Baboon Research Paves Way for New Fertility Preservation for Cancer Patients

A section of a baboon ovary from the Xu et al. paper

Many women who preserve their reproductive potential prior to fertility-threatening cancer treatments currently choose ovarian stimulation and subsequent banking of their eggs or fertilized embryos. Unfortunately, women who choose these techniques must delay cancer treatment for up to three weeks. During that time, injectable hormones help mature follicles within the woman’s ovaries to produce oocytes which then become eggs that are retrieved during an outpatient surgery.  Since some women are not able to delay chemo- or radiation therapy, there is a need for fertility preservation that does not require hormone stimulation.

Experimental techniques such as ovarian removal and tissue banking can provide an opportunity for women to have children. One caveat of ovarian tissue banking is the risk of reintroducing the cancer when the ovary is transplanted back into the cancer survivor. Given this, researchers at the Oncofertility Consortium are developing ways to mature ovarian follicles in vitro, outside a woman’s body. Once these advances are made ovarian tissue may be removed, the follicles matured in vitro, and then go through traditional in vitro fertilization (IVF) techniques without the risk of reintroducing any cancer cells.

A recent publication by Min Xu et al. at the Oncofertility Consortium highlights advances in the in vitro culture of ovarian follicles and maturation of those follicles into oocytes. While some of these techniques are successful in rodents, the translation to non-human primates, such as baboons, has made less progress. The article, “In Vitro Oocyte Maturation and Preantral Follicle Culture from the Luteal Phase Baboon Ovary Produce Mature Oocytes,” describes how researchers are able to use the developing cells within an ovary to produce oocytes.

In the ovary, the more developed oocyte precursors, called cumulus oocyte complexes (COCs), lay underneath the outer region of the tissue, called the cortex. Xu was able to remove these COCs and mature them in vitro to produce oocytes. COCs with more layers of support cells surrounding them were more likely to mature in vitro and up to one quarter of the oocytes were then able to be fertilized by baboon sperm and begin dividing. In addition, Xu was able to remove the less mature follicles from the interior of the ovaries and culture them with a specialized growth system called a fibrin-aliginate matrix (FAM). The high-tech FAM provides support to the growing follicle but can also partially degrade and allow the follicle to expand in size as it develops into a COC. The researchers also examined the effect of follicle stimulating hormone during this growth. The detailed work published in the Biology of Reproduction provides a framework to produce new needed fertility preservation techniques for women who undergo fertility-threatening cancer therapy.

Read the entire Xu et al. article.

Fertility Preservation Patient Navigation: Tiffany’s Story

Tiffany and her husband, Dave, at a "Pre-Chemo" party the week before she started chemotherpay

Around this time last year, Tiffany found a small lump under her arm near her breast. The 28-year old knew that the lump was most-likely a benign cyst so she didn’t worry to much about it. Plus, as a typical health care consultant, she traveled Mondays through Thursdays during the week and wanted to spend weekends relaxing with her husband, not at a doctor’s office. Even as she scheduled the appointment, Tiffany was more focused on planning an upcoming spring trip to Italy and Greece than the lump. Then the tests came back. Breast cancer that had spread to her lymph nodes.

Tiffany barely remembers those first blurry days after the diagnosis. Her husband and parents came with her to the surgical consult where the physicians, “directed me to make appointments with a list of specialists including a fertility expert, medical oncologist, and genetic counselor,” she said in a recent interview at the Oncofertility Consortium. Tiffany recalls how her family scheduled appointments and helped her begin the treatment process. She soon met Kristin Smith, the oncofertility patient navigator in the Division of Fertility Preservation at Northwestern University, who explained her options. When asked about the decision-making process, Tiffany explained,” There was no choice. Of course I would do it.”

Tiffany and her husband decided to undergo embryo cryopreservation and Smith worked with the rest of the medical team to incorporate fertility treatment into the oncology schedule. According to Tiffany, “My oncologist wanted me to do chemotherapy first but knew that I wanted to undergo fertility preservation so she agreed that I could do surgery first.” After surgery, Tiffany began three weeks of hormone injections before egg extraction, fertilization with her husband’s sperm, and embryo freezing.

After completing the fertility preservation process, Tiffany underwent five months of chemotherapy and is currently more than half-way through two months of almost daily radiation and physical therapy. When reflecting on the fertility preservation process, she says, “At the time it was the littlest thing but now it is the most important,” since it gives her something to look forward to after treatment. Working with the oncofertility patient navigator Smith, “was the best part of treatment,” she says.

Though she is still in treatment, Tiffany has already begun to share her story. I first met her when she discussed her experience at an oncology nursing conference and almost brought the room to tears. She may also provide her personal perspective on fertility preservation to some of the high school students at the Oncofertility Saturday Academy. As Tiffany’s nine months of chemo- and radiation therapy come to a close in the middle of January, she is looking forward to starting her job again and, once her Tamoxifen treatment is completed, using those frozen embryos. But first there is that well-deserved European vacation…

Delivering Hope: A New Perspective on Surrogacy After Cancer

Newborn Hope, May 2001

In the late 1990s, Lauren and Henry were a young married couple looking forward to starting a family when Lauren was diagnosed with cancer. Lauren and Henry were advised by her doctors to retrieve eggs and bank embryos but the couple was still left with a dilemma. How would they find a surrogate carrier for the embryos? In the end, the couple didn’t have to look far.

Henry and his cousin Pamela were close as children but as they grew up and started their own lives they also grew apart. Married with three children, Pamela did not have a lot of time to spend with her cousin and his wife but when she heard about their plight, she knew she wanted to do something. In a recent interview with the Oncofertility Consortium, Pamela MacPhee discussed her experience carrying and giving birth to Henry and Lauren’s child. When Pamela was making that decision she wasn’t able to find information about, “the challenges of sharing a pregnancy with another couple or anything comprehensive about what to expect as a surrogate,” which led her to write a book about the story.

Delivering Hope: The Extraordinary Journey of a Surrogate Mom covers many aspects of Pamela’s experience, from dealing with painful hormone injections to forming an incredible bond with Henry and Lauren. In fact, MacPhee states, “Our relationship was the most unexpected and wonderful byproduct of the pregnancy.” Pamela gave birth to Henry and Lauren’s baby in 2001 and, as a precocious 9-year old, Hope is immensely proud of her unique birth journey. MacPhee recounted that, at an event just after the book’s release, Hope, “was there signing books with me.” MacPhee also enjoyed watching her children, then ages three, six, and eight, embrace the surrogate pregnancy. She relates that, “Kids are so good at grasping that there is more than one way to raise a family,” and have remained close to Hope since she was born.

Through the book, MacPhee recounts the personal side of the legal and bioethical issues of surrogacy that are investigated in the Oncofertility Consortium’s research. She states, “I wanted to share the message of hope of our journey,” through her book, which may help potential surrogates as they make the complex decision to provide biological children to people who have lost fertility due to cancer or its treatment.

Virtual Grand Rounds on Pediatric and Young Adult Survivorship

Four times a year, the Oncofertility Consortium hosts its Virtual Grand Rounds series, a public online forum that addresses topics in oncofertility. These clinical, research, and patient presentations engage the diverse oncofertility community to understand broader fertility issues for cancer patients. On November 18, the fall grand rounds, “Clinical Management for Pediatric and Young Adult Cancer Patients and Survivors,” included discussions by two experts in cancer survivorship, Barbara Lockart, APN/CNP, CPON and Karen Kinahan, RN, PCNS-BC.

Barbara Lockart, a pediatric nurse practitioner at Children’s Memorial Hospital in Chicago, Illinois, focused her talk on the survivorship issues of children, as pediatric cancer survival rates are on the rise and approach 80% for some cancers. When dealing with young children, Lockart stressed the importance of having age-appropriate discussions with both children and their parents. While children may not understand the intricacies of fertility, she stressed that even preschoolers have some concept of parenthood. Additionally, it is important for parents to act as surrogate decision-makers independently from their own desires.

Lockart differentiated the long-term effects of cancer care, which begin during treatment and continue throughout the rest of a survivor’s life, from late effects. The late effects of treatment may not begin until years after beginning remission. Some cancer patients may lose fertility immediately during treatment while others may find themselves entering premature menopause years later. Survivors may not be aware of either of these effects on their fertility and Lockart stressed the role of nurses, such as herself, in educating parents and patients.

Lockart frequently works with Karen Kinahan, an experienced clinical nurse practitioner at Northwestern Medical Faculty Foundation and the Survivors Taking Action and Responsibility (STAR) Program who helps childhood cancer survivors transition into adulthood. In Kinahan’s Virtual Grand Rounds presentation, she noted that over time, long-term follow-up for survivors decreases as the late effects of cancer treatment increase. By highlighting case studies and further research, Kinahan showed that infertility is one of the most common chronic medical problems reported by survivors of childhood cancer.

Like previous Virtual Grand Rounds, the full video of the November 2010 seminar is available on the Oncofertility Consortium’s Website. Stay tuned for the next Virtual Grand Rounds: The History of Infertility to be held on February 10, 2012 with Margaret Marsh, PhD and Wanda Ronner, MD. To receive further information about participating in this Adobe Connect session and additional oncofertility events, contact us!

Oncofertility Publication: Fertility Preservation Attitudes and Actions

In 2006, the American Society of Clinical Oncology published recommendations that oncologists discuss fertility preservation with cancer patients. A recent survey, funded by the Oncofertility Consortium’s pilot grant program, investigated pediatric oncologists’ attitudes about fertility preservation and their patterns referring young people for fertility consultations. The results of this study are now available in the Journal of Assisted Reproduction and Genetics.

The article, “Results from the survey for preservation of adolescent reproduction (SPARE) study: gender disparity in delivery of fertility preservation message to adolescents with cancer,” determined that disparities exist between the opinions of oncologists and their behaviors. While most of the responding oncologists agreed that fertility is a significant survivorship issue for them and their patients, less than half of the respondents refer 50% or more of their patients for fertility preservation consultations.

There are also significant differences in referral patterns for male and female patients. While 46% of the pediatric oncologists regularly refer male patients for fertility consultation, only 12% do the same for female patients.  The authors, Tobias Köhler, Laxmi Kondapalli, Amul Shah, Sarah Chan, Teresa Woodruff, and Robert Brannigan, speculate that one barrier preventing oncologists from referring patients to fertility specialists are gaps in their own fertility preservation knowledge.

As discussed previously on this blog, some of the other important barriers to fertility preservation care include time to treatment and the costs of fertility preservation. Since 93% of the respondents were pediatric oncologists, they must also deal with issues regarding underage minors who cannot legally consent to medical treatments. Instead parents must make decisions that may contradict the child’s later wishes. One final issue raised by the authors is that many medical centers do not allow girls under age 18 to undergo many assisted reproductive technologies, such as embryo cryopreservation, due to ethical issues. Together, these barriers highlight the need to develop alternative oncofertility techniques.

Oncofertility Publication: Insuring Against Infertility for Young Cancer Fighters

In 1985, Maryland passed innovative legislation that required health insurance companies to cover the costs of fertility treatments. Since that time 15 U.S. states followed suit and now require insurance companies to cover the costs of egg retrieval, in vitro fertilization, and other infertility treatments for people who have trouble conceiving children. A new paper in the Journal of Law, Medicine, and Ethics by Oncofertility Consortium researchers discusses the barriers to expanding existing infertility mandates to include preventative fertility preservation for cancer patients.

The paper, “Insuring Against Infertility: Expanding State Infertility Mandates to Include Fertility Preservation Technology for Cancer Patients,” describes why cancer patients do not currently fall within the scope of existing mandates. These laws require that patients be diagnosed with infertility before receiving coverage. Authors Daniel Basco, Lisa Campo-Engelstein, and Sarah Rodriguez explain that while different legal and health organizations have their own definitions of infertility, most require that individuals engage in one year of unprotected intercourse without achieving a pregnancy. Since most cancer patients do not fall under that definition, state mandates do not cover fertility preservation.

Fertility preservation mandates may be necessary because patients interested in fertility preservation prior to beginning chemotherapy or radiation may not be able to afford the treatments. Since no health insurance company uniformly covers fertility preservation, cancer patients may need to appeal to their companies in the short time between diagnosis and treatment. Patients may not know how to navigate this complex process, especially while simultaneously dealing with a recent cancer diagnosis, and thus lose the ability to have biological children.

Basco, Campo-Engelstein, and Rodriguez also examine how current infertility mandates could be altered to incorporate the needs of young cancer patients who would like to preserve their fertility. Using the Massachusetts mandate as a model, they discuss the potential legislative routes to providing fertility preservation coverage to cancer patients. Cancer organizations may use these routes to advocate that health insurance companies cover fertility preservation at the state and federal level. In the meantime, patients should utilize their local medical advocates or the national FERTLINE’s patient navigators, who have had success increasing fertility preservation coverage for young cancer patients.

Cancer Care After Katrina

During the summer of 2005, many people were undergoing cancer treatments in New Orleans, Louisiana. Their whole lives had been turned upside down by cancer and they were completely focused on fighting their disease.  That all changed when Hurricane Katrina struck the Gulf Coast in late August.

The hurricane and its aftermath changed the landscape of the entire city of New Orleans, including the healthcare system. Short-term effects included flooding and a loss of electricity to medical centers and clinics while the long-term ramifications of the storm are still being felt. Almost immediately, the state of Louisiana permanently closed Charity Hospital, which cared for most of the city’s uninsured and underinsured residents. Many residents moved away after the storm, including healthcare professionals. At Tulane Medical Center, only 140 out of 617 primary care physicians returned. The healthcare professionals that did return to New Orleans were tasked with caring for a changed population and simultaneously rebuilding their medical system.

The director of the Tulane Cancer Center, Timothy Pearman, PhD, recently discussed the rebuilding process in a presentation at the Robert H. Lurie Comprehensive Cancer Center in Chicago, IL. The center’s patient navigator was first tasked with finding previously diagnosed cancer patients whose treatments had been disrupted by the hurricane, which was difficult given that many people were displaced from their homes and phone lines did not work. One patient who re-started her treatments after a two-month hiatus explained her absence saying, “Cancer is not my biggest problem.”

The center’s patient navigator also used the rebuilding period to increase services for patients. For example, cancer screenings were incorporated into standard care practices throughout the hospital. In addition, all newly diagnosed patients were given an orientation from the patient navigator, a patient care journal, and invited to attend new support groups. To care for the new population of uninsured and underinsured patients, healthcare support staff also learned how to enroll patients in Medicaid and Medicare. Through these activities, the dedicated medical staff converted one of the worst natural disasters in American history into an opportunity to build a new, better, face of healthcare in New Orleans.

The patient navigator at Tulane Cancer Center was integral to the rebuilding efforts by developing and implementing programs in the post-hurricane city. His role was very different from the Oncofertility Consortium’s patient navigator, who walks cancer patients through the options and opportunities for fertility preservation. However, both the patient navigators reduce patients’ barriers to care during stressful times.

So long, Movember!

Congratulations to all of the Mo Bros and Mo Sistas who participated in Movember 2010!  The month quickly flew by and it was great following along many Movember adventures through their Twitter account and website.  Almost half a million people worldwide registered for Movember, bringing in approximately $56.9 million.  While the total fundraising amounts from each region will not be confirmed until next year, the nearly 65,000 Movember registrants in the United States raised over $6.2 million to support the Prostate Cancer Foundation and LIVESTRONG.  The hair-growing movement not only garnered financial support from across the nation and the globe, but also increased awareness among men and their friends and families about the importance of men’s health.

For now, many Movember participants will be sporting clean shaven faces and planning next year’s facial landscape.  The number of people joining Movember is sure to increase and we look forward to being a part of the initiative again.  My husband certainly enjoyed the challenge and I encourage everyone to form a team in 2011.  Please be sure to visit the Movember website to take a glance at pictures, stories, and videos of the past month.  And remember, donations to Movember are accepted all year round, so feel free to share some holiday love at anytime!

Genetic and Environmental Factors of Twinning

The Gemini Twins in the Zodiac

Have you noticed that there seem to be more twins running around these days? If so, you are right. Since the mid-1970s, the rates of twin births have been increasing steadily and not just in the United States. Historians can track twin birthrates as far back as the 17th century using religious records from across the globe. Modern birth reports show that the rates of twin births started to fall around 1900, reached its low point in the mid-1970s, and have since rebounded. While twinning rates vary across time and place, they tend to follow similar trajectories in most countries.

The two different types of twins, fraternal and identical, are created by two very different mechanisms. Fraternal, dizygotic twins form when a woman releases two eggs in a menstrual cycle, which are then fertilized by two sperm. Fraternal twins are as related as any other siblings from the same parents. In contrast, identical twins, also called monozygotic, are formed when a sperm fertilizes a single egg and the early embryo splits to form two genetically identical embryos. Birthrates of identical twins generally stay constant over time, thus, changes in the rates of fraternal twins cause overall fluctuations in twinning.

What is causing the modern day increase in fraternal twin birthrates? Advances in assisted reproductive technology are commonly cited as the primary cause of increased twinning. However, maternal age and genetics also affect the likelihood that a woman will have twins. Research that occurred prior to the popularization of modern day fertility treatments identified that a woman is four times more likely to have twins at age 35 than at age 15. Since that time, the average age of an American woman’s first child increased from 21.4 years to 25 years. European and Asian women have even higher average first-birth ages that vary from 25.9 to 29.4 years old.

Genetics has long been attributed to playing a role in twinning rates. At the turn of the 20th century, physicians discovered familial clusters of twin pregnancies that eventually lead to the finding that the likelihood of giving birth to fraternal twins could be inherited from either a mother or father. Since fraternal twins are born when a woman releases two eggs in one menstrual cycle, only women can express this trait. More recently, research in genetics identified a variety of genes in humans and other animals that may contribute to fraternal twinning, including ones called bone morphogenic protein 15 and growth differentiation factor 9.

Many of these genes are involved in the development of immature eggs, called oocytes. Altered activity of the resulting proteins may cause women to mature multiple eggs per menstrual cycle and have predispositions to fraternal twinning. Interestingly, environmental factors may also affect twin rates. Studies of modern and historical records show that more twins are conceived during the summer and autumn months, which may be attributed to changes in day light or food supply. Conflicting research data also indicate that smoking, folic acid intake, and recent oral contraceptive use may also affect the likelihood of having fraternal twins. Hopefully, further research will determine if suspected environmental factors of twinning are genuine and if they affect the same biological pathways as genetic causes.

Fertility at the 13th Annual Oncology Nursing Conference

In 1998, the Robert H. Lurie Comprehensive Cancer Center at Northwestern University assembled a group of nurses and other oncology experts together for an inaugural oncology nursing conference. Every year since, this successful conference has highlighted emerging topics to oncology nurses from around the Midwest. This year’s 13th Annual Oncology Nursing Conference will be held on Friday, December 3, 2010 at Northwestern University’s Prentice Women’s Hospital.

Oncology nurses act in diverse capacities for cancer patients as educators, navigators, and subject experts. As such, these oncology professionals must continually stay on top of advances in patient care. Megan Mitchell, manager of education programs at the Lurie Comprehensive Cancer Center states that the Oncology Nursing Conference will, “focus on topics that affect patient care and treatment experiences, including the new health care reform act, cancer-related fatigue issues, and managing anemia during cancer treatment.” Additionally, this year’s conference will provide oncology nurses with information on therapies for specific cancers, as well as information on FDA-approved prostate cancer immunotherapy.

The conference will also include a session on fertility with speakers from the Oncofertility Consortium. According to Mitchell, “The panel will provide attendees with unique insights into the decisions and questions that cancer patients encounter when faced with a cancer diagnosis.” Teresa Woodruff, PhD will provide an overview of existing and emerging fertility preservation options for cancer patients. Laurie Zoloth, PhD will discuss some of the complex ethical issues in oncofertility for patients and providers. A third panelist in the session will discuss her personal experiences undergoing oncofertility treatments.

More than 200 nurses are currently registered for the daylong conference, which will provide continuing medical education credits to attendees. While registration for this popular meeting is still open, it is close to reaching capacity so register today!

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