Hospital Explores Fertility Fix for Cancer Patients- National Post

Canadian doctors exploring ‘radical’ new procedure that promises to save fertility of child cancer patients

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 | June 29, 2014 11:31 PM ET
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Dr. Abha Gupta, staff oncologist at The Hospital for Sick Children, poses for a photograph at the hospital on Thursday, June 26, 2014. Dr. Gupta is researching fertility preservation in paediatric cancer patients.

Matthew Sherwood for National PostDr. Abha Gupta, staff oncologist at The Hospital for Sick Children, poses for a photograph at the hospital on Thursday, June 26, 2014. Dr. Gupta is researching fertility preservation in paediatric cancer patients.

Canadian doctors are looking at offering a fascinating new procedure for saving the fertility of pre-pubescent cancer patients, where pieces of ovary or testicle are frozen before toxic treatments, then transplanted back years or decades later.

A national study recently found strong support for the service among parents and health-care workers, and at least one hospital is actively exploring the experimental techniques.

Scientific and ethical questions still hang over the concept, and a little-known Canadian law could actually prevent lab research on it here.

But the ovary procedure has already produced almost 40 babies elsewhere, and raised the prospect of remarkable spin-off benefits that could transform the lives of healthy older people, too.

Why wouldn’t you want a nice, young ovary in the freezer?

Some experts say transplanting younger, preserved ovaries into middle-aged women might stave off or even eliminate menopause altogether.

“This whole thing sounds very, very radical … [But] it isn’t some wild idea or theory I’m throwing at you. It’s all backed up by data,” says Sherman Silber, an American obstetrician-gynecologist and pioneer of the technique. “Why wouldn’t you want a nice, young ovary in the freezer?”

The procedures’ most conventional applications lie with child cancer patients, who are increasingly likely to be cured by modern medicine, but are often left unable to have children.

For patients at or beyond puberty, egg or sperm samples can be taken and frozen for future use — a relatively novel process itself called “onco-fertility.” Until now, though, there was no way to reverse the sterilizing effects of chemotherapy and radiation on the youngest of patients — babies, toddlers and grade-schoolers.

A national study of parents, cancer survivors and health-care workers in Canada recently found strong support for offering even the more experimental testicular procedure, a conference of the Canadian Bioethics Society heard last month.

Toronto’s Hospital for Sick Children is now doing the ethical and legal groundwork for eventually offering at least the male procedure, said Dr. Abha Gupta, the Sick Kids oncologist who spearheaded the study.

Matthew Sherwood for National Post

Matthew Sherwood for National PostDr. Abha Gupta, staff oncologist at The Hospital for Sick Children, poses for a photograph at the hospital on Thursday, June 26, 2014.

Yet the concept faces a major impediment in Canada. Continued research is needed, especially to determine exactly how to use that frozen, prepubertal testicular tissue to create sperm. Federal legislation, however, bans scientific experimentation on reproductive material from anyone under 18, said Dr. Gupta.

“It’s truly obsolete and quite a barrier,” she said. “We’re not protecting children, we’re actually preventing science from moving forward.”

Chemotherapy leaves almost half the boys with cancer unable to produce sperm and brings on menopause as early as the late 20s for many girls, while radiation and stem-cell transplants can render some girls infertile, said Dr. Gupta.

Even amid the life-and-death drama of the cancer ward, it seems those risks are taken seriously by patients and parents. The Sick Kids oncologist encourages doctors to overcome a traditional reluctance to discuss fertility preservation, and says families are invariably thankful when the topic is raised.

For pre-pubertal children who cannot produce mature eggs or sperm for preservation, the new ovarian-transplant procedure is at the most advanced stage.

Thin slices of one of two ovaries are removed in a procedure that Dr. Silber said is less invasive than extracting eggs, and lasts as little as 15 minutes. The excised tissue is later grafted back onto the remaining ovary.

Vardit Ravitsky, a University of Montreal bio-ethicist, worked with a team in Israel which took ovary tissue from girls as young as three.

“Most of these parents desperately want to have grandchildren,” said Dr. Silber. “The parents are very highly motivated.”

Most of these parents desperately want to have grandchildren

It will be years before tissue is transplanted back into those young girls, proving whether the procedure works for them. At Dr. Silber’s Infertility Center of St. Louis, though, he has grafted preserved tissue into 22 older patients whose ovaries were mature when they had cancer treatment.

Just under 60% had babies — 15 in total. About 37 births have occurred worldwide.

The testicular procedure is less developed. It involves freezing spermatogonial stem cells, sort of baby sperm, then transplanting them back into the testicles. Studies in mice have successfully made male animals fertile again, but human evidence is so far lacking.

The field is also clouded by ethical issues, including the financial burden on parents of storing frozen tissue for years, and whether that would put undue pressure on survivors to have children.

Evidence also suggests that cancer cells could be reintroduced during transplants, though techniques are being explored to negate the risk. Dr. Silber said all 22 of his transplanted patients remained cancer-free.

They’re cured of cancer and now they have a 17-year-old ovary in the freezer just waiting for when they need it

Despite the unresolved issues, Prof. Ravitsky said she believes parents of young, pre-pubertal children should at least be offered the choice of having tissue extracted, “rather than have regrets later.”

“It’s a complicated topic, at a complicated time for the family, with very little data,” she said. “[But] it’s a parent’s responsibility and ethical obligation to do anything they can to allow their child in the future to make those decisions.”

In the meantime, Dr. Silber has already removed tissue from healthy women who desire simply to have young ovaries as they age. The process offers the potential to delay menopause — and extend child-bearing potential — for decades, and evidence from animal studies suggests that could actually help women live longer, said Dr. Silber.

The number and quality of eggs declines dramatically over the years, meaning teenagers who have frozen ovaries re-implanted during their early 30s gain a substantial fertility benefit, an exciting prospect for many young patients, he said.

“They talk about how grateful they are,” said the physician. “They’re cured of cancer and now they have a 17-year-old ovary in the freezer just waiting for when they need it.”

National Post

• Email: tblackwell@nationalpost.com

Shoebox IVF hope for infertile couples – BBC News

‘Shoebox IVF’ hope for infertile couples

By Cathy EdwardsBBC Health Check

IVFTraditional IVF can prove too expensive for many

Could an IVF kit that fits in a shoebox and some kitchen cupboard essentials provide hope for people who long for children?

Infertility is a source of distress the world over, but in many places the terrible stigma attached to childlessness makes it even harder to bear.

The answer could be a pared-down system that can fit inside a shoebox and uses cheap ingredients you might find in a kitchen cupboard.

In the past infertility has been neglected in developing countries, partly because of a focus on controlling overpopulation.

But experts argue that true reproductive health has to address both sides: family planning for those who want to avoid pregnancy, and fertility treatment for those who long to have children but can’t conceive naturally.

Nosiphiwo, from South Africa, had been trying to conceive for years when her husband’s family asked her for their lobola back – the bride price they paid when she married their son.

She was ostracised by her in-laws for being childless, and felt cut her off from the rest of her community too. She says women in her situation sometimes turn to suicide.

“I thought of doing that. Because you don’t have any option.”

Sophisticated labsThe prohibitive costs of fertility treatment mean that worldwide, most couples cannot afford it – though their desperation can be such that many become destitute trying to pay for it, selling property or going into debt.

One of the biggest obstacles is the cost of the complex, sophisticated labs where “in vitro” egg fertilisation takes place.

tray of baking soda and a wedge of lemonThe carbon dioxide needed to create the right conditions for the embryo was made using baking soda and citric acid

Belgian obstetrician Dr Willem Ombelet worked in South Africa in the 1980s and saw many cases like Nosiphiwo’s.

He carried out IVF treatment for those who could afford it. Those who couldn’t came to the hospital on other pretexts – but the real reason was their longing for a child.

“They would wait shyly around the corner and ask if there was anything we could do for them.”

Back then, the heartbreaking answer was no.

But he has campaigned ever since to improve global access to infertility care, co-founding The Walking Egg non-profit organisation to raise awareness of fertility in developing countries.

DIY embryo transport

Willem Ombelet in front of art installationWillem Ombelet teamed up with artist Koen Vanmechelen to raise awareness of infertility in developing countries

The centrepiece of the Walking Egg’s mission is a simplified system for egg fertilisation.

Continue reading the main story

“Start Quote

The embryos didn’t care if they were in an expensive triple walled incubator or a thermos flask.”

Professor Jonathan Van BlerkomEmbryologist, University of Colorado

The best conditions for a sperm to fertilise an egg outside the body are slightly alkaline, at a temperature of 37C (98F).

Usually this involves a sophisticated laboratory equipped with huge ventilators, complex incubators and a supply of expensive gases.

But when Dr Ombelet met the embryologist Jonathan Van Blerkom in 2008 the idea of a cheap, portable lab was born.

Van Blerkom revived a technique he used in the 1980s when transporting cow embryos long distances across Nebraska.

By mixing baking soda and citric acid he created his own CO2, periodically adding it to the solution holding the embryos to maintain the optimal CO2 concentration and alkalinity levels.

IVF in a shoeboxFor humans the technique had to be refined to create a closed system and thus minimise any risk of contamination.

Eight test tubes in a metal block, in pairs connected by plastic tubingThe test tubes are held inside an aluminium heating block

Precise quantities of citric acid and sodium bicarbonate are mixed in one test tube. The CO2 bubbles this creates are fed via a tube into a second test tube containing a culture medium for the embryo.

To maintain the perfect temperature for egg fertilisation and embryo development, Van Blerkom tried out various low-tech methods.

“I put the test tubes into a thermos at the right temperature – that worked. I put them in an aluminium heating block, and that worked too. The embryos didn’t care if they were in an expensive triple walled incubator or a thermos flask.”

Once the atmosphere has stabilised, the egg and then the sperm are injected into the test tube containing the culture medium.

The next day this test tube goes under a microscope to see if it contains an embryo – meaning egg fertilisation has taken place.

If a successful embryo is created, it is transferred from the test tube to the woman’s womb after about six days.

This simplified system reduces the whole IVF lab to an aluminium heating block containing one pair of test tubes for each embryo, all inside a shoebox-sized container.

IncubatorThe whole system would be housed in a self-contained incubator in places without access to sterile labs

For additional safety the human trials of the system have so far been conducted inside a sterile laboratory.

The team are developing a self-contained unit to house the system in hospitals or health centres that don’t have advanced lab facilities. This would provide heated, sterile air and space to examine the embryo under a microscope.

The researchers believe that – because of the closed nature of their system – this unit is not strictly necessary, but will help convince health authorities of the quality of the system.

“Embryo quality”Trials began in Genk, Belgium in 2012, and so far 17 healthy babies have been born using the system.

Dr Ombelet is thrilled with their preliminary results, saying they indicate fertilization and pregnancy rates are similar to expensive IVF methods.

“We have proved that with our system embryo quality is at least as good as with regular IVF.”

Geoffrey Trew, a consultant in reproductive medicine and surgery at Hammersmith Hospital in London who is not connected with the research, agrees this is an exciting technique.

“It has been shown to work in a developed country. Now we’ve got to see how well it is reproduced in the developing world where the conditions are more fickle.”

Fertility on a shoestringThe trials are due to be rolled out in South Africa and the UK later this year, and the team hope that by early next year the system can be tested in the kind of low-resource settings it was designed for.

Each IVF cycle costs less than 200 euros (£159) using this system, not including staff and medication costs, which vary from country to country.

But Dr Ombelet says they can decrease the normal price for IVF in any given country by at least 70-80%.

“With very low dose medication schemes we hope to perform IVF in developing countries for less than 500 euros (£399)”

Prof Thinus Kruger and Dr Matseseng are fertility experts from Tygerberg Hospital in Cape Town.

They already have a special fertility programme that cuts costs by economising on medication and staffing – Nosiphiwo was one of the many women who was helped to conceive by this programme.

Nosiphiwo eventually conceived through a low cost fertility programme in Cape Town

Now they want to see how the tWE system compares to their normal laboratory procedure.

“It’s really theoretically amazing,” says Professor Kruger.

“But we will have to see how patient and scientist friendly this system is. It is a little lab, so you still need the knowledge to handle those small embryos.”

Prof Van Blerkom believes that efforts to bring the cost of fertility treatment down would please the IVF pioneer Robert Edwards, whose work led to the birth of the first test tube baby, Louise Brown.

“People can make fortunes through IVF. But Bob Edwards was a real believer that IVF should be universal, because he knew the suffering that infertility caused.”

Listen to The Truth about Life and Death: Fertility on a Shoestringon the BBC World Service on Wednesday 25th June 1932 GMT.

 

NPR- Painful Path to Fatherhood Inspires Poet’s New Collection- NPR Staff

Painful Path To Fatherhood Inspires Poet’s New Collection

by 

Douglas Kearney’s new book of poetry, Patter, is not something you pick up casually. It demands a lot from its audience — one reviewer wrote that the book’s readers must be “agile, adaptive, vigilant and tough.”

But the payoff is worth it. Kearney takes his readers into an extremely private struggle, shared with his wife: their attempt to conceive a child. The poems trace a journey through infertility, miscarriage, in vitro fertilization and, finally, fatherhood.

The book’s acknowledgements include an unusual note: “Thank you to the Mrs. Giles Whiting Foundation, whose generous award paid for the IVF procedure that made much of this book possible,” Kearney writes.

“We literally paid for the procedure with some of this prize money. You know, a lot of prizes and grants that artists and writers can receive, you actually have to produce something,” Kearney tells NPR’s Rachel Martin. “Not necessarily a child — or, in our case, two. But I wanted to acknowledge that here.”

Kearney and his wife spent eight years trying to conceive before they tried IVF; now, they’re the parents of twins. The poet tells Martin about the emotionally complicated process of achieving fatherhood, and the heartbreaks along the way.


Interview Highlights

On whether he was prepared for the emotional pain of trying to conceive

I had family who’d been through a number of miscarriages. So I was expecting that there was going to be a certain level of difficulty — that it was going to be, you know, really an emotionally harrowing experience.

But nothing actually prepares you for what it feels like to go through this. I mean, the miscarriage. … I almost got into a fight at a drugstore the day we found out. It was just — it was just really difficult.

And even when I was writing about it, I kept trying to write something that would feel like it. You know, I tried to make it so that I could write a poem that a reader would, would take in and they would go, ‘Oh, my gosh, that’s what that feels like.’ And of course, all of those things failed because I ended up either magnifying it so much and then second-guessing myself and turning it into this sort of allegorical thing, or, you know, just completely underwriting it.

And it was a very difficult process to deal with just from an emotional, psychological processing standpoint — let alone to try to make some art from it.

On the real-life experiences that inspired this poem:

The Miscarriage: A Bar Joke

two guys walk into a bar. first guy says “yo guy, why so down?” second guy replies, “my wife just had a miscarriage.” first guy says “I know exactly how you feel, I just had my girl get an abortion!”

I had two male friends, on two separate occasions, take me out after the miscarriage, and each one of them talked about a girlfriend. One had had his girlfriend get an abortion, and the other had been worried that she might be pregnant, but it hadn’t taken.

At the time, there’s this huge mix of feelings, of this anger — ‘How dare you compare your not wanting a kid with my wanting a kid?’

And so there was that, but there was also this real thing which is, how are men supposed to talk about this? What are we supposed to say to each other when this happens? And I didn’t think of it ultimately as a purely gross miscalculation, it really was this attempt … you just have to laugh about it later.

I mean, this poem in particular took a while to get to because it was — there was a lot of anger, and that was what was coming out in those earlier versions of this poem. And I wanted it to be a little less like I was throwing these guys under the bus for really, actually, trying to help me, but we just didn’t have the tools.

On the twins Kearney and his wife had — and the children they didn’t have

With IVF, if you end up having a lot of eggs, the doctor will … attempt to fertilize them all. And after you’ve had a success, you suddenly have to have this question of, ‘What do we do with the other ones?’ And there’s not a rule of what you’re supposed to do.

And, you know, these are full siblings — it’s not half, it’s not potential, they are their siblings. One day, we’re going to have to explain that to them. …

I think that [the twins] should know a bit about what it took to bring them here. That they are special, you know, that we wanted them so badly — and here they are.


Poems

You can hear Kearney read these poems, as well as “The Miscarriage: A Bar Joke,” in the interview audio above.

The Miscarriage: A Magic Trick

1. stash scarlet silks in a lady’s skirt.
2. plant her among the crowd.
3. call your shill to the dias.
4. lay her on your table.
5. conceal her with your bed sheet.
6. distract the crowd with patter.
7. apply a sleight between her thighs.
8. take hold the silk’s loose corner.
9. pull till it pools on the floor

PRESTO!

New Parents

pick through your blood but you won’t find
what must be done with the others
the ones in ice, where you belong

choosing worries you in its mouths:
lose them to strange names and houses
board them ever in dear freezers
or let them thaw and spoil?

those you’ve chosen doze under wool
think of all the nights cool siblings
take them hand-in-hand and lead them
down the bleak rounds to your judgment

and when their cries rise through night’s slab,
driving you, beset against their cribs,
do they grieve for those whom they have lost
or what they must have:
Your eyes burnt with love,
Your teeth keen on silence?

From Patter by Douglas Kearney. Copyright 2014 by Douglas Kearney. Excerpted by permission of Red Hen Press.

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National Post- The Fertility Clinic Guessing Game- Tom Blackwell

The fertility clinic guessing game: Canadians have no way to find out success rates of pricey IVF treatments

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 | June 22, 2014 1:35 PM ET
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Rhonda Levy, founder and CEO of Empowered IVF, at her home in Toronto. Levy, who had twin boys using IVF, wants clinics to make statistics on their success rates available to potential clients.

Matthew Sherwood for National PostRhonda Levy, founder and CEO of Empowered IVF, at her home in Toronto. Levy, who had twin boys using IVF, wants clinics to make statistics on their success rates available to potential clients.

Even as the  U.K. and U.S. break new ground in medical transparency, Canadians know relatively little about how their health facilities perform. Saturday we asked why surgeons’ OR results are not published. Today: how Canada lags in reporting success rates of fertility clinics.

For all Rhonda Levy knew when she sought out fertility treatment 20 years ago, one clinic offered much the same odds of having a baby as another.

Then she endured three fruitless rounds of artificial insemination and four of in-vitro fertilization with her chosen facility, at a cost roughly equivalent to a high-end luxury sedan.

When Ms. Levy finally switched clinics, she conceived after the first IVF treatment she received.

The experience left the former high-finance lawyer convinced that the quality of Canada’s many fertility centres varies enormously.

For patients seeking out the pricey, emotionally wrought service, however, choosing the right facility is virtually a guessing game.

There has to be some way for patients, who are making such a profoundly important choice … of conducting an analysis of what their odds for success might be

Government agencies in both the U.K. and the United States require clinics to report their success rates — how many pregnancies or births they produce per treatment — which are then published online. Despite the growing popularity of the largely for-profit business in Canada, this country lacks any independent source of information about which clinics will give patients the best chances of having a child.

In fact, a federal agency tasked with at least collecting that data — and possibly releasing it — was disbanded a year ago.

“There has to be some way for patients, who are making such a profoundly important choice, … of conducting an analysis of what their odds for success might be,” said Ms. Levy, now a Toronto-based consultant who guides others through the process. “It’s better than having to take a completely blind leap of faith.”

Hard evidence from other countries suggests that results can differ markedly from clinic to clinic, arguably due in part to varying abilities at creating embryos and transferring them into patients’ uteruses.

Some doctors in the specialty, while warning of possible pitfalls, agree it may be time to take action here.

“I think there’s a lot of value in trying to provide transparency and honesty to patients,” said Tom Hannam, who heads a Toronto-based clinic. “If there’s a good painter for your house and a bad painter, you want to know which is which. It’s probably the same for fertility clinics.”

Meanwhile, getting medical help to have children continues to surge in popularity, with 23,000 treatment cycles performed in 2011 at 32 clinics across the country, up 50% just since 2008. It can be lucrative work; a recent Quebec lawsuit indicated that the director of a Montreal clinic was earning more than $1.5-million a year as long ago as 2005.

AP Photo/Sang Tan

AP Photo/Sang TanIn this Aug. 14, 2013, photo, an embryologist works on embryo at the Create Health fertility clinic in south London.

Patients spend as much as $10,000 per in-vitro cycle, not including the cost of ovary-stimulating drugs. Quebec is the only province where IVF is routinely subsidized by medicare, though the Ontario government has promised to follow suit.

The association representing assisted-reproduction physicians and other professionals has for years collected statistics on its members’ work, with a small sub-committee examining clinic-specific success rates and even offering remedial help to outliers who fall well below the average.

But the Canadian Fertility and Andrology Society [CFAS] has always rejected the idea of letting the public see those individual-clinic results, suggesting the figures could be misleading to patients — and potentially prompt dangerous changes in practice.

Different couples have different chances of getting pregnant depending on their medical condition, and success rates do not necessarily reflect the mix of patients at each clinic, said Al Yuzpe, head of Vancouver’s Olive Fertility Centre and a spokesman for the CFAS.

The fear has always been that clinics would try to goose their statistics by cherry-picking the easiest cases to treat, leaving more challenging patients in the cold, he said.

“If patients just look at the number as an isolated number, they can’t really appreciate the clinic for how good it is,” said Dr. Yuzpe.

South of the border, complaints about the public reporting of success rates are common, said Dr. Hannam, though he still favours releasing the numbers.

If there’s a good painter for your house and a bad painter, you want to know which is which. It’s probably the same for fertility clinics

“It has dramatic implications on the financial health of that clinic,” he said. “They feel themselves under immense pressure to distort their practices in ways that, as clinicians, they don’t want to do.”

Proponents of the idea respond that the information could be adjusted to reflect patient characteristics, and that some transparency, even if flawed, is better than none.

The experience elsewhere shows that odds do differ from practice to practice, sometimes dramatically. The chances of giving birth after a fresh-embryo IVF treatment at clinics in Australia and New Zealand, for instance, ranged from 3.6% to 25.9% in 2011, a university research team reported.

The report cautioned that the blend of patients at individual facilities, and the small number of procedures in some could skew the results. A 2010 study, though, found that a wide, three-fold range in pregnancy rates between clinics in the Netherlands narrowed only slightly when patient attributes were factored in.

“If you look across Canada, there is variation among clinics,” argued Art Leader, head of the Ottawa Fertility Centre. “People are putting a lot of their hopes, emotions in the treatment they’re getting. … It would be nice to know what the chances are in the clinics they’re going to.”

In the United States, Congress passed legislation more than 20 years ago that requires clinics to report their rates to the Centers for Disease Control (CDC), after some facilities were accused of putting out false results to lure customers.

The CDC website offers up a variety of figures, including percentage of single births, triplet births and pregnancies per IVF cycle, for several different age groups. It does not factor in other patient characteristics that might affect outcomes, though. Still, the high, out-of-pocket cost of the service makes reporting results particularly critical, argued Dr. Dmitry Kissin, head of the agency’s assisted-reproduction team.