Breast cancer and infertility Lynette Leighton, MD January 14, 2009 I was taking my morning shower when I found

my lump. As a new doctor in residency, I have instructed many patients for routine self-breast exams. The lump was hard and difficult to move around with my fingers, and I knew to be concerned. I waited through my next period, just as I had instructed others to do, hoping the lump would declare itself as a cyst, or magically resolve, but it continued to grow. The lump was worrisome by mammogram and more so on biopsy. I was 37 years old and I had invasive breast cancer. Ironically, I had spent the previous month working with cancer patients in a breast care clinic, so I was familiar with my options. I was un-phased when my surgeon discussed local surgery, mastectomy, chemotherapy, and hormone therapy. I would not know the extent of my treatment or my own survival rate until after my lymph node dissection. I read a lot, asked tons of questions, and chose to expect the best and ignore the worst until I knew more. When she suggested I meet with a fertility specialist, though, I was caught off guard. Most of my patients at the breast care clinic had been in their fifties, sixties, or seventies. Most had already had children, so the subject of their fertility had never came up. But it made sense: chemotherapy drugs target fast growing cells, whether they be cancer cells, hair follicles, or ovaries. Even if my ovaries survived, I would be on Tamoxifen, a drug that causes birth defects, for several years. As much as I had wanted to, I had not yet had children. My husband had children from a previous marriage, and by the time I was sure I wanted one of my own, he resisted. After several years of discussion, he agreed to have children, and we made plans for pregnancy. He changed his mind in the end, and decided he no longer wanted to be in a committed relationship. I was diagnosed with cancer one month after my divorce was finalized. No partner. No children. One of the loneliest times during my cancer treatments to date was sitting in the fertility doctors waiting room the first day. I had a lot in common with the other women in the waiting room, but there was one noticeable difference: each of the other women had a partner; someone to hold her hand in the waiting room, reassure her at night, and help parent her children. I wondered if I would dare to have a child on my own. I also wondered if I would be alive long enough to be a mother. My doctor recommended I have embryos made and frozen for future uterine transfer, a process with greater chance of resulting in live births than freezing my eggs alone. I charged ahead, not wanting to one day regret having missed my chance to become a mother. We agreed: we would try to stimulate two cycles of eggs and harvest them before I began chemotherapy, so we needed to hurry. There was a problem: I didnt have sperm and was uneasy with the idea of an anonymous donor. As instructed by my doctor, I began to look at donors through local sperm banks. The profiles

had height, skin color, profession, and grade point average listed in a chart like cars for sale, but without showroom photos. Did I want my child to be attractive, academically successful, artistic? Were any of the donors warm, funny, confident, thoughtful? Would the gene for becoming a physicist be passed on to my child? Was I an elitist for choosing my baby daddy by grade point average? Did the information on the donor forms have anything to do with my childs happiness or success as an adult? Would I feel guilty one day for choosing poorly? I had to process all of this cancer, infertility, the genetic make-up of my future children and make a decision within two weeks. My decision changed several times as I processed the experience, and it involved many discussions with family, close friends, a fertility social worker, and my fertility doctor. I also found lesbian friends to be a great resource, as many of them had used or contemplated use of sperm donation in the past, and had already processed some of the issues I was facing. I found it helpful to be open and honest with my health care providers. Even though it was impossible for them to truly understand my individual concerns and emotional needs, most were willing to listen and try to accommodate me. At first, having a known donor seemed preferable. It made the fertility experience seem warmer, more personal, less lonely. Friends tried desperately to help me. Girlfriends offered their husbands, always with a disclaimer. He does have a quick temper. Hes prone to overeating. He has a learning disability. Every coworker, waiter, and sales clerk in San Francisco got the up and down from friends looking to find acceptable genes, or a future father for me. One friend told me: Im scouring the streets! A close friend vouched for an out of state friend; that he was a virtual Adonis, kind, intelligent, and willing to donate sperm. This scenario seemed personal yet uncomplicated given the distance. In the end, it was the distance that made it impossible given my time constraint. The nearest I came to choosing a known donor came in the form of an offer from a close friend. He, his partner, and I met with a social worker, and talked about it extensively. For the first time in the whole process, I did not feel alone. In the end, though, the support his offer provided was all I needed to make a decision that felt best for me. I would go with an unknown donor to avoid complicating my childs and my friends families lives in the future. He had admitted that, were something to happen to me later in life, he would have felt obligations to the child. I could not place that burden on him or his family. I went to a sperm bank to choose a donor. I sat with piles of binders filled with hundreds of profiles on my lap in a small waiting room. I methodically narrowed down my list of donors by men taller than me (Im six feet tall), having an education, and a clear family health record. Just as I became overwhelmed, a nurse from the bank came to sit with me. She had heard my story and seen my distress. She looked over the profiles with me and reassured me that I made some good selections. Families have done this many times before, she promised, and they are always happy when their baby is born. I realized that there was no great solution to my pending infertility. Having my friends offer to help me made me feel less alone now, but could be complicated later for me, for my child, and for any future men in our lives. I chose an anonymous donor for the embryos, and also had eggs frozen alone in the event that another man becomes involved in the process. I now believe that when I first see the face of my child, he or

she will become real to me, a being of their own, and their genetic origin will fade to the background. Im now recovering from five months of chemotherapy, awaiting radiation, and looking forward to returning to my last year of medical residency training. My lymph nodes were negative for cancer. That means no mastectomy for me at this time, and it makes it much more likely that I will be around to become a mother. It has been a difficult two years, but filled with deep introspection and tremendous personal growth. I am grateful to be alive and am several steps closer to meeting my future child.