Infertile patients cannot afford to wait for treatment while their eggs get older.
Dr. Sherman Silber, Infertility Center of St. Louis, is offering free video consultations for patients who need to plan now for their treatment while stay-at-home orders are in place. He is talking to and evaluating patients in their home via to comply with social distancing measures.
Dr. Silber is discovering that patients actually prefer this method of telemedicine consultation over the conventional office visit. Patients have conveyed that “it is so much more convenient and less stressful” to have a free telemedicine personal consultation than to take a day off from work to travel to the doctor’s office and sit with other nervous patients in the waiting room.
The COVID-19 pandemic is thus changing much of the way we will do things in the future, and for the better. "Our patients are surprisingly much happier with this approach. Of course, at some point we need to perform hands on treatment. But with this new manner of seeing patients, we can come to the right diagnosis and treatment plan for most patients more efficiently, quickly, and painlessly, with no loss of personal one-on-one communication.” This is a very welcome new era of telemedicine that has been forced on us by the current difficult times.
But this operation, performed on Feb. 5, is believed to the first whole-ovary transplant ever done in the United States. And the fact that Lagos and Chaney are not identical twins makes the surgery even more remarkable.
While Lagos will have to wait for three months to see whether the transplanted ovary allows her to ovulate and conceive normally, Silber and other fertility experts are already looking at the advancement as a possible therapy for more women in years to come.
Delicate Surgery a Technical Feat
The advanced microsurgery required to transfer one of Chaney’s ovaries into Lagos’ body is a feat of medicine that would not have been possible years ago.
“Technically it is very difficult, because the artery that supplies the ovary is tiny,” Silber said. “It’s about a third of a millimeter in diameter. This is about a smaller blood vessel you could ever imagine.”
Because of this, much of the work had to be done under a microscope, and the stitches were made using a thread and needle invisible to the naked eye.
Another issue that would normally have made the transfer difficult — or even impossible — is that of compatibility. Normally, a recipient’s immune system will reject tissue from a donor, even if that donor is a sister or other close relation. Only identical twins would normally have immune systems so similar that sustained doses of immunosuppressive drugs would not be necessary.
But in an odd twist of fate, the same bone marrow transplant that saved Lagos’ life from cancer had the side effect of making her immune system compatible enough with that of her sister’s for her to accept the ovary.
“The reason they were perfect, is because Joy had already gone through the immune suppression that would be necessary for a non-identical transplant,” Silber said.
“There was no question mark about it. We knew there would be no fear of rejection.”
Silber has also carried out such procedures on twins. In 2004, he transplanted strips of ovarian tissue from a fertile twin into her prematurely menopausal sister. That woman, Stephanie Yarber, has since given birth to two children.
Since then, Silber has performed similar surgeries on six other sets of twins. But the case involving Lagos and Chaney marks the first time he has transplanted an entire ovary.
If the surgery is a success, the transplanted ovary could function normally for decades – far longer than the one to two years offered by strips of ovarian tissue.
“I think the ovary is going to last a lifetime,” Silber said. “That’s the advantage of doing it this way.”
Silber said the procedure was a fairly simple one for Chaney; her ovary was removed through her belly button in a relatively quick procedure.
However, the procedure presented a serious decision for Chaney. While she already had two daughters of her own, she now faces the possibility of an earlier menopause.
“She won’t notice any difference at all in terms of her hormone production or her fertility, except for the fact that, we are predicating, that she will go through menopause two or three years earlier than she would have otherwise,” Silber said.
But Chaney says she did not hesitate at the chance to allow her sister to have a natural pregnancy.
“She’s my sister,” Chaney said. “I think anyone in that same circumstance would do the same thing; just not many people are put into that circumstance. I get to be the lucky one to have all these great experiences.”
The New IVF?
Silber says that he hopes the technique will someday lead to female cancer patients being able to freeze their ovaries before they undergo therapy, allowing them to preserve their fertility after treatment.
But will the procedure become widely available to most infertile women? Not likely, said Dr. Richard Paulson, director of USC Fertility in Los Angeles.
He said that for most women, the immunosuppressant drugs necessary to prevent rejection could also severely limit their ability to maintain and complete pregnancy.
“Those medicines are typically quite toxic to the developing fetus, and they would also be toxic to the reproductive tract,” he said.
Paulson added that a far simpler method currently exists.
“In most circumstances, it is far easier to transfer one egg than the whole ovary,” he said. “It would still be safer to stimulate the sister’s ovaries, get a few eggs out, and transfer them to the recipient. This is far and away a simpler way to go.”
He says, however, that such operations could be plausible for a wider range of women in the future if researchers perfect the techniques used to freeze whole organs for later use.
And however unusual, the procedure may prove to be a precious gift for Lagos and her husband Rodrigo, Chaney’s rare gift is a true blessing.
“The best thing I can do is be the best parent I can be, the best husband I can be and take care of her sister forever and ever — love her, be her friend, have her be a part of our lives to really also enjoy what she has given to our family,” Rodrigo Lagos said.
“I don’t think there’s a way to say thank you,” Joy Lagos said. “I will thank her by being the best mom that I can. The kind of mom that she is.”