Fertility, Pregnancy and Family Planning after a Cancer

Fertility, Pregnancy and Family Planning after a Cancer

Fertility, Pregnancy and Family Planning after a Cancer Diagnosis Terri Lynn Woodard, MD Assistant Professor MD Anderson Cancer Center The Objective

2 Breast Cancer, Fertility and Family Building Approximately 6% of women diagnosed with breast cancer are of reproductive age (<40 years) Many will not have started/completed their childbearing plans Importance of addressing fertility and family building issues

Impact of Breast Cancer Treatment on Fertility Age Depends on type of therapy Chemotherapy Age The risk of amenorrhea after receiving typical adjuvant chemotherapy regimens in women under 40 is 21-71% versus 49-100% for those over 40.

Baseline fertility status Type Dose Impact of Breast Cancer Treatment on Fertility Endocrine therapy: Tamoxifen Selective Estrogen-Receptor Modulator Used in the treatment of premenopausal estrogen-receptor positive breast cancers

Teratogen Recommended for 5-10 years Age becomes the biggest obstacle! In an Ideal World: Fertility Preservation Discussion should be encouraged Various methods available ART

Ovarian tissue cryopreservation Ovarian Suppression Some challenges and limitations Doing Your Due Diligence What is my current fertility status? Safety

Is it Safe for me to become pregnant? Will pregnancy affect my prognosis? Can my future children be affected? When should I try to conceive

What are the different ways that I can build my family? What is My Current Fertility Status? Fertility Status MENSES FERTILITY

MENSES 10 The Truth about Fertility in Women We are born with all the eggs we are ever going to have Fertility declines with age How We Assess Ovarian Reserve

Hormones Follicle Stimulating Hormone (FSH), estradiol, inhibin B Antimullerian Hormone (AMH) Ultrasound Ovarian volume, antral follicle count Antral Follicle Count

Poor antral follicle count Good antral follicle count Photos used with permission from Texas Childrens Hospital Family Fertility Center Interpreting the Testing: Odds and Probabilities Must be considered in the context of age and your medical history

Does not predict ability to become pregnant Just tells us how easy or difficult it might be Special Considerations for BRCA1/2 Mutation Carriers Some suggest lower ovarian reserve Increased risk for development of ovarian cancer Recommendation is to have a risk-reducing bilateral salpingo-oophorectomy (RRBSO)

Can transmit mutation to offspring Role of Pre-implantation Genetic Diagnosis (PGD) Is it Safe for Me to Become Pregnant? Safety of Pregnancy No guarantees about anything

Must consider effects of treatment on other aspects of health Pregnancy in general is a stressful condition Consultation with a Maternal Fetal Medicine (MFM) Specialist Preconception counseling Management of medication Management of coexisting medical conditions 17

Will Pregnancy Affect My Prognosis? Pregnancy and Prognosis Previously, pregnancy was thought to be contraindicated More recent data has been reassuring 19

Pregnancy after Breast Cancer Survivors who become pregnant do not appear to suffer worse outcomes than those who do not Meta-analyses Azim et al 14 studies with 1244 cases and 18,145 controls For overall survival, pooled relative risk was 0.59 (95% CI: 0.50-0.70), favoring survivors with subsequent pregnancy Valachis et al

9 studies Pooled hazard ratio of death was 0.51 (95% CI: 0.42-0.62), favoring survivors with subsequent pregnancy Similar findings for women with estrogen-receptor positive tumors Limitations of the data Can My Future Children Be Affected?

Impact on Offspring No increased risk of birth defects No increased risk of vertical transmission Exception: Genetic syndrome: Pre-implantation Genetic Diagnosis (PGD) Higher risk for cesarean section, pre-term delivery, low birth weight infants and delivery complications 22

When Should I Try to Conceive? Timing of Conception It depends requires thoughtful discussion with you and your health care providers Usually recommended once you are out of window of early relapse/recurrence Must have period of adequate treatment washout

24 What are the different ways that I can build my family? 25

Building Your Family Sometimes requires you to reshape the way you thought about building your family Range of options Natural intercourse Ovulation induction +/- intrauterine insemination Assisted Reproductive Technology (ART) Oocyte cryopreservation (egg freezing) In vitro fertilization (IVF)

Third-party Reproduction Donor Egg Donor Embryo Surrogacy Adoption Ovulation Induction with Intrauterine Insemination

ART: In Vitro Fertilization (IVF) Picture used with permission from MD Anderson Cancer Center Embryos or Oocytes? Embryos Most common and successful Need a partner or donor sperm

Oocytes Experimental label removed No partner required; provides reproductive autonomy; Bypasses some religious objections Takes approximately 2 weeks Requires ovarian stimulation Success rates approximately 30-35%

$13,000 + medications Takes approximately 2 weeks Requires ovarian stimulation Success rates rapidly improving: 25% $9000 + medications Preimplantation Genetic Diagnosis (PGD)

Biopsy of Day 3 or Day 5 Embryos Testing for Genetic Mutation + Mutation

(No transfer) Mutation (Transfer) Third-party Reproduction The use of eggs, sperm, or embryos that have been donated by a third person (donor) to enable an infertile individual or couple (intended recipient) to become parents May be known or anonymous

Complex Third-party Reproduction: Donor Egg Picking donor versus using an egg bank Identifying a donor Evaluating a donor Evaluating the intended parent(s) Donor stimulation/Recipient preparation

Success rates >50% Cost: $25,000-30,000 Third-party Reproduction: Donor Embryo Embryo Adoption Evaluating the intended parent(s) Recipient preparation Legal counsel VITAL

No good stats on success rates Cost: $15,000-35,000 Third-party Reproduction: Surrogacy Traditional Surrogacy: woman is biologically related to the pregnancy she is carrying RISKY!!!

Gestational Carrier: no biological relationship; carries the intended parents embryo(s) Third-party Reproduction: Gestational Surrogacy Selection of gestational carrier (GC) Evaluation of GC and intended parent(s) Counseling Legal

Recipient preparation Cost: $60,000 to 100,000+++ Adoption Various types Lifelong process Process:

Application Home study Identification of child (or being ID d) Supervisory period Legal adoption

Special considerations for survivors Cost: $0-$50,000+++ Psychosocial Aspects Resources RESOLVE Livestrong

American Society for Reproductive Medicine (ASRM) Reproductivefacts.org Conclusions Building a family after a breast cancer diagnosis is possible There are many different options that are available Sometimes you have to reframe how you think about building your family Assert yourself; be proactive!

Advocate!

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