cwallace's blog

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.

Patients with cancer and those in need in of stem cell treatments often risk losing their fertility in exchange for a clean bill of health. Fertility preservation options give these patients the ability to have children. Additional patients, such as those with autoimmune diseases, can also benefit from fertility preservation.

Many people develop autoimmune diseases, such as rheumatoid arthritis, systemic lupus erethematosus, and sclerodoma, before or during their childbearing years. These diseases may inherently affect fertility or require treatments that inhibit reproductive ability. A variety of treatments, such as nonsteroidal antinflammatory drugs (NSAIDs) and chemotherapeutic agents can cause decreased sperm counts or affect the functioning of the ovaries.

As many of 80% of women with systemic lupus erethematosus, or lupus, who are treated with the alkylating chemotherapeutic agent called cyclophosphamide, experience at least a year without any periods, called amenorrhea. Another treatment for lupus, MMF, short for mycophenolate mofetil, may help women with less severe forms of the disease and who would like to preserve their fertility. Even women who do not initially lose ovarian function, indicated by amenorrhea, may still be at risk for early menopause and should be aware of this risk.

So what factors make people more or less likely to lose fertility from autoimmune diseases? Age, dose of treatment, and the inherited genetics of a patient all play a role. Prior to treatment, men may want to proceed with sperm banking. Women can undergo hormone stimulation to release multiple eggs that can either be immediately cryopreserved, or fertilized and then cryopreserved. Unfortunately, hormones may aggravate autoimmune diseases so women should also consider ovarian tissue cryopreservation. People who are interested in learning more about their fertility and autoimmune diseases should contact their doctor or call the FERTLINE.

This past Monday, Sarah Halberstadt, the National Program Manager for the group Bright Pink came to visit us at the Oncofertility Consortium. Bright Pink is a not-for-profit organization that educates and supports young women who are at high-risk for breast and ovarian cancer. The members of Bright Pink include women with a family history of these cancers and those who have high-risk mutations of the BRCA breast and ovarian cancer genes. These women have many issues to deal with at a young age, including a greatly increased chance of developing cancer and fertility issues. Halberstadt stated that at Bright Pink, “We divide our programs into three areas: education, support, and providing a sense of community for women who are at high-risk.”

These women have many options and decisions to deal with, which is actually a good thing. “Especially with breast and ovarian cancer, we are so lucky that there are incredible surveillance programs, preventative drugs, and surgeries, if that is what you want to do,” Halberstadt said. One pre-emptive treatment that these women often consider is ovarian tissue cryopreservation. Ovarian tissue cryopreservation decreases a woman’s risk for ovarian cancer and may allow her to preserve her fertility. These high-risk women can turn to the FERTLINE for medical advice from a Patient Navigator and to Bright Pink for community support.

Bright Pink provides the Pinkpal One-On-One Peer Support Program, which Halberstadt describes as, “A matchmaking service without all the romance and fancy dates. Basically, It is a one-on-one peer support program that pairs a women who is looking for some support with one who has walked a mile in her shoes.” They also provide Breast Cancer 101 presentations to communities around the country and will be launching an online video of the information in September with the help of the Cancer Support Community.

They provide printed materials to physicians around the country to pass around to patients including two Little Bright Books. One is targeted to young women who are themselves at high-risk for breast and ovarian cancers. According to Halberstadt, “It is an A to Z guide on how to be proactive with your health as a young woman and how to know what your family history means about your risk.” The other book targets breast cancer fighters and survivors. It guides them through talking to family members about their risks, a process that is also therapeutic.

As the members of Bright Pink are mostly young women, they also like to relax through fun outreach events. As the organization grows, so will their programs. We look forward to hearing more about Bright Pink in the future!

The links between breast cancer and genetics are well established. However, it is not know exactly what makes some women more likely than others to lose their fertility after cancer treatment. We recently wrote a blog post on the correlation between amenorrhea, the absence of a menstrual period, and cancer survival. A new study titled Association of Cyclophosphamide Drug-Metabolizing Enzyme Polymorphisms and Chemotherapy-Related Ovarian Failure in Breast Cancer Survivors from the University of Pennsylvania recently found that menopause after chemotherapy is linked to certain genes, and therefore may be inherited.

In the study, published in the July version of the journal Fertility and Sterility, scientists used a method called a “candidate gene approach” to determine the relationship between a year of amenorrhea, which is the clinical definition of menopause, and genetics. They examined a group of genes, called CYP, which may be involved in the metabolism of a chemotherapy reagent used in most breast cancers. The scientists looked at sites of common variations, called single-nucleotide polymorphisms, or SNPs, within the candidate genes, and recorded menstrual history after chemotherapy treatment. They found that women under the age of 45 at the time of chemotherapy were less likely to enter menopause if they had a specific variation of the CYP3A4 gene that may increase the breakdown of some chemotherapy drugs.

Irene Su, MD, the first author on the study hopes to use this information to predict the likelihood that a woman will enter premature menopause with cancer treatment. With her research,” The goal is to give you a more accurate idea of the risk factors for ovarian failure and in what timeframe,” states Su. Armed with this information, she hopes that doctors can better advise their patients about fertility options and “make better decisions prior to chemotherapy.”