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NEW PROCEDURES HELP PEDIATRIC CANCER PATIENTS WITH FUTURE FERTILITY

Wednesday, September 18, 2013

New Procedures Help Pediatric Cancer Patients With Future Fertility

By Peter Loftus

Farah Contractor had to think about her future in a way that few other 14-year-old girls must.

The Churchville, Pa., teenager was diagnosed with a type of leukemia in 2011. The standard treatment—which includes a bone-marrow transplant—was known to damage the reproductive system and could make her infertile.

Soon after she was diagnosed, Ms. Contractor's doctor advised her that if she wanted to have children someday, she could improve her chances by undergoing, before treatment, a procedure to remove and freeze some of her ovarian tissue, as part of a research study. The tissue would be reimplanted or used to mature eggs outside the body at a later date if she chose to try to have children. The method is still considered experimental, though reimplantation has been shown to work in some cases.

"I pretty much immediately said yes," says Ms. Contractor, now 16 and in remission after undergoing the fertility-preservation procedure and cancer treatment at the Children's Hospital of Philadelphia. "I've always wanted kids."

She is among a growing number of pediatric cancer patients undergoing fertility-preservation techniques before treatments known to damage the reproductive system.

Rising cure rates mean that more kids with cancer are surviving into adulthood, when they may want the option of having children of their own. Doctors say the infertility risk deserves as much attention as other residual health problems for childhood cancer survivors.

"Our job is more and more not only curing a child's cancer, but curing a child's cancer so that they have as normal as possible health as an adult," said Lisa R. Diller, chief medical officer of the Dana-Farber/Boston Children's Cancer and Blood Disorders Center.

Some children and their parents say the fertility discussion provides a ray of hope because it implies an expectation that the child will survive into adulthood.

The diagnosis "was already a big blow to us," said Ms. Contractor's mother, Ghazala Contractor, a pharmacist. "This sort of actually gave us hope, and gave her hope that something positive could come out." Her daughter, a high-school student, wants to become a pediatric oncologist someday.

About 12,000 new cases of pediatric cancer are diagnosed annually, with leukemia and tumors of the brain and central nervous system among the most common types, according to the National Cancer Institute.

Treatment advances have caused death rates to drop by 66% for childhood cancers over the past four decades, according to the American Cancer Society. About 83% of children with cancer live at least five years, up from 58% in the mid-1970s. Many are considered cured after treatment.

However, some of these treatments can be toxic to the reproductive system, including bone-marrow transplants, radiation administered to the pelvic region and certain drugs known as alkylating agents.

Fertility-preservation techniques for children range from the proven to the experimental, depending on a child's age and gender.

Boys who have reached puberty can produce a sperm specimen that can be frozen for years, then thawed and used at a later date to try to fertilize a woman's eggs. Jill P. Ginsberg, an oncologist who leads the cancer survivorship program at the Children's Hospital of Philadelphia, said male patients at her hospital are routinely referred to a sperm bank before undergoing treatment.

Physicians' conversations with boys and their parents about sperm-banking can sometimes be awkward because it involves talk of masturbation. But oncologists say they've gotten better at speaking matter-of-factly and confidently about potential benefits, while families have become more comfortable with such topics.

Boys unable to produce a sperm specimen can undergo a technique known as electro-ejaculation, in which an electric current is administered under general anesthesia to produce a sample.

There is no proven method of fertility preservation for boys who haven't yet reached puberty. Some as young as infants undergo a technique that involves taking a biopsy from the testicles and freezing it. Researchers hope it will become possible to later harvest stem cells from the preserved tissue, and reimplant them into the testicles to allow sperm production.

After successfully using the technique to produce offspring in lab rodents, Ralph L. Brinster, professor of reproductive physiology at the University of Pennsylvania's School of Veterinary Medicine, is testing ways to enable the method to work in humans.

Like adult women, girls who have reached puberty can undergo cryopreservation, or freezing, of embryos. However, that requires a sperm donor, something that may not be feasible for single female teenagers. Another, more experimental option involves freezing the oocyte, or immature egg, a technique that has resulted in some pregnancies.

But it can take a couple of weeks to harvest an egg for freezing, which for some patients is too long to delay treatment. For them, or pre-pubertal girls, freezing of ovarian tissue is an option. The experimental method of reimplanting the tissue later, when the woman is ready to have a baby, has worked in a handful of cases.

There are risks. Some research has raised concerns that reimplanting ovarian tissue taken from girls with certain cancers could reintroduce cancerous cells. To minimize anesthesia risks, the more invasive fertility-preservation procedures are sometimes performed when a patient is already under sedation for a separate procedure. Ms. Contractor, for example, had her ovarian tissue removed while under anesthesia to have a catheter inserted in her chest.

Ethical and cost considerations also enter the mix. While parents may make the fertility-preservation decisions for younger children, Arthur Caplan, professor of bioethics at New York University's Langone Medical Center, said children around 10 and older who have demonstrated maturity should have a say.

Families should understand that the more experimental fertility-preservation methods might not work, said Dr. Ginsberg. They also need to decide what should be done with preserved reproductive material if a patient dies, ideally spelling out the options in a written consent agreement.

Sperm-banking can cost several hundred dollars in upfront and annual storage fees, while the costs of embryo and oocyte preservation typically run at least several thousands of dollars. Insurance coverage varies.

Write to Peter Loftus at peter.loftus@dowjones.com

A version of this article appeared September 3, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: Young Patients Face Fertility Choices.

Article can be accessed here: http://online.wsj.com/article/SB1000142412788732400930457904294230973339...

 

 

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