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t m c » p u l s e | m a y 2 0 1 6 17 We said, 'We still have this dream and desire of having kids.' For them to say, 'We can integrate that into the plan of what we're going to do and how we proceed forward,' it gave us total comfort and peace of mind. — MICHAEL LINGERFELT Father-to-be A n ultrasound screen lights a small room at Texas Children's Pavilion for Women. Patricia and Michael Lingerfelt watch with bated breath as the image of a 13-week-old fetus flickers onto the screen—their first child, a girl. It's a sight that, at times, the Lingerfelts thought they might never see. In 2014, after years of trying to have a child, the couple was dealt an additional blow: a routine annual exam and mammogram showed Patricia had breast cancer. The call came a week before they were scheduled to see an IVF specialist. The cancer diagnosis was frighten- ing enough in itself, but for the cou- ple, already in their 40s, it presented another setback to starting a family that they never expected. "The very first doctor who gave me the diagnosis told me I would not be able to have kids, that I could just kiss that goodbye," Patricia said. "At that point, I'm already devastated. One, I have cancer, and two, the doctor is saying I will not be able to have kids ever. When I got to MD Anderson, find- ing out that there was still a possibil- ity changed everything." During a pre-surgery appoint- ment at The University of Texas MD Anderson Cancer Center, Patricia happened across a pam- phlet about preserving fertility before, and building a family after, cancer treatment. For a couple whose hopes for a family had so recently been dashed, it felt like fate. That was their first introduction to Terri Woodard, M.D., a reproductive endocrinologist who holds joint appointments in MD Anderson's Department of Gynecologic Oncology and Reproductive Medicine and Baylor College of Medicine's Division of Reproductive Endocrinology and Infertility. The American Cancer Society estimates over 800,000 women are diagnosed with cancer in the United States each year. A cancer diagnosis brings numerous questions and fears—"What stage is it? Will I need surgery, radiation or chemother- apy? What is my long-term prog- nosis?" With so many immediate concerns, thoughts like, "How will this affect my future fertility?" can easily fall by the wayside. A close relationship between MD Anderson and Texas Children's Hospital seeks to ask that question before it's too late, and to make its answer a part of treatment plans. Patricia and Michael had their first meeting with Woodard before Patricia's surgery. Luckily, her cancer was stage one and would not require chemotherapy. The plan was for her to undergo a lumpec- tomy surgery, followed by six weeks of radiation treatment. Through close teamwork between Woodard and Patricia's oncology team, the Lingerfelts saw their desire to have children worked into her care plan from the very first step. "It's hard for me to put into words how we went from being ner- vous and scared to just comforted and reassured, feeling like we knew what was going to happen from that very first visit," Michael said. "We said, 'We still have this dream and desire of having kids.' For them to say, 'We can integrate that into the plan of what we're going to do and how we proceed forward,' it gave us total comfort and peace of mind." The American Society of Clinical Oncology published its first guidelines for fertility pres- ervation in cancer patients back in 2006, but it's still a topic that is not routinely discussed among all cancer patients. Furthermore, few cancer centers even of the caliber of MD Anderson have a reproductive expert actually embedded in the center as Woodard is. The spirit of collaboration that is a central part of the Texas Medical Center makes it easier for patients to deal with such a complex issue. "One of the big barriers in fertil- ity preservation in general is trying to navigate the system. Having to go out to another practice some- where and tell your story again," Woodard said. "Here, I talk with the oncologist every time I see the patient. Everyone is on the same page. When the patient is done getting her eggs harvested, we call the oncologist and say, 'She's done. She's all yours.' It really makes for streamlined care. Patients like Patricia come to Woodard in a variety of ways. Some are referred by their primary provid- ers, some come across pamphlets like the one Patricia found, and oth- ers are already cancer survivors who never had the opportunity to talk Terri Woodard, M.D., a reproductive endocrinologist with joint appointments at MD Anderson and Baylor College of Medicine. about their fertility before treatment and are curious about their options. Each consult with Woodard involves several major parts. First, they discuss medical history and determine the patient's current ovar- ian status—and whether there is any prior history of infertility. "Based on that assessment we talk about their risk for infertility based on their testing, their age, their medical history," Woodard said. "From there, we move into the different options for fertility preservation. We talk about the pros and cons of each of those, the time required, the costs and the side effects." Cancer treatment affects fertility in a variety of ways: Chemotherapy drugs can damage or destroy a woman's eggs, or cause early meno- pause. The intense energy used in radiation therapy can also dam- age the eggs. The type of surgery required for certain cancers may remove integral parts of the repro- ductive system, including ovaries, uterus, cervix and surrounding tissue. Finally, some medications recommended for use after treat- ment, such as tamoxifen, essentially require the use of birth control because they can cause severe birth defects. While tamoxifen itself does not cause infertility, the now 10 years recommended use can put a woman past childbearing age. The main options offered to women prior to treatment are egg or embryo cryopreservation, or freezing.