When Michele Foust received a diagnosis of Stage 2 breast cancer this spring, she typed out a list of questions about her treatment.
At the top of the 26-year-old's concerns was an unknown that haunts many young cancer patients: "If I survive, will I be able to have children?"
Foust's breast surgeon was unsure and told her she thought it was likely that chemotherapy would impair her chances by damaging healthy eggs as fast as it killed other rapidly dividing healthy cells such as hair follicles.
Indeed, says Neelima Denduluri, a breast medical oncologist at Virginia Hospital Center, "chemo is a real risk to fertility." Certain regimens, she says, "are more likely to cause infertility and decreasing of sperm count," with up to 80 percent of patients affected, with exact rates depending on the type of cancer treatment and age at diagnosis.
Despite this, medicine has come a long way recently toward helping cancer patients -- women especially -- preserve fertility prior to treatment.
The most common and successful option for a woman with cancer is freezing an egg or embryo before undergoing chemotherapy or radiation. Once the patient decides she is ready to get pregnant, she is given estrogen and progesterone to prepare the lining of the uterus. The embryo is then thawed (or the egg is inseminated) and transferred into the uterus. Success rates specifically for cancer patients have not yet been studied. But in vitro fertilization rates are around 50 percent for women younger than 35.
(For men with cancer, freezing sperm before treatment is far less invasive and less expensive.)
There are also experimental options such as ovarian tissue freezing, in which all or part of an ovary is removed and the outer area, which contains the eggs, is frozen in strips for later use. The ovary can be reimplanted when the patient is well. The procedure typically costs around $12,000; because it is experimental, research centers often provide funding, according to Teresa Woodruff, a professor of obstetrics and gynecology at the Feinberg School of Medicine at Northwestern University. Woodruff refers to such procedures as part of oncofertility, a new discipline that bridges oncology and reproductive medicine.
"I really appreciated there were so many advances in cancer therapy, yet so many young survivors were ending up sterilized," Woodruff said. "There was a real need for a focus specifically in this field."
About 140,230 Americans younger than 45 will receive a cancer diagnosis this year, the American Cancer Society projects. The large majority of them are likely to survive for five years or more.
But only recently has fertility been factored into a patient's treatment plan, according to Mark Payson, a reproductive endocrinologist at Dominion Fertility, a practice based in Arlington, Va. When he speaks to breast cancer support groups, patients say that "only half of their oncologists talk to them about fertility options."
A recent study by researchers at the University of Sheffield in England found that only 40 percent of young female cancer patients were happy with the way their doctors discussed the options they had to preserve fertility.
Most doctors are typically more concerned with saving the patient's life than with fertility options, Payson said.
When Ilana Brunner's breast cancer was discovered in 2009, she quickly embarked on fertility treatments in order to freeze some embryos before chemo began. But she was concerned others might not know to take the same steps.
"When I started chemo, they hooked me up to the machine and made me watch a video about cancer and chemo. But the video never mentioned fertility for women," though it mentioned it for men, said Brunner, a 40-year-old lawyer who lives in Silver Spring, Md. "I actually complained. To me, it was a travesty."
Foust's fate was different. A few days after her initial conversation, she and her husband got an urgent phone call with a new plan for her treatment.
Her breast surgeon at Virginia Hospital Center had set up a conference call with Stephen Lincoln, a reproductive endocrinologist with the Genetics & IVF Institute's fertility preservation center for cancer patients:
She would be able to try to freeze her eggs or embryos before her treatment.
Genetics & IVF, along with other well-known fertility centers, is part of a nationwide effort to encourage oncologists and their staffs to talk to cancer patients about their increasing fertility options.
"Everyone is recognizing now that talking about fertility is a part of dealing with cancer," Lincoln said. "People aren't just being rushed right into treatment anymore."
Denduluri concurs. "The awareness is just much higher now, whereas before many were concerned with finding the so-called cure and saving the patient's life," she said. "It's more a balancing act now, and there are more strident feelings about the importance of bringing up fertility issues at the beginning of treatment."
In late May, Foust went to the Genetics & IVF pharmacy near her home in Annandale, Va., and went home with a supply of vials of gonadotropins, hormones that stimulate the ovaries to produce eggs for retrieval.
She would have to give herself injections every day for the next two weeks. Then Lincoln and his team would extract her eggs, a procedure done with light sedation. (The process is typically the same one used for any woman who would like to have her eggs frozen to preserve her ability to have children.)
In breast cancer cases, doctors want to keep estrogen levels low because of concern that raising them might accelerate the growth of a tumor. Foust's doctors combined a low dose of gonadotropin and a medication that promotes ovarian stimulation while keeping estrogen levels low.
"It was amazing that they could actually do this, safely. At the same time, you never think as a 26-year-old that the ability to bear children -- something I was looking forward to -- will be taken away from you," said Foust, an emergency room nurse.
She decided to freeze eggs instead of embryos because she was concerned about having embryos she might not use. There was also a chance that she could have children naturally, depending on how much harm chemotherapy caused to her fertility.
"If I had children somewhere frozen, I would wonder what to do: Do you donate them? Do you send them to science?" she said.
Just a few years ago, Foust wouldn't have been able to consider this problem.
Back then, egg freezing had far lower success rates and was considered experimental by the American Society for Reproductive Medicine. That label was lifted in October, thanks to improved success rates with a new flash-freezing technology known as vitrification.
"It's been a massive leap forward," said Frank Chang, a reproductive endocrinologist at Shady Grove Fertility Center, which has offices in Washington, Maryland, Pennsylvania, and Virginia.
A growing number of oncologists reject the traditional view that the hormones used to stimulate eggs for retrieval -- as well as pregnancy itself -- might increase the risk of developing certain cancers. Today many doctors see both the freezing process and pregnancy as safe after three to five years of tamoxifen, a hormone drug used with breast cancer patients, according to Denduluri.
And although large-scale data are still being collected about recurrence rates after pregnancy, tumor histories are also looked at on a case-by-case basis to see if carrying a baby is safe, according to Denduluri.
There are also smaller studies showing that pregnancy after a breast cancer diagnosis does not carry a negative outcome as long as a patient waits two to three years after starting treatment with tamoxifen, Denduluri said.
For many patients, dealing with infertility treatments amid a cancer diagnosis is an emotional (and sometimes physical) encumbrance. It is also expensive.
Treatments are viewed as elective and are rarely covered by insurance. Fertility drugs can cost $6,000 a round or more; egg retrieval and freezing can be another $5,500. For freezing embryos, the process can run $6,500 and more.
Many fertility centers help cancer patients find help with funding their drugs. The Livestrong Foundation's Fertile Hope program has helped close to 4,000 survivors since 2004, said Ashley Koenings, senior navigator for fertility services. Each month, the program helps about 80 people.
Shady Grove works with Walgreens, which donates drugs to patients whose insurance does not cover them. Shady Grove also has financial assistance for egg retrieval, depending on a patient's income level.
But even with financial help, the emotional toll is often severe. Dealing with fertility issues is a roller-coaster ride for anyone, but for cancer patients and survivors, it can feel even more burdensome.
"For once, could my body work with me instead of against me?" Brunner said of her efforts to retrieve her eggs. "During that time, a pregnant woman in a supermarket put me in tears."
Brunner froze her eggs twice -- once before her double mastectomy and another time before chemotherapy. "Someone said, 'Are you sure you want to do this and start poking yourself with needles?' And I said, 'This is nothing compared to what I have to do with cancer.'"
After two unsuccessful embryo transfers, including with a gestational carrier (a woman who volunteered to carry the pregnancy for Brunner), she tried again, post chemo. She was able to get one viable egg the first round and one more the second. Both were fertilized with her husband's sperm using IVF and were implanted in a new gestational carrier. Her positive outcome in retrieving viable eggs after chemo is uncommon, doctors said. Today, she has twins who are 9 months old.
At a recent Shady Grove Fertility's Family Day, her twins wore onesies that said, "Made with love ... and science."
"Even when they are both crying and I've had no sleep, I am so thankful," she said.
Meanwhile, Foust was able to freeze 15 eggs. When she is ready to become pregnant, the eggs can be thawed, fertilized and transferred to the uterus as embryos.
She is currently going through eight rounds of chemotherapy. Knowing that her eggs are frozen brings her comfort.
"I remember seeing a picture in my breast surgeon's office that has a list of things that cancer cannot do," she said. "And I wanted that to include that it couldn't take a pregnancy away from us. Even if we never use the eggs or get pregnant on our own, it would be a blessing. I refer to my frozen eggs as my pocketful of sunshine."