fertility preservation after breast cancer - a guide for oncologists

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What oncologists ( and their patients) need to know about preserving fertility in young women with breast cancer

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  • 1.Doctor, help me to have a baby ! Life after breast cancerDr Aniruddha Malpani www.drmalpani.com

2. The young woman with breast cancer Earlydiagnosis, 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 3. IVF specialists are seeing two types of breast cancer patients: Newlydiagnosed patients ; and Long-term survivors. 4. Long term survivors 5. Newly diagnosed patients Needto 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 ! 6. Refer to Specialtymulti-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 ! 7. Having babies enhances quality of life for survivors Many cancer survivors have a strong urge to have a family. Their brush with death makes them better parents 8. Cancer-related Infertility Chemotherapycompromises 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 ! 9. You have breast cancer ! Youneed 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. 10. The two things every oncologist needs to know about fertility Breast cancer chemotherapy damages ovarian reserve and can cause infertility Fertility preservation techniques can help to mitigate this damage 11. Testing Ovarian Reserve Before Starting Cancer Therapy AMH ( 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. 12. Testing Ovarian Reserve After Cancer Therapy Ifpatient 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. 13. Chemotherapy induced Amenorrhea Ratesof 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 14. Dramatic improvements in preserving fertility Takeproactive 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 15. IVF for Freezing Embryos and Oocytes Menstruation MenstruationStimulate Ovaries Stimulate OvariesOocyte Retrieval Oocyte RetrievalInseminate oocytes Inseminate oocytesFreeze Embryos Freeze EmbryosEmbryo Cryopreservation Embryo CryopreservationFreeze oocytes Freeze oocytesOocyte Vitrification Oocyte Vitrification 16. Followinghormonal stimulation, oocytes are aspirated directly from the ovaries, using ultrasound guidance. About 10-15 oocytes are retrieved (which typically produces 3 quality embryos) 17. In Vitro Fertilization 18. Embryo Cryopreservation Mostestablished 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 19. Hormone-sensitive cancers Forwomen 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 20. Oocyte Vitrification Partner not required New technology- fastfreezing 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. 21. Cryopreservation of Ovarian Cortical 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 22. Cryopreservation of Ovarian Cortical TissueAdvantages: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) 23. Retrieval and In Vitro Maturation ( IVM) of Immature Oocytes Anotheroption 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. 24. Newly diagnosed patient Yourmajor focus is to design the best treatment plan. You have lots of things to do Establish a diagnosis Stage the disease Select the best protocol Refer to a medical oncologist Refer to a radiation therapist Refer to a support groups Discuss costs 25. Think of the future as well ! Manyyoung 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 26. Doctor, why didnt you tell me to freeze my eggs ? This is a question your survivors will ask you when their cancer is treated and they come for a 5year followup How will you answer ? You will have wasted their golden opportunity 27. Pregnancy after Cancer Recommendedafter 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. 28. Using Frozen Embryos and Oocytes 29. Potential health benefits of pregnancy? Pregnancy does not decrease breast cancer survival rates May improve survival Pregnancy is safe or even beneficial However, bias of healthy mother effect 30. Referrals to IVF specialist Oncologistsshould 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. 31. Additional online educational resources www.savemyfertility.org www.fertilehope.org www.myoncofertility.org 32. FAQs Howlong 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)? 33. FAQs Howlong 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? 34. FAQs Doeshaving 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)? 35. FAQs GnRHanalogs for ovarian suppression Contraception BRCA gene mutations and IVF/PGD ( preimplantation genetic diagnosis) 36. Please protect your patients fertility !

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