In 2010, around the time that Holly Church and her husband had begun talking about starting a family, she was diagnosed with stage 2 breast cancer.
"I was told that after the chemo, my fertility might be taken away from me," said Church, of Lebanon. "At age 25, that's kind of a scary thing. When I went to UConn for consultation about fertility preservation, they said there were many different things they could do."
She and her husband didn't have much time to decide; her doctors wanted her to begin chemotherapy soon. The Churches had 10 of their embryos frozen, a process called cryopreservation that took about three weeks, and Holly Church started chemotherapy shortly after that.
She's been cancer-free since her treatment and is now waiting for blood work to see how her treatment affected her fertility. If she's infertile, Church said, she'll use the embryos to try to get pregnant. In either case, she said they'd like to get started within a couple months. Having the frozen embryos, she said, gave her peace of mind while going through the cancer treatment.
At the University of Connecticut Health Center, Lisa Pepin, a registered nurse and the coordinator of the oncology fertility department, said that a little more than a year ago her office would receive calls from cancer patients about once a month. This past week, she took at least one call each day.
"There's definitely an uptick," Pepin said. "I think the awareness is really starting to get out there."
The changes have happened fast.
"In the old days — two or three years ago, there was really no time for producing eggs or egg-freezing or embryo freezing," said Dr. Pasquale Patrizio, director of the Yale Fertility Center's in vitro fertilization program. "The oncologist called and would say, 'I have a patient that has breast cancer and now we are set to start chemotherapy in three or four days.'"
"Before, we needed four weeks to harvest the eggs, but today, two weeks is plenty of time to do the egg-freezing," he said. "Before, we did not know how to stimulate the ovaries in a woman with breast cancer. The worry was that by stimulating the ovaries and thus increasing the level of estrogen, we could feed the growth of the breast cancer tissue. Today, we have some medications which allow us to do stimulation and collect eggs without raising the level of estrogen. That's a big breakthrough in the last two or three years."
Looking At Her Options
S.B., a 34-year-old woman from the Bridgeport area, recently visited the Yale Fertility Center "to look at my options." Two years ago, a few months after she was diagnosed with breast cancer, S.B., who asked that her full name not be used, had both her eggs and an embryo frozen, in case her treatment left her unable to have children.
"I was 31 when I was diagnosed and it was a lot to deal with. Not knowing what would happen with my cancer situation, it was a lot to take in," she said, adding that her doctors mentioned the possibility of cryopreservation. "The chemo can cause you to become sterile, so they wanted me to have something to preserve. They didn't want me not to have an option."
How much chemotherapy affects the fertility of a patient can vary.
"It depends on the type of chemotherapy agent that is used," said Dr. August Olivar, a fertility specialist at Hartford Hospital. "Some are more toxic than others. We have to be in touch with the oncologists and know exactly what kind of chemotherapy agent they're using."
A patient's oncologist will advise a woman how soon after cancer treatment she might begin trying to get pregnant.
"Remember, when they get pregnant, there's an increase of estrogen and progesterone," Olivar said. "We have to be sure that she is cured or that [the cancer] is in remission, because estrogen and progesterone increase the chances of recurrence."
Dr. Kristen Zarfos, surgeon and medical director of the Comprehensive Breast Health Center at St. Francis Hospital and Medical Center, said the general recommendation used to be to wait about five years after treatment before trying to get pregnant. Recent studies have shown that waiting two to three years is safe in most cases, Zarfos said, although it can vary depending on the patient's condition.
A Quicker Freezing Technique
Up until a few years ago, freezing fertilized embryos was by far the more successful of the two cryopreservation options. But with the development of a freezing technique known as vitrification, that's changed, said Dr. John C. Nulsen, director and a lead physician at UConn's Center for Advanced Reproductive Services. Instead of the slow-freezing process used previously, vitrification is a rapid cooling process that takes five to 10 minutes. The eggs are then frozen in liquid nitrogen and stored until the woman is ready to have a child, at which time they're thawed, fertilized and re-implanted. In their frozen state, the eggs can last indefinitely.
"That process has become extremely successful and in the last few years, freezing eggs has become a very viable option," Nulsen said, adding that it is now almost as effective as freezing embryos.
How successful either will be depends a lot on the woman's age when the eggs or embryos are frozen.
"If you have someone in her early 30s, her chances [of pregnancy] are as high as 50 percent," Nulsen said. "If she's 42 or 43, her chances will be perhaps less than 20 percent."
Another reason for the increase in cryopreservation is a change in attitude among oncologists.
"Before, the issue of sterility preservation was not at the top of their list of things to discuss with the patients; the first and foremost was always 'OK, let's start taking care of your breast cancer,'" Patrizio said. "But with the spread of more knowledge about fertility preservation and the fact that there are many more women surviving breast cancer, the issue of fertility preservation is at the top of their list to discuss with the patient."
Nulsen said he thinks most oncologists in Connecticut are aware of fertility preservation and do a good job of letting their patients know about it. Nationally, he said, there's still a lot of work to do.
"Unfortunately, for a certain number of women — about 30 percent — the concept of what the treatment will do to their fertility is never discussed," he said. "If you're presented with a diagnosis of a life-threatening disease, it's understandable that [there are] a lot of questions you wouldn't think to ask, but hopefully the oncologist would be aware of that and discuss it with you."
Zarfos said it's important for doctors to initiate the discussion about fertility with breast cancer patients, because patients have so many other things to take care of after a diagnosis.
"I think it's important to get it out there," Zarfos said. "I think many times in the heat of the moment they're thinking about the kids they already have or about their own lives."
An Expensive Hurdle
Cost can be a major hurdle. Connecticut law requires that insurance companies cover the costs of cryopreservation for patients in certain situations. But Pepin said doctors and insurance companies don't always agree on when cryopreservation is necessary.
"You try and tell them that they will be [infertile] after the treatment," she said, but that often doesn't get very far. "We have a lot of women come to us, and they're very excited to learn they have these options, and then they find that their insurance won't cover it."
Generally, the cryopreservation procedures cost about $10,000 and the medications cost $4,000. Even with discounts on both, Pepin said, it's expensive. They recently saw a woman just out of college, who wanted to freeze her eggs after receiving a breast cancer diagnosis. "She didn't have $7,500 kicking around," Pepin said.
Church said that, despite several long conversations with her insurance company, "nothing was covered."
"It was a big decision for me and my husband to decide whether to go ahead," she said. It was well worth the money, she added.
"I couldn't imagine not knowing whether or not you'd ever be able to have children," she said. "At least with fertility preservation you have that as a backup. Whether fertility is taken from you or not, you have that."