Advances in the diagnosis of breast cancer have led to earlier detection while combined therapy has rendered many smaller tumors potentially curable in a high percentage of cases. Since 15% of new breast Ca cases occur under the age of 45 years, a large number of women receive the diagnosis before they have completed, or in some cases even begun, building their families. Hence, preservation of fertility ranks high on their list of priorities. However, their reproductive options are extremely complex and fraught with potential risks. Multiple medical, social, psychological and financial factors need to be taken into account in selecting the best course of action for each patient.
Optimal management requires close cooperation of the breast surgeon, radiation and medical oncologists and the reproductive endocrinologist. Special attention is given to the psychological needs of patients who all of a sudden face the combined stress of a life-threatening disease and the life-long consequences of irreversible reproductive choices. Furthermore, new treatment options are emerging rapidly and current practices are based on a limited number of studies which have yet to be reproduced in most centers.
A few facts are well established. Clearly, immediate conception is not safe while delaying pregnancy until after completion of treatment is likely to require use of donor eggs. Most treatment protocols, in addition to surgery and regional radiation, include either chemotherapy or prolonged hormonal therapy (tamoxifen) both of which markedly reduce the chance of conception with the woman’s own eggs. Chemotherapy is toxic to ovaries. Consequently, many women in their late 30s and early 40s (What is Age Factor?), whose ovarian reserve (How Do We Test for Ovarian Reserve?) is fragile to begin with, either lose the ability to produce multiple eggs after chemotherapy, or stop ovulating altogether and enter menopause early. While tamoxifen treatment does not damage the ovaries directly, this therapy is usually given over a prolonged period of time, such as 5 years, which itself markedly reduces the number of healthy eggs and makes the chance of successful pregnancy unlikely.
Fortunately, the continuing progress in assisted reproductive technologies (A.R.T.) has led to a wide range of options available for preservation of fertility in women with breast cancer. This multiplicity of choices can in itself be overwhelming. One of the major choices that a woman with breast cancer desiring a future family needs to make is to decide how important it is to her that her children are created using her own eggs thus preserving a genetic link. If the genetic link is not essential, then the reproductive choices can be postponed until the breast cancer therapy is finished (Donor Egg Program, Embryo Donation). Current evidence indicates that breast cancer survivors who have completed their therapy can carry pregnancy without significant increase in their risk of recurrence. However. some breast cancer survivors choose to rely on a gestational surrogate to carry the pregnancy (Surrogacy).
Women who wish to have children created with their own eggs must undergo the complex and stressful procedures of ovarian stimulation and egg retrieval during the brief time interval between surgery and radiation, and the start of chemotherapy. Dr. Chetkowski has recently developed a new approach which suppresses ovarian function with leuprolide and thus allows extension of the interval from surgery and radiation and chemotherapy in good prognosis patients who wish to use a gestational surrogate. Since standard IVF treatment results in extreme elevation of estrogen which might lead to spread of the cancer, modified ovarian stimulation protocols have also been developed. These protocols permit development of multiple follicles while maintaining relatively low estrogen levels through the use of either letrazole or tamoxifen medications.
What to do with the retrieved eggs depends upon each woman’s life circumstances. Most women who are married or in stable heterosexual relationships elect to have the eggs fertilized with their partner’s sperm and either transferred into a gestational surrogate for immediate establishment of pregnancy (Surrogacy) or frozen for future transfer (Embryo Freezing). Embryo freezing has been a safe and reliable technique for more than two decades in contrast to the newer techniques of freezing of unfertilized eggs (Freezing of Unfertilized Eggs) which are rapidly evolving but are still considered experimental. Single women may elect either to freeze their eggs for future fertilization or to have the eggs fertilized with donor sperm and either transferred into a gestational surrogate for immediate pregnancy or frozen for a future transfer.
Top of Page