TMC PULSE

t m c » p u l s e | m a y 2 0 1 6 18 cause an increased risk of breast and ovarian cancer, made some patients hesitant to have biological children, not wanting to pass that gene to future generations. Thanks to the advent of preimplantation genetic diagnosis (PGD), it's now possible to test embryos for specific genetic conditions, like BRCA muta- tions, before implantation and then use only those embryos without the condition. A more experimental option for preserving fertility that is not widely available is ovarian tissue freezing. This involves surgically removing pieces of ovarian tissue. This is the only fertility preservation option for girls who have not gone through puberty yet. "In that ovarian tissue, there are immature eggs," Woodard said. "The tissue is frozen and after treat- ment you can thaw and re-implant it. Almost 70 babies have been born this way." Researchers are working on maturing eggs from this tissue in the lab so that one day, they won't even have to transplant the tissue back into the body. Though this option is not currently offered at MD Anderson, Woodard said they are working on a protocol to get a program up and running in the future. Another fertility preservation option is ovarian suppression— using injectable medications called gonadotropin-releasing hormone agonists to make the ovaries quies- cent during treatment. "It's thought that an ovary that is not actively cycling might be more resistant to chemo than one that is," Woodard said. "However, this is experimental, and the data is mixed about whether it really works or not. But for most women, the risks of using it are low and if a woman is willing to try it, it might be better than nothing." In terms of the issue with tamox- ifen, some patients will opt to take it for several years, then stop while they try to conceive and restart once again after the child is born. Other patients may opt to delay tamoxifen to try to have a child immediately, or even delay indefinitely. While there are more options today than even just a few years ago, Woodard said after consulting with patients and oncologists, sometimes For both of these processes, hor- mone injections stimulate the ova- ries to produce multiple eggs. The eggs are then retrieved while the patient is under sedation, and either immediately frozen or fertilized with sperm, in the case of embryo freezing. The embryos are allowed to develop for several days and are typ- ically frozen. For Woodard's patients, these processes take place at the Family Fertility Center in the Texas Children's Pavilion for Women. "Until a few years ago, we didn't do a very good job of freezing eggs," Woodard said, noting that the water content in eggs lent itself to the formation of ice crystals, which can damage the eggs to the point of destruction. "Now we've become a lot better at it, so that has really expanded the options for women who don't have a partner at the time of treatment and don't want to have to pick a sperm donor. Furthermore, it gives women reproductive autonomy; her eggs will always be her eggs." Another recent improvement that has made egg and embryo cryopreservation a more viable option for women is the fact that it's no longer dependent on a woman's natural cycle. The process used to take up to eight weeks, and many patients simply did not have the time to delay treatment for that long. "We've come a long way in realizing that we can do what's called a random start. We can start a stimulation at any part of a wom- an's cycle," Woodard said. "I had a patient that the day I met her, she started her stim that night. Twelve days later she had her retrieval, and that night she was getting her chemo. We can do this in less than two weeks now." Even with these options avail- able, the discovery that mutations in the BRCA1 and BRCA2 genes can Top left and bottom: Khalied Kaskar, embryologist and laboratory manager at Texas Children's Hospital Family Fertility Center, uses a pipette to move an egg in a drop of culture media. Top right: A five-day-old embryo, or blastocyst, contains two types of cells—the inner cell mass, which will develop into the fetus, and the trophectoderm cells, which will develop into the placenta. We want women to know their dreams of motherhood don't have to be squashed. There are so many ways to build families now, and if they're open to it, they can still be a parent. — TERRI WOODARD, M.D. Reproductive Endocrinologist at MD Anderson's Department of Gynecologic Oncology and Reproductive Medicine and Baylor College of Medicine's Division of Reproductive Endocrinology and Infertility

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