When Trish Michelle got stage 3 cancer, she felt unprepared to make decisions about her fertility. Many women with cancer diagnoses face a crushing, immediate choice of whether to freeze their eggs or give up on future children.
Young women who find out they have breast cancer often have a very short window to make lifelong decisions about their futures.
Two weeks before her 23rd birthday, Roshni Kamta was diagnosed with stage 2 breast cancer. That was the first shock. The second came a few days later, when she found out that the chemotherapy that would save her life might prevent her from having children.
Her oncologist told her that freezing her eggs would give her the best chance at a future pregnancy. But she would need to do it immediately, before starting her cancer treatment.
Ms. Kamta, who had recently graduated from college and moved to New York for her first job, had never thought about whether she wanted kids. And now, in the throes of coping with a distressing diagnosis, she also had to decide whether to undergo an expensive, demanding fertility procedure.
Within just 48 hours, she started the regimen of fertility shots to prepare her to harvest her eggs.
“I didn’t know if it was working, if I was doing it right,” said Ms. Kamta, who is now 27. “I was so overwhelmed and stressed.”
Breast cancer is the most commonly diagnosed cancer in women of reproductive age; around 9 percent of new cases in the United States are in women under 45. Those women tend to get the more aggressive types that require chemotherapy, which can damage the ovaries and affect fertility.
Women are usually advised to wait at least two years after finishing chemo to pursue pregnancy, and even then they may or may not produce healthy eggs. In addition, many women also receive hormone therapy for five or more years after treatment, during which time they either cannot get pregnant or are strongly advised not to.
As a result, the window of time for child bearing can shrink significantly, particularly for women diagnosed in their 30s, when fertility starts to decline.
For women simultaneously navigating cancer and the egg-freezing process, the journey can be emotionally and physically brutal, from traversing the red tape of insurance companies to grieving lost opportunities. What’s more, the ongoing debate over reproductive rights — and more recently, the Alabama Supreme Court decision that frozen embryos be considered children — is compounding the stress of cancer and fertility, with some women questioning whether they will be able to freeze their eggs or embryos at all.
The day Annie Holschuh brought her first child home from the hospital in August 2020, she was diagnosed with stage 2 breast cancer. At her first appointment, the oncologist asked Ms. Holschuh, then 37, if she and her husband were done having children.
“We had a five-day-old baby,” said Ms. Holschuh, who works in marketing in Milwaukee. “You can’t even wrap your head around it, you’re dealing with so much.”
Dr. Monique James, a psychiatrist at Memorial Sloan Kettering Cancer Center who specializes in treating women in their reproductive years, said this excruciating one-two punch can be hard for patients to reconcile. “You’re trying to save your own life and someone asks you to think about a future life that hasn’t been formed yet,” Dr. James said.
Some research has suggested that the potential for infertility after cancer treatment can be more stressful than the diagnosis itself; for many women, the fear of infertility ranks second only to the fear of cancer recurrence.
Ms. Holschuh decided to freeze embryos with the hope of eventually having a second child, but she worried that delaying chemo to harvest her eggs — a process that usually takes around two weeks — might cause her cancer to spread. “You just want it out of your body so quickly,” she said.
But for patients with early-stage breast cancer — usually defined as stages 1 to 3 — there is typically enough time to complete one round of egg harvesting safely, assuming they can start the process quickly, said Dr. Hope Rugo, a medical oncologist specializing in breast cancer research and treatment at the University of California, San Francisco.
However, fertility preservation before cancer treatment can be expensive. Though prices vary by fertility clinic, a single round of egg or embryo freezing can cost up to $15,000. For someone facing potential financial stress brought about by cancer treatment, adding the wild card of fertility treatment can make things even more challenging. “There is a real equity issue here,” Dr. Rugo said.
According to a spokeswoman with a national association of health care insurers, in most states the amount of coverage people can get for fertility treatments is determined by employers — unless states mandate it.
As of January 2024, 16 states and the District of Columbia have passed laws requiring insurance companies to cover fertility preservation procedures for cancer patients. Even then, said Joyce Reinecke, executive director of the Alliance for Fertility Preservation, many people with limited coverage can still be denied.
Roshni Kamta dealt with these issues. A few days into the egg-freezing process, Ms. Kamta learned that her insurer would not cover it. She appealed the decision and was again denied. “I felt like no one was on my side, or validating that this horrible thing was happening,” she said.
Allie Brumel was diagnosed at 28. “I kept thinking, ‘Am I even going to survive breast cancer? Is this all worth it?’” she said. She went on to co-found a nonprofit for people impacted by breast and gynecological cancers. Credit: Anthony Nazario for The New York Times
Ms. Kamta eventually received a grant to cover the cost of her egg freezing from The Chick Mission, a nonprofit that helps cancer patients preserve their fertility and advocates for more states to require fertility treatment coverage for cancer patients.
Even if a woman hasn’t decided yet whether she wants children after cancer treatment, “let’s give people the option,” said Amanda Rice, 47, a three-time cancer survivor who started The Chick Mission. “It’s not for cancer to decide, it’s not for insurance to decide. It’s up to us.”
For women who may have already sacrificed things like their breasts or hair to cancer, it can feel particularly unfair to also contend with “the grief and loss and mourning of something more abstract,” Dr. James said.
Kamilla Linder, 34, a self-employed language teacher in Santa Cruz, Calif., was able to freeze her eggs in October 2023, with financial help from several nonprofits. But her treatment will likely include five to 10 years of the estrogen-blocking medication tamoxifen, and Ms. Linder, who is currently single, worries about when and how she will turn those eggs into embryos.
While a growing body of research suggests it’s safe to take a break from such hormone therapies to get pregnant, she can’t shake the feeling that something has been taken from her.
“I have this fear that I will not have children at all,” she said.
This feeling has become more common since the Alabama Supreme Court decision in late February, said Allie Brumel, a co-founder of a nonprofit for people impacted by breast and gynecological cancers called The Breasties. She has heard from many members of the community concerned about what it means for their own frozen eggs and embryos.
“Those eggs on ice are my only option to have a biological child,” said Lindsey Baker, 39, a nonprofit consultant in Tucson, Ariz., who opted to have her ovaries and fallopian tubes removed in 2022 after finishing active treatment for stage 2 breast cancer. “Thinking about the ramifications of politics taking that away from me, when I’ve already lost so much to cancer in my 30s, is heartbreaking.”
When Trish Michelle, 45, of Queens, N.Y., was diagnosed with stage 3 breast cancer in 2016, “no one, not once, brought up fertility,” she said. Ms. Michelle, who was 37 and already a mother to two teenagers, made the quick decision not to pursue it, a choice she often regrets. “At that point, you’re fighting for your life, you have to do a quick triage on what’s most important.”
Dr. James said that the landscape around fertility preservation after a cancer diagnosis is slowly changing, with more providers willing to engage in thoughtful discussion.
Amanda Rice is a three-time cancer survivor who founded a nonprofit called The Chick Mission after she had to use her own emergency savings to freeze her eggs. Credit: Montinique Monroe for The New York Times
Her biggest piece of advice for young female cancer patients is to “ask questions, ask questions, ask questions.” Request an immediate referral to a reproductive endocrinologist specializing in oncofertility. Inquire about ways to be connected to fellow cancer survivors who preserved their fertility, and about financial grants from organizations like Livestrong Fertility and the Heart Beat Program.
Also, talk to your oncologist about the impact of cancer treatment on your fertility, Dr. Rugo said. Ask about ways to mitigate its effects, like temporarily shutting down your ovaries during chemo.
Ms. Michelle, who now works for The Breasties, said that while she is proud of pushing for the mammogram that saved her life, she laments not advocating for the option to have more children.
“I let it be the dream that died,” she said.
Holly Burns is a frequent contributor to The New York Times and a breast cancer survivor.