient was officially diagnosed as brain dead. Despite this poor prognosis, the patient’s husband and parents requested that the woman be kept alive so she could undergo egg banking.

As you may know, egg stimulation requires hormone stimulation for at least two weeks. While there are some cases of sperm banking when men are in comas, or even after death, these procedures take a matter of minutes.  Since egg banking would take weeks, the doctors at Massachusetts General Hospital decided to bring a variety of experts in on the case to decide the ethics of keeping the brain-dead woman alive for two weeks in order to stimulate her ovaries to produce eggs. They examined the legal, ethical, historical, medical, and personal issues in the compelling case

In the end, the doctors made a decision based on the best interests of the woman. I won’t give away the ending but I highly suggest thateveryone interested in fertility preservation read the article attached here:

Greer DM, Styer AK, Toth TL, Kindregan CP, Romero JM. Case 21-2010 — a request for retrieval of oocytes from a 36-year-old woman with anoxic brain injury. N Engl J Med. 2010 Jul 15;363(3):276-83.