Realizing Dreams

Winter 2013

For a time in 2004, Angela Boylan’s life seemed charmed. She had just married the man she loved in a beautiful wedding on Wachusett Mountain. Angela and her husband, Pablo Ruiz, began eagerly making plans to start a family. But within a few months, that dream looked as though it had come to an abrupt end when, at the age of 34, she was diagnosed with a rare form of uterine cancer.

Above: Angela Boylan, Pablo Ruiz and their sons, Naoise and Cian.

The first doctor she saw at a local hospital told her the cancer was curable but only if she underwent a hysterectomy, a procedure that the doctor urged her to have in three weeks. Even worse, the doctor told her that there was no chance of them ever having a child. A second doctor at a different hospital delivered a similar diagnosis and treatment plan.

Although Angela’s overall prognosis appeared good, the couple was devastated by what her cancer treatment seemed to mean for their dream of having a family.

But Angela, a native of Ireland, was determined to look for hope in any situation. She used her network and all the resources available to her and through a combination of perseverance and serendipity, Angela connected with a friend who put her in touch with a cancer specialist at Massachusetts General Hospital.

That doctor let her know that Mass General’s In Vitro Fertilization Unit was achieving promising results with fertility preservation. He referred her to Thomas Toth, MD, the director of the IVF Unit (which is part of the MGH Fertility Center), who is well known for his compassion as well as his expertise in fertility preservation technology.

Until recently, fertility preservation was not a typical part of cancer treatment discussions. The focus was on survival. In spite of Mass General’s long and accomplished history of providing IVF services, cancer patients were not routinely referred to the fertility center. In 2010, led by John Petrozza, MD, chief of the MGH Fertility Center, the departmental leadership decided to develop a more formal fertility preservation program for cancer patients.

The timing was right to develop this program. Technology offered more fertility options and cancer patients like Angela were seeking information and options on their own. “Thanks to better screening and early detection techniques, we were seeing patients who were of reproductive age with cancers that were quite treatable,” Dr. Petrozza says. “And good survival rates meant that patients could think about life beyond cancer.”

Mass General had all the components, starting with a respected fertility center located in the same facility above one of the best cancer centers in the country. On the research front, colleagues from IVF and the Mass General Cancer Center had been collaborating for nearly two decades to develop methods that would achieve higher success rates with freezing unfertilized eggs.

“What really makes our collaboration with the cancer center unique is that we can help with the whole spectrum of care for patients diagnosed with cancer,” Dr. Petrozza points out. Patients may experience other problems — premature ovarian failure, sexual dysfunction or irregular bleeding, for instance. Mass General has a team of experts who can step in and provide comprehensive care to address these and other issues.

The vision was in place, but the challenge was to pull all the pieces together. Because of her background, Mary Sabatini, MD, PhD, was chosen by Dr. Petrozza to spearhead this vital program. Dr. Sabatini had extensively researched IVF outcomes of cancer patients during her reproductive endocrinology and infertility fellowship. She became interested in this area when caring for a young woman with breast cancer who eventually wanted children. Treating this patient showed Dr. Sabatini just how complex a cancer diagnosis was for young patients and how little information was available about clinical outcomes.

The launch of the new fertility program reflected Mass General’s tradition of focusing on the patient’s quality of life while also pursuing innovative disease treatments. Dr. Sabatini initially met with a number of cancer center physicians along with Sally Hooper, LICSW, director of Mass General Cancer Center’s Blum Cancer Resource Room. Together, the team developed a new model of care for cancer patients with fertility concerns. Now called the Cancer and Reproductive Health Program, one of the major goals is to help recently diagnosed cancer patients understand options to protect their fertility. As part of this process, the group created a fertility and cancer pamphlet.

“We wanted to give patients a way to initiate discussion and ask for a consult themselves,” Ms. Hooper says. “It also raises awareness with clinicians and opens the door to more collaboration between the reproductive endocrinology and oncology teams.”

Current options to preserve fertility for men include freezing sperm and protecting testicles from radiation. For women, says Dr. Sabatini, the gold standard involves embryo freezing. This process requires in vitro fertilization (IVF), which consists of taking injectable medications to mature multiple eggs at one time and then having a minor surgery to retrieve the eggs. The eggs are then inseminated with a partner or a donor’s sperm and the resulting embryos are frozen. The IVF cycle generally takes about two weeks to complete.

“Our hope is that patients can have an IVF cycle before chemotherapy or radiation,” Dr. Sabatini explains. “It’s not always possible, but the consultation is important. We don’t want patients to feel like they have missed an opportunity.”

Breast cancer patients represent a high percentage of the female patients in the cancer center. As a result, this clinic has had a long history of helping its patients learn about fertility treatment. In the United States, one in five women diagnosed with breast cancer are of reproductive age.

The breast cancer team includes social workers like Julie Berrett-Abebe, LICSW, who helps support patients through what can be a double blow — the trauma of cancer coupled with a potential loss of fertility. To make it easier for patients, she will meet them while they are having chemotherapy in the infusion unit. Breast cancer patients are often advised to take hormonal treatment for five-plus years during which time they are told to avoid becoming pregnant. “Information and understanding options can help reduce the loss of control,” she says.

“Fertility concerns are often at the forefront of our patients’ minds after a diagnosis,” Beverly Moy, MD, MPH, clinical director of Mass General’s Breast Oncology Program says. “By working together, the cancer center and the fertility center can present all the options available.”

At the fertility center, Abigail MacDonald, LICSW, works with the cancer team to counsel individuals and couples on any aspect of infertility related to diagnosis or options. “With cancer treatment getting better, we want to help patients not only survive, but also to realize their dreams,” she comments. “While there are no guarantees, the hope of resuming a life interrupted can’t be minimized — and may affect how people receive and understand cancer treatment. Their family may be different than first imagined and involve donor eggs or sperm, a gestational carrier or adoption, but that hope for life after cancer is something worth fighting for.”

Hope and perseverance played a big part in Angela Boylan’s experience as a young cancer patient wanting children. “I always wanted to be a mom,” she says. “When I heard hysterectomy, all I heard was that we can’t have children.”

It wasn’t until Angela began receiving treatment at Mass General that cancer surgeons looked at the possibility of extracting the tumor and saving the uterus. Unfortunately, they determined that the tumor was too deep and the organ could not be saved.

Pablo’s first reaction was to worry about the cancer spreading and to focus on Angela’s health. “But right away,” he says, “our close friend Ann Tavenner volunteered to carry our baby [be a gestational carrier], whatever we needed. And as time went by, I wanted both things — my wife to be well and to have kids.”

A gestational carrier helps patients who can’t carry during pregnancy. The many reasons to use a gestational carrier include uterine anomalies, underlying medical reasons and patients who have had or are undergoing treatment for cancer, according to Julie Gold, RN, the nurse coordinator for the Third Party Reproduction Program within the MGH Fertility Center, who helps patients interested in using donor eggs or gestational carriers.

Ann and Angela had been friends since college in Dublin. In Massachusetts, years later, they became each other’s support system. The job description for gestational carrier suited Ann who had had no complications with the pregnancies of her own three children. She and her husband, Tom Tavenner Jr., didn’t plan to have any more. The families were already intertwined with Pablo and Angela serving as godparents for two of Ann and Tom’s children.

Mass General provided psychological counseling and testing to ensure that Ann and Tom were comfortable with what they would experience both physically and emotionally. Counseling is provided to all families considering this option. Angela had six weeks to harvest her eggs before the hysterectomy. During the entire experience, Dr. Toth encouraged her not to give up hope. “Dr. Toth never sugarcoated the odds,” Angela recalls, “but his compassion was so apparent. He understands where people are coming from.”

On Nov. 16, 2006, two of Angela’s previously frozen embryos were transferred into Ann, who had been taking fertility medication to prepare her body for pregnancy. Two weeks later, a Mass General nurse called Angela and said, “Hi, mom.” Angela was overcome with excitement, which doubled when they found out later that it was twins.

On July 13, 2007, Ann gave birth to two healthy boys Naoise (nee-sha) and Cian (key-an). Today the boys are in kindergarten and Angela remains cancer free as the disease did not spread beyond her uterus.

The families live two miles apart in a northern Boston suburb, and Ann is Cian’s godmother. “I still want to pinch myself some mornings that this has all happened,” Pablo says.

“If I were in Ireland or even anywhere else in Boston other than Mass General would I have reached this point? Probably not,” says Angela. “I went from the floor opening up underneath me to having a family.”

She was especially touched when, in response to a Christmas card with the twins’ photo, Dr. Toth sent her and Pablo a handwritten note expressing his pride in their efforts to go forward and have a family.

At the time, Angela was one of a small group of patients with cancer seen by Mass General’s fertility center. As survival rates and technology have improved, the interest has dramatically increased. From 2010 to mid 2012, more than 70 patients with cancer have consulted with the fertility center — resulting in many success stories including women with non-reproductive cancers who froze embryos and returned after treatment to have their own babies. Today, the Program for Cancer and Reproductive Health includes training and research as well as comprehensive patient care.

“There are lots of ways to build a family and be a parent,” says Dr. Sabatini, who leads the program. “We want to help people think about the day when cancer is no longer part of their life.”