Interview with Dr. Karine Chung, MD, founder and the director of USC Fertility Preservation Program for cancer patients
by Diana Price Medically reviewed by C. H. Weaver M.D. 01/2018
Q. Is pregnancy still a possibility for me after completing cancer treatment?
If you have undergone cancer treatment, you may already be aware that cancer therapies—including chemotherapy and radiation—can cause infertility and premature menopause. These treatments can dramatically reduce your egg supply, with higher doses leading to greater degrees of loss. As a result, the remaining pool of eggs (or ovarian reserve) may become so low that pregnancy using your own eggs is no longer possible regardless of whether menstrual cycles are occurring. Once you have completed cancer therapy, some of the following tests may be useful in estimating your egg supply, an important determinant of your current fertility.
Egg Supply Testing after Cancer Treatment
The most reliable way to assess fertility after cancer therapy is to measure hormone levels in the blood, typically timed to specific phases of the menstrual cycle. An ultrasound of the ovaries can also be useful to approximate fertility potential. These tests are best performed and interpreted by a reproductive endocrinologist.
Basal (Day 3) Follicle-stimulating Hormone
Every woman is born with a set supply of eggs. Each egg is contained within a structure called a follicle, which is composed of layers of ovarian cells surrounding fluid that provides nutrients for the egg. Follicle-stimulating hormone (FSH) is produced by the pituitary gland in the brain, and its purpose is to stimulate follicles to grow. At the beginning of a menstrual period, FSH acts as the signal to the ovaries that it is time to prepare eggs for ovulation. One of the earliest indications that the ovarian reserve (the number of remaining eggs) is becoming critically low is an increase in FSH levels at the beginning of a menstrual period. FSH production increases as though it is trying to compensate for the tiring ovaries. For this reason, measurement of FSH in the blood is commonly used as a test of fertility.
It is important that this test be performed on or very near the third day of the menstrual cycle to be informative, and the test should be measured in conjunction with the estrogen level to ensure accurate interpretation. Higher day 3 FSH values correspond to reduced fertility. Normal values are different, depending on where your blood is drawn, but in general values above 10 to 15 international units per liter (IU/L) are considered abnormal. It is expected that the values will fluctuate from month to month, but even with one elevated test result, the chances of becoming pregnant are much lower.
Clomid Challenge Test
Because the basal FSH level will not detect every occurrence of a diminishing egg supply, the Clomid® (clomiphene citrate) challenge test can be used to unmask the problem. Clomid is a pill that is taken for five days starting on the fifth day of the menstrual cycle. FSH levels are measured on day 3 and day 10. In women with a normal supply of eggs, the FSH levels will be low on day 3 and day 10 after the five days of Clomid are completed. If either value is high (greater than 10 to 15 IU/L), the test result is considered abnormal.
Antral Follicle Count
Follicles can be seen and counted during a vaginal ultrasound examination in the early part of a menstrual period (on or around day 3). These follicles are thought to represent the ones that are getting ready to grow during that menstrual cycle. They also reflect the total number of follicles left inside the ovary. There are no well-established cutoff values for normal and abnormal, however, and the expected count definitely varies depending on a woman’s age. In general, the more antral follicles there are, the more plentiful the total egg supply is likely to be. For a woman under 40, 10 or more on each side is promising. For a woman who is 40 or older, six or more on each side is a good sign.
Using vaginal ultrasound, three diameters of each ovary (length, width, and height) can be measured in the early part of the menstrual period (on or around day 3), and total ovarian volume can be calculated. In general, ovarian volume is known to decrease with age and has been used to approximate ovarian reserve. Ovarian volume of less than 3 centimeters cubed (3 cm3) per ovary has been reported to indicate severely reduced ovarian reserve and very low likelihood of pregnancy.
Inhibin B and Anti-Müllerian Hormones
Inhibin B (ONHB) and anti-Müllerian hormone (AMH) are produced by the cells in the ovary that make up the outer layers of follicles. When these hormone levels are low, it suggests that the number of remaining follicles is low. Like FSH, inhibin B should be measured on or around day 3 of the menstrual period. AMH levels, however, do not vary throughout the menstrual cycle and can therefore be measured at any time. ONHB levels of less than 50 picograms per milliliter (pg/mL) and AMH levels less than 0.2 micrograms per liter (mcg/L) have been proposed to indicate severely diminished ovarian reserve. While these are very promising tests for fertility and ovarian reserve, they are not available everywhere, and doctors have not yet agreed upon the best way to interpret their results.
If you are interested in having children after completing cancer treatment, you should consider consulting a fertility specialist and having your ovarian reserve evaluated. Because the impact of cancer treatment on a woman’s fertility varies from individual to individual, it is helpful to be informed about your current fertility status before you begin trying to conceive.
Karine Chung, MD, MSCE,is one of three physician partners at USC Fertility (USCF), the not-for-profit private fertility practice of the University of Southern California, Los Angeles. She is also the founder and the director of USCF’s Fertility Preservation Program for cancer patients. For more information please visitwww.uscfertility.orgorwww.uscfertilitypreservation.org.
Can a woman who is in ovarian failure or menopause as a result of cancer treatment successfully carry a pregnancy and give birth?
It is known that chemotherapy and radiation to the pelvis can dramatically reduce a woman’s supply of eggs. Higher doses of certain chemotherapy agents, such as cyclophosphamide, and radiation directly to the pelvic area have been associated with the most damaging effects on the egg supply. The risk of ovarian failure after cancer treatment also increases with the age of the woman at the time she is undergoing treatment, ranging widely from 35 percent in younger women to up to 90 percent in women over age 40.
When a woman experiences ovarian failure or menopause, her egg supply is essentially depleted, and achieving pregnancy with her own eggs becomes highly unlikely if not impossible. This is considered “premature” if it occurs at or before the age of 40.
An effective way to overcome infertility due to depletion of the egg supply is through the use of donor eggs. Egg donation is a type of fertility treatment that allows women who have no eggs of their own, or who have eggs of poor quality, to achieve pregnancy successfully. Because of this technology, tens of thousands of infertile and menopausal women in their forties and fifties have been able to give birth to healthy babies since the first birth from egg donation was reported in 1984.
In the United States alone, well over 15,000 cycles of in vitro fertilization (IVF) using donor eggs are performed each year. At the present time, it is most often used for women who fail to become pregnant after multiple cycles of IVF using their own eggs, for those with premature ovarian failure or elevated levels of follicle-stimulating hormone (FSH), and for those beyond the age of 43. Interestingly, women in their fifties are nearly just as likely to have good outcomes from donor egg IVF as women in their thirties and forties.
The basic principle of egg donation is that it is an IVF cycle for two—the egg donor and the recipient (also referred to as the intended parent). Thedonorundergoes the first part of IVF, including ovarian stimulation and egg retrieval. The eggs are fertilized with the recipient’s male partner’s sperm (or donor sperm), and therecipient undergoes the embryo transfer, carries the pregnancy, and gives birth.
Egg donors may be anonymous donors who are unrelated to the recipients and who donate for altruistic and/or monetary reasons. Anonymous donors are often found through donor agencies (organizations that focus efforts on recruiting and screening potential egg donors) or through the fertility clinic where the recipient is receiving treatment. Alternatively, the donors may be designated donors such as a friend or relative identified by the recipient to serve as a donor specifically to help her.
The egg donor is required to undergo a thorough medical examination, which includes a pelvic exam, an ultrasound to examine her ovaries and uterus, and a blood draw to check hormone levels, to test for infectious diseases, and to screen for certain genetic disorders. In addition, she will be evaluated by a psychologist, who will determine whether she is mentally suitable to complete the donation process. Prior to initiating the egg donation cycle, the donor signs legal contracts that waive her rights of ownership and custody to all resulting eggs, embryos, and offspring.
Once the screening is complete and the legal contracts are signed, the egg donor will begin the donation cycle, which typically takes three to six weeks. The key is to synchronize the recipient’s cycle with the donor’s cycle. This is achieved by a combination of birth control pills and a medication called lupron (which prevents ovulation and quiets a woman’s hormones). Once the women’s cycles are synchronized, the donor receives hormone injections to stimulate the growth of multiple eggs (typically 10 to 15), while the recipient takes a combination of estrogen and progesterone to prepare the uterine lining for the implantation. When the donor’s eggs are mature, she undergoes egg retrieval, a minor surgical procedure done under conscious sedation. The recipient’s partner provides the sperm, and fertilization takes place in the laboratory as with standard IVF.
Embryo transfer is the procedure by which embryo(s) are placed into the recipient’s uterus. It is usually scheduled for five days after the egg retrieval. After the embryo transfer is completed, the recipient continues to take estrogen and progesterone through the end of the first trimester of pregnancy. This is because in natural conception the ovaries produce these hormones to support the implantation. At the end of the first trimester (13 weeks of gestation age or about 10 weeks after embryo transfer), the placenta makes all the hormones that are needed, and estrogen and progesterone supplementation is stopped.
Across the nation egg donor cycles are very successful, with an estimated 60 to 70 percent chance of pregnancy. If excess embryos are frozen for future use, when a “fresh cycle” is followed by a “frozen cycle,” the success rate with donor eggs goes up to approximately 80 percent. Multiple births, particularly twins, is a common outcome, and the risk of multiples depends on how many embryos are transferred. At the present time, the American Society for Reproductive Medicine recommends that no more than one or two embryos are transferred in any given donor egg cycle. Any remaining embryos are typically frozen for future transfers.
Egg donation is clearly the most successful fertility procedure available today, and it can be a wonderful option for women who are menopausal after cancer treatment. Women who are infertile or in menopause can successfully carry a pregnancy using eggs from an anonymous or known donor. In women with male partners, donor eggs can be fertilized with the partner’s sperm to create embryos that are genetically related to the father. For women without a partner or women in same-sex relationships, donor eggs can be fertilized with donor sperm, and some of these couples may elect to have the cancer survivor’s female partner serve as the egg donor.
Donor egg IVF is not ideal for all cancer survivors, however, particularly women who have been advised not to carry a pregnancy for reasons related to their type of cancer (such as some breast cancer survivors) or to their medical conditions (women who have heart problems as a consequence of their chemotherapy). For these reasons it is important that you discuss all fertility questions with both your oncologist and a fertility specialist.
Healthy Tips and Treats for Halloween
by Laurie Wertich
Halloween—kids live for it and parents dread it. But Halloween doesn’t have to be a trick-or-treating free-for-all of candy and binging. There are many creative ways to enjoy Halloween so that both kids and parents can be happy.
Try these Halloween alternatives for a fun, festive evening:
- Try a trick-or-treat alternative. Attend a carnival, party, or other alternative to traditional trick-or-treating. Many churches, shopping malls, or businesses offer these events for free or for a nominal charge.
- Host a party. By hosting a party, you get to control the environment, activities, and treats. Your child will be thrilled that all of his/her friends are gathered together in costume for fun and festivities and you’ll be thrilled that you’re not making the neighborhood rounds in a cold drizzle.
- Organize a progressive Halloween. A progressive Halloween is a compromise between a party and trick-or-treating. Pool your resources with a few favorite families. Gather at one house for appetizers and then trick-or-treat on that street. Move on to the next house for dinner and then trick-or-treat on that street. You’ll balance the frenzied trick-or-treating with some healthy food—and spend time with friends.
Conquer the Candy Conundrum
Face it—kids equate Halloween with candy, and lots of it. None of us want to feed our kids copious amounts of candy, but outlawing it altogether is sure to backfire. Instead, find middle ground with these tips:
- Eat before trick-or-treating. The best defense is a good offense. Feed your kids a healthy snack or meal before roaming the streets for candy. If they aren’t hungry, they’ll be less likely to overeat candy throughout the night.
- Say yes. Offer your kids a “hall pass” on Halloween and let them enjoy their candy. It’s likely a treat you don’t allow every day, so one day isn’t going to undo all of the healthy habits you’ve tried to instill.
- Make it disappear. Let your kids enjoy their Halloween candy for two or three days and then toss it. Dentists insist that they would rather see kids eat a lot of candy for a few days than a little candy every day—a daily dose of candy is a recipe for cavities, not to mention bad habits.
Tis the Season
Halloween may come only one day a year, but you can choose instead to focus on the Halloween season for a healthier holiday. Enjoying the build-up may prevent the binge once the big day arrives. Try these tips for savoring the season:
- Decorate the house and yard. Have your kids help you adorn the house, porch, and yard with fall and Halloween decorations. They’ll enjoy expressing their creativity and you’ll help them focus on more than candy.
- Visit a harvest festival. Take the kids to a farm or harvest festival where they can enjoy corn mazes, pumpkin picking, apple bobbing, apple cider, and more.
- Boo! Start a neighborhood tradition of “boo-ing” your friends. Leave an anonymous Halloween decoration on someone’s door with instructions to “pay it forward.” Before you know it, the entire neighborhood will be in the spirit.
- Carve pumpkins. Host a pumpkin-carving party or simply carve pumpkins as a family. Let your kids get involved in the design and excitement of creating pumpkin works of art.
- Create costumes. Help creativity soar. Involve your children in the process of creating a fun, simple costume. Hopefully, they’ll be just as excited about modeling their unique creation as they are about collecting candy!