By Dr. Sissy Sartor, The Fertility Institute of New Orleans, 4770 South I-10 Service Road, Suite 201, Metairie, LA 70001, (504)454-2165.
While the incidence of breast cancer increases with age, there are still many womendiagnosed in their prime reproductive years with 11% of women being 45 years of age or younger. One out of three of these women will have early stage cancer that can be successfully treated (70% survival at 10 years from diagnosis). Many of these women will not have started or completed their families, reflecting the growing tendency of women to delay childbearing until after age 30. Since the 1990s, the number of first time mothers older than age 30 has increased to over 21%.
Seek Fertility Advice Before Treatment
If you fall into that group of women, it is important that you discuss your future fertility with your oncologist early on, preferably at the time of initial diagnosis. Depending on the stage and character of the breast cancer, the oncologist may recommend chemotherapy (in addition to surgery) which is toxic to the ovaries, and can cause early menopause. Additionally, once surgery and chemotherapy are completed, some patients will be placed on hormonal treatment for 5-10 years (tamoxifen, letrozole) to help prevent recurrence. Unfortunately, this will preventconception until one is older, near menopause, resulting in very low to impossible chances for conception. Therefore, laying the foundation for possible conception after treatment, often means utilizing fertility preservation strategies initiated before treatment.
Three Options for Preserving Fertility
1) Ovary Protection. A medicine called a GnRH agonist (gonadotropin releasing hormone agonist) can be taken by intramuscular injection once a month during chemotherapy. This medicine places the ovaries in a resting or inactive state, which has been shown to provide some protection from the damaging effects of the chemotherapy. This option is usually chosen by the patient if she does not wish to undergo the other options: egg harvesting or ovarian tissue harvesting.
2) Freezing One’s Eggs. The second option is to remove eggs (oocytes) from the ovaries and either freeze them immediately, or fertilizing and then freezing the fertilized eggs (embryos) 3 to 5 days later. This process would be overseen by a fertility specialist and does require the use of fertility medicines to stimulate the ovaries (approximately 10 days) and then trans-vaginal retrieval of the oocytes (under intravenous sedation). This approach can usually be done prior to cancer treatment, but requires tight coordination between the oncologist and fertility specialist.
3) Freezing Ovarian Tissue. The last option is to have same-day, laparoscopic surgery to remove an entire ovary, so that egg-containing areas can be frozen for later use. This third option is still considered experimental and is being performed in only a few centers around the world. To date, less than 50 babies have been born from this approach. That’s in contrast to the freezing of embryos, which has a long track record with births numbering in the hundreds of thousands over the years and making it the recommended approach. Oocyte freezing is relatively new and success rate (survival from subsequent thaw, fertilization and pregnancy) will be dependent upon the integrity of the eggs at the time of harvesting, with eggs from younger women tending to perform better than eggs from older women. Finally, the cost for these procedures can vary from center to center, so it is best to discuss this with the consulting fertility specialist.
Studies suggest that less than 50% of patients have a meaningful discussion about fertility preservation with their oncologist before moving on to treatment. This is easy to understand since the patient may be under significant stress from dealing with a cancer diagnosis, and more concerned about life and death issues rather than later survivorship issues. Hopefully, however, with gentle guidance by the oncologist, and questions from the informed patient, this discussion will occur.