You are a breast cancer survivor, what next? Roadmap to pregnancy after treatment

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 fertilizationcarry 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

Posted on