If his mother hadn't struck up a conversation with a stranger in a waiting room, Dan Shapiro would never have become the biological father of Alexandra, 13, and Abigail, 9. Dan was a 20-year-old junior in college when doctors diagnosed stage 2 Hodgkin's disease. His treatment was to be six cycles of highly toxic chemotherapy followed by radiation.

He and his mother were waiting in the doctor's office when his mother began chatting with a woman whose 14-year-old son was being treated for leukemia, writes Shapiro, now 42 and a professor at Penn State College of Medicine, in his book, "Mom's Marijuana."

"Has he banked sperm?" the woman asked Mrs. Shapiro. "He should bank sperm. I had my son do it." To which Mrs. Shapiro replied, "I didn't realize the treatment would make him sterile. The doctors haven't said anything."

At Mrs. Shapiro's insistence, Dan's treatment was delayed long enough for him to bank sperm, which for a few hundred dollars a year was kept frozen until he was ready to start a family nine years later.



A neglected issue

Although more attention is now paid to loss of fertility among cancer patients, it is still too often overlooked by oncologists and patients, who may survive their disease but be left unable to reproduce. Neglect of fertility issues is especially common in cases involving children yet to reach puberty.

Yet in guidelines issued nearly three years ago, the American Society of Clinical Oncology stated that "any oncologist seeing reproductive-aged patients for consideration of cancer therapy should be addressing potential treatment-related infertility with them or, in the case of children, with their parents." The guidelines noted that "sperm and embryo cryopreservation are considered standard practice and are widely available."

What often happens instead is that patients, who are naturally terrified by the diagnosis and focused on survival, fail to ask whether treatment will leave them infertile. And oncologists, who are focused on beginning effective treatment as soon as possible, fail to consider the effects on their patients' future fertility.

The University of North Carolina's Fertility Preservation Program estimates that only a quarter of oncologists nationwide address fertility issues with patients before treatment begins.

In December 2007, Margaret Kresge Poe of Atlanta was 32 and getting ready to start a family with her husband when she was shocked to discover that what she thought were hemorrhoids was stage 3 rectal cancer. The proposed treatment - surgery, chemotherapy and pelvic radiation - would have left her unable to bear children, yet the doctor never mentioned that.

"It was family members who raised the issue," Poe said in an interview. "At the time, I could barely think straight."

Her treatment was delayed long enough to harvest eggs and have them fertilized and frozen as embryos, and Poe entered a clinical trial that used aggressive chemotherapy but none of the organ-damaging radiation that would have left her infertile. "Hopefully," Poe said, "we'll have those embryos as real children before long."

Each year, an estimated 16,000 women younger than 45 find out they have breast cancer, according to a report in February in The New England Journal of Medicine. "Many of these young women were planning to have children or contemplating the possibility," Dr. Jacqueline S. Jeruss and Teresa K. Woodruff of Northwestern University Feinberg School of Medicine wrote in the journal. "In some, but not all patients, options for the preservation of fertility can be explored before the initiation of therapy."

Complicating matters is the fact that health insurance may not cover fertility treatments for women about to be treated for cancer, and out-of-pocket costs for harvesting eggs, creating embryos and having in vitro fertilization can reach tens of thousands of dollars. Timing is another obstacle; it can take months to secure an appointment at a fertility clinic, and cancer patients cannot wait so long.



For men and children

For men with cancer, the solution is usually simple and involves little delay: a visit to a sperm bank where a semen sample can be obtained. Sperm can be frozen and stored, remaining able to fertilize an egg for up to 28 years and perhaps longer. Even men who have no sperm in their ejaculate can sometimes undergo a testicular biopsy to isolate sperm, the Northwestern experts said.

Children's cancers are typically treated with highly toxic chemotherapy and often radiation that threatens their future fertility. Yet, the journal authors wrote, "Children with cancer and their families have not typically been offered options for fertility preservation."

Before treatment, boys who have gone through puberty can provide semen samples. For younger boys, research is under way to see whether freezing sperm-forming stem cells will preserve their future fertility.

Adolescent girls facing the prospect of pelvic radiation can have their ovaries moved temporarily outside the radiation field. Or ovarian tissue can be removed and frozen in hopes that research now being pursued will one day allow viable eggs to be developed in the laboratory.