During my first appointment with Dr. Gorsuch, she asked me if I planned or had ever thought about having children. This question caught me completely off guard. My thoughts and research up to that point had completely been focused on my new cancer diagnosis and understanding it and the treatment options. In that, I had glossed over the fact that infertility one of the larger and more concerning side effects of R-CHOP. My thoughts on having children have always been mixed. I absolutely adore playing with friends’ children and focus most of my charity and pro bono work on advocating and working with children and for child-focused organizations; however, Jason and I have talked about the possibility of maybe having one child in may 4-5 years from now, but in the scheme of planning for life events and goals and placing importance on those, we had put having a child pretty far down that list behind our careers, each other, travel, and a number of other things. We assumed it would happen “someday” and have had intimate and happy conversations about our future child, but have spent the past almost six years together blissfully enjoying each other and our adventures together without any hurry to get to that “someday” point. As everything has been since receiving my cancer diagnosis, our conversations, world, and reality have completely changed, and now in regard to our potential future child.
The data on the impact on fertility is pretty unclear in women treated for Non-Hodgkin Lymphoma with R-CHOP and radiation. Cyclophosphamide (the “C” in R-CHOP) is an alkylating agent, which presents a risk of infertility, premature ovarian failure, and early menopause. Just as chemotherapy attacks the active cancer cells to kill them, it also attacks other active, rapidly-dividing cells such as those in the hair follicles, mouth, gastrointestinal tract, and ovaries. Hair will regrow, and mouth sores and gastrointestinal issues will subside, but the effects on the ovaries will not be known until after chemo is completed. Studies currently show that most women of child-bearing age regain their menstrual cycles after completing R-CHOP, but the effects on fertility are unknown. After ending treatment, we will monitor my AMH levels to determine the damage caused by chemotherapy and predict the likelihood of achieving a successful pregnancy. We will also have conversations with my oncologist to determine the length of time that we should wait before trying to conceive. The advisable waiting period ranges from six months to five years.
Given the likelihood of infertility, I am pursuing fertility preservation. I am fortunate that my cancer is localized and stage one, because that means that I can delay starting treatment for about a month to go through fertility preservation. On Friday, Jason and I met with Dr. Mark Fritz at UNC Fertility to discuss the options for fertility preservation. We started the appointment by having a very long conversation with Dr. Fritz where we first discussed our health and backgrounds, our relationship, our ideas on having children, and the options for preserving my fertility. Dr. Fritz had an exceptional bedside manner, and in the initial part of the conversation about our backgrounds/goals did very well listening and retaining the information we told him. He also used that part of the conversation to appropriately gauge our intelligence, which was reflected in the way that he presented the material and our options on a higher level and in a more scientific manner and provided honest responses when we asked him his opinion with which he would choose if presented with the same situation with his wife. Because I had gone into the meeting relatively well informed on the options and timeline for each option and my treatment, and, more importantly, because of Dr. Fritz’s presentation and manner, Jason and I were confident in proceeding immediately with fertility preservation, which option we preferred, and that Dr. Fritz is the right physician for us. At the conclusion of the meeting, we told Dr. Fritz we were ready to proceed as soon as possible, at which point he informed us that his goal was to start that day and be done in a maximum of three weeks from Friday. He introduced us to our nurse, Mindy, who has an amazingly charismatic, compassionate and up-beat personality, which gave me more confidence in our new and quick decision and that we are going to the right place. She immediately had us meet with the patient financial coordinator (who was also very kind) and set up our initial labs, which were done Friday, scheduled our next appointment, and started working with Dr. Fritz on finalizing the timeline and getting the orders for my medicines in place. Before we left, she gave me her email address and asked my preferred method of communication and said she would be in touch shortly to confirm the things they were working on. By the time we left and got to a restaurant to have lunch, I already had an email from Mindy with the calendar and information. Throughtout Friday afternoon and into the weekend, she had continued to correspond with me updating me with new information as she receives it, has relayed questions and answers between me and Dr. Fritz, and has continued to provide encouragement and her and Dr. Fritz’s excitement to work with me on this portion now and their optimism on this preservation providing Jason and I with a good chance of starting a family in a few years and being a part of that process with us.
There were three options presented: In Vitro Fertilization (IVF) with Embryo Freezing, Ovarian Stimulation with Oocyte Freezing, and Leuprolide Acetate Treatment. The preferred and most successful method for preservation is IVF with Embryo Freezing, which is identical to the IVF treatments that couples will use to have a child when otherwise having trouble conceiving; it only differs by the accelerated period in which I will complete this process and by freezing the fertilized embryos instead of implanting them immediately, so that I may complete my treatment and regain my health. This is the method we have chosen, and it will take about three weeks from this past Friday to complete, which consists of several steps. This past Friday, we both had our blood drawn to be tested. They took 8 vials of blood from me to test for everything from STDs to overall health to genetics. A large part of the genetics test was to see if I’m a carrier of the genes for cystic fibrosis or spinal muscular atrophy, which are recessive genes carried often by white people of European descent. If I carry either of the genes, Jason will also have to be tested, and if we both test positive as carriers, then that would bar us from completing this process because it would mean there would be a 1 in 4 chance that our child would have one of those genetic disorders.
On Tuesday we will return to the clinic to have Jason provide semen sample for sperm analysis to ensure that the fertilization will be successful. Providing the semen sample and also the ultimate sample to be used for fertilization, requires Jason to abstain from ejaculation for 2-5 days prior to providing semen and also refrain from drinking alcohol and caffeine. Also, on Tuesday, we will meet with Dr. Fritz and Mindy (our nurse) to fully discuss the treatment, understand the timeline, and learn how to administer the injections. I also will have a baseline ultrasound done and check my estradiol level. Next, I will discontinue my normal birth control pill from this Wednesday through Saturday. Starting on Saturday the 17th, I will begin the stimulation period, which should last between 8-12 days, during which I will be giving myself injections of Bravelle and Menopur (these are Gonadotropins aka “fertility drugs”) at home and Jason will take an antibiotic. Three days after beginning the stimulation (January 20th), we will return to the clinic for Dr. Fritz to check my response to the stimulation and readjust the dose if necessary. Over the next week, I will continue the injections and attending appointments every couple of days to check response by ultrasound and testing estradiol levels. During the last days of stimulation, I will take Antagon (GnRH-antagonist, which prevents premature ovulation), and finally HGC (human chorionic gonadotropin, which is a natural hormone used to induce the eggs to become mature and fertilize (it causes an LH surge). 35 hours after this injection, we will return for egg retrieval. The egg retrieval will be done under a deep intravenous sedation, and a small needle/retrieval tool is inserted through the through the cervix, and eggs will be retrieved from both ovaries. The total procedure should be about 20 minutes, and I should be fully alert within an hour. The goal is to harvest 10-15 eggs. This same day, Jason will provide sperm to be used for fertilization, and generally Dr. Fritz sees about a 60-80% fertilization rate, where the eggs will be fertilized and cultured to blastocytes, which takes about 5-6 days. There is about a 40-60% chance that the embryos will develop to the blastocyte stage, which means that we are hoping to end up with 6-10 viable embryos that will be frozen through cytopreservation, stored, and eventually implanted when we decide to start a family.
The other two methods have less known success rates. Ovarian stimulation with ooycte freezing, is similar to IVF with embryo freezing with the stimulation process; however, at the end of it, the eggs are not fertilized and are instead frozen alone. This is a newer technique. The outcomes are much less known, and the chance of successful pregnancy is significantly less than IVF with embryo freezing. The third method of the Leuprolide Acetate Treatment is a common treatment, but unproven. With it, an injection is given to temporarily turn off the ovaries with the hope of preventing injury to them from chemotherapy. This injection causes estrogen levels to plummet to post-menopausal levels, which causes fatigue, night sweats, hot flashes, and other symptoms, which may exacerbate the side effects of chemotherapy, but since my cancer is not a hormone sensitive one, it could possibly combat those side effects using estrogen injections. When talking with Dr. Fritz on Friday, I asked him about the possibility of using this in addition to IVF to basically double-down on preserving my chances of fertility. He was very straightforward and said that he wasn’t sure what, if any, benefit that it would provide, but it presents an interesting idea to discuss further after completing IVF based on the number of viable embryos we have, and determine whether the potential safeguard is worth the side effects, and could present an interesting area for him to monitor and use as the base for future research since I’m otherwise very healthy, stable personally and professionally, and of child-bearing years.
As the story of my cancer journey has continued to unfold, I have found this part to be particularly challenging. It has felt like added insult to injury, and my thoughts over my potential infertility have often times been “Are you fucking kidding me?!” As if dealing with cancer and with the fears of unsuccessful treatment and death aren’t enough, the treatment that gives me the hope of living another 50/60/70 years is the same thing that could render me barren. But instead of completely succumbing to frustration and being lost in anger, I have been challenging myself through this process to find the light in the darkness and use those points to propel me forward. With this, I am thankful for a number of things. I am thankful that I have the time and ability to pursue fertility preservation before starting chemo. I am thankful that Jason has completely blown me away in his constant support, compassion, love, braveness, and willingness to walk with me through every piece of this, always reminding me of the many years of happiness and better times to come. I am thankful that I will only have to go through at most 12 days of the side effects of the hormone stimulation (bloating, pressure in the pelvic region (due to the ovaries going from the size of a walnut to the size of a lemon), and mood swings). I am thankful that we will have prevented the risks of older pregnancies by preserving embryos from my 28 year old eggs and Jason’s 35 year old sperm. I am thankful that I am being treated by some of the best doctors and that they are responsive, thorough, and compassionate with me. Finally, I am thankful for each person who has completely blown me away with the ways in which they have supported, loved, and encouraged me through this process, and reminded me that my optimism and attitude will be a huge part of getting through all of this.