When Sarah Lisle was diagnosed with breast cancer at 25, she didn't remember anyone cautioning her about how treatment might affect her fertility. And children were nowhere on her radar; unmarried and poised to go to graduate school, Lisle just wanted to have surgery, get chemo over with and move on with her life.
And she did -- she got married, got her master's in historic preservation, moved to Austin and took a job planning exhibits for the Texas State Parks. She and her husband got excited to start a family, which they could do once she finished her five-year course of tamoxifen, a drug used to combat estrogen-driven breast cancer.
But two months before five years was up, Lisle, then 31, found a new lump. It was cancer, estrogen-driven, making removal of her ovaries likely, pregnancy a dangerous prospect.
"I thought, there goes kids," Lisle said.
But this time, her oncologist sprang into action, advising Lisle to freeze her eggs.
By freezing eggs, embryos or, in rare cases, ovaries, to be implanted later in their own bodies or into surrogates, women preserve the option of having biological children if chemotherapy or radiation treatment deplete their egg reserve or push them into menopause. But many women are not aware of the option.
"Ten or 12 years ago, this was not a topic on people's mind," said Dr. Kutluk Oktay, director of the Division of Reproductive Medicine and the Institute for Fertility Preservation at New York Medical College.
In one survey of 1,000 female cancer survivors younger than 40, researchers from the University of California's San Francisco School of Medicine found almost half did not recall receiving any reproductive counseling, and 88 percent did not recall receiving information about fertility preservation, according to a July report in the Journal of Cancer Survivorship. A Swedish study published in June's Journal of Clinical Oncology found men were much more likely than women to receive reproductive counseling.
"The biggest error that we're seeing is that people are not having the conversation based on assumptions -- that they're too old, or too young, or that it's not safe, or they don't think it's affordable," said Emily Eargle, navigation manager for national services for the Lance Armstrong Foundation's Fertile Hope Initiative, which provides counseling and financial support to cancer patients with reproductive concerns.
While a woman's risk of losing fertility as a result of breast cancer treatment depends on a host of factors -- her age, the type and stage of cancer and the type treatment -- in general, when the typical ovary-damaging chemo agent cyclophosphamide is used, a woman loses 10 years of her egg reserve, Oktay said.
So a 40-year-old woman's reproductive age will be 50 after chemo, making it highly likely she'll be menopausal, Oktay said. A 30-year-old woman will have an egg reserve like a 40-year-old post-chemo, and then she must wait another two years to increase her odds of surviving the pregnancy -- or, if her cancer is estrogen-receptor-positive, five years to complete the tamoxifen regimen. Tamoxifen interferes with fetal organ development.
Depending on the dosage, radiation also can hurt fertility, leading to total or partial termination of ovarian function, Oktay said.
Women who want to have genetic children post-cancer should seek help from a reproductive specialist as soon as possible after diagnosis to begin the process of in vitro fertilization, involving egg harvesting, which must happen before a woman starts treatment and requires at least 10 days of hormonal stimulation to get good eggs, Oktay said.
Pregnancy does not increase the risk of cancer recurrence, several large studies have shown, and in fact might increase a woman's chance of survival, he said. Getting pregnant post-cancer treatment presents no increased risk to the fetus, Oktay said. There may be increased risks to mothers, however, as certain chemotherapy agents can be damaging to the cardiac muscles, he said.
Fertility preservation is not advised for women who are past 45, pre-menopausal, medically unstable or who have already experienced ovarian failure, Oktay said.
Encouraged by her oncologist, Lisle underwent IVF. With help from Fertile Hope, she paid half the regular cost for the IVF. (Fertile Hope secures discounts from fertility providers for at least 25 percent off the procedure's costs, which tend to be about $15,000 to $20,000 upfront for IVF, plus annual storage fees and medication.)
While Lisle was preparing for chemotherapy, her sister-in-law, Lisa Cover, offered to be the surrogate.
Concerned about Lisle becoming pregnant after her ordeal, everyone agreed. After extensive psychological and physical evaluations and legal paperwork, Cover had three embryos implanted.
Lisle, undergoing radiation at the time, said she was "just focused on getting through that and waiting for the other side."
On April 8, 2011, Lillian DeAnne Lisle was born. They call her Lily D.
"She's been an excellent baby," said Lisle, describing her joyful, well-behaved daughter who "sleeps like a champ."
"I think she knows how she got here."
Less than 10 percent of women younger than 40 who develop invasive breast cancer have children after being diagnosed, despite survey results suggesting about half want to, the American Society for Reproductive Medicine said in a report last year.