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.
Looking back now, to the summer of ’97 she’d rather forget, Amy Tucker then 19, was launching out of her teens and not exactly thinking about children. She knew wanted them—her family was a big, close Catholic brood—but she had other things on her mind, like college. And also the nagging fever and swelling on the side of her neck that simply wouldn’t subside. A doctor diagnosed a case of mononucleosis, but it wasn’t mononucleosis; it was Hodgkin lymphoma. By the time she was correctly diagnosed, the cancer had progressed to Stage IIIB.
Like a lot of cancer patients just receiving their first diagnosis, pretty much everything after the word “cancer” turned into massive clouds of white noise. Her thoughts, Tucker recalls, were along the lines of, “I don’t want to die,” and, “I don’t want to miss school.”
The effects of treatment on her body would leave their mark, deep inside her vascular and immune systems, yet they were also nearly as abstract as her thoughts about having children someday. “I just figured I would deal with any side effects that came from the treatment later,” she says.
She began a running battle with the cancer, including long, repeated rounds of chemotherapy, whole-body radiation, remissions, relapses, and a bone marrow transplant that, finally, helped her achieve a lasting remission now going on 10 years. Along the way she made it through college, and then entered nursing school. She graduated, became a registered nurse, and met her husband, Jason, not long after. They married in 2008.
It was then that a chance conversation she had with a nurse back when she was about to undergo full-body radiation became the most important conversation of her life. The nurse had happened to walk in the room as an oncologist was discussing treatment protocols with Tucker.
It was, to say the least, an unconventional experiment. “But by then I was just going with the flow so I said,‘OK, fine.’” In surgery Silber removed one of Tucker’s ovaries and froze it by vitrification, In January of 2009, Silber placed three slices of the outer layer of Tucker’s saved ovary (where the eggs are to be found) into a bed constructed within her now non-functioning ovary, which had remained in her body. He carefully plumbed the saved tissue with a blood supply. Everyone waited. By June, Tucker had a menstrual period. She was pregnant by September. Her son, Grant, is now a year old. All because a nurse who had been to a talk happened to walk into her room.
There was a time when a diagnosis for many types of cancers was a notice that the patient would probably be infertile forever. This was an especially crushing blow, particularly to younger patients who did not yet have children, or to the parents of pediatric cancer patients who knew that in order for their child be cured, the potential for any future biological family had to be sacrificed.
As a result of work by Silber and other pioneers, ovarian tissue can be saved, frozen, and replaced after treatment.
GUYS’ EYES ON THE PRIZE
Preserving a man’s fertility is usually even simpler: 15 minutes in a quiet room with a cup. For some cancers, however, like childhood leukemia, the issue of preserving male fertility can be more problematic if the boy isn’t yet ejaculating, or there is concern that leukemia cells could be present. One experimental procedure is enabling scientists to remove testicular tissue, harvest the stem cells that give rise to sperm, and culture these. As these cells undergo passage from one generation to another, leukemia cells die off.
“So for a little boy, when he turns 20 or whatever, you can then culture these spermatogonial stem cells and get a pure colony,” Silber explains. “Then you inject those into seminiferous tubules [in the testes, where semen is produced] and get normal spermatogenesis. It’s been done in animals so far, and there’s no reason it won’t work in humans.”
Such technologies sound exciting, of course. But even when technology can preserve or rescue fertility, too many patients either don’t know about the possibilities, or they can’t afford it. That’s where groups like Fertile Hope, a national LIVESTRONG initiative, come in.
Consider: If Amy Tucker’s treatment had not been free of charge as an experiment, her son Grant would be but a dream. Simple sperm freezing can cost several hundred dollars plus a yearly storage fee; and one round of in vitro fertilization to create frozen embryos and implant them later can cost roughly $20,000. The fees for the ovary freezing (which Silber now does for free) would be much less than egg freezing, namely about $6000 instead of the $20,000 that IVF can cost. Unlike breast reconstruction for breast cancer survivors, which is usually covered by insurance, reproductive therapies are considered elective even when the need for those therapies is a direct result of cancer treatment. Silber says, “we are pushing for legislation that would mandate coverage for this complication of cancer treatment, that is, preservation of fertility.”
“In order to move the meter you have to get consumers to push hard, get a whole movement going,” Silber says. “I was in Washington recently, talked to senators, even in the White House, and everybody told me the same thing. And that was: ‘You have got to contact the LIVESTRONG people. They know how to mobilize the public.’”
Such testing can be important even if a woman has restarted her periods. While she may have regained her fertility, her reserve of eggs may have been depleted by the cancer treatments. If she isn’t yet ready to start a family, she could have some of her remaining eggs, or some ovarian tissue, harvested and banked as a backup.
Tucker, now 33, undergoes regular hormone testing to check on her ovarian function because she knows that the effects of the groundbreaking slice transplant won’t last indefinitely. And she may go into menopause again soon. Then, it appears, she may need another transplant because she and Jason are hoping for more children. This is a serious call, and no fun, of course. But when she sees Grant, she thinks it’s well worth the pain and stress. “It truly is a miracle,” she says. “Every morning I wake up and I am so grateful we were blessed with him.”