fertility preservation after breast cancer - a guide for oncologists

Doctor, help me to Doctor, help me to have a have a baby ! baby !

Life after breast Life after breast cancercancer

Dr Aniruddha Malpaniwww.drmalpani.com

The young woman with The young woman with breast cancerbreast cancer

Early diagnosis, because of better awareness and better imaging techniques, means the diagnosis is being made more often in younger women

Newer treatment protocols and the increasing role of neo-adjuvant chemotherapy translates into more effective treatment and better survival rates

IVF specialists are IVF specialists are seeing two types of seeing two types of breast cancer patients:breast cancer patients:

Newly diagnosed patients ;

and Long-term survivors.

Long term survivorsLong term survivors

Newly diagnosed Newly diagnosed patientspatientsNeed to cope with diagnosis of a life-threatening disease.

Significant shock and emotional distress

Shortened “window of opportunity” for treatment. Time is of the essence.

Please refer as soon as possible !

Refer to Refer to Specialty multi-disciplinary clinic

for a second opinion ?Surgical oncologist for staging?Medical oncologist for

chemotherapy ?Radiation therapist ?Please also refer to IVF specialist

for fertility preservation !

Having babies enhances Having babies enhances quality of life for quality of life for survivorssurvivorsMany cancer survivors

have a strong urge to have a family.

Their brush with death makes them better parents

Cancer-related Cancer-related InfertilityInfertilityChemotherapy compromises future fertility. More powerful drugs = better survival and more infertility

Infertility is a source of long-term distress in survivors – especially if this could have been prevented !

You have breast cancer You have breast cancer !!You need to discuss many emotionally-charged topics

Cancer-related infertility and fertility preservation also need to be discussed because you can take proactive steps toward preserving their fertility

Their future ability to have children will significantly improve their quality of life.

The two things every The two things every oncologist needs to know oncologist needs to know about fertility about fertility Breast cancer chemotherapy damages ovarian reserve and can cause infertility

Fertility preservation techniques can help to mitigate this damage

Testing Ovarian ReserveTesting Ovarian Reserve Before Starting Cancer Before Starting Cancer TherapyTherapyAMH ( anti Mullerian

hormone) blood test – on any day of the cycle

Antral follicle count – vaginal ultrasound scan

Tests can be ordered before referring to an IVF specialist.

Testing Ovarian Reserve Testing Ovarian Reserve After Cancer TherapyAfter Cancer TherapyIf patient desires future children, ovarian reserve should be tested as soon as possible

Even if menses resume, these patients are at risk for premature ovarian failure. Patients may have the opportunity to freeze remaining oocytes.

Chemotherapy induced Chemotherapy induced AmenorrheaAmenorrheaRates of amenorrhea depend on patient age; and type and dose of treatment

Most women who remain amenorrheic after 1 year have premature ovarian failure.

Resumption of menses does not mean ovulation. They often have decreased ovarian reserve

Dramatic improvements Dramatic improvements in preserving fertilityin preserving fertilityTake proactive steps to preserve fertility before initiating cytotoxic therapy

Decisions should be made as early as possible. Even one dose of chemo can impair fertility

We can freeze◦Embryos◦Eggs◦Ovarian tissue

IVF for Freezing Embryos and IVF for Freezing Embryos and OocytesOocytes

MenstruationMenstruation

Stimulate OvariesStimulate Ovaries

Oocyte RetrievalOocyte Retrieval

Inseminate oocytesInseminate oocytes Freeze oocytesFreeze oocytes

Freeze EmbryosFreeze Embryos

Embryo CryopreservationEmbryo Cryopreservation

Oocyte VitrificationOocyte Vitrification

Following hormonal stimulation, oocytes are aspirated directly from the ovaries, using ultrasound guidance.

About 10-15 oocytes are retrieved (which typically produces 3 quality embryos)

In Vitro FertilizationIn Vitro Fertilization

Embryo CryopreservationEmbryo CryopreservationMost established procedure. First choice if patient has a partner

Needs 2 weeks of ovarian stimulation with daily injections of follicle-stimulating hormones from Day 1 of menses

Chemo has to be postponed for a few weeks

Hormone-sensitive Hormone-sensitive cancerscancers

For women with hormone-sensitive breast cancers, alternative hormonal stimulation approaches using letrozole and tamoxifen have been developed , to theoretically reduce the potential risk of estrogen exposure

Oocyte VitrificationOocyte VitrificationPartner not requiredNew technology- fast freezing of vitrification. Much better results

•Fast freezing prevents ice crystal formation that can damage DNA

No increase in congenital anomalies compared with naturally conceived infants.

Cryopreservation of Ovarian Cryopreservation of Ovarian Cortical TissueCortical Tissue

Experimental. May be only option for patients who can not delay treatment or are unwilling to undergo ovarian stimulation

Summary of procedure:◦Retrieve ovarian tissue by

laproscopy◦Freeze strips of ovarian

cortical tissue ( contains primordial follicles)

◦Later, reimplant tissue; hip, arm

◦Or graft ovarian tissue onto the remaining ovary

Cryopreservation of Ovarian Cryopreservation of Ovarian Cortical TissueCortical Tissue

Advantages: no partner or donor sperm needed, available to prepubertal patients, no hormonal stimulation, no time delay

Disadvantages: ◦ Experimental procedure; few live births

◦25% follicles die because of initial ischemia (particularly for women over 40, few follicles remain)

◦Concern for reimplantation of cancer cells with ovarian tissue implantation (not suitable if there may be metastases in the ovaries)

Retrieval and In Vitro Retrieval and In Vitro Maturation Maturation ( IVM) of Immature Oocytes( IVM) of Immature Oocytes

Another option might include aspiration of immature oocytes from the small “antral” follicles of the ovary with maturation of these oocytes in a laboratory setting in the future.

Newly diagnosed Newly diagnosed patientpatientYour major focus is to design

the best treatment plan. You have lots of things to do

Establish a diagnosisStage the diseaseSelect the best protocolRefer to a medical oncologistRefer to a radiation therapistRefer to a support groupsDiscuss costs

Think of the future as Think of the future as well !well !Many young cancer survivors feel they received inadequate information on their fertility preservation options.

Fertility preservation gives patients hope for a high quality life after cancer

Please discuss this proactively

Doctor, why didn’t you tell Doctor, why didn’t you tell me to freeze my eggs ?me to freeze my eggs ?This is a question your survivors will ask you when their cancer is treated and they come for a 5-year followup

How will you answer ?You will have wasted their golden opportunity

Pregnancy after Pregnancy after CancerCancerRecommended after 2 years

because most disease recurrences occur within this time frame

For women receiving hormone therapy such as tamoxifen are recommended to wait 5 years before conceiving, to allow completion of therapy.

Current studies do not indicate increased risk of recurrence or decreased risk of survival, even in hormonally sensitive tumors; however, studies are limited.

Using Frozen Embryos Using Frozen Embryos and Oocytesand Oocytes

Potential health Potential health benefits of pregnancy?benefits of pregnancy?

Pregnancy does not decrease breast cancer survival rates

May improve survivalPregnancy is safe or even beneficial

However, bias of “healthy mother effect”

Referrals to IVF Referrals to IVF specialistspecialistOncologists should refer interested

patients to reproductive specialists as soon as possible

Pretreatment fertility counseling and fertility preservation improves quality of life in reproductive age women with breast cancer.

“ Losing my hair would be temporary, but losing my ability to have children would be permanent and devastating.”

Additional online Additional online educational resourceseducational resources

www.savemyfertility.org

www.fertilehope.orgwww.myoncofertility.org

FAQs FAQs How long does each treatment take?

Is it safe to delay the chemo ? Does egg/tissue freezing really work? What are the success rates of each treatment? How many babies have been born?

What is the safety of fertility treatments (especially for hormone sensitive cancers)?

FAQsFAQsHow long can the eggs/embryos be

stored ? What happens if the patient dies or gets divorced?

How much do the treatments cost? Insurance coverage? Financial assistance?

What is the birth defect rate of children born to cancer survivors?

FAQsFAQsDoes having children after

cancer increase the chance of the child having cancer?

Does pregnancy increase the risk of recurrence?

How long should a patient wait to attempt pregnancy or IVF after completing cancer treatment?

What are the age limits for these treatments and how do they affect outcome (e.g. over 40)?

FAQsFAQs

GnRH analogs for ovarian suppression

ContraceptionBRCA gene mutations and IVF/PGD ( preimplantation genetic diagnosis)

Please protect your Please protect your patient’s patient’s fertility ! fertility !