Young women treated for breast can­cer at risk for decreased fer­til­ity  due to expo­sure to chemother­apy and delay­ing preg­nancy for sev­eral years after treat­ment. Twenty per­cent of women diag­nosed with breast can­cer are in their repro­duc­tive years. By the year 2010, 2.9 mil­lion breast can­cer sur­vivors are pre­dicted in the US, approx­i­mately 2% of the female pop­u­la­tion. Cal­i­for­nia, Florida and New York will rank first among states in the num­ber of survivors.

Women con­sid­er­ing preg­nancy after com­plet­ing breast can­cer treat­ment  require exten­sive coun­sel­ing of risks and ben­e­fits as well as dis­cus­sion  of avail­able options to achieve preg­nancy, tai­lored to their med­ical and social cir­cum­stances. Psy­cho­log­i­cal coun­sel­ing is also help­ful  in cop­ing with stresses of treat­ment.  I usu­ally start with con­sul­ta­tion ses­sion to get to know the indi­vid­ual woman as well as infor­ma­tion about her breast can­cer. Dur­ing this ses­sion I ini­ti­ate test­ing for ovar­ian reserve through blood work and ultra­sound. I also present her with printed mate­r­ial to read about ovar­ian stim­u­la­tion and preg­nancy after breast can­cer. With her per­mis­sion, I also con­tact her oncol­o­gist to dis­cuss assess his or her opin­ion in rela­tion to preg­nancy after breast can­cer treat­ment. I request that the woman or cou­ple visit me few days later to dis­cuss  test results and options for fer­til­ity treatment.

Test­ing & Coun­sel­ing. 1. Ovar­ian reserve. This indi­cates the num­ber and qual­ity of the eggs remain­ing in the ovary. Its related to the woman’s age, type and dose of chemother­apy received. There is marked vari­a­tion among women in their ovar­ian reserve due to genetic fac­tors and type and inten­sity of chemother­apy. Esti­mat­ing ovar­ian reserve may pre­dict response to treat­ment and chance for suc­cess of fer­til­ity treat­ment. Ovar­ian reserve can be esti­mated using ultra­sound to visu­al­ize the tiny fol­li­cles in the ovary. Blood tests for mark­ers such as FSH, LH, Estra­diol and AMH can  also help in deter­min­ing ovar­ian func­tion. Patency of the fal­lop­ian tubes is also tested using a hys­teros­alp­in­gogram. Part­ner semen analy­sis is also ordered. 2. Safety of ovar­ian stim­u­la­tion. To enhance fer­til­ity, stim­u­la­tion of egg pro­duc­tion in the ovary is com­monly employed.  Com­mon ovar­ian stim­u­la­tion meth­ods result in increase of estra­diol. To avoid this increase in estro­gen sen­si­tive can­cer, we have  shared in devel­op­ing a pro­to­col that employ a drug that pre­vent the ovary from mak­ing estro­gen. When tested this method did not appear to increase breast can­cer recur­rence. We how­ever do not know the effects of ovar­ian stim­u­la­tion on the long term, 5 years or more. 3. Safety of  preg­nancy. Stud­ies pub­lished so far indi­cate that preg­nancy does not increase the risk of recur­rence in women treated for breast can­cer. More­over, some stud­ies even detected reduced risk of recur­rence and death due to breast can­cer in women who became preg­nant. 4. Trans­mis­sion of BRCA muta­tion to the baby. Five to ten per­cent of young women diag­nosed with breast can­cer carry muta­tions in BRCA1 or 2 genes. These muta­tions can be trans­mit­ted to their chil­dren. It is pos­si­ble to avoid this trans­mis­sion by test­ing their embryos before plac­ing them into the uterus. Pre-implantation genetic diag­no­sis — PGD was suc­cess­fully per­formed in women car­ry­ing these mutations.

Options. If preg­nancy is judged to be safe, sev­eral options for repro­duc­tion exist 1. Timed inter­course. Women with reg­u­lar men­strual cycles and good ovar­ian reserve, can attempt preg­nancy spon­ta­neously for 6 months to a year. Ovu­la­tion can be mon­i­tored using home pre­dic­tor kits that test urine for LH hor­mone. When a surge is indi­cated by the test, inter­course for the next three days is usu­ally advised.  2. Ovar­ian stimulation-IUI. Stim­u­la­tion of the ovary aim­ing at recruit­ing two or three eggs can be accom­plished using letro­zole or letro­zole and gonadotropins. This is usu­ally fol­lowed by intrauter­ine insem­i­na­tion when the eggs are judged to be need matu­rity. This is usu­ally attempted for three cycles. 3. Embryos or oocytes frozen prior to breast can­cer treat­ment frozen / thaw embryo trans­fer. Women who pre­served their fer­til­ity prior to can­cer treat­ment can thaw those and trans­fer one or two embryos into the ovary. This com­monly carry a rea­son­able preg­nancy rate for embryos, about 30% per cycle. In case of frozen eggs, they need to be fer­til­ized using ICSI-direct injec­tion of a sin­gle part­ner or donor sperm into the egg. Thawed eggs usu­ally carry lower preg­nancy rates than embryos. 4. IVF. In vitro fer­til­iza­tion carry the  high­est preg­nancy rates of all fer­til­ity treat­ment. Its suc­cess, how­ever, depends on age and ovar­ian reserve. a. Nat­ural cycle IVF. Women inter­ested in avoid­ing exces­sive estro­gen expo­sure and cost can con­sider nat­ural cycle or min­i­mal stim­u­la­tion IVF b. Ovar­ian stim­u­la­tion IVF. In this option the ovary is stim­u­lated to pro­duce mul­ti­ple fol­li­cles, eggs are aspi­rated , fer­til­ized and  the result­ing embryos are trans­ferred into the uterus. 5. Third party reproduction-egg dona­tion and ges­ta­tional car­ri­ers. Donor oocytes are con­sid­ered in women with very low ovar­ian reserve or who develop ovar­ian fail­ure after treat­ment. The use a ges­ta­tional car­rier is con­sid­ered for women who can­not carry a preg­nancy due to breast can­cer or other con­di­tion. Woman’s bio­log­i­cal embryos are trans­ferred to the uterus of another woman.

Women treated for breast can­cer show vari­abil­ity in terms of ovar­ian reserve after chemother­apy. They require test­ing for ovar­ian func­tion and coun­sel­ing about the most fea­si­ble and safe method to get preg­nant after treat­ment.  Read more at http://nycivf.org