By Dr. Mary E. Sabatini and Dr. Don S. Dizon
As physicians practicing in the worlds of oncology and gynecology, we have used this word countless times—hope that cancer will not return, hope that intimacy can be restored, hope that parenthood can be realized despite cancer. Hope conveys the sense of optimistic anticipation that a desired outcome can be realized. Indeed, the word “hope” is everywhere—on our hospital posters and even on display in the world at large, on greeting cards and in advertisements.
At its root, we always believed in the positivity that hope encompasses, yet there are situations when it seems hope can morph into something else altogether—something unhealthy. I had brought this up in passing with Mary, in relation to a patient we shared in common. Alice* had been referred to The Sexual Health Clinic due to pain with sex. At the time I had seen her, she would be easily considered a long-term survivor, but her situation was also a stark reminder to me that survivorship is not the proverbial walk in the park; indeed, surviving cancer meant living with long-term problems. In her case, it had led to pain with intercourse. As we talked it became apparent to me that while she had enjoyed sex, it had become something even more—the means towards motherhood.
Following my visit, I called Dr. Sabatini to discuss her case; what came of it was so interesting to me, and provided me with so much more to consider. I asked her to share it here.
Dr. Sabatini: When I first met Alice, she was a 32-year-old ambitious graduate student whose trajectory was halted due to a diagnosis of breast cancer; a subsequent work-up also revealed she harbored a genetic mutation in BRCA. When her doctors told her she should receive chemotherapy, she was alarmed because she very much wanted to have a baby someday and was afraid that chemotherapy would render her infertile, which prompted the initial referral to the Oncology Fertility program.
We discussed fertility options during those initial conversations, including oocyte freezing. Unfortunately, circumstances beyond both of our control prompted initiation of chemotherapy before she could freeze her oocytes. I still remember calling her prior to the start of medical treatment, knowing how much her fertility meant to her, encouraging her to remain hopeful about the possibility of conceiving after her treatments were over.
Following chemotherapy, she returned for follow-up in the oncofertility clinic. She was amenorrheic and having hot flashes. She worried she might not be able to have children. Once more, I reassured her and let her know I was hopeful that chemotherapy-induced amenorrhea would not be permanent—indeed, it was common for amenorrhea to persist immediately after chemotherapy, but often women will subsequently get return of menses.
A few months passed and she returned for follow-up. Menses had resumed and testing for her ovarian reserve was encouraging. She was in a relationship. She was hopeful—and so was I. Because her relationship was new, she wanted to wait for a while to consider her treatment options. I wished her well as we made plans to see each other only on an as-needed basis.
Six years after the initial consult she showed up on my schedule; by that time she was 38. At that visit, she described how she had been in several relationships since our last meeting, but that none of them worked out. While her menses continued, she had started to miss an occasional month, which was the source of alarm for her. We talked about reasons for menstrual irregularity, and I told her that I suspected her ovarian reserve was declining as a result of her prior treatments. We launched into a wide-ranging discussion of options, including donor insemination and possible traditional fertility treatments, donor oocytes, and even adoption. Despite this, she maintained her hope of becoming a mother, and even broached the topic of single parenting.
At this point, I saw her hope, but I could not share it. We did some testing which indicated she was perimenopausal. I told her that the probability of pregnancy was low now, even if she proceeded with aggressive treatments. I did my best to present her with a balanced discussion, including the risks associated with treatment and the low possibility of benefit based on the data. We even discussed how she was at a heightened risk of ovarian cancer on the basis of her BRCA mutation. My hope for her own parenthood laid with alternatives—adoption or the use of donor oocytes. However, her hope was to become pregnant with her “own” child.
As I saw an abyss developing between me and my patient, I struggled with how to close it. Yet, how long could I join her, continue down this path? While I am one to never to say never, it was clear that her drive to become pregnant could engulf her life, and she might be at risk of losing everything else.
Over the next few months Alice developed a near obsession with getting pregnant. She purchased ovulation predictor kits and, when she did not have a partner, even tried donor sperm inseminations. However, none of these strategies resulted in a pregnancy.
After many months, I knew that a very difficult conversation was required, and perhaps, long overdue. We had to stop the fertility drugs and talk about oophorectomy. As we talked, she started to cry. She had worked so hard and had wanted a child so badly and for so long. But, she knew she had run out of time. Her vision of motherhood—of pregnancy with her own genetic offspring—was not to be. I let her cry, and then we talked about how she could—and needed to—move on. Instead of hoping for her child, I hoped she saw that her own life held realities and promises which were good, and I did not want her to miss them. I told her I was sorry I could not help her make her dream of having a baby a reality. She thanked me for my candor and she left.
I cannot say that any of my time with her left me with any sense of satisfaction that I had done any good. I knew going into medicine that I would not be able to fix everything but I did hope that I could make some things better. I can only hope that I did make her life better in some way, but I will probably never know.
*Name and circumstances changed to protect privacy.